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EFT with Couples facing End-of-Life

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Presentation on theme: "EFT with Couples facing End-of-Life"— Presentation transcript:

1 EFT with Couples facing End-of-Life

2 Find your partner

3 Couples Movie Clip

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

5 Literature Review End-of Life Impact: Partner with Illness
Physical Social Emotional Depression Anxiety Spiritual (Mohr, Moran, Kohn, Hart, Armstrong, Dias, Bergsland, & Folkman, 2003) Physical – pain, mobility, loss of functioning Social – relationships change, roles shift, potential for isolation Emotional – depression and/or anxiety increase as the illness progesses Spiritual – what does it all mean, what happens after death, what now

6 Literature Review End-of Life Impact: Caregiver partner
Need to provide emotional support Need to provide instrumental support 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 Common symptoms: increased fatigue, health problems, and social isolation Demands on Caregiving Partner can be great and usually consist of providing both instrumental and emotional supports. Instrumental support - direct care such as feeding, washing and toileting, managing medications, providing other forms of physical care, interacting on the patient`s behalf in the medical community, maintaining adequate income, and managing finances`` (Armstrong et al., p. 621, 2003). Emotional support: Support given to the patient by the Caregiving Partner to affect the patient`s overall emotional well-being. Common symptoms are developed by Caregiving Partners as the patient`s health declines (Mohr et al., 2003)

7 Literature Review End-of Life Impact: Relational
Communication Adjustment to changes in roles Adjustment to demands of illness Coping strategies (McLean & Jones, 2007; Mohr et al., 2003) Communication – difficulty talking about end of life issues, cancer itself; ease of communication is related to emotional security, distress, relationship stability Caregiving partners are likely to feel more distress as they become unsure what their partner wants or needs from them; hence the patient can help their caregiving partner if they are able to communicate these things to them. (Mohr et al., 2003) Coping and defensive strategies such as withdrawal

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) 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) In addition to the points outlined in our video, taken from McLean & Jones, 2007 and Mohr et al., 2003, we would like to point out the following: Relational growth – couples who function well (which includes high support, cohesion, and expressiveness, and low conflict) have lower levels of distress, depression, and anxiety

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

10 Rationale for EFT use Terminal cancer occurs in the context of relationship 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) EFT creates a positive emotional environment 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) Useful in highly emotionally charged experiences (textbook ref), such as terminal illness 1st subpoint - Relationship and cancer affect each other in circular reciprocity (Stiell, Naaman, & Lee, 2007). Cancer affects the relationship, the relationship affects the cancer. 4th major point - EFT especially helpful in construction of 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 - Helps people understand the nature of relationships more clearly - Took its form in 1980s - Looks for patterns with emotional interaction - Emphasizes the power of EMOTIONS - Emotions are often seen as the problem with couples - Often emotions are avoided

12 EFT Overview Origins: Experiential/Gestalt
Therapeutic alliance itself is healing Acceptance and validation of client experience Belief that people are to make healthy choices Examine how inner and outer realities define each other People are formed and transformed in relationship with others Use here-and-now experience of therapy session to foster corrective experiences Johnson & Greenberg knew that emotions are the music to the couples dance The experiential/Gestalt perspective has always seen the wisdom in focusing on emotional responses and using them in the process of therapeutic change. Experiential/Gestalt - EFT follows the basic premises of experiential therapies, including these: 1st point – alliance should be egalitarian 3rd point - if given the opportunity. The therapist helps to articulate the moments when choices are made in the relationship drama 4th point - The inner construction of experience evokes interactional responses that organize the world in a particular way. These patterns of interaction then, in turn, shape inner experience. The EFT therapist moves between helping partners reorganize their inner world and their interactional dance.

13 EFT Overview Origins: Systemic Influences
Focus is on interaction between members of system Problems are due to interactions Breaking a negative cycle will effect positive change EFT focuses on using emotion to help break negative cycles and enact new patterns of interaction 1st point - In systems theory, the focus is on the interaction (feedback) that occurs between members of the system. It cannot be said that action A "caused" action B. We must consider behaviour in context. To understand the behaviour of one partner, it must be considered in the context of the behaviour of the other partner. The elements of a system have a predictable and consistent relationship with each other. All behaviour is assumed to have a communicative aspect. What is said between partners, as well as the manner in which it is communicated, defines the role of the speaker and the listener. 2nd point - The assumption is that symptoms/problems are a consequence of what happens in the interaction between people. 3rd point - The hallmark of all family systems therapies is that they attempt to interrupt the repetitive cycles of interaction among family members that include problem/ symptomatic behaviour. Breaking a negative cycle = a positive change The task of the family systems therapist is to interrupt these negative cycles of interaction so that a new pattern can occur. How family systems therapies differ is in how they attempt to break these cycles. The structural family therapist may have clients physically move to help create a boundary The strategic family therapist may give a paradoxical directive to bypass resistance in motivating clients to change the cycle of interaction Solution-focused therapists may assert that they have rejected the family systems metaphor in understanding families A focus on occasions where the cycle does not occur and directing clients (for example) to perform more of these" exceptional" behaviours. EFT can be understood as falling within this tradition of family systems therapies 4th point - Its focus on the enactment of "new" patterns of interaction, the unique contribution of EFT is the use of emotion in breaking destructive cycles of interaction. By helping partners identify, express, and restructure their emotional responses at different points in the interactional cycle, the EFT therapist helps the couple to develop new responses to each other and a different "frame" on the nature of their problems.

14 EFT Overview Origins: Experiential-Systemic Synthesis
Focus on present experience, not past Person is seen as fluid entity Experiential approaches focused within the person; excluded relational influences Systemic approaches focused on interactions; excluded individual internal responses and meanings 2nd point – fluid, not rigidly resistant to change

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) 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)

16 EFT Overview Relationship Health
A healthy relationship is one in which there is a secure attachment bond Mutual emotional accessibility and responsiveness Depathologizes dependency in adults Allows activation of attachment seeking behaviours Model of others as dependable and trustworthy, model of self as lovable and entitled to care 2nd point - Focus on interdependency challenges N. American ideals of individualism and myth of self-reliance ; Not possible for infant or adult to be too dependent or truly independent 3rd point - helps people be resilient during crises 4th point - Healthy internal working models allow people to be curious and more open to new evidence to explain behaviour of others (don’t jump to negative conclusions)

17 EFT Overview Relationship Distress
Due to attachment insecurity and separation distress Sequence of responses to threat against attachment security Anger Clinging and seeking Depression and despair Mourning and detachment Rigid interaction patterns such as demand-withdraw can be disastrous Typically, anger is the first response. This anger is a protest against the loss of contact with the attachment figure. The next step in separation distress consists of clinging and seeking, which then give way to depression and despair. Finally, if all else fails, the relationship is mourned and detachment ensues.

18 EFT Overview Key Principles
Collaborative alliance provides secure base from which to explore Therapist is consultant to process Emotion is primary in forming attachment behaviours, guiding perceptions, motivating attachment responses Therapist privileges emotional responses Attachment needs are healthy and adaptive 1st point - A collaborative alliance offers the members of a couple a secure bases from which to explore their relationship. The therapist is best seen as a process consultant to the couple's relationship. 2nd point - Emotion is primary in organizing attachment behaviours and determining how self and other are experienced in intimate relationships. Emotion guides and gives meaning to perception; motivates and cues attachment responses; and, when expressed, communicates to others and organizes their response. The EFT therapist privileges emotional responses and deconstructs reactive, negative emotions (such as anger) by expanding them to include marginalized elements (such as fear and helplessness). They also uses newly formulated and articulated emotions (such as fear and longing or assertive anger) to evoke new steps in the relationship dance. 3rd point - The attachment needs and desires of partners are essentially healthy and adaptive. It is the way such needs are enacted in a context of perceived insecurity that creates problems.

19 EFT Overview Key Principles Cont’d
Problems are maintained by interactional organization and by dominant emotions Therapist deescalates negative patterns and reactive emotions; help shape new, positive interactions Change occurs through new emotional experience in present interactions The actual “client” is the relationship, not individual members of couple 1st point – Problems are maintained by the ways in which interactions are organized and by the dominant emotional experience of each partner in the relationship. 1st subpoint – therapist shapes new cycles of positive interactions, in which positive emotions arise and negative emotions can be regulated in a different way 2nd major point- change does not occur through insight into past, catharsis, or negotiation, but through new emotional experience in the present context of attachment-salient interactions. The EFT therapist first deescalates negative interactions patterns and the reactive emotions associated with them. They then helps partners shape new cycles of positive interactions, in which positive emotions arise and negative emotions can be regulated in a different way. 3rd point - In couple therapy, the actual "client" is the relationship between partners. The attachment perspective on adult love offers a map to the essential elements of such relationships. Problems are viewed in terms of adult insecurity and separation distress. The ultimate goal of therapy is the creation of new cycles of secure bonding that offer an antidote to negative cycles and redefine the nature of the relationship.

20 EFT Overview: Three Tasks Task 1 – Create and maintain therapeutic alliance
Four qualities of building alliance: Empathic attunement Acceptance Genuineness Continuous active alliance monitoring 1st subpoint - using words, phrases, and non verbal responses to enable the connection with a client’s experience – empathy creates the safety needed 2nd subpoint - the therapist takes a non-pathologizing stance and actively resists the tendency to see her clients as deficient or defective. The therapist seeks to understand how the client’s problematic behaviours may make sense in the context in which those actions occur. 3rd subpoint - a therapist’s openness to being impacted by the client and sharing this impact through self-disclosure extends the felt sense of security a client experiences through his or her alliance with the therapist. A therapist’s genuineness is evidence of the accessibility and responsiveness of the therapist to the client. 4th subpoint - a therapist takes active steps to monitor his or her engagement with each partner. Active monitoring underscores the value of each partner’s experience and the therapist’s conscious attention to pacing with the couple.

21 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions
EFT therapists recognize key universal emotions anger/rage, fear/anxiety, joy/elation, shame/disgust, sadness/despair, surprise/curiosity Step-wise process of emotions: Appraisal Arousal Reappraisal Action Tendency The focus on the expression and expansion of emotional experience in EFT is pivotal to the restructuring of interactional patterns among couples Emotion process subpoints Appraisal: rapid assessment of stimulus involving limbic system of brain, indicating warning of potential danger or threat Arousal: physiological activation, preparing to respond Reappraisal: re-evaluation of initial assessment of stimuli involving more cognitive processes Action tendency: behavioural response to stimuli

22 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions Cont’d
Emotions inform interactions and help in organizing adaptive responses to a person’s environment Primary emotions Secondary emotions Instrumental emotions 3 key issues in focusing on emotion: Involvement Exploration New emotion Primary emotions: direct responses to a present situation i.e. anger, fear, hurt Secondary emotions: secondary reactive responses to the primary emotion that enable the person to cope with the primary responses. These responses typically obscure the initial emotional response that a person has to a given situation. Instrumental emotions: an emotional expression used to influence others, i.e. expressing anger in an aggressive fashion leads others to back down 3 key issues in focusing on emotion: Involvement: working with emotions requires the direct engagement and experience of those emotions. The therapist works with the concrete experience of the relationship to provide a safe working distance from a potentially overwhelming emotion. Exploration: The therapist leads the couple in a process of emotional discovery based on their personal experience and their experience of the other. This includes helping clients “unpack” an emotion enabling them to name a variety of emotional experiences that have come to be represented by one emotional label. New emotion: the discovery and expansion of previously unrecognized or unformulated emotional experience. Here the focus is on supporting a couple’s engagement with primary emotions, which will enable the couple to respond with a new level of engagement that changes the couple’s pattern or dance.

23 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions Cont’d
Skills for Emotional Engagement RISSC Validation Evocative Responding Heightening Empathic conjecture and interpretation Self-disclosure RISSSC R – repeat key words and phrases for emphasis i.e. “so its painful to feel the hurt, the sadness” I – therapist uses images or word pictures that evoke emotions more than abstract labels tend to do i.e. “reaching for him is like jumping off of a cliff” S – therapist frames responses to clients in simple and concise phrases i.e. “so a part of you just wants him to be there for you” S – the therapist will slow the process of the session and the pace of her speech to enable a client’s deepening of emotional experience i.e. using pauses S – the therapist will use a soft and soothing tone of voice to encourage a client to deepen his or her experience C – The therapist uses client words and phrases in a supportive and validating way i.e. if a client uses the phrase “she’s never happy with a thing I do”, the therapist can use this phrase later on as a connection to a similar experience Validation -communicates acceptance and recognizes the legitimacy of a client’s emotional experience therefore promoting the therapeutic alliance It is important in validation for the therapist to affirm the client’s unique experience (which may be very different from the other partner’s intention or experience) Evocative Responding -the use of questions and prompts to call up emotions into the conversation -the therapist may use evocative responding to help clients express emotions that are being communicated non verbally through somatic indications or verbal cues e.g. you say you are open to discussing this topic, yet your arms and legs are crossed and you are looking out the window. I wonder what is going on for you now as you think about what happened? Heightening -intensifies a client’s emotional experience creating a more vivid emotional engagement with the experience through heightened engagement the therapist will facilitate new patterns of interaction in the relationship -can take many forms, i.e. repetition, metaphors, images and enactments Empathic conjecture and interpretation -the goal is to promote a more intense awareness and experience of emotion -interpretations are exploratory responses to enhance client’s emotional experience -they are based on the therapist’s empathic immersion in client’s world of experience -in conjecture, the therapist takes one step beyond the client’s stated experience e.g. I hear that you are angry with Jim for not listening to you when you asked him not to landscape the backyard, and I see tears in your eyes as you talk about this. I wonder if you are also saying that you are hurt because he did not seem concerned about your opinion. Does that seem to fit? Self-disclosure - occasionally the therapist will use self-disclosure to strengthen the alliance with the couple - can normalize a client experience, facilitate further emotional exploration - focus should remain on the client’s experience, not the therapists personal experience - should be brief and focused

24 EFT Overview: Three Tasks Task 3 – Restructure Key Interactions
Tracking and reflecting interaction Simple reflection: when he does this, you do that Framing and reframing interactions Example EFT Reframes: Fighting against the Enemy of the Negative Cycle Withdrawal as an attempt to Protect the Relationship Pursuing to Fight for a Connection Restructuring interactions using enactments Structured, focused, choreographed The EFT model assumes that change does not come simply from new emotional experience but rather from new contact and interactions that arise from that new emotional experience. - Interventions aimed at restructuring interactions and reprocessing emotional experience are always intertwined Tracking and Reflecting Interaction - The therapist tracks the couple’s response patterns by observing and noting the steps in the couple’s interactions, and then reflects the couple’s response pattern back to them - As the therapist tracks and reflects the couple’s patterns over time, the ways in which each partner pulls for a particular response from the other becomes tangible and clear. - Through tracking and reflecting, the therapist eventually constructs a frame for understanding the couple’s distress in the context of the negative cycle Simple reflection: when he does this, you do that Framing and Reframing Interactions - As the therapist tracks and reflects the couple’s interactions, she frames their experience to give meaning to their distressing dance and to create a context for the process of therapy Example EFT Reframes: Fighting against the Enemy of the Negative Cycle Fighting for Secure Attachment Withdrawal as an attempt to Protect the Relationship Pursuing to Fight for a Connection Painting a Picture and Implying the Possibility of Secure Attachment Restructuring Interactions Using Enactments - Enactments provide the therapist with a flexible and process-oriented intervention that allows the therapist to be attuned and responsive to each partner as the partners confront new experiences within themselves and new behaviours and reactions from their partner - Structured, focused, choreographed - By creating many small moments of successful contact, the therapist gradually moves the process each time one step closer to shaping more secure bonding interactions

25 EFT Overview Further Interventions
Resolving attachment injuries 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. 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. 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 other’s experience of the event. 1st point - Often new emotions develop at this point and the individual is able to connect the injury to the negative interaction cycle. 2nd point – after the noninjured partner understands, they are then able to discuss how the event affected them.

26 EFT Overview Process of Change
Nine treatment steps, organized into three stages 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 Begin with one or two conjoint sessions, then one with each partner Typically lasts 8 to 15 weekly sessions 1st point - One step incorporates and leads into the next 4th point - If during the individual sessions, one partner reveals information that their partner is unaware of, the therapist helps the individual to share the information with their partner during the next session. 5th point - The couple may seek further sessions if one partner has or may have PTSD (Johnson and Denton, 232, 2002).

27 EFT Overview Mechanisms of Change
Levels of Change: Expansion of Experience Engagement of the Partner in a Different Way New View of the Partner is Offered to His/Her Mate New Cycle is Initiated A Bonding Event Occurs in the Session Shifts in Both Partners’ Sense of Self EFT initiates change by walking “with each partner to the leading edge of his/her experience and expands this experience to include marginalized or hardly synthesized elements that then give new meaning to this experience” (Johnson and Denton, 237, 2002). Levels of Change: Expansion of Experience – “emotions tell us what we need”. Engagement of the Partner in a Different Way – “new emotions prime responses/actions”. A New View of the Partner is Offered to His/Her Mate A New Cycle is Initiated – negative interactions are removed from relationship. A Bonding Event Occurs in the Session – allows for increased communication, positive problem solving skills, coping mechanisms. Shifts in Both Partners’ Sense of Self – “both can comfort and be comforted” (Johnson and Denton, 238, 2002).

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

29 EFT Overview Stage 1: Cycle De-escalation
Step 1: Identify relational conflict issues 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 4: Reframe problem in terms of the cycle, accompanying underlying emotions, and attachment needs.

30 Role Play: Stage 1 Scenario #1

31 EFT Overview Stage 2: Changing Interactional Patterns
Goals Have withdrawn partners reengaged in the relationship Partners are able to confide in and seek comfort from each other 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 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 5 - Attachment needs may include need for reassurance and comfort Step 7 restructuring is based on new understandings

33 Role Play: Stage 2 Scenario #2

34 EFT Overview Stage 3: Consolidation and Integration
Goals To consolidate new responses and cycles of interaction If you practice the new cycle enough times it will become the norm 1st point - This is done, for example, by reviewing the accomplishments of the partners in therapy and helping the partners create a coherent narrative of their journey into and out of distress. The therapist also supports the partners in solving concrete problems that have been destructive to the relationship.

35 EFT Overview Stage 3: Consolidation and Integration
Step 8: Facilitate the emergence of new solutions to old problems 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 Therapist outlines positive changes that have occurred during therapy Discuss goals for the future and any feelings about termination Couples are welcomed to return During stage three the therapist is less directive and allows the couple to create their own problem solving techniques and new ways for interacting. The therapist will outline the positive changes that have occurred during therapy. Goals for the future are discussed as well as any feelings towards termination. Couples are always welcome to return for therapy if new crises develop. (Johnson and Denton, 238, 2002).

38 EFT Overview Predictors of Success
Positive therapeutic alliance = success With male partners who have been described by their partners as “inexpressive” 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. 1st point - The quality of the alliance between the therapist and the couple will predict success. The couple’s ability to respond to the therapist and the tasks outlined during therapy is crucial to the success of therapy. Clients must participate. Johnson and Denton stated that “EFT works best when partners still have an emotional investment in their relationship and are able to view their problems in terms of insecure attachment and conflicts around closeness and distance. The first concern of the EFT therapist must be to form and maintain a strong supportive alliance with each partner” (Johnson and Denton, 233, 2002). 2nd point - Male partners who have been described by their partners as “inexpressive”. Therapy is often successful with male partners because once skills and tools are developed to express their emotions, it is often a compelling experience for both partners. 3rd point - Female partner’s who feel that their partner still cares for them. In Western culture, females typically maintain the positive bonds within a family. If the female partner does not have faith that her partner still cares for her, then the female may not be invested in promoting positive change (Johnson and Denton, 233, 2002).

39 EFT Overview Applicability & Diversity
Used with diverse ages, classes, backgrounds, and sexual orientations Positive outcomes for males and females Often used with gay and lesbian couples Couples with issues of low sexual desire are often difficult to treat in a few sessions Effective with traumatized partners, depressed partners Can be used with couples where there is mild and infrequent violence and/or emotional abuse EFT is used with many different couples who experience many different issues. EFT is used with couple of diverse ages, classes, backgrounds, and sexual orientations. EFT develops positive outcomes for males and females and Johnson and Denton report that “the model focuses on connection and mutuality, and validates both men’s and women’s need for a sense of secure connectedness that also promotes autonomy. The ability to share power and to trust, rather than to coercively control the other, is inherent in the creation of a secure adult bond” (Johnson and Denton, 239, 2002). EFT is often used with gay and lesbian couples. Many of the issues that LGBTQ couples experience are similar to those of straight couples. Couples seeking EFT for issues surrounding low sexual desire are often difficult to treat in a few sessions (Johnson and Denton, 239, 2002). Traumatized Partners Research has found that EFT is successful in working with couples where one partner is suffering from PTSD (physical illness and/or abuse, violent crime, childhood sexual abuse). This type of therapy appears to be effective when working with traumatized partners since it focuses on emotions and attachment. According to Johnson and Denton, “trauma increases the need for protective attachments, and at the same time undermines the ability to trust and therefore to build such attachments. If the EFT therapist can foster the development of a more secure bond between the partners, this not only improves the couple relationship but also helps partners to deal with the trauma and mitigate its long-term effects” (Johnson and Denton, 239, 2002). The individual who has suffered the trauma typically seeks individual counselling before couple counselling. Once the couple seeks EFT, an educational component is included during the early intervention stage in order to help the couple understand the effects of trauma on attachment. (Johnson and Denton, 240, 2002). Depressed Partners EFT therapists often work with couples where one partner is suffering from depression. Those suffering from depression often recover more rapidly if they are receiving support and compassion from their partner (Johnson and Denton, 240, 2002). According to Johnson and Denton, “attachment theory views depression as an integral part of separation distress that arises after protest and clinging/seeking behaviors have not elicited responsiveness from an attachment figure” (Johnson and Denton, 240, 2002). Research has found that depression and relationship stress increases if a partner feels insecure and does not feel close to their partner. Those suffering from depression and distressed relationships often feel unloved and unworthy by their partner (Johnson and Denton, 240, 2002). EFT can affect a partner’s depression. During the first stage of therapy, the depressive responses are targeted in terms of the negative interaction cycle and the attachment needs that are not being met. During the second stage, the depressive experience is discussed in terms of emotions including grief, longing, anger, and shame. The therapist assists the couple is formulating new positive interactions (Johnson and Denton, 241, 2002). Violence in Relationships EFT can be used with couples experiencing mild and infrequent violence and/or emotional abuse and as long as the abusive partner takes responsibility for the abuse and does not intimidate the abused partner into seeking counselling. The therapist will ensure that safety procedures are in place immediately and therapy will begin if the therapist feels that the couple is not in danger (Johnson and Denton, 242, 2002).

40 Popular Notions of End-of-Life Issues

41 Resources for Couples

42 Group Member Reactions
Topic: Couple Therapy at End-of-Life Similarities Differences We engaged in much discussion about whether the illness should be chronic (e.g. MS) or something terminal Approach: EFT 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

43 References Engler, B. (2003). Personality theories: An introduction, 6th 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), McLean, L.M., & Jones, J.M. (2007). A review of distress and it’s management in couples facing end-of-life cancer. Psycho-Oncology, 16, 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, 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, Sabo, D., Brown, J., & Smith, C. (1986). The male role and mastectomy: Support groups and men’s adjustment. Journal of Psychosocial Oncology 4(1-2), 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) Steinglass, P. (2000). Family processes and chronic illness. In Cancer and the Family, Baider, L., Cooper, C.L., & Kaplan-DeNour, A. (Eds.), pp John Wiley: West Sussex, England.

44 Reduce psychosocial distress
Rationale for Couple Therapy at End of Life optional slide –already covered in video Reduce psychosocial distress 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) In addition to the points outlined in our video, taken from McLean & Jones, 2007 and Mohr et al., 2003, we would like to point out the following: Relational growth – couples who function well (which includes high support, cohesion, and expressiveness, and low conflict) have lower levels of distress, depression, and anxiety

45 Application of Attachment Theory
Dying represents a threat to the attachment and attachment behaviours are activated in times of threat (McWilliams, 2004) Potential relationship issues 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)

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

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

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