by Ian Witter, LMFT
Sarah and Robert have been married for five years. When scheduling the appointment, Sarah tells you that they’ve been having “communication difficulties.” During the first session, Sarah states that they have been arguing and that the arguments can get pretty nasty. She elaborates, saying that she feels attacked, and blamed for the distress in their relationship, and that she perceives Robert as having an anger problem. Robert, who was sitting quietly up to this point explodes with, “I wouldn’t get so angry if you weren’t such a nag!” Sarah responds with “This is exactly what I was talking about, I don’t know why I even try! Why do you have to be such a dick?!” Robert responds with another derogatory statement about Sarah’s character, and you, the clinician, are left wondering about career options at Starbucks. What causes these seemingly out-of-control outbursts among couples? What can you, as their clinician do to help slow them down and get them to a place of safety and connection?
For clinicians who work with couples, such “escalated” couples can be the most daunting of cases. These are the couples who come to therapy seeking assistance, but frequently end up engaging in yelling matches, during which they seem more interested in name-calling and making threats than working on their relationship. As a clinician who specializes in Emotionally Focused Therapy (EFT) in my work with couples, I appreciate the challenges posed by taking on escalated couples as clients and understand why many clinicians refuse to work with them. Escalated couples can make us question our skills as a clinician, and push our buttons personally. Fortunately, EFT was created to work with clients experiencing distress in their relationship, and can be very effective in working with highly escalated couples. For those unfamiliar with the EFT model, here is a brief overview.
EFT is a systemic, evidence-based approach to couples therapy, based in attachment theory. Its underlying assumption is that every individual longs to find a sense of belonging, safety, and acceptance with at least one other person in his or her life. This seemingly innate need for attachment to another exists across socioeconomic classes and cultures. But what happens when the interactions with our partner doesn’t feel safe or secure? How do we respond to this relational stress? Couples with an insecure attachment to one another can respond with defensiveness, anger, blaming, and accusations, or distancing and withdrawal. Common manifestations of relational distress include infidelity, substance use, or physical or emotional abuse. EFT views these negative responses as a reaction to perceived abandonment and a fracturing of the desired secure attachment by a partner. By putting these responses in the context of heightened emotional need, EFT helps couples reframe these negative emotional responses as a desire for safety and security. This is done by helping the couple recognize their primary emotions and how these are connected to the underlying attachment needs of each partner. EFT is also experiential, i.e., part of the therapeutic process is to structure new conversations in which the couple can communicate these attachment needs. In short, EFT helps to drive connection through emotional vulnerability as opposed to emotional reactivity.
EFT also views negative interactional patterns within a distressed relationship as consistent and predictable, regardless of the content of the argument. Each partner’s relatively predictable relational role is usually related to their underlying attachment style (secure, avoidant, or anxious). As clinicians, how many times have we heard one partner say, “I can never get anything right, so now I don’t even try” (avoidant attachment style) and the other state, “I feel like I’m all alone in the relationship, and that my partner doesn’t care about my feelings at all” ( anxious attachment style). The typically avoidant tend to withdraw into themselves in times of stress. The typically anxious tend to find comfort through interactions with another, and when they don’t get comfort, can become critical and blaming in their attempts to find it. When one partner creates distance and avoidance, and the other craves closeness and intimacy, trouble results. EFT recognizes this pattern as the “cycle” that occurs for distressed relationships, regardless of the content of the communication.
EFT is comprised of three stages and nine steps. The typical course of treatment is 8-20 sessions, but underlying issues (trauma, substance use, infidelity) affecting the relationship can extend the length of treatment.
Stage One: Assessment and de-escalation of current negative cycle
Step 1: Create alliance with couple and assess issues that create conflict, with a focus on how these issues are related to the underlying attachment issues for each partner.
Step 2: Identify the negative cycle, and each partner’s position in that cycle. Focus on each partner’s behaviors, thoughts, secondary and primary emotions, and unmet attachment needs.
Step 3: Access underlying emotions both partners feel in the course of the negative cycle. Hearing their partner’s relational experience attached to other vulnerable emotions instead of rigid negative emotions helps to temper their own interactional patterns.
Step 4: Reframe the presenting relational conflict in terms of unmet attachment needs and primary emotions. Frame the negative cycle as the source of the relational distress, thereby externalizing the cycle they experience.
Stage Two: Changing interactional process; restructuring emotional bond between partners
Step 5: Foster identification of previously disowned aspects of self (emotions and attachment needs) and integrate these into relationship by sharing with the other partner. Identify how these disowned emotions have prevented the partner from reaching out authentically.
Step 6: Promote acceptance of the sharing partner’s experience, with the goal of each partner believing and trusting what the other partner is sharing, particularly, that partner’s underlying emotions and attachment needs.
Step 7: Help facilitate the authentic expression of attachment needs driven by primary emotions directly to one another, so as to dispel the old negative relational pattern.
Stage Three: Consolidation and integration
Step 8: Facilitate new solutions to old relational problems. Given the new pattern of relating to each other, it is easier for the couple to create new dialogues around previous topics they found difficult.
Step 9: Consolidate new relational positions and emotional engagement with one another.
Using these nine steps, EFT restructures the attachment bond between partners, and moves them from a place of functioning independently to functioning from a place of security. Being able to feel as if they are being experienced by their partner from a secure place helps resolve any lingering attachment injuries from childhood. Successful completion of EFT is an effective way of healing from traumas experienced in childhood or from previous relationships.
Structurally, working with highly escalated couples is no different from working with less-escalated couples. In both cases, partners feel that they are unheard and alone, and are protesting what they perceive to be an emotional abandonment. The only difference is that the escalated couple is more verbally critical about it. Many individuals who are so quick to “go on the attack” have experienced what we would call “little t” trauma at some point in their history. While not enough to cause symptomatology associated with Trauma, the injuries experienced in their past are enough to cause an extreme defensive reaction in times of relational stress. These individuals are more likely to externalize what they perceive to be the source of their distress, in this case, their partner. Because they are so quick to escalate, it can be difficult to remain focused on their underlying emotional needs, and to recognize that these moments of distress are the moments in which they most need connection with their partner.
The following are some pointers to help clinicians stay connected and focused when working with highly escalated couples:
- During the course of treatment, you may become the focus of either partner’s anger. If this occurs, remember that the expressed anger is directly correlated with to the pain of being in a distressed relationship. It can be difficult to remain focused on the underlying emotional pain that a client is experiencing when their defensiveness is directed toward you. Notice that they are becoming reactive because you are touching on the place of their emotional injury – the place where they need support and validation the most. Also keep in mind that their negative response would be no different with a different therapist, working with a different model. The best approach is to validate their emotions and empathize fully.
- Be patient. These couples are often locked into these negative cycles for years. It will take time, patience, a willingness to meet the couple where they are, and persistent validation to help them begin to de-escalate. Continue placing their defensiveness and anger into the cycle.
- Be directive. When highly escalated couples first come in, it is imperative that they speak to you and not to each other. In the beginning, you need to gather information about the negative cycle between them. Letting them speak to each can be like putting a match to gasoline in that they will quickly fall into their negative cycle. Stress that they might hear something from their partner that they disagree with, but emphasize that you need to understand both sides of the relationship.
- Learn to recognize the non-verbal cues indicating your client’s reactivity, especially by watching the non-speaking client. Examples include a tapping foot, crossed arms, an eye roll, etc. To be able to say to them, “I know that what Robert is saying is upsetting you, Susan, and you may disagree with what he is saying, but it is important for me to hear how he makes sense of what is happening between you two. I also want to hear how you make sense of this place in which you two find yourself” can be enough to mollify any angry attacks. Remember, their underlying emotional experience is probably hurt, sadness, fear of being abandoned (anxious response), or feeling incompetent, and that they are failing as a partner (avoidant response). Your job is to help them recognize this and be able to share this with one another.
RISSSC (elaborated below) is one of the primary “tools” employed in EFT in order to help clients feel heard and validated. RISSSC helps clients to slow down and engage with their emotional processes rather than their defensive, cognitive processes. It also helps them to stay focused on the emotional content rather what they feel is ‘wrong’ with their partner.
Repeat: repeat key words and phrases. “It’s scary. It’s scary to think he won’t be there for you. It’s scary to feel alone and abandoned in this relationship.”
Images: use of images that have emotional content. “You feel shut out – like he’s locked himself in a vault, and there’s nothing you can do to reach him.
Simple: use simple, concise phrases. “You want to feel connected to him. You long for it.”
Slow: use the pace of your speech to create space in room for deeper emotional experience.
Soft: use a quieter tone to provide comfort and connection.
Client words: used to validate and support the client in their story. Repeating key emotional words can heighten the emotions related to their attachment fears, which can help clients engage with their hurt and sadness instead of their anger and defensiveness. “You feel alone, like he’s not there for you in those moments when you need him the most.”
Working with highly escalated clients can be incredibly challenging, but also incredibly rewarding. If we focus on their anger as an expression of their attachment fears rather than an intentional move to injure, we can start to see the deep bonds these couples have toward one another. Be aware that that working with highly escalated couples means being witness to the horrible things they say to each other. You cannot prevent that, but you can make these moments constructive by putting them into the interactional cycle that brings the couple into treatment; that, ultimately is the goal of working with these distressed, difficult couples.
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