A Primer for Emotionally Focused Individual Therapy (EFIT)

Cultivating Fitness and Growth in Every Client

Susan M. Johnson, T. Leanne Campbell

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000462685
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicoterapia

From best-selling author, Susan M. Johnson, with over 1 million books sold worldwide!

This essential text from the leading authority on Emotionally Focused Therapy, Susan M. Johnson, and colleague, T. Leanne Campbell, applies the key interventions of EFT to work with individuals, providing an overview and clinical guide to treating clients with depression, anxiety, and traumatic stress.

Designed for therapists at all levels of expertise, Johnson and Campbell focus on introducing clinicians to EFIT interventions, techniques, and change processes in a highly accessible and practical format. The book begins by summarizing attachment theory and science – the theoretical basis of this model – together with the experiential approach to change in psychotherapy. Chapters describe the three stages of EFIT, macro-interventions, such as the EFIT Tango, and various micro-interventions through clinical exercises, case studies, and transcripts to demonstrate this model in practice with individuals, highlighting the unique benefits of EFT as a cross-modality approach for treating emotional disorders. With exercises interwoven throughout the text, this book is built to accompany in-person and online training, helping the practicing clinician offer targeted and empirically tested interventions that not only alleviate symptoms of distress but expand the client's emotional balance, agency, and sense of self.

As the next major extension of the EFT approach, this book will appeal to therapists already working with couples and families as well as those just beginning their professional journey. Psychotherapists, psychologists, counselors, social workers, and mental health workers will also find this book invaluable.

1
What Is EFIT? Let’s See!

DOI: 10.4324/9781003090748-1

This chapter will lead you through snapshots of the change process with an EFIT client suffering from very high levels of post-traumatic stress disorder due to extreme childhood sexual and physical abuse. In fact, Henny fits all the criteria for complex developmental post-traumatic stress disorder (PTSD). Therapist interventions will be outlined to give the reader a picture of what EFIT looks like in practice. The goal here is to give you a visceral sense of what EFIT is about before explaining theory and practice in more abstract terms.

The portrait of change with Henny will focus first on beginning sessions, then on transcripts from the end of Stage 1 of EFIT – Stabilization, and one point in Stage 2 – Restructuring, Expanding Models of Self and Other, where Henny makes significant changes in ordering her emotional world, and shifting her sense of self. In EFIT we think of our ultimate goal as expanding the self. This is in contrast to the constriction of the sense of self and engagement with others that is typical in chronic mental and emotional distress. The moment-to-moment attunement of the EFIT therapist is guided by the map to basic human vulnerabilities and needs set out by attachment theory and science (Johnson, 2019).

The macro-intervention sequence we call the EFT Tango is used in every session of EFIT, in the EFT model for distressed couples and in EFFT with distressed families. It will be briefly pinpointed and referred to in this chapter. These interventions and more micro-interventions will be clarified in detail in the rest of the book. There follows a case description. Specifically, examples of key sessions with a client conducted by the first author, Sue Johnson.

Henny bounces into my room, all blonde curls, big hiking boots, and giggles. She talks very fast and immediately engages with me. She tells me she is 50 years old, has had a varied career as a specialized editor and as a teacher of gymnastics, and has two adolescent children, Vinnie and Veronica, who now live with her since the breakup of her marriage 9 months before coming for therapy. She asked her husband, Tom, a dentist whom she met when she was 18, to leave because of his complete withdrawal into his addiction to alcohol, cocaine, and gambling. This was the third time she had left him. Twice before this had involved “running away” to new cities but this time was “final.” She confides that she came for therapy because, “I have always lived in survival mode, just focusing on taking the next breath,” but now she was, “tired out.” She states, “I just shut down and sleep for a whole day now.”

In a breathless rush, she then tells me that she was diagnosed with PTSD after the birth of her second child when Tom turned up high at the hospital and her parents, who live on the other side of the country, paid her a surprise visit to see the new baby. She reports that she went into a “trance” and was “catatonic” for a week in the hospital. Indeed, at the beginning of therapy, her scores on Briere’s Trauma Symptom Inventory (TSI-2, Briere, 2011) were elevated and in the clinical range on all but one (i.e., suicidality) of the key factors on this test. After this catatonic episode she was heavily medicated but currently was taking a moderate dose of anti-anxiety medication only. She tells me that her symptoms had abated for a while but, since asking Tom to leave, she has suffered from nightmares and feelings of hopelessness, panic attacks, and intense flashbacks of her past trauma with her father, who would drug his two girls and repeatedly rape them until they reached puberty. He would always arrange where the girls slept and if you were the one in the most isolated room, then you were “hunted.” Her mother witnessed many of these incidents but would then deny they had occurred.

In spite of this traumatic history, Henny immediately comes across as honest, vivacious, highly intelligent, and eager to grow. She is resourceful, telling me, “I can fix anything. I can rebuild a house if I have to.” She describes holding down three jobs at a time and teaching gymnastics, stating that her skill at gymnastics was an ongoing joy for her. She shares that, as a child, she remembers moving a dresser in front of her bedroom door to keep her father out and other “victories.” She says, “I want a life that feels safe, I want to break the pattern. But now it’s hard – Tom was the only person who ever loved me. Seemed to love me. I don’t trust anyone.”

The goal of Stage 1 of EFIT, Stabilization, is to build a positive alliance and stabilize the client, pinpointing sources of strength and resilience, shaping coherence and emotional balance, and formulating core treatment themes, dilemmas, and goals with the client. (See the list of EFIT Stages and the goals for each stage at the end of this chapter.) Henny tells me that her life was a “whirlwind” and indeed, she spoke very fast, moving from story to story and from childhood to recent events in an intellectualized, haphazard way that was very difficult to make coherent sense of. I struggled to piece together key events and timelines for childhood experiences, for her relationship with Tom, and for the recent breakup. We moved through assessment (see Chapter 6) and I stayed in empathic reflection mode for most of the first ten sessions, clarifying defining moments in Henny’s emotional life, how she dealt with those moments, and also patterns in how she engaged with others in her life. (We call this process EFIT Tango Move 1 – more later.) If I tried to slow her down, go deeper into any particular moment or theme, she would stop and begin another story.

I focused on shaping a safe EFIT alliance – being emotionally open and available, responsive and engaged with her, normalizing and validating her pain and her dilemmas, and waited for a sense that she was ready to deepen her emotional engagement in the session. At one point, she said she could draw a traumatic scene for me where she was with her mother and sister outside a church. When she gave me the drawing it was simply of the church. I pointed out that the people and the meaning were missing and she laughed and then changed the subject. I continued with the focused attunement and relentless empathy that an attachment-oriented model fosters and waited for her to step past giving me pieces of information and let me into her life. As always in EFIT and in the general EFT model, I wanted her to move into deeper levels of experiencing in the here and now of the session; to move from the detached recounting of ideas and events to a fully engaged, alive, visceral exploration of her present experience. (This can be measured by the Experiencing Scale which we will discuss in Chapter 4.) The deliberate, gradual creation of an attachment-oriented EFT therapeutic alliance is essential to this process. The alliance as characterized by Carl Rogers (1961) is authentic, transparent, and accepting. As suggested by attachment research, the therapist attempts to be open and accessible, emotionally responsive, and fully engaged with the client (Johnson, 2019), in a way that parallels a stronger, wiser security shaping attachment figure.

Gradually, I was able to slow Henny down and help her deal with some of her grief and fear around the breakup of her marriage so she felt more grounded and able to do tasks like filling out the custody agreement with Tom and setting limits on him seeing the girls when he was intoxicated. We also focused on searching for resilience moments to serve as a safe haven – a refuge for her when opening up to a painful experience was hard to tolerate. Most often in EFIT this involves a positive moment with a safe past attachment figure where the self of the client was recognized and valued. However, any kind of moment like this was hard for Henny to access so we searched instead for a moment when she felt “strong and competent.” We found such a specific moment in gymnastics where she did well and was acclaimed. I asked her to close her eyes and I evoked a vivid, alive experience. I summarized this.

Therapist: So you are about 11 and you are up on the balance beam, feeling the beam under your feet, strong, sure of yourself. You run and leap into the air and turn your body, feeling the power, and touch the beam and leap and turn again. You know where the beam is. You know you can leap and curve your body into an arc and then leap again and land perfectly with your arms high. You see your coach’s face smiling at you – at your skill and your courage and your fierce leaps – your risks. Can you feel that in your body as we touch it? (She nods emphatically.) Good. The leap, the turn, the landing. You knew where the ground was – what was real. And you were in your body. This is a good place to go when you are scared and unsure. (She nods again.) And you were just a child – a child who couldn’t let go and sleep for fear of your father coming for you. But part of you was still strong and whole. Henny, you knew you could fly.

We return to this image and use it again and again all through the therapy process.

Gradually, Henny was able to be more emotionally present in sessions and begin to pinpoint key scenes in her childhood that continued to haunt her in nightmares and flashbacks. Her story became more coherent and we began to identify key traumatic scenes. She began to be able to enter and stay in deeper experiencing, which I would systematically assemble and deepen with her. (This is the Tango Move 2 process.) For example, she accessed dinner table scenes as a child when she was in her father’s “strike zone,” and would get so scared she would gag and throw up. There was “no safety anywhere.“ She was able to identify and begin to stay with and explore memories that induced “total panic,” such as walking in as her father was raping her younger sister. Generally, she began to be able to connect with her “frightening, alien and unacceptable emotions,” (Bowlby, 1988, p. 138) and to begin to feel them rather than “numbing out and fighting to cope, to fix stuff all the time.” She told me, “Fight, Fix, Numb but don’t Feel,” wasn’t working. She reflected that she wanted to “save others” and fix things in order to not feel so helpless and alone and to “matter to someone at least for a moment,” but usually she would get hurt and numb out and “escape” into a new place or activity. I would help her turn her more vivid and alive emotions into interactions – dramas with key figures in her life (Move 3 of the EFIT Tango). The encounters we worked with were short, such as closing her eyes and telling Tom, “I can’t fix you. I have to give up on us.” After telling me a dream where she was in a “trap” where she “treads water out in the ocean and swims to people trying to save them all the time,” we also have an encounter between us where I ask her if she can be in the water and let me hold her up sometimes and she weeps and agrees she can.

I always ask her to process key emotional scenes (Move 4 of the Tango), inquiring as to how her body feels and what comes up for her when accessing these memories and relating them to her present pain. I also continually and explicitly validate her and her experience (the last move – Move 5 of the Tango).

After approximately 15 sessions, the process moved to Zoom meetings online due to the pandemic.

A Snapshot Excerpt from EFIT – The End of Stage 1

At the end of Stage 1, we typically see more emotional balance in a client, which translates into more focused awareness and acceptance of emotions, and more ability to reflect on emotional experiences and make coherent sense of them – a sense that challenges definitions of the self as inadequate, unworthy, or helpless. Clients move with the therapist, who is now a safe haven and a secure base, into active discovery mode, and at the same time their window of tolerance widens.

Henny comes into the session saying she is “bitter.” It is her birthday and she remembers, like watching a film, a birthday party where her father started beating on one of her friends at the party. The girl’s parents came to the house to complain but “As usual, NOBODY DID ANYTHING!” The other kids then ostracized her.

Henny: It was brutal. I can see it. He pummeled her. So I told Tom I didn’t want to go out for a celebration. No more roller coaster where he is nice to me for an hour and then … Gone.

Therapist: Yes. A kind of bitter helplessness comes up when you think of your dad and when you think of Tom.

H: It was all pretending. I remember Mom making cookies! Little morsels of caring. When Dad was nice to you it was off, kind of scary. He was planning something. I’d refuse his gifts. And Tom won’t accept he is an addict. He says it’s me and my PTSD that is the problem, that I’m too needy. That I can’t do regular things like close or lock doors. Always need an escape. Dad said I was crazy too when I resisted him.

Th: Yeah. He robbed you of your reality – denied the brutal reality that you were all alone and helpless and he was a predator – a terrifying, abusive dad. And Tom too … he let you down.

H: She, my mom, took me to the doctor once cause I was so sore and bleeding down there … but nothing happened. She made some excuse. I always said I would escape … but … feels like I am still in prison. My sister says she doesn’t remember anything but she is a mess so …

Th: How are you feeling as you say this Henny? You are telling me that you have had to deal with this, what did you call it – life sentence of fear – with no one to turn to, to see you and tell you your pain is real – that it matters – no comfort – and you are heroically fighting for your life again and again. All by yourself. (Tango Move 1 – Reflect emotional processes occurring within self and between self and others.)

H: I don’t know. I’ve done pretty good – lots of jobs – I can s...

Table of contents

• Cover
• Endorsements
• Half-Title
• Title
• Copyright
• Dedication
• CONTENTS
• ABOUT THE AUTHORS
• Introduction
• Chapter 1 What Is EFIT? Let’s See!
• Chapter 2 What Is the Guiding Framework for EFIT?
• Chapter 3 Shaping Safety: How Does the EFIT Therapist Engage the Client?
• Chapter 4 How Does Emotion Move the Client into Change in EFIT?
• Chapter 5 What Is the Macro-Intervention Sequence, the EFIT Tango?
• Chapter 6 What Are the Key Micro-Interventions Used in EFIT?
• Chapter 7 How Does the EFIT Therapist Tune In and Find Focus – Assess the Client?
• Chapter 8 How Does the Therapist Shape Stabilization in Stage 1 of EFIT?
• Chapter 9 How Does the Therapist Restructure Self and System in Stage 2 of EFIT?
• Chapter 10 How Does the Therapist Guide Consolidation In Stage 3 of EFIT?
• Chapter 11 What Do Key Change Events Look Like in EFIT?
• Chapter 12 Epilogue
• APPENDIX
• RESOURCES
• REFERENCES
• INDEX