Resolving Attachment Injuries in Couples [624174]

Resolving Attachment Injuries in Couples
Using Emotionally Focused Therapy:
A Process Study
John W. Millikin
Dissertation submitted to the Faculty of the
Virginia Polytechnic Institute and State University
in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
in
Human Development
APPROVED
Scott W. Johnson, Committee Chair
Susan M. Johnson
Howard O. Protinsky
Anne M. Prouty
Jon L. Winek
April 28, 2000
Blacksburg, Virginia
Keywords: Attachment Injury, Emotionally Focused Therapy, Attachment Theory, Process
Research
Copyright, 2000 John W. M illikin

Resolving Attachment Injuries in Couples
Using Emotionally Focused Therapy:
A Process Study
John W. Millikin
ABSTRACT
The current study identified attachment injuries in couples and developed a preliminary model
for the resolution of attachment injuries using Emotionally Focused Therapy (EFT). Anattachment injury occurred when one partner betrayed or broke the trust of the other in aspecific incident and that incident became a clinically recurring theme or stuck-point of taskresolution. Couples with attachment injuries were identified by an expert clinician and theresearcher. Subjects were couples with moderate to mild distress. The attachment injurieswere resolved using EFT, an empirically validated approach to couples therapy. The model(N = 3) was developed using task analysis. Audiotaped segments of “best sessions” of markerevents were reviewed by raters to determine change events throughout the therapy process. Arational, conceptual map of expected change was compared to an empirically developed map.The marker events emerged at the assessment, de-escalation, and resolution phases oftreatment. Pre- and post-tests measured overall resolution of the attachment injury andprocess measures identified in-session changes. The results of this study yield a proposedtheoretical model of change for couples who sustain an attachment injury.

iiiAcknowledgments
I gratefully thank Scott Johnson for providing clear guidance during my clinical and
research training, and for his critical and supportive eye while reviewing my drafts. A thankyou to the whole committee, Drs. Scott Johnson, Howard Protinsky, Anne Prouty, JonWinek, and Sue Johnson, for allowing me the freedom to determine my path and redirectingme when I veered from it.
A thank you to Sue Johnson for providing such inspirational ideas and giving me an
opportunity and place to develop as a researcher, clinician, and a person.
A final thank you to the EFT team in Ottawa, notably Judy Makinen and Janice
Hansen, for their tireless accessib ility and responsiveness throughout this work, and to the
couples who gave their time and trust in this process.

ivTABLE OF CONTENTS
List of Tables………………………………………………………………………………………………….. vi
Chapter I: Introduction………………………………………………………………………………………1
Attachment Injury……………………………………………………………………………………1Definition of Attachment Injury………………………………………………………………….2Emotionally Focused Therapy……………………………………………………………………3Attachment Theory………………………………………………………………………………….4Overview of Methodology: Task Analysis…………………………………………………..5Research Questions………………………………………………………………………………….6Rationale and Summary of The Study…………………………………………………………7
Chapter II: Review of Literature…………………………………………………………………………..9
Attachment Theory………………………………………………………………………………….9Emotionally Focused Therapy………………………………………………………………….16Methodological Issues in Process Research………………………………………………..20Task Analysis………………………………………………………………………………………..21Summary……………………………………………………………………………………………..23
Chapter III: Methodology…………………………………………………………………………………24
Overview of the Research Design……………………………………………………………..24Research Questions………………………………………………………………………………..25The Resolution of Adult Attachment Injuries Using Task Analysis:
The Discovery Phase……………………………………………………………………25
Sample Description and Sample Selection Procedures………………………………….26Data Collection Procedures……………………………………………………………………..28Description of Pre- and Post-Treatment Instruments……………………………………31Description of Process Measurement/Instrumentation………………………………….34Data Analysis Process…………………………………………………………………………….36
Chapter IV: Results …………………………………………………………………………………………38
Sample Description ……………………………………………………………………………….38Research Questions ……………………………………………………………………………….39How did clients describe the attachment injury before treatment?…………………..39What were the results of the pre-test scores for couples? ……………………………..41What were the post-test scores and did the scores result in “successful”
resolvers according to the measures’ norms? ………………………………….43
What were the results of the SASB and ES process measure scores
within each marker or phase of resolution? ………………………………………45
How did clients describe the attachment injury
after the resolution phase of treatment?……………………………………………48

vIn what ways did the event pathways of the proposed rational model of
attachment injury resolution differ from those of the empirical model?….51
Summary……………………………………………………………………………………………..54
Chapter V: Discussion ……………………………………………………………………………………..55
Introduction …………………………………………………………………………………………55Attachment Injury as a Useful Clinical Concept…………………………………………..56Shortcomings………………………………………………………………………………………..60Future Research ……………………………………………………………………………………61
References ……………………………………………………………………………………………………. 63
Appendix A: Participant Forms…………………………………………………………………………..72Appendix B: Self-Report Measures……………………………………………………………………..77Appendix C: Process Measures…………………………………………………………………………..89Appendix D: Attachment Injury Measure Self-Report Descriptions ………………………….95Appendix E: “Best Session” Transcripts for Markers of Change ……………………………..99Appendix F: Post-Treatment AIM Interviews……………………………………………………..117Vita…………………………………………………………………………………………………………… ..126

viLIST OF TABLES
Table 1: Preliminary Empirical Model of Attachment Injury Resolution Process …………..8
Table 2: Classification of Adult Attachment………………………………………………………..14Table 3: Data Measures and Procedures……………………………………………………………..37Table 4: Demographics…………………………………………………………………………………….39Table 5: Summary of Pre-Treatment Attachment Injury Measure…………………………….41Table 6: Pre-Assessment Measures Results………………………………………………………….42Table 7: Results of Post-Treatment Measures………………………………………………………44Table 8: Summary of Post-Treatment Attachment Injury Interviews…………………………50Table 9: The Empirical Attachment Injury Resolution Model………………………………….53

1Chapter I
Introduction
When couples enter therapy, partners have often experienced considerable emotional
distress. They report feeling absorbed in negativity toward their partner and trapped in limitedways of relating to one another. The person they used to turn to for comfort and support nolonger seems available. Some may react to their distress through blame and criticism, othersthrough distance and withdrawal. Research has indicated that distressed couples report lowerlevels of adjustment and satisfaction (Collins & Read, 1994; Simpson, 1990), lower levels of
intimacy and trust, and higher levels of defensiveness, hypervigilance, and fear ofabandonment than non distressed couples (Hazan & Shaver, 1987).
Lower levels of intimacy, trust, and relationship satisfaction often indicate insecure
attachment bonds (Hazan & Shaver, 1987). Couples with insecure attachment bonds tend tointeract through defensive emotional patterns and block accessib ility, trust, and responsiveness
(Johnson, 1996). These couples are susceptible to attachment alarms, manifested throughbehaviors such as protest and hostility, and feelings of despair and detachment (Bowlby,1969). Secure attachment bonds, on the other hand, have been characterized by emotionalaffiliation, trust, and accessibility. The secure relationship bond serves as a safe base and
buffer against distress (Johnson, 1996).
From a systems perspective, pinpointing a cause of distress and the dissolution of an
attachment bond ignores the complexity and context of the relationship. From a client’s pointof view, however, significant events can occur which punctuate desultory attachment bondinsecurities. Johnson (1996) proposed that distress and attachment insecurities can frequentlybe traced to a specific incident when one partner feels a strong sense of betrayal by the actionsof the other. In therapy, this incident stands as a nodal transition in the couple’s relationship:the injurious event becomes a recurring theme, representing a wound in the attachment bondand marking patterns of mistrust and distress.
Guided by Emotionally Focused Therapy (EFT), attachment theory, and clinical
experience of the developers of EFT, this study tested the utility of attachment injuries as aconcept and developed a preliminary model for the resolution of attachment injuries in mildlyto moderately distressed couples using EFT as the treatment. The model was developed bytask analysis. A conceptual map of expected change processes were refined by an empiricallydeveloped map. The results of this study validated the hypothesized concept of attachmentinjuries and yielded a proposed resolution model of change for couples who sustain anattachment injury.
Attachment Injury
An attachment injury is a newly developed concept in the marriage and family therapy,
counseling, and psychology literatures. The concept stems from the theoretical underpinnings

2of child and adult attachment theory (e. g., Ainsworth, 1960; 1990; Bartholomew &
Horowitz, 1991; Bowlby, 1969; 1973; 1980; West & Sheldon, 1988),Emotionally Focused Marital Therapy (e. g., Johnson & Greenberg, 1985a), and expertrecommendation from clinical experience (Susan Johnson, Personal Communication, June1998).
EFT theory maintains that a secure attachment bond in couples is fostered by
emotional accessib ility and responsiveness (Johnson, 1996). Accessib ility implies being
available for emotional and physical contact when the other partner is in distress. Responsiveness refers to the willingness to respond to the needs and desires of the other. When one partner is inaccessible or unresponsive to the psychophysical needs of the other, aninsecure attachment can ensue (Johnson & Whiffen, 1999). Based on EFT theory, anattachment injury is characterized as a betrayal that contributes to insecure attachment bondsand that is continually used, whether implicitly or explicitly, as a standard for the dependabilityof the other. The loss of trust, and the accompanying insecure attachment, are hypothesizedto lead to negative interactional cycles between the couple that may escalate into severemarital distress (Johnson, 1996).
Definition of attachment injury. An attachment injury occurs when one partner does
or says something to the other partner that “damages the nature of the attachment bond”
(Johnson, 1996). The damaging incident can be as grave as an extramarital affair or asseemingly minor as being left out of a photograph at a family gathering (Susan Johnson,Personal Communication, June 1998). The actual incident of an attachment injury is notnecessarily the cause of the disruption of the relationship bond. Some partners may haveendured insecure attachment bonds over time and the incident serves as a symbolic marker ofthe insecure attachment state. Others may have a secure bond and the incident prompts thebeginning of relationship distress.
Johnson (1996) defined an attachment injury as:[an] attachment betrayal or crime, that is, traumatic incidents that have damaged the
nature of the attachment and actively influence the way the relationship is defined inthe present . . . For example, a small current incident where one partner isdisappointed may become an enormous issue because it evokes a key incident in thepast, where one partner experienced traumatic abandonment, rejection, or betrayal atthe hands of the other . . . As the emotions underlying interactional positions areprocessed, these incidents come alive in the session. (p. 103)
Johnson and Whiffen (1999) further defined attachment injuries and the resulting
interactional patterns:
These injuries may appear insubstantial to an outside observer or they may be obvious
betrayals of trust, such as an affair. They often occurred at particularly critical

3moments of need when a person was particularly vulnerable. These events may
become a touchstone, an incident that, for them, defines the security of therelationship. The anxious partner will bring the incident up again and again in anattempt to get closure. This becomes aversive for the spouse who withdraws from thediscussion. (p. 28)
The attachment injury event serves as an alarm, a warning system that sends the
message that the other cannot be trusted to provide security and comfort. The injured partnerexperiences a decrease in the level of trust in his/her partner and may decide implicitly not toreach out to their partner for security and comfort. Johnson (1996) wrote that highlydistressed couples and couples who describe an attachment injury often speak in life-or-deathterms and metaphors such as, “You let me drown,” or “You didn’t care that I crashed andburned after that argument.”
Clients who report attachment injuries may enter therapy and talk about the
attachment injury incident in the assessment stages of therapy having well-formulatedmeanings ascribed to the event (Johnson, 1996). Some clients may report the incident as atraumatic flashback; others may report an incident as symbolic of the dissolution of the bond. Other clients who report attachment injuries may enter therapy and have little memory of theincident until after initial presenting problems have been discussed, until a safe therapy alliancehas been created, or until the injured’s defensiveness has abated enough so the incidentappears in more clarity (Johnson, Personal Communication, July 1998).
As identified by the researcher, the therapists providing treatment, and clients who
entered the Ottawa Civic Hospital (Ontario, Canada) for couples therapy, an attachment injuryfor purposes of this study occurred when one partner betrays or broke the trust of the other ina specific incident and that incident became a clinically recurring theme and stuck-point of taskresolution. The injurious event weakened the attachment bond and then promoted negativeinteractional cycles, leading to relationship distress.
Emotionally Focused Therapy
EFT (Johnson & Greenberg, 1985a) is a short-term structured approach to couples
and family therapy. EFT is one of few family therapy models that has provided replicableprocedures, has stipulated specific interventions, and has tested the effectiveness of theinterventions. EFT has been empirically tested on numerous presenting problems, mostnotably marital distress, and has shown to create stronger attachment bonds and higher levelsof trust and intimacy in couples (Johnson, 1997; Johnson, Hunsley, Greenberg, & Schindler,1998). EFT has shown that partners sustain long-term change (Johnson, Hunsley, Greenberg,& Schindler, 1998). Overall, EFT has shown to have large effect sizes (1.3). An effect size of1.3 suggests that the average couple treated with EFT reports more marital satisfaction, trustand affiliation than 90% of untreated control group couples (Johnson, Hunsley, Greenberg, &Schindler, 1998). The primary goals of EFT are: (a) to expand and reorganize key emotional

4responses; (b) to create a shift in partners’ interactional positions and; (c) to foster the
creation of a secure emotional bond between partners.
EFT theory postulates that emotions serve to organize experiences of self and
responses to others. When the attachment bond is threatened, powerful emotional signalsshape behavioral responses. For example, the perceived inaccessib ility of the other can create
powerful negative emotional and interactional cycles and distress (Johnson, 1996). Maritaldistress tends to create absorbing states of negative affect that limit the range of otherbehaviors. Partners with insecure bonds tend not to have the behavioral flexibility as thosewith secure attachment bonds (Johnson & Whiffen, 1999). Insecure bonds tend to be played
out in negative interactional patterns such as pursuing and avoidant behaviors which “createan interaction pattern that actually exacerbates each partner’s insecurity and precludes safeemotional engagement” (Johnson, 1996, p. 24).
The proposed conceptual resolution model for attachment injuries for this study
followed the empirically validated treatment process of EFT. The three phases of EFTtreatment are: cycle de-escalation, re-engagement and interactional shifts, and theconsolidation and integration of change (Johnson & Greenberg, 1985a).
Attachment Theory
EFT draws from principles of child-parent and adult attachment theories. Attachment
theory (Bowlby, 1969) generally connects neurophysiological and social phenomena andemphasizes the interactions that center around the development of affiliative bonds betweenchild and parent and between partners in adult relationships. The crux of adult attachment isthe individual’s capacity for concern, trust, and accessib ility.
Adult attachment theory was developed as an offspring of child-parent attachment.
Sperling and Berman (1994) defined adult attachment as:
The stable tendency of an individual to make substantial efforts to seek and maintain
proximity to and contact with one or a few specific individuals who provide thesubjective potential for physical and/or psychological safety and security. This stabletendency is regulated by internal working models of attachment, which are cognitive-affective-motivational schemata built from the individual’s experience in his or herinterpersonal world. (p. 8)
The above definition has served as the model for classifying adult-love relationships into
various attachment styles. The broadest categorizations are secure and insecure attachmentstyles.

5Overview of Methodology: Task Analysis
The task analysis protocol was followed in this study. Task analysis, a discovery-
oriented or rational-empirical research method, identifies, describes and analyzes the processesof change within a given clinical context (Greenberg, 1984; 1986; Greenberg & Newman,1996). Task analysis can be used for several research purposes: to identify major clinical in-session change events; to build models of therapy; to refine models of therapy; and to predictcomplex therapy outcomes from in-session change processes (Greenberg & Newman, 1996).
There are two phases of the task analysis strategy: the rational-empirical phase and
the verification of the rational model of change. In the rational-empirical phase, the clients’moment-to-moment successful performances are identified as they resolve a meaningfulclinical task (Greenberg, 1984; Pascual-Leone, 1976). The researcher describes the sequencesof events from the assessment marker event such as an attachment injury to the resolutionevent. The goal is to develop a conceptual model of the interactions of resolved or“successful” performances. The verification phase consists of comparing groups of resolutionand non resolution performances to ascertain whether components of the model discriminateat a statistically significant level between successful and unsuccessful performances. Thisstudy included only the rational-empirical phase and not the verification phase.
The eight steps of the rational-empirical phase of task analysis are (Greenberg,
Heatherington, & Friedlander, 1996):
1. The explication of the implicit map of experts of the process.
2. The selection and description of a task.3. The specification of the task environment.4. The evaluation of the potency of the task environment.5. The rational task analysis.6. The empirical task analysis.7. The construction of the rational-empirical model.
The first step begins with an expert clinician who has an explicit theory or model of
therapy. The clinician has an implicit map of some important event that has not beenempirically tested. The event should be based on the clinician’s theory or model of therapy,and the clinician’s clinical experience. The clinician’s map identifies an event or clientperformance to be studied and guides the investigation of change (Greenberg, 1986). In thesecond step, the researcher selects a task to be investigated and delineates a detaileddescription of the task event and the behavioral components of the client marker. Theresearcher then develops a strategy for identifying the markers’ occurrence or non occurrence (Greenberg, Heatherington, & Friedlander, 1996).
The third and fourth steps involve descriptions of change events of client performance
that follow a “when-then” format such as when clients show a negative blame-withdraw cycle,

6then the therapist can begin to explore the clients’ primary affect cycles (Greenberg, 1986).
The client performance patterns are markers of change. The marker, the therapist’sintervention, the resulting client process and the resolution performance make up the changeevent. According to Greenberg (1986), the event is worthy of study when it occurs acrossclients over time. Self-report questionnaires can obtain the verification of the potency of theevent (an optional step) to determine if the client thought that the task resolution hadoccurred.
The purpose of the fifth step is for the researcher to map out a framework or rational
model for understanding client performances and how the task can be ideally resolved. Theresearcher diagrams a flowchart that spells out and hypothetically predicts the possibilities ofthe performance. The investigator proposes how the tasks will be measured and how thebehavioral tasks can be identified and rated. Examples of measures used in task analysisresearch are the Experiencing Scale (Klein, Mathieu, Kiesler, & Gendlin, 1969), the StructuralAnalysis of Social Behavior (Benjamin, 1974), and the Emotional Arousal Scale (Daldrup,Beutler, Engle, & Greenberg, 1988).
The sixth step involves studying clinical performances which involve successful
resolution in moderately to mildly distressed clients (Greenberg, 1986). The researcher
observes client performances to identify and describe the sequences of events from the markerto the resolution. Process measures and/or statistical tests should be used to verify that eventpatterns are actually taking place in different points of the marke r-resolution process.
In the seventh step, the empirical model is compared to the rational model in order to
construct a more specific performance model. Quantitative and qualitative methods can beused to explicate differences between the models.
After the confirmed working model has been identified, the researcher, typically in
further studies, can perform repetitive testing of the model (verification) by comparing,through hypothesis testing, resolution versus non resolution performances and, in addition,relating outcome to process through long-term outcome studies. This last verification stepwas not researched in this study.
Research Questions
The research questions for this study were as follows:1) How did clients describe the attachment injury?2) What were the results of the pre-test scores for couples?3) What were the post-test scores and did the scores result in “successful” resolvers
according to the measures’ norms?

74) What were the results of the Structural Analysis of Social Behavior (Benjamin,
1975) and Experiencing Scale (Klein, Mathieu, Kiesler, & Gendlin, 1969) process measurescores within each marker or phase of resolution?
5) How did clients describe the attachment injury after the resolution phase of
treatment?
6) In what ways did the event pathways of the proposed rational model of attachment
injury resolution differ from those of the empirical model?
Rationale and Summary of The Study
This study tested the utility of the hypothesized concept of attachment injuries in
couples and developed a preliminary model for the resolution of attachment injuries usingEmotionally Focused Therapy. This study served several functions. First, there were noreferences to attachment injuries other than Johnson’s (1996; 1998) conceptualization. Thisstudy may further solidify Johnson’s (1996) conceptualization through clients’ points of view. Second, there were no empirical studies in the literature on attachment injuries. This studyattempted to build a preliminary model of how attachment injuries can be resolved clinically. Third, EFT has shown a high effect size for couples with general distress, but has notaddressed couples who relapse to initial distress levels during treatment or who terminatetreatment as non resolvers. Forth, this study may contribute to the programmatic efforts ofEFT.
For this study attachment injuries were validated by the client, an expert clinician and
the researcher. Couples were given assessment measures to ascertain the nature and extent ofthe injury. “Successful” couples with moderate to mild distress were used to develop themodel. “Successful” couples were identified by: (a) passing the screening; (b) having anidentifiable attachment injury; (c) completing EFT treatment and; (d) showing improvementsto “normal” ranges on pre- and post-test measures. Also, pre- and post-tests measured overallresolution of the attachment injury and process measures will identified in-session changes.
The model (N = 3) of resolution was developed by task analysis. Audiotaped segments
of “best sessions” of marker events were reviewed by the researcher and a rater to determinechange events throughout the therapy process. The proposed marker events emerged at theassessment, de-escalation, and resolution phases. A rational map of change pathways ofexpected change was compared to an empirically developed map of change pathways.

8The Attachment Injury Resolution Model
The following is a preliminary model that outlines the process of an attachment injury
resolution (See Table 1 for Preliminary Empirical Model of Attachment Injury ResolutionProcess):
Table 1
Preliminary Empirical Model of Attachment Injury Resolution Process
Marker Resolution
Attachment Injury De-Escalation Re-Engagement/
Softening
(Partner A)
Blames and
is hostile(Partner A)
Differentiates
affect(Partner A)
Discloses and
expresses needs;
Is less hostile and
has more trust
(Partner B)
Withdraws,
defends, denies,
or minimizes(Partner B)
Less defensive(Partner B)
More engaged and
empathic;
Responds and
is accessible
The first phase marks the attachment injury to be studied. This marker should occur in
the assessment phase or the first two steps of the EFT model. The markers are statements ofan incident of betrayal or rejection from partner A (e.g., of an affair, not being emotionally
available, or other events having priority over the spouse). The injured partner A accuses and
blames in a hostile manner, while the other partner B withdraws and takes a defensive stance.
Second, in the de-escalation phase, partner A begins to articulate the significance of the
injury, differentiates affect (e.g., hostility and hurt), and relates underlying feelings such ashurt and fear to the past and present cycle in the relationship. Partner B becomes less
defensive and more responsive. However, the couple continues to interact in the similar rigidinteraction cycles as in the first phase.
Third, in the re-engagement phase, partner A continues to differentiate affect,
expresses vulnerability, and describes the attachment meanings in terms of safety andtrust. Partner B becomes more engaged, listens and acknowledges the other partner's
pain, and accepts responsib ility for his/her part in the attachment injury. Fourth, the
resolution phase, partner A softens (i.e., becomes less hostile and more trusting) and
expresses the need for comfort, safety, and reassurance. Partner B responds to the needs of
partner A , is accessible, and offers comfort.

9CHAPTER II
Review of Literature
Introduction
In an effort to describe the underpinnings of the hypothesized attachment injury
concept and model of resolution, the following reviews the literature on child-parent andadult-adult attachment theory, the programmatic efforts of emotionally focused therapy, andthe construction of process research and task analysis. The purpose of this attachment reviewis not to cover comprehensively the development of attachment, but to describe attachmenttheory and the various influences of attachment theory, particularly adult attachment, on thetheoretical foundations and clinical applications of EFT.
The first part of the chapter traces the roots of attachment theory as conceptualized by
Bowlby (1969) and its subsequent development pertaining to child-parent bonds. The firstpart also includes links of child-parent attachment to characteristics of adult attachment. Thesecond part of the chapter reviews the theoretical and clinical course of emotionally focusedtherapy, including process and outcome studies, and its relation to adult attachment theory. The third part explores process research and the justification for the use of task analysis forthis study.
Attachment Theory
In the past twenty years, there has been an abundance of publications in the child-
parent attachment literatures. Attachment theory began as a theoretical framework fordescribing the significance of child-parent bonding. Bowlby (1969) proposed that attachmentbonds are not only a universal human phenomenon, but also a mammalian phenomenon. Attachment bonds connect biological and social phenomena and emphasize the interactionsthat center around the development of affiliative and affectional bonds between child andparent. Campbell and Taylor (1980) described attachment as a long-term emotional tie. Themost common conceptualization of attachment theory is the individual’s capacity for concernand trust, particularly in distress. Attachment behaviors have been described as not merely areaction to separation but a natural response to any distress or uncertainty (Ainsworth, Blehar,Waters, & Wall, 1978; Bowlby, 1969). In the child-parent bond, strong aff iliation and trust
(or the lack thereof) are built as primary caregivers recognize and attend to the developmentalphysical and emotional needs of the child.
In his three-volume description of attachment, separation, and loss (1969; 1973;
1980), Bowlby’s developed his theory from his observations of infants who were separatedfrom their primary caregivers. He explored how infants become emotionally attached to theirprimary caregivers and how separation from these caregivers created a context of distress. He

10discovered that the infants who were separated from their parents went through predictable
behavioral stages from distress to protest to despair to detachment. He hypothesized thatchild attachment behaviors had a biological and evolutionary function of achieving proximityto caregivers under potential or actual threats of harm (Bowlby, 1969). Thus, attachmentbehaviors are thought to be crucial for survival.
Attachment styles. The research of child-parent attachment has generally involved
the following goals (Weiss & Sheldon-Keller, 1994): (a) the identification of parental
behaviors that activate child attachment behaviors (e.g., Ainsworth, Blehar, Waters, & Wall,1978; Bowlby, 1969/1980); (b) the investigation of infant attachment behaviors into earlychildhood (e. g., Lamb, 1985; Main, Kaplan, & Cassidy, 1985) and; (c) the correlation ofattachment patterns with psychological well-being (e. g., Cohn, 1990; Matas, Arend, &Sfoufe, 1978).
The bulk of research has examined how the interaction behaviors of mothers and
infants vary in relation to the security of the attachment bond and the classification ofattachment styles in child- parent interactions (Ainsworth, Blehar, Waters, & Wall, 1978;Bowlby, 1988; Main & Solomon, 1990). Ainsworth and colleagues (1978) classifiedattachment styles through the Strange Situation procedure, where the child’s parent wastemporarily replaced by a stranger and then reunited with the mother. Three attachment styleswere identified through this procedure: secure, anxious-ambivalent, and anxious-avoidant.
A secure emotional bond has been described as an emotional bond formed between an
infant and one or more adults such that the infant will: (a) approach them especially in periodsof distress; (b) show no fear of them, particularly during the stage when strangers evokeanxiety; (c) be highly receptive to being cared for by them and; (d) display anxiety if separatedfrom them (Reber, 1985; Shaver, Hazan, & Bradshaw, 1980). The secure child feels assuredthat the parent will be responsive, comforting, and protective, allowing the child to meetdevelopmental needs (Ainsworth, Blehar, Waters, & Wall, 1978).
A child with an anxious-ambivalent attachment style has been characterized as being
reluctant to get close to others. The child shows uncertainty as to the availability andprotection of the parent. Behavioral manifestations of anxious-ambivalent children includebeing clingy, greatly distressed by separation, and often fearful of their environments (Ainsworth, Blehar, Waters, & Wall, 1978). The parent has been described as beinginconsistently emotionally available.
The anxious-avoidant attachment style has been characterized by the child having little
confidence that the parent will be emotionally available and caring. These children tend todevelop an overly self-reliant internal model of self, hide dependency needs and withdrawfrom others (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1988).

11In observational studies of parent-child interactions, Main and Solomon (1990)
proposed a fourth parent-child style, a disorganized/ disoriented attachment. The authorsreported that these children seemed confused when presented with tasks under separation andwere engaged in “incomplete or undirected movements or expression” (Main & Solomon,1990, p. 122). These children were often victims of abuse/neglect (Crittendon, 1988; Main &Solomon, 1990).
The origins of attachment. Many studies have speculated on the etiology of
attachment. In a review of literature, Colin (1996) stated that some authors treated
attachment as an innate potential while others viewed it as patterns of behavior, making noassumptions about genetic foundations. Bowlby (1969) assumed that humans have an innateattachment instinct for bonding that serves as an alarm system for threats of harm. Bowlby(1969) also assumed that behavioral manifestations are learned and malleable.
Attachment behavior is Bowlby’s term for the behavior of an infant in relation to
attachment figures. The essential feature of this behavior is that the infant will seek out theadult and behave so as to maintain close contact through distress with responses such asclinging, crying, protesting, and withdrawal. Bowlby (1969; 1973) postulated that infantsconstruct an internal working model of self and others through their attachments to significantothers.
Ainsworth et al. (1978) examined the effects of attachment and children’s cognitive
advances and showed that the children depended less on physical proximity to the caregiverbecause they had developed secure internal working models of the attachment figure and wereaware that parental distance did not imply inaccessib ility and absence of protection. The
development of internal working models allowed for the child to explore new environmentswithout being in constant proximity to the caregiver. Ainsworth et al. ( 1978) termed this
internal model the "secure base phenomenon."
Attachment theorists have conjectured that attachment is of vital importance
throughout the life-span and that even though attachment behaviors or behavioral styles arerelatively stable over time, they can change due to other attachment figures or environmentalcircumstances (Bowlby, 1969; Cicchetti, Cu mmings, Greenberg & Marvin, 1990; Main,
Kaplan, & Cassidy, 1985). Bowlby (1969) also postulated that the internal models guide aperson’s primary relationship behaviors throughout life. Ainsworth (1985) stated thatattachment patterns are stable throughout life, but are not fixed personality characteristics.

12Adult Attachment
A majority of the theoretical and clinical research on attachment theory has focused on
child-parent bonds. Since the mid-1980s, the foundational work of Bowlby and Ainsworthhas been extended to adult-adult attachment and the classification of adult attachment styles(e. g., Hazan & Shafer, 1987, Kobak & Hazan, 1991; Shafer, Hazan, & Bradshaw, 1990;Simpson & Rholes, 1998; Sperling & Berman, 1994; Weiss & Sheldon-Keller, 1994).
Bowlby (1979) stated that attachment extends from “the cradle to the grave” and that
“there is nothing intrinsically childish or pathological about it” (pp. 127/131). He describedadult caregiving as the need of human beings to form and maintain emotional bonds with afew specific others. He discussed the sense of emergency one feels when separated withprimary partners particularly while under distress. Ainsworth (1990) defined adult attachmentas an affectual bond that is long-enduring with a seemingly irreplaceable other. Sperling andBerman (1994) departed from Bowlby’s caregiving label for adults to the label of adultattachment bonds. They defined adult attachment as the tendency of one to seek and maintainproximity to those who provide physical and/or psychological safety and security.
Adult attachment research. Early research on child-parent attachment dealt with
normative responses to a child’s separation from his/her attachment figure. The seminal work
of adult attachment dealt with observing reactions to the disruption of the attachment bond intraumatic events such as in cases of separation (Weiss, 1975) and the death of a spouse(Glick, Weiss, & Parkes, 1974; Parkes, 1972). Reactions to adult bond disruption followedsimilar processes to that of child-parent separation: protest, despair, anddetachment/reintegration (Sperling & Berman, 1994).
Theoretical connections have been made from child-parent attachment to adult-adult
attachment. Weiss (1982) posited that the behaviors that meet child-parent features are alsofound in adult attachments. The central defining features of child attachment are: proximity-seeking, secure base, and separation protest. Weiss (1982) described three characteristicsthat differentiate adult from child-parent attachment. First, in adults, attachment relationshipsare between peers rather than care receiver and caregiver. Second, attachment in adults is notas susceptible to being overwhelmed by other behavioral systems and life contexts. Adultshave cognitive and behavioral strategies to cope with distressful situations. Third, attachmentin adults typically includes a sexual relationship.
Researchers have studied attachment distress in phase-of-life nodal events such as the
transition from high school to college (Kenny, 1987; Sperling & Berman, 1994). Findingswere that students maintained attachment to their parental attachment figures and that thequality of attachment corresponded with their adjustment and emotional distress to college. Other studies have looked at changes and continuities throughout the life cycle (e. g., Levitt,Weber, & Clark, 1986) and have shown that a secure child attachment style promoted secureadult behaviors to parents, spouses, and friends despite life transitional stresses.

13Extensive research has focused on the correlation of attachment styles and DSM-IV
mood and personality disorders (Florsheim, Henry, Benjamin, 1996). Sperling and Berman(1994) reviewed the literature describing how insecure attachment can contribute tosusceptibility to depression, anxiety, and greater degrees of interpersonal conflict. Theydescribed studies showing how the sensitivity of attachment or how quickly one gets involvedin relationships can be correlated to dependent and borderline personality disorders. Sperling and Berman (1994) classified general topics covered in adult attachmentsuch as the activation of attachment behaviors. They reported that couples differ in the degreeand frequency of responses to distress and how the activation of attachment behaviors tendsto be less in secure couples. The authors reviewed studies on how frustration tolerance andthe reliance of defensive behaviors tend to be higher in insecure styles. Sperling and Berman(1994) applied systems theory to attachment, maintaining that disturbances in the dyadicrelationship “account for differences in attachment style” (p. 9), whether secure or insecure,and for differences in emotional and behavioral adjustment.
Adult Attachment Styles. Research in adult attachment has involved classifying
individual differences in attachment style. Perhaps a limitation in adult attachment theoretical
development, most theorists have suggested that there is one secure style and various insecurestyles. Adult attachment styles have generally referred to one’s behavioral responses toperceived and actual distress, and to the separation and reunion to attachment figures(Sperling & Berman, 1994).
There has been no agreement on the overall classification of adult attachment styles.
Some styles have overlapping characteristics. In general, a secure adult to adult attachmentstyle is characterized by internal working models in which the person has a positive view ofself and others, has high levels of intimacy, and has high levels of trust and perception of theavailability and responsiveness of others in both relationship and external distress (Ainsworth,1985; Bartholomew & Horowitz, 1991).
A secure adult attachment style has been correlated to adjustment and satisfaction in
adult relationships (Collins & Read, 1990; Simpson, 1990), having a wider range of responses
to conflict (Simpson, Rholes, & Phillips, 1996), seeking and giving support (Simpson, Roles,
& Nelligan, 1992), and having higher levels of intimacy and trust and lower levels of
hypervigilance, jealousy, and fear of abandonment (Hazan & Shaver, 1987). Also, attemptsare being made to correlate secure attachment to the quality of physical health (Colin, 1996).
Approximately nine “insecure” styles have been identified in adult-adult attachment.
The styles used primarily for research purposes have been secure, preoccupied, dismissive,and fearful-avoidant. A preoccupied person has a negative view of self and a positive view ofothers and tends to need the acceptance of others for self-acceptance and self-definition(Bartholomew & Horowitz, 1991). A dismissive person has a positive view of self and anegative view of others (Bartholomew & Horowitz, 1991; Main & Goldwyn, 1985) and tends

14to avoid emotional closeness and vulnerability (Bartholomew & Horowitz, 1991). A fearful-
avoidant person has a negative view of self and others, and tends to avoid emotional
involvement with others. A fearful-avoidant person also expects betrayal, rejection, and
criticism (Bartholomew & Horowitz, 1991).
Other styles have been identified such as compulsive self-reliant (Bowlby, 1977; West
& Sheldon, 1988), compulsive caregiving (Bowlby, 1977; West & Sheldon, 1988),compulsive care-seeking (West & Sheldon, 1988), and angry withdrawn (West & Sheldon,1988). (See Table 2 for Classification of Adult Attachment)
Table 2
Classification of Adult Attachment
Attachment Type Description
View of Self View of Others Relationships
Secure positive positive high intimacy and
autonomy
Preoccupied negative positive self-acceptance
from valued others
Dismissive positive negative protects self by
avoiding closeness;independent andinvulnerable
Fearful-avoidant negative negative expects betrayal,
rejection andcriticism; protectsself by avoidingcloseness
Adult Attachment As Applied to Emotionally Focused Therapy
Few empirical studies have focused on the psychotherapeutic restructuring of insecure
attachment behaviors except in the theory and clinical applications of EFT. Adult attachmenttheory is central to EFT theory. The goal of EFT from an adult attachment point of view is tofoster the creation of a secure bond and reduce attachment insecurities (Johnson, 1996). Attachment in EFT concerns itself not so much with naturalistic explanations of attachment

15styles in the daily routine of people’s live, but with how attachment styles manifest themselves
when couples in distress make sense of their relationship bond in a therapeutic context.
Attachment theory posits that seeking and maintaining an emotional bond in primary
relationships is a survival force and a dependency need. Some sources characterize thisdependency in insecure styles as pathological (Bowlby, 1980; Colin, 1996). From the EFTperspective, attachment dependency is an innate characteristic throughout life and thecornerstone of healthy relationships. Johnson (1996) stated that the power of this affect isassociated with a “wired in” evolutionary survival system. EFT’s use of attachmentdepathologizes attachment needs, such as dependency, which are seen as healthy and adaptive(Johnson, 1996; Jordan, Kaplan, M iller, Stiver, & Surrey, 1991). Johnson and Whiffen (1999)
also stated that attachment styles are not necessarily fixed or characterlogical, but representinfluence tendencies under stress. One may have a secure style in day-to-day mildly stressfulsituations but exhibit an avoidant style in distress.
EFT theory maintains that the emotional experience of self and responses to others
make up interactional patterns that can be classified into attachment styles, or more generallyput, into either secure or insecure attachment styles. EFT has empirically shown that couplescan access the primary emotions said to be crucial for fostering more secure affectional bonds(Johnson, 1996). Secure attachments help partners regulate negative emotional experiencessuch as experiences of sadness, loss, anger, fear and shame (Johnson, 1996).
When one’s security is threatened, affect organizes cognitive and behavioral responses
into predictable sequences, parallel to Bowlby’s theoretical mapping, of protest and anger toclinging and seeking to depression and despair (Johnson & Whiffen, 1999). Negativeattachment styles such as anxious, avoidant fearful, and avoidant dismissing (Bartholomew &Horowitz, 1991) sustain an insecure, threatened bond. Insecure bond behaviors are playedout in reactions such as fight, flight, or freeze, and “predictable behavioral sequences” such asprotest, anger, clinging, depression, and despair specifically (Bowlby, 1969).
Secure attachment can create a secure base (Ainsworth, 1978; Bowlby, 1988) or a
safe haven (Johnson, 1996), which acts as a buffer to stress and helps partners respond to newcontexts and developmental needs. In a secure attachment style, the person has a positive viewof self and others, and a moderate to high level of intimacy and autonomy (Bartholomew &Horowitz, 1991).
The main clinical issues concerning attachment are the degree of connection and
disconnection, and the degree of separateness and closeness. Johnson (1996) stated:“[t]herapy focuses upon the deprivation, loss of trust and connection, isolation, andattachment fears of the partner, and the ways in which their interaction patterns maintain thedistress” (p. 21). In therapy, attachment issues are manifested when partners show theircapacity to express fear and hurt and for providing comfort, trust, and acceptance.

16Emotionally Focused Therapy
EFT then focused on improving partners’ affectional bonds. Numerous studies have
shown the efficacy of behavioral marital therapy (Gurman, Kniskern, & Pinsof, 1986). Therehas been an absence of empirical research, however, of non behavioral models anddynamically-oriented approaches in the couples and family literature (Johnson & Greenberg,1985a) until the development of Emotionally Focused Therapy (EFT) in the early -1980s(Johnson & Greenberg, 1985b).
The EFT programmatic effort has addressed crucial questions facing the field of
couples therapy (Johnson, Hunsley, Greenberg, Schindler, 1998). Targets of intervention ofmarital distress had not been pinpointed or under empirical investigation. There had been noclear empirical models of marital change other than behavioral approaches. A definition ofadult love and attachment in adult relationships and appropriate interventions to address theseissues clinically had been underdeveloped (Johnson & Whiffen, 1999; Roberts, 1992). Finally,most interventions targeted behavioral or cognitive change (Gurman, Kniskern, & Pinsof,1986) and the role of affect had been virtually ignored as an agent of change and as acontributor to marital distress (Greenberg & Johnson, 1986a). EFT began to provide answersto the above concerns.
The development of the EFT model has been practice-driven (Johnson, Hunsley,
Greenberg, & Schindler, 1998) and is based on task analysis (Johnson & Greenberg, 1985a). EFT is empirically validated and has been further developed through process research(Greenberg & Foerster, 1996; Greenberg, Ford, Alden, & Johnson, 1993; Paivio &Greenberg, 1995; Johnson & Greenberg, 1987a; Johnson & Greenberg, 1988), outcomeresearch (Dandeneau & Johnson, 1994; Goldman, 1987b; Goldman & Greenberg, 1992;Greenberg & Johnson, 1986a; Greenberg & Johnson, 1986b; James, 1991; Johnson &Greenberg, 1985b; Johnson & Greenberg, 1987; Gordon-Walker, Johnson, Manion, &Cloutier, 1996; MacPhee, Johnson, & Van Der Veer, 1995), process to outcome studies(Johnson & Greenberg, 1988; Greenberg & Webster,1982), case studies on incest survivors(Johnson, 1989), and predictive studies (Johnson & Talitman, 1997). Recent investigationshave been on the use of EFT with couples dealing with trauma (Johnson & Williams-Keeler,1998), adapting EFT to attachment styles (Johnson & Whiffen, 1999) and studying theresolution of attachment injuries.
EFT: The Theoretical Composition
The roots of EFT lie in the integration of gestalt/experiential therapy, systemic family
therapy approaches, and attachment theory (Bowlby, 1969). Gestalt/experiential therapy,developed by Perls (e.g., Perls, 1973; Perls, Hefferline, & Goodman, 1951), emphasizes therole of affect both intrapsychically and interpersonally. By focusing on affect in the here-andnow, clients remove patterns of unresolved conflict and are more able to be spontaneous andcreate new experiences (Perls, 1973). Systemic fa mily therapy focuses on the role of

17communication sequences and identifies redundant interactional patterns in the “maintenance
of problem states” (Sluzki, 1978). EFT identifies rigid negative interactional patterns togauge the amount of control and closeness in the relationship bond. Attachment theory(Bowlby, 1969) connects neurophysiological and social phenomena and emphasizes theinteractions that center around the development of affiliative bonds between parent and childand between partners in adult relationships. The crux of attachment is the individual’scapacity for concern, trust, and accessib ility.
EFT process of change. The process of change in EFT occurs when “the emotional
responses underlying interactional positions are experienced and reprocessed so as to create a
change in such positions in the direction of increased accessib ility and responsiveness”
(Johnson & Greenberg, 1988, p. 176). The reprocessing of emotional interactional patternsenables couples to create new experiences of self which then enable the partner to respond indifferent ways.
EFT postulates that if a partner has a weak attachment from their upbringing or
resulting from present relationships, he/she will con ceal the “primary emotions” such as
vulnerability, fear and the need for attachment with “secondary emotions” such asdefensiveness, coerciveness, blaming or needing to withdraw. Patterns of secondary emotion,according to EFT theory, lead to negative interactional patterns, identified by such cycles asdistance-pursue or blame-withdraw (Johnson & Greenberg, 1994). The cementing of theseinteractional patterns, particularly under distress, impedes the integration of such primaryemotions into patterns of relating such as sharing and positively coping. The cementing ofnegative patterns also fosters defensive processing such as the shifting of hurt into criticalanger. EFT theory maintains that the accessib ility of primary affect crucial for the
maintenance of healthy attachment bonds, a sense of security and connection, the creation ofnew experiences, and the growth and maintenance of intimacy.
Gottman (1979) has shown that the primary reasons for distress in relationships are
negative affect, negative content patterns such as criticism and blame (secondary emotions),and over-repetitive interaction patterns. EFT theory makes a distinction between secondaryand primary emotion and successfully alters negative emotional and over-repetitive interactionpatterns.
Goals of EFT. The goals of EFT are to change negative affect intrapsychically and
interpersonally, to help the partners access primary emotions, revitalize the emotional bond,
and change the relationship event and negative interaction patterns (Johnson & Greenberg,1987). Distressed partners are said to have “insecure bonds” in which “healthy attachmentneeds are unable to be met due to rigid interaction patterns that block emotional engagement”(Johnson & Greenberg, 1987a, p. 553). EFT attempts to access and reprocess the emotionalresponses underlying couples’ interactional positions. New emotional responses can assist inthe growth of safety and trust, crucial for secure attachment. EFT typically re-engages thewithdrawn partner and “softens” the attacking partner so that he/she can show vulnerability,

18yearning and fear. This clears the way for “the ultimate goal of EFT–healing the attachment
bond” (Johnson, 1997, p. 41).
The Nine Steps of EFT
The EFT procedure involves nine steps which can be carried out in ten to fifteen
sessions (Johnson & Greenberg, 1987). The following is the usual course of EFT treatment:
1. Delineating conflict issues in the core struggle. The focus is on content presenting
problems and on instrumental and secondary intrapsychic affect. Instrumental and secondaryaffect refers to defensive emotional reactions such as blaming, denying, or min imizing conflict.
The therapist assesses how these issues reflect core problems in the areas such asseparateness/connectedness. The therapist also contracts for change.
2. Identifying the negative secondary interaction cycles such as pursue-withdraw or
attack-defend. Both individual’s content presenting problems are made relational through thenegative interaction cycles.
3. Accessing the unacknowledged feelings underlying interaction positions. The
therapist begins to identify and validate the primary emotional responses, such as fear, trust,and longings for connection, the content presenting problem, and the secondary emotions.
4. Reframing the problem in terms of underlying feelings, attachment needs, and
negative cycles. The content level of problems is relabeled in light of primary emotions.
5. Promoting identification with disowned needs and aspects of self and integrating
these needs into relationship interactions. A primary emotion cycle is identified and reinforcedthrough relational patterns.
6. Promoting acceptance of the partner’s experience and new interaction patterns.
The therapist attempts to build safety and trust in partners and to accept difference from pastrelational patterns and difference between partners’ perspectives.
7. Facilitating the expression of individual needs and wants to restructure the
relational interaction and to create emotional engagement.
8. Facilitating the emergence of new solutions to problematic interactions and issues.
The therapist encourages the reconstruction of relational content patterns based on primaryaffect.
9. Consolidating new positions. The therapist reinforces new patterns.
The above protocol will be the treatment for this study. Steps 1-4 identify the
presenting problem and are the de-escalation phase; steps 5-9 are the re-engagement andresolution phases. The steps of change parallel the preliminary model of change proposed forthe resolution of attachment injuries.
The Development of EFT
EFT has a sound theoretical and empirical history. The model is based on task
analysis (the study of change processes) and combines both intrapsychic and relational

19perspectives, (i.e., a systems-based model that also includes the perspective of the individual’s
history and unique contribution to the relationship). The model was first tested throughcomparative methodology to show efficacy; next, the researchers set out to stipulate thenature of change through process research; and finally, researchers tested change variablesthrough predictive research to show which variables work best with what clinical problem andpopulations.
Theoretical development. The first step in the development of EFT involved
Greenberg and Safran’s (1984; 1984b) and Greenberg and Johnson’s (1986) pre liminary
exploration of the role of affect in the context of therapeutic change. The researchersattempted theoretically to integrate affect, cognition and behavior. The authors argued thatthere is a complex “interdependence of cognition and affect” (Greenberg & Safran, 1984a, p.577) and that the profound influence of affect has been ignored in the development of clinicalmodels. The authors argued that many clinical problems “involve a breakdown in theemotional synthesis process” (Greenberg & Safran, 1984, p. 579). Greenberg and Korman(1993) wrote that the reconstruction of emotional experience and emotionally focusedinterventions were needed for different emotional problems (Greenberg & Korman, 1993).
The development of the model. Johnson and Greenberg (1985a) used process
research, or task analysis, to develop the EFT model. The authors used Greenberg and
Safran’s (1984) theory of the role of affect, systemic communication theories (Sluzki, 1978),and attachment theory (Bowlby, 1969) to help identify clinical events. Theory and clinicalempirical description in the steps of change were bridged to develop the model. Theresearchers isolated “key episodes” in therapy to identify significant change processes. Aninitial intensive task analysis of change processes in Emotionally Focused Couples Therapy(Johnson & Greenberg, 1988) suggested that high levels of experiencing (i.e., high emotionalinvolvement), and affiliative interpersonal responses (i.e., high acceptance and low host ility)
were essential elements in resolving marital conflicts. The study also noted the value ofanalyzing qualities of experiencing and the quality of interactions in therapy.
The authors produced a manual to be followed for clinical and/or research use. The
same nine steps of EFT were used throughout the programmatic effort (Johnson &Greenberg, 1985a). The authors postulated that the model fosters intimacy and fac ilitates
conflict resolution. In addition, the authors purported that emotional responses such as love,trust, and respect are not “teachable” but “may be evoked in a process of mutual emotionalexpression” (Greenberg & Johnson, 1985a, p. 3).
Outcome studies. Outcome studies were implemented in the first years of EFT to
show its efficacy compared to other types of marital interventions. In experimental outcome
studies (e.g., Goldman & Greenberg, 1992; Greenberg & Johnson, 1986a; Greenberg &Johnson, 1986b), researchers compared the effectiveness of EFT to a cognitive-behavioralintervention; to interventions that focused on teaching problem-solving sk ills; and to an
experiential intervention that focused on the emotional experience underlying interaction

20patterns. The results showed that all treatment groups demonstrated significant gains over
untreated controls and that EFT was as effective as other treatments.
Relating process to outcome. Research was needed to show how change occurs in
therapy (Gurman, Kniskern, & Pinsof, 1986). Through outcome studies, EFT had shown
empirical validation but the issues of how outcome related to the processes of EFT remained(Johnson and Greenberg, 1988). The focus of EFT research then began to focus on processissues such as client performance and response rates in the manifestation of negativeinteraction cycles. Researchers used the Experiencing Scale (Klein, Mathieu, Kiesler, &Gendlin, 1969) to measure intrapsychic change processes and the Structural Analysis of SocialBehavior (Benjamin, 1974) to measure interpersonal change processes. The aforementionedscales had been previously validated in linking process events in therapy to successfuloutcomes (Greenberg & Webster, 1982).
In the process to outcome studies (Greenberg & Webster, 1982; Johnson &
Greenberg, 1988) the occurrence of particular change events arising from the theoreticalprinciples of EFT correlated to the process events and higher levels of experiencing and moreautonomous and affiliative interactions characterized “best sessions.”
A series of studies conducted by Greenberg and Korman (1993) demonstrated a
number of interactional patterns that seem to be more prevalent among improved couples thanamong unimproved couples. They noted that unimproved couples showed more hostile,controlling behaviors (i.e., " accuses and blames other") at the beginning of therapy and moved
to being more supportive, affirming and understanding after several sessions. There were alsomore affiliative and depth of experiencing statements in peak sessions than in poor sessions.
Overall, these studies demonstrated that intrapsychic experience is deepened, and that
interactions become more affiliative, over the course of treatment. The expression ofunderlying feelings and needs leads couples to change from negative interactional patterns tobeing more accessible and responsive to each other.
Recent studies. More recent studies have confirmed the efficacy of EFT of distressed
couples with partners suffering from depression (Desaulles, 1991) and chronic illness
(Gordon-Walker, Johnson, Manion, & Cloutier, 1996). Another study focused on the
theoretical development of EFT as applied to post-traumatic stress disorder (Johnson &Williams-Keeler, 1998).
Methodological Issues in Process Research
Process research has entered its fifth decade of development. Process research
addresses specific events that take place in-session, observing variables such as therapistbehaviors, client behaviors, and interactions between therapist and client during treatment(Hill, 1991). Intents and methods of study until recently, however, have remained

21underdeveloped. A goal of process research has been to consolidate methodological
information on process research so that current and future investigators have amethodological base from which to proceed (Greenberg & Pinsof, 1986). Attempts have beenmade to stimulate research of the process of psychotherapy, particularly in couples and familytherapy, to explain how psychotherapy produces change (Greenberg, 1986; Greenberg, Ford,Alden, & Johnson, 1993; Greenberg & Newman, 1996; Greenberg & Pinsof, 1986; Hogue,Liddle, & Rowe, 1996; Jacobson & Addis, 1993; Johnson & Greenberg, 1988).
In a recent review of process research, authors reported that treatment adherence to
process procedures has been congruent with the methods, goals, and theoretical frameworkthat guide process research. Targets of study have become more specific, and more reliableand valid measures have been developed and implemented (Hogue, Liddle, & Rowe, 1996). Methods of process research have become more standardized over the past few years andmore specific protocols have been developed.
Efforts have been made to classify the dimensions of process measures such as direct
versus indirect measurement, perspective, focus, aspects of process, use of classical orpragmatic coding schemes, types of scaling, and theoretical perspective (Hill, 1990; Russell &
Stiles, 1979). The above dimensions also help the researcher make sure that guidelines arecompatible with the chosen methodology.
Task analysis. One major development of process research is that the process of
psychotherapy can be studied in smaller in-session units and post-session outcomes can be
linked to specific client-therapist interactions (Greenberg & Rhodes, 1994). In addition, focushas been extended to how process research can better serve the practicing clinician, howclinician and researcher can form partnerships to “preserve the richness and complexity of thepsychotherapeutic process as it unfolds over time” (Greenberg & Rhodes, 1994, p. 217).
Task analysis and the events-based approach (Greenberg, 1986) have been developed
to study change events that work within the theoretical framework and operational level of theclinician and to study the specific therapist-client interactions that fit coherently within theresearcher’s theory of change. A number of researchers from diverse therapeutic orientationsare using task analysis to study change processes (Clark, 1996; Friedlander, Heatherington,Johnson & Skowron, 1994; Greenberg & Foerster, 1996; Greenberg, Ford, Alden & Johnson,1993; Greenberg & Webster, 1982; Paivio & Greenberg, 1995; Safran & Muran, 1996).
Task analysis is a discovery-oriented research or rational-empirical method
(Greenberg, 1986) which identifies, describes and analyzes the processes of change within agiven clinical context (Greenberg, 1984; 1986; Greenberg & Newman, 1996). As in thisstudy, task analysis can be used for several research purposes: to identify major clinical in-session change events; to build models of therapy; and to refine models of therapy. After in-session change events are identified and preliminary models are built, task analysis can beused to predict complex therapy outcomes from in-session change processes (Greenberg &

22Newman, 1996). Future studies w ill use the findings of this study to link processes to
outcomes.
Greenberg (1986) argued that context-sensitive process research needs to be
developed and that variables such as speech act, episode, and relationship need to beexamined in the context in which they occur and that the context of one process project doesnot necessarily have the same meaning under different theoretical premises. “To explainprocesses of change, it will be important to measure three types of outcomes–immediate,intermediate, and final–and three levels of process–speech act, episode, and relationship(Greenberg, 1986, p. 4). This approach would result in the use of a battery of processinstruments to measure process patterns in context and to relate these to outcome.
The study of the processes of change brings up the issue of how events are identified
and then measured. Task analysis delineates seamless therapy interactions into frameworks ofunits such as content, speech acts, episodes, and relationship levels (Greenberg, 1986). Riceand Greenberg (1984) suggested bracketing specific events or episodes as targets of study: theclient problem marker, the therapist operation, the client performance, and the immediate in-session outcome. Episodes can be identified by markers or by a set of statements that indicatea particular problem or event is imminent and amenable for intervention. The therapistoperation, described in an operation manual, is a set of interventions that promotes problemresolution (Greenberg, 1986). Client performance is how the client responds to the therapistoperation which typically ends in some form of in-session outcome.
Task analysis has studied three types of changes over the course of therapy: immediate
outcomes, intermediate outcomes, and ultimate outcomes (Pinsof, 1981). An immediate
outcome is the change event that takes place in the session that results from specifictherapeutic markers, interventions, or the overall interaction. Immediate outcomes are thenrelated to intermediate changes. Intermediate changes are change markers (or target attitudesor behaviors) identified through observations of several client episodes by session outcomemeasures. The markers or targets are observed over time for validation and to be linked tothe process of ultimate outcomes.
A series of studies conducted by Greenberg and colleagues (1993) demonstrated a
number of interactional patterns that seem to be more prevalent among improved couples thanamong unimproved couples. They noted that couples showed more hostile, controllingbehaviors (i.e., "accuses and blames other") at the beginning of therapy, and moved to beingmore supportive, affirming and understanding after several sessions. Researchers also foundthat there more affiliative and depth of emotional experiencing statements in peak sessionsthan in poor sessions. Overall, these studies demonstrated that intrapsychic experience isdeepened, and that interactions become more affiliative, over the course of treatment. Theexpression of underlying feelings and needs leads couples to change from negativeinteractional patterns to being more accessible and responsive to each other.

23Summary
EFT theory and clinical practice (Johnson, 1996), supported by child and adult
attachment theories have aided in the conceptualization of attachment injuries. EFT hasclearly demonstrated the effectiveness of moderating distress and creating more secureattachment bond through validated replicable interventions. Recent studies in EFT havedeveloped the model beyond the focus of general distress to more specific presentingproblems as depression, eating disorders, and sexual dysfunction. Similarly, attachmentinjuries is a new concept designed to expand EFT’s application to specific presentingproblems. In this study, task analysis (Johnson & Greenberg, 1988; Greenberg et al., 1993),and retrospective studies (Greenberg et al., 1988) were used in the construction of apreliminary model of resolution performances in couples with attachment injuries (see Table1). The results of this study will validate the hypothesized concept of attachment injuries andwill yield a theoretical resolution model of change for couples who sustain an attachmentinjury.

24CHAPTER III
Methodology
Overview of the Research Design
The purpose of this study was to investigate the hypothesized concept of attachment
injuries in couples and to develop a preliminary model for the resolution of attachment injuriesusing Emotionally Focused Therapy. For this study, the definition of an attachment injury waswhen one partner betrayed or broke the trust of the other in a specific incident and thatincident became a clinically recurring theme or stuck point of task resolution. The attachmentinjuries were identified by Dr. Susan Johnson, an expert clinician, and the researcher. Unstructured pre- and post-treatment interviews of the couple were conducted to ascertainthe nature and extent of the injury. This study suggests that attachment injuries may bepresent for some couples, and they theoretically can follow the process of resolution identifiedin this study.
The model was developed by task analysis and proposed to correspond to the
following pathway markers: presenting problem, de-escalation, and re-engagement andsoftening/resolution. Based on task analysis protocol for this stage of model development(Greenberg, 1986), three “successful” couples with moderate to mild distress were used to
develop the model. “Successful” couples (a) passed the screening criteria; (b) had anidentifiable attachment injury; (c) completed EFT treatment; (d) and showed normal rangescores on pre- and post-test measures.
The empirical map was developed as follows: Pre- and post-tests measured overall
resolution of the attachment injury and process measures identified in-session changes. Thepre- and post-measures were the Dyadic Adjustment Scale (DAS) (Spanier, 1976),Relationship Trust Scale (RTS) (Holmes, Boon, & Adams, 1990), Revised Adult AttachmentScale (RAAS) (Collins, 1996), and the Attachment Injury Measure (AIM). Audiotaped
segments of “best sessions” were rated by a doctoral level student and the researcher todetermine change events throughout the therapy process. “Best sessions” were rated usingthe Structural Analysis of Social Behavior (SASB) (Benjamin, 1975), and Experiencing Scale(ES) (Klein, Mathieu, Kiesler, & Gendlin, 1969).
At the resolution session the researcher interviewed couples based on pre-assessment
AIM responses to identify change events from the clients’ point of view. The TargetComplaints Discomfort Box Scale (TCDBS) (Battle, Imber, Hoehn-Saric, Stone, Nash, &Frank, 1966) and Post-Session Resolution Questionnaire (PSRQ) (Orlinsky & Howard, 1986)were used to measure the successful resolution of the attachment injury. A rational map ofexpected change (See Table 1) was compared to the empirically developed map. (See Table 3for data measures and procedures)

25Research Questions
The research questions for this study were as follows:
1) How did clients describe the attachment injury?
2) What were the results of the pre-test scores for couples?3) What were the post-test scores and did the scores result in “successful” resolvers
according to the measures’ norms?
4) What were the results of the Structural Analysis of Social Behavior (Benjamin,
1975) and Experiencing Scale (Klein, Mathieu, Kiesler, & Gendlin, 1969) process measurescores within each marker or phase of resolution?
5) How did clients describe the attachment injury after the resolution phase of
treatment?
6) In what ways did the event pathways of the proposed rational model of attachment
injury resolution differ from those of the empirical model?
The Resolution of Adult Attachment Injuries Using Task Analysis: The Discovery Phase
The first and second steps of the rational-empirical phase of task analysis (Greenberg
& Foerster, 1996; Greenberg, Heatherington, & Friedlander, 1996) for this study involved anexpert’s identification of the concept and clinical process of an attachment injury, and theselection and description of how attachment injuries were to be investigated. For thisprotocol, an “expert” in a particular model or theory identifies a concept of clinical interest, and draws a preliminary rational mapping of how the processes may unfold.
Emotionally Focused Couples Therapy is an empirically based form of couples therapy
(Johnson & Greenberg, 1987). EFT is based in attachment theory (Bowlby, 1969) and acomprehensive theory and research on emotions and emotional process (Johnson &Greenberg, 1994). One premise of EFT is that emotion signals a partner’s availab ility and
responsiveness, and the extent of the security and trust of the attachment bond. Anotherpremise is of EFT is that a secure attachment bond is critical to emotional well-being(Johnson, 1996).
A primary goal of EFT is to create security and connection in the attachment bond and
to re-engage couples from rigid negative “secondary” emotional cycles to “primary” emotionalcycles. The “primary” emotional patterns create the safe emotional engagement necessary forsecure bonding. The typical clinical process of EFT in the resolution of conflict involvesidentifying the presenting problem and negative emotional cycles; the de-escalation of cyclessuch as blame/withdraw; and the re-engagement, resolution and softening events identified byhigher levels of trust, accessib ility, and responsiveness.
Guided by EFT, attachment theory, and clinical experience of the developers of EFT,
this study tested the utility of attachment injuries as a concept and the resolution of attachment

26injuries using EFT as the treatment. Attachment injuries have not been identified in the
literature (Literature Review). An attachment injury was hypothetically defined as clients whoentered therapy and became stuck on one significant episode in the relationship that marked adisruption in the level of trust, security, responsiveness and accessib ility of partners (Johnson,
Personal Communication, 1998).
The attachment injury marker for purposes of this study was an incident that came up
in therapy as the emblematic problem event that lead to a sense of betrayal of the attachmentbond, which later organized and promoted negative interactional cycles that later lead torelationship distress (Johnson, 1996). The injury became a recurring theme of topicaldiscussion and stood as the obstacle to the couple’s capacity to become re-engaged andincrease the level of trust, security, responsiveness and accessib ility.
The third and fourth steps are the evaluation of the potency of the task environment
and the rational task analysis. This study compared a rational model of attachment resolutionto an empirical model of task resolution. The attachment injury was identified through self-report of clients and the verification of Dr. Susan Johnson and the researcher. Theidentification of attachment injuries was based on clinical experience (Johnson, PersonalCommunication, 1998) and the rational model (See Figure 1) was based on validated EFTprocess markers and a hypothetical map (Johnson, Personal Communication, 1998).
The fifth step involved the empirical task analysis and the construction of the rational-
empirical model. The following were the markers of the rational model: First, clients havebeen clinically observed to describe a betrayal or attachment injury marked by partner A
expressing blame and hostility and by partner B withdrawing, defending, or minimizing.
Second, clients de-escalate conflict marked by partner A differentiating affect and partner B
becoming less defensive. Third, clients re-engage emotionally and resolve the targetcomplaint marked by partner A disclosing and expressing needs, becoming less hostile, and
achieving higher levels of trust and partner B becoming more engaged, empathic, responsive
and accessible. (See Table 1)
The sixth step, the empirical task analysis and the construction of the rational-
empirical model, involve data collection of the specified task, mapping the empirical resultsbased on the data, and comparing the rational and empirical models. For this study, theempirical task analysis and model construction were performed by the procedures describedbelow:
Sample Description and Sample Selection Procedures
This study used data collected from three “successful” couples who entered therapy at
the Marriage and Family Therapy Clinic at the Ottawa Hospital – Civic Campus in Ontario,Canada. The clinic team members, supervised by Susan Johnson, were family therapists,psychologists and social workers who had been trained in EFT. The clinic members served as

27therapists and the reflecting team during the assessment session. The hospital clinic typically
gets one to two referrals (couples) per week from family therapists, psychologists andpsychiatrists in the Ottawa area; or couples themselves contact the clinic for therapy.
When clients make an appointment at the Marriage and Family Therapy Clinic, they
are informed that the clinic is for training purposes and that they can be subject to beingviewed by a therapy team, being video or audiotaped, and possibly being part of a researchproject. All couples are asked to come into the clinic for an assessment session which isviewed by team members behind a one-way mirror. Sessions after the assessment are notviewed by the team. Before the first session, couples typically fill out various assessmentmeasures, although not all specific to this study, such as demographics questionnaires, trustand attachment questionnaires, and the Dyadic Adjustment Scale. At the end of the session,couples are assigned to a team therapist or co-therapists.
For this research, couples were screened for attachment injuries by the researcher and
the team during the assessment session. If one partner recalled an instance of an attachmentbetrayal or rejection in the relationship associated with the current problem, or if a partnergave a strong indication that an injury had occurred, the couple was asked if they wanted toparticipate in a project which studies how clients, in therapy, attempt to resolve past conflicts.
The DAS was scored before the assessment session in order to identify prospective
couples. To be included in the study, the mean couple score on the DAS had to be between75 and 97 (which indicates mild to moderate distress). If a couple's mean score was less than75, they were not considered for the study, even if they report an attachment injury.
For purposes of this study, couples met the following criteria in the initial screening:
1) Both partners consented to participate in the study and both were expected to
attend the therapy sessions conjointly.
2) The couple, whether married or in a committed relationship, lived together for a
minimum of one year. Minors were not included.
3) Neither partner had reported problems related to drugs nor alcohol. The sample
did not include participants who reportedly used drugs recreationally or participants who tookmore than five drinks per week. To ensure that clients accurately reported how much alcoholthey consumed and whether or not they used recreational drugs, clients were verbally asked toconfirm that the information they had provided was valid and that by signing the consent form,they reported information as accurately as possible.
4) The couple was not included in the sample if either had received any psychiatric
treatment or medication in the past year, received any form of psychological or psychiatrictreatment, or had participated in any form of psychological or psychiatric treatment in theduration of the study.
5) Neither partner could have a reported history of physical nor sexual abuse.

286) Finally, partners were asked to recall an instance of betrayal or rejection in the
relationship associated with the current problem.
Couples were informed that the study had been approved by the Institutional Review
Board for Research Involving Human Subjects of Virginia Tech and the Ottawa Hospital -Civic Campus, that the study was conducted by therapists experienced in working withcouples, and that therapy was supervised by a registered psychologist in the province ofOntario, Canada.
Couples who met the inclusion criteria were informed that participation in the study
involved both partners participating in therapy for a total of about fifteen counseling sessionsof approximately one hour duration on a weekly basis. Couples were informed that theirparticipation in this study was voluntary and that they could withdraw from the project at anytime without jeopardizing access to further counseling. Referrals were provided in case ofearly termination.
The researcher met with clients immediately after the team assessment session. They
were given more information about their responsibilities in the study, asked to read and sign aconsent form, and were assured of confidentiality before completing the questionnaires. Couples were also notified that sessions would be audiotaped and informed that all tapeswould be securely filed.
Both partners were asked to fill out additional questionnaires after the intake session
to determine their participation in this study. They completed the Revised Adult AttachmentScale (RAAS), Relationship Trust Scale (RTS), the Attachment Injury Measure (AIM), and ademographics questionnaire. Couples were given the AIM for a self-report description of theattachment injury and a problem-severity rating of the injury on a scale of one to seven. (SeeAppendix C for all self-report measures)
The number of expected subjects was six to ensure the intensive study of three
“successful” couples. The minimum number accepted for scrutiny was three in the event thatall successfully resolve the attachment injury. Therapists for this research included EFT teammembers and the researcher. Couples who did not meet the inclusion criteria were treated bythe team, but not for purposes of this study, or were asked if he/she would like to be referredelsewhere for treatment. (See Appendix A for a referral list)
Data Collection Procedures
Pre- and post-treatment assessment measures. Couples who met the inclusion criteria
after the intake session completed the DAS, RTS, RAAS, AIM and a demographic
questionnaire. The researcher used the couple’s improvements on the DAS, RTS, and RAASpre- and post-treatment measures, as well as the mutual confirmation of the couple and thetherapist, to substantiate the “successful” resolution of the attachment injury.

29The demographics questionnaire was used for general information regarding length of
the relationship, the couples’ income, education level, and occupational status.
The DAS was used to screen potential participants and as a post-treatment “success”
measure. To be included in this study, each couple's mean total scale score must be less than98 but not less than 75. Couples were expected to score at least above an average score of 98to be considered “successful.” The DAS cut off for distressed couples is 98 and the meantotal score of happily married couples is 114.8. (Spanier, 1976).
The RTS was used to measure the amount of trust gained through treatment.
The RTS’s range of scores is from 30 to 210. Couples were expected to score above 150(normal range trust of partner) to be considered “successful.”
The RAAS was used to measure the amount of change is the participants’ perception
of attachment style. A change in attachment style was not a criterion for whether treatmenthad been successful or the resolution of attachment injury. Changes in the degree of styleswere expected such as high “Preoccupied Style” scores at pre-treatment would be low“Preoccupied Style” or in any range of “Secure Style.”
The Attachment Injury Measure (AIM) is a self-report measure constructed by the
researcher. The researcher asked the couple to describe the attachment injury in detail. Theclient who sustained the injury rated the injury on scale of 1 to 7 from “Not a Problem” to“Extremely Severe Problem.” “Successful”couples were expected to score from “ModerateProblem” to “Not a Problem” at the end of treatment.
Post-treatment unstructured interviews were conducted based on each participant’s
pre-treatment written responses on the AIM. The post-treatment interviews were intended toget participants’ validation that the attachment injury had been satisfactorily resolved. Theuse of attachment language (Johnson, 1996) was also analyzed, as such language is typical of“successful” treatment in EFT.
At the termination session, both partners were asked to complete the Post-Session
Resolution Questionnaire (PSRQ) and the Target Complaints Discomfort Box Scale(TCDBS). The PSRQ measures the amount of in-session change perceived by the couple. The scores range from 5 to 33 where low scores indicate little change and higher scoresindicate greater change. Couples were expected to score at least 20 or above to beconsidered “successful.” The TCDBS measures whether clients experience continueddiscomfort in light of the initial presenting problem. The scores of the target issue range from“Couldn’t be Worse” to “Not at All.” “Successful” couples were expected to score from “ALittle” to “Not at All.”

30In-session process measures. To determine the de-escalation, re-engagement, and
resolution sessions, couples were seen weekly for approximately fifteen weeks or until they
resolved their attachment injury. The session in which the re-engagement and softeningoccurred was considered the resolution session for this study.
The identification of de-escalation, re-engagement, and resolution sessions was a two-
step procedure (i.e., identification of essential steps by therapists and identification ofresolvers by raters). The first step, therapist identification, required each therapist to identifypotential de-escalation, re-engagement, and resolution sessions. Following each session thetherapist made a record of any resolution components that occurred in the session.
At the end of treatment, therapists were asked to review the taped sessions marked as
having the most advanced component of de-escalation, re-engagement, and resolution andindicate the best example of that component for each couple. These components were used asa midpoint for a ten minute segment (i.e., five minutes prior to the identified component, thede-escalation, re-engagement, and resolution component itself, followed by another fiveminutes of tape).
The second step was rater coding of the “best session” examples. In this step, taped
segments were presented to two raters, a doctoral student trained in EFT and the researcher. The raters received sufficient training on the process measures to code the de-escalation, re-engagement, and resolution segments. The units for the ratings were statements from thecouples, and were rated using the SASB and the ES. (See rater criteria below in RaterSelection and Training).
Using the above process measures, couples were considered “successful” if the
resolution session contained a re-engagement/softening event along with positive scores onthe pre- and post-test measures. Based on intensive task analysis (e.g., Johnson & Greenberg,1987) the following criteria were the hypothesized process measure scores for identifying thecomponents of the model of the resolution of attachment injuries:
A) De-escalation
1. On the SASB, statements from Partner A were expected to be rated as 1-6
(belittling and blaming), 1-7 (attacking and rejecting), or 2-1 (asserting and separating). Statements from Partner B were expected to be rated as 2-6 (sulking and appeasing), 2-7(protesting and withdrawing ), or 1-1 (freeing and forgetting).
2. On the ES, statements from both partners were expected to be rated as a level 3.
B) Re-engagement
1. On the SASB, statements from Partner A (injured) were expected to be rated as 2-
2 (expressing and disclosing of needs). Statements from Partner B (violator) were expectedto be rated as 1-2 (affirming and understanding).
2. On the ES, statements from both partners were expected to be rated as a level 4.

31C) Softening/Resolution
1. Sequential responses from both partners were expected to be rated as falling in
Quadrant I or IV on the SASB (autonomous/affiliation).
2. Sequential responses from both partners were expected to be a level 4 rating
(description of feelings and personal experiences) on the ES, with at least one of theseresponses reaching a peak of 5 or 6.
The softening criteria were met in order for a couple to be considered a resolver.
Cohen's Kappa (Cohen, 1960) yields a coefficient of agreement for nominal scales and wasused to determine the extent of agreement between the raters.
Description of Pre- and Post-Treatment Instruments
Instruments were chosen based on their use in previous EFT studies. The following
self-report instruments were selected on the basis of their theoretical relevance to EFT andbecause of their ab ility to predict outcome in distressed couples (Johnson & Talitman, 1997).
The Dyadic Adjustment Scale (DAS). The DAS (Spanier, 1976) is a 32-item self-
report rating scale designed to measure the quality of adjustment between married or
cohabiting couples. The scale yields a total adjustment score, as well as scores on foursubscales: Consensus, Satisfaction, Cohesion, and Affectional Expression. The DAS wasused in this study to select mild to moderately distressed couples, and to ensure that resolvingattachment injuries in these couples actually made a difference in their marital relationship.
There is evidence that the DAS is a valid and reliable measure of dyadic adjustment.
Internal consistency has been determined for each of the subscales and for the total measureusing Cronbach's Coefficient Alpha (Cronbach, 1960). Reliab ility coefficients ranged from .73
to .94 for the subscales, and .96 for the total dyadic adjustment scale. Content validity wasdetermined by evaluating the pertinence of each item to contemporary relationships, itsconsistency with nominal definitions of adjustment and the components, and its carefulwording with the fixed choice responses.
Criterion-related validity was established by assessing the difference of each item with
the external criterion of marital status (divorce vs. married couples). On the total scale score,divorced and married couples differed significantly (p < .001). Construct validity was
established through factor analysis and by correlating this scale with the Locke-WallaceMarital Adjustment Scale, which was one of the most frequently used scales. Correlationswere .86 for married and .89 for divorced respondents.
The DAS is scored by summing the scores of each fixed response. The scale score has
a theoretical range of 0-150. High scores are indicative of less distress and better adjustment.

32 The mean total scale scores were 114.8 for happily married couples and 70.7 for divorced
couples. The distress cut off point of 98 has been set at one standard deviation below themean for the married samples. Any couple scoring below 98 will be considered distressed. The average of the individual couple's scores yields the couple's mean total score. (SeeAppendix C for a copy of this scale)
Relationship Trust Scale (RTS). The RTS (Holmes, Boon, & Adams, 1990) is a 30-
item self-report inventory. It was specifically designed to assess interpersonal trust in married
or cohabiting couples. This scale consists of five subscales: Responsiveness of Partner (8items), Dependability/Reliability (6 items), Faith in Partner's Caring (6 items), ConflictEfficacy (5 items), and Dependency Concerns (5 items). The scale is a reconstruction of theRempel, Holmes, and Adams (1985) Trust Scale in order to render it more compatible withrecent empirical findings and theoretical speculation regarding issues of insecurity andinterpersonal trust in marriage (Holmes et al., 1990), attachment styles (Co llins & Reed,
1994), and emotion (Gottman & Levenson, 1986).
Reliability for this scale was established for each of the component subscales, as well
as for the total scale using Cronbach's Coefficient Alpha (Cronbach, 1960). The standardizedreliabilities for the above subscales were .89, .83, .84, .84, and . 83 respectively. Reliabilityfor the entire scale was .89. Test-retest reliability over a three-year period was approximately.72.
Construct validity was obtained by assessing the relationship between this scale and
other measures designed to assess individuals’ comfort level at being close to their partner,and believing in the availability and responsiveness of their partner. This sample consisted of70 married couples and the results showed a strong relationship between scores on the trustscale and the couples' experiences in their relationship. This revised scale also hasdemonstrated discriminant validity by contrasts with measures of self-disclosure, ambivalence,and anger, for both partners.
To obtain a score for this scale, individuals are asked to respond to the 30 items on a
7-point scale ranging from strongly disagree (1) to strongly agree (7). The theoretical rangeof scores is 30-210. Subscales are summed to provide an overall score. High scores areindicative of a stronger presence of trust between partners. A couple’s mean score is obtainedby averaging the sum of each partner's score. (See Appendix C for a copy of this scale)
The Revised Adult Attachment Scale (1996). The RAAS (Co llins, 1996) is a 18-item
self-report inventory. The RAAS was designed to measure the amount of closeness,
dependability and fear of abandonment in intimate adult relationships. The scale containsthree subscales composed of six items. The three subscales are Close, Depend and Anxiety. The Close scale measures the extent to which a person is comfortable with closeness andintimacy. The Depend scale measures the extent to which a person feels he/she can depend onothers to be available when needed. The Anxiety subscale measures the extent to which a

33person is worried about being abandoned or unloved. The revised scale is similar to the 18-
item Adult Attachment Scale (Collins & Read, 1990) which also measured the amount of
closeness, dependability and fear of abandonment in intimate adult relationships.
Reliability for this scale was established for each of the component subscales, as well
as for the total scale using Cronbach's Coefficient Alpha (Cronbach, 1960). The standardizedreliabilities for the above subscales were .75, .72, and .69 respectively. Reliability for theentire scale was .89. Test-retest reliability over a three year period was approximately .72. Reliability also was established through Factor Analysis. Construct validity was obtained bycomparing the RAAS with the Rosenberg Self Esteem Scale (Rosenberg, 1965), the TexasSocial Behaviour Inventory (Helmreich & Stapp, 1974), the Personal Attributes Questionnaire(Spence & Helmreich, 1978), the Opener Scale (M iller, Berg, & Archer, 1983), the Rotter
Trust Scale (Rotter, 1969), the Philosophies of Human Nature (Wrightsman, 1964), and theLove Attitudes Scale (Hendrick & Hendrick, 1986). From each scale, the RAAS differed at p
< .05 according to a Scheffe test.
Individuals are asked to respond to the 18-items on a 5-point scale ranging from Not
At All characteristic of Me (1) to Very Characteristic of Me (5). The 6-item subscales areindividually summed. The range of scores is 6-30 for each subscale. A midpoint split is usedto determine closeness, dependability and anxiety scores. For example, a secure personshould score above the midpoint score of around 18 on the close and depend dimensions, andbelow the midpoint score of around 18 on the anxiety dimension. Individuals who score at themidpoint will be scored as no definable attachment style or as mixed styles. Secureattachment styles will score high of closeness and dependability and low anxiety items; Preoccupied attachment styles will score high on anxiety and closeness and low ondependability; Fearful attachment styles will score high on anxiety and low on closeness anddependability subscales; and Dismissing attachment styles will score low on closeness,dependability and anxiety subscales. (See Appendix C for a copy of this scale)
Attachment Injury Measure. The Attachment Injury Measure (AIM) is a self- report
measure written by the researcher. The AIM asks the couple to describe the attachment injury
in detail. The AIM also asks couples to rate the injury on a severity scale of 1 to 7 or “Not atAll Severe” to “Extremely Severe.” “Successful” resolvers were expected to report“Moderately” to “Extremely Severe” at the beginning of treatment and report below“Moderately Severe” after treatment. (See Appendix C)
Description of Other Session Outcome Instruments
The following self-report measures were selected on the basis of their ability to
identify post-session change in individuals and couples (e.g., Greenberg & Webster 1982;Paivio & Greenberg, 1995).
Post-Session Resolution Questionnaire (PSRQ). The PSRQ is designed to measure
the amount of in-session change perceived by the couple. The questionnaire, which is adapted

34from the Orlinsky and Howard (1975; 1986) Therapy Session Report Questionnaire, consists
of three 5-point session evaluation scales and a 7-point scale evaluating how resolved thecouples feel they are in relation to the issues that brought them into therapy. Thequestionnaire has only face validity but has been used in previous studies successfully toidentify best sessions (Greenberg & Foerster, 1996; Greenberg, Ford, Alden, & Johnson,1993).
The first scale asks the couple to identify whether the issue dealt with in the session
was related to the issue identified at the beginning of therapy. The remaining two five-pointLikert scales and the seven-point scale are grouped together to derive a single PSRQ changescore. High scores are indicative of no change and low scores are indicative of much change. (See Appendix C)
Target Complaints Discomfort Box Scale (TCDBS). The TCDBS (Battle, Imber,
Hoehn-Saric, Stone, Nash, & Frank, 1966) is a rating scale consisting of a single column
divided into thirteen boxes. The words "Not at All" are written beside the bottom box; "ALittle" beside the fourth box; "Quite a Bit" beside the seventh box; "Very Much" beside thetenth box, and "Couldn't be Worse" beside the top (thirteenth) box. This scale has shownsatisfactory pre-post session reliability (Battle et al., 1966). (See Appendix C)
Description of Process Measurement/Instrumentation
These measures were selected on the basis of their utility to describe in-session
changes (e.g., Greenberg & Foerster 1996; Johnson & Greenberg, 1988).
The Structural Analysis of Social Behavior (SASB). The SASB (Benjamin, 1974:
1977) is a coding system designed to analyze and rate interpersonal processes. This methodof analysis is based on a circumplex model of social interactions and is comprised of threetwo-dimensional grids. The first grid depicts communications in which the speaker focuses onthe other person. The second grid describes communications in which the speaker focuses onself. The third grid, which has an intrapsychic focus, will not be used in this study.
Each grid consists of 36 points, forming eight clusters. Statements are characterized
as belonging to one of the 36 points that belong to one of four quadrants on one of two grids. Affiliation (measured by the horizontal axis) intersects with autonomy (measured by thevertical axis) and combinations of these two axes represent a full range of behaviors. In thepresent study, SASB will be used to measure the changing quality of interaction between thecouple.
This system has shown high inter-rater reliab ility and has been extensively validated.
Inter-clinician reliability for difficult material containing multiple and complex messagesyielded kappas between .70 and .85. By using trained undergraduates, kappas ranged from.61 to .79. However, by using group consensual judgments (two independent coders followed

35by two additional coders and then group consensus) kappa coefficients ranged from .80 to .84
with a mean of .81 for process codes.
The Experiencing Scale (ES). The ES (Klein, Mathieu, Kiesler, & Gendlin, 1969), is a
7-point rating scale that measures in-session level of experiencing and is very sensitive to
changes in the couple's involvement in therapy. Moving up the scale, there is a gradualprogression from superficial, interpersonal self-references to simple, limited, or externalizedself-references, to a synthesis of newly emerged feelings and new awareness that leads toproblem solving and better self-understanding.
The validity of the scale has been supported by its correlation with client variables such
as introspectiveness and cognitive complexity (Klein et al., 1986). The scale has been used topredict client change, especially in client-centered therapy (Orlinsky & Howard, 1986). Thescale has been highly reliable in terms of measuring client involvement or "experiencing" intherapy (Greenberg & Foerster, 1996). Interrater reliab ility coefficients from several studies
were in the high .80s and .90s. General descriptions of the seven scale stages and short formdescriptors are provided in Appendix B.
Rater Selection and Training. One graduate level doctoral student/therapist from the
Ottawa Civic Hospital was selected, along with the researcher, to rate the process data. Thetwo raters had been previously trained in EFT to identify the specific components of themodel. The raters received formal training on the process measures. The SASB and EStraining consisted of two 2-hour sessions, which involved rating practice segments (10 foreach session). At the end of training, inte r-rater reliab ility was to be above .80.
Transcription process. After couples were selected for the study, therapists, trained in
EFT, were asked to select sessions that best exemplified the de-escalation and re-engagement
events in relation to the attachment injury. Audiotapes of all sessions were reviewed by theresearcher. Transcripts of “best sessions” were chosen by both therapists who identifiedsignificant change events during sessions and the researcher while reviewing the tapes. Examples of “best sessions” were transcribed and coded by raters. The “best sessions” wereused to map the empirical model of change.
Implementation Check. Upon completion of the therapy sessions, an implementation
check was used as a guide by the researcher to ensure that the therapy condition was
implemented according to EFT practice standards. The focus was on client change processesand not the client-therapist interaction. The checklist of interventions used in previous studieswas informally used (Dandeneau & Johnson, 1994; Johnson & Greenberg, 1985a; Johnson &Talitman, 1997). The checklist consists of 16 interventions. Eight interventions are selectedfrom the EFT manual are considered to be EFT interventions. Eight interventions consideredto be non-EFT interventions have also been included. Interventions considered to be specificto EFT are 1, 3, 5, 7, 9, 11, 13 and 15 (See Appendix C for a copy of the checklist). Theresearcher verified that interventions were conducted according to EFT protocol.

36Data Analysis Process
For a majority of the pre- and post-tests such as the DAS, RTS, PSRS, and TCDBS,
“successful” scores were chosen within normal ranges of non distressed couples according tothe tests’ “normal” range scores. The RAAS scores were expected to improve from pre-assessment, however, couples were not expected to score in the “Secure” attachment style. “Successful” scores for each couple were combined as an average. The AIM”s “successful”range was a self-report description based on a Likert scale. The pre- and post-tests showedthat couples had satisfactorily resolved their presenting issues, the attachment injury inparticular.
The in-session measures showed changes within the process of treatment. The in-
session SASB and ES scores were coded from “best session” audiotapes chosen by therapistsand researcher. The researcher typed transcripts of the “best sessions” and the raters markedthem according to SASB and ES codes. Rater reliab ility was done using Cohen’s Kappa
(1960) inter-rater reliab ility procedure.
The descriptions on the pre- and post-AIM interview were grouped thematically.
Themes were identified by the type of injury and the injury’s effects on trust andintimacy/closeness. The improvement of trust and closeness are goals of EFT treatment and suggest more secure emotional bonds (Johnson, 1996). The post-AIM interviews also wereanalyzed by participants’ use of attachment language such as expressing vulnerabilities, wants,needs, desires for contact (Johnson, 1996).
The empirical model was mapped by either adding or deleting interpersonal cycles and
general thematic processes from the rational model, depending on responses in “bestsessions.” All new details in the empirical model were based on SASB and ES scores.
In summary, “successful” couples were expected to score in “normal” ranges of
generally well-adjusted couples. The process measures (SASB and ES) were used to presentthe ranges of behavioral responses during each “best session” phase. Based on the processscores and the proposed resolution model (See Table 1), the researcher diagramed thepathways of resolution. Any markers of change not included in the empirical model wereadded to the empirical model.

37Table 3
Data Measures and Procedures
Type of
MeasurePre
assessment AssessmentDe-
escalation ResolutionPost-
measures
Measure
Demo-
graphicsSelf report
Y e s N oN oN oN o
DAS Self report Yes No No Yes No
Relationship
Trust ScaleSelf report Yes No No Yes No
Revised
AdultAttachmentScaleSelf report Yes No No Yes No
Attachment
Injury MeasureSelf report
ResearcherY e s N oN oN oY e s
SASB Raters No Yes Yes Yes No
ES Raters No Yes Yes Yes No
Implemen-
tationChecklistR a t e r N oN oN oN oY e s
Post Session
ResolutionScaleSelf report No No No Yes No
Target
ComplaintScaleSelf report No No No Yes No

38CHAPTER IV
Results
Purpose and Summary
The purpose of this study was to identify attachment injuries in couples and to develop
a preliminary model for the resolution of attachment injuries using Emotionally FocusedTherapy. The definition of an attachment injury was when one partner betrayed or broke thetrust of the other in a specific incident and that incident became a clinically recurring themeand stuck point of task resolution.
The model (N = 3) was developed using task analysis. Moderate to mildly distressed
couples with attachment injuries were identified by the researcher and an expert clinician. Theattachment injuries were resolved using EFT. Audiotaped segments of “best sessions” ofmarker events were reviewed by the researcher and raters to determine change eventsthroughout the therapy process. The marker events were proposed to occur at the de-escalation, re-engagement, and resolution/softening phases of treatment. Pre- and post-testswere used to measure overall resolution of the attachment injury and process measures wereused to identify in-session changes. Couples were interviewed at the completion of treatmentin order to assess their own perceptions of the attachment injury and their levels of change andcloseness.
Sample Description
The three couples for this study were selected from the Marital and Family Therapy
Clinic at the Ottawa Hospital Civic-Site. Participants voluntarily entered the clinic for generaltherapy services and were not solicited to come to the Ottawa Hospital to participate in thisstudy. The participants passed the initial screening requirements: all were married, had pre-treatment DAS scores between 75 and 97, had no history of alcohol or drug abuse, had nohistory of physical or sexual abuse, and had an identifiable attachment injury based on thetheoretical judgment of the MFT clinic team and the researcher.
Six couples were chosen over the course of four months. Three couples were not used
for this study because they either discontinued therapy or did not demonstrate a clear exampleof an attachment injury that was previously conjectured by the team and the researcher. Ofthe couples in the study, two were assigned to the researcher and a co-therapist, and onecouple was assigned to other co-therapists. All therapists were trained in EFT.
The average age for the couples was 37.1 and all had been married for about eight
years. The average income was around 95,000 Canadian dollars. All were employed outsidethe home except one who was entering a graduate program. All were university graduatesexcept one couple who had earned associate degrees. Two couples had two children under

39eight years of age. The wife of the third couple had three children 16 years of age and older
from a previous marriage. (See Table 4 for Demographics Description)
Table 4
Demographics

Couple 1
Female/MaleCouple 2
Female/MaleCouple 3
Female/Male
Age 43/43 32/35 36/34
Years together 9 11 7.5
Number of
Children32 2
Annual income 110,000 53,000 120,000
Occupation Accounting depart-
ment/ Self-employed:computersAdministrative
assistant/Drug storemother, student/
Software designer
Education Bachelor’s degree/
Bachelor’s degreeAssociate’s degree/
High schoolBachelor’s degree/
Bachelor’s degree
Research Questions
How did clients describe the attachment injury before treatment?
Attachment Injury Measure scores. The pre-treatment AIM asked how partners rated
the severity of the injury. A score of 1 indicated “Not a Problem,” and 7 indicated “ExtremelySevere Problem.” AIM scores for all couples were approximately 5 or “Very Much aProblem” and 6 or “Severe Problem.” In Couples 1 and 3, partners reporting the attachmentinjury had more distressed scores than their partners; Couple 2 reported the same score. (SeeTable 5 for AIM scores)
Qualitative description of Attachment Injury Measure. The AIM asked participants to
report a significant negative event in the relationship. They were also asked to include how
the event affected the level of trust and intimacy between them and their partner. (See Table 5for themes in AIM results and Appendix E for full description)

40One partner in all couples reported an attachment injury. The event tended to be a
specific incident that marked a change in the injured’s perception and emotional issues such aslevel of trust and level of intimacy in the relationship. Partners reporting the attachment injurywere brief in their descriptions, but nonetheless touched upon an event that later became thesignificant event that interrupted the progress of treatment. Non-attachment injury partnerseither focused on different “negative events” or reported ongoing problems instead of aspecific event that changed interpersonal dynamics.
AIM examples. The female partner in Couple 3 reported a specific event when she
was having a miscarriage and her partner refused to come home from work to help her. She
remarked that the miscarriage frightened her and she called for comfort. His refusal to comehome marked a feeling of distance between them. She wrote:
About 1 ½ years ago, I had my second miscarriage in 3 months. I called Mike at work
to tell him to come home because I was hemorrhaging and was really scared. Herefused to come home because he was working late on an important project with adeadline. I begged him to come home, but he refused to come. This situationcompounded my distance of Mike being there for me even in a crisis.
Earlier in her AIM statement, the injured partner in Couple 3 reported an attachment
injury concerning career plans and her partner’s refusal to honor a promise. She remarkedthat the injury gravely affected her level of trust. She stated:
I was devastated that he was backing out on a very important promise. I had told him
that I would never marry someone who didn’t support my goal of being a careerwoman and mother . . . I went into a deep depression, developed a chronic healthcondition from the stress, and tried to get professional help without success. I wasclinically depressed for over four years. I felt trapped. I was too depressed to leavethe relationship, although I felt like leaving many times. My trust in him wascompletely destroyed along with my self-esteem. I gained over 30 pounds of extraweight and felt terrible. I felt I had no place, or money, or self-esteem to go anywhereor do anything. We started fighting regularly after this event. I also lost a lot ofrespect for him as a person, and became quite bitter and critical.
The female partner in Couple 2 also reported an incident when she has a miscarriage
and her partner did not respond to her emotional needs, thus resulted in a felt decrease ofintimacy. She wrote:
This became glaringly obvious after my miscarriages. He just didn’t seem to know
what to do. It hurts me that can’t show me his feelings. I still trust him but I knowthat I can’t depend on him for emotional support. The miscarriages themselvesdecreased the level of intimacy between us. . .

41Table 5
Summary of Pre-Treatment Attachment Injury Measure
AIM Score Negative Event Effect on Trust Effect on
Intimacy
Couple 1
Female“Very Serious
Problem”son’s ongoing
behaviorproblemsresentment for
choosingbetween sonand husbandstress and
resentment
Male (AI) “Severe
Problem”child’s ongoing
behaviorproblemsfeelings will be
stomped onseparation;
anger, grief;non- loving
Couple 2
Female (AI)“Extremely
SevereProblem”miscarriage still trusts, but
undependablecan’t get
emotionalsupport
Male “Very Much a
Problem”“her” control
issuesbelittled by
partneravoid “heated”
contact,intimacy
Couple 3
Female (AI)“Extremely
SevereProblem”partner backs
out of promise;miscarriagetrust
completelydestroyeddoesn’t feel
supported;bitter andcritical
Male “Very Much a
Problem”puts him and
family downfelt emotionally
stalkedneeds ignored
What were the results of the pre-test scores for couples?
The following scores were from the pre-test measures of the Dyadic Adjustment Scale,
Relationship Trust Scale, Revised Adult Attachment Scale, and Attachment Injury Measure. All couples passed initial screening criteria such as appropriate DAS scores and had anidentifiable attachment injury. (See Table 6 for pre-test results)
Dyadic Adjustment Scale. The DAS score for divorcing couples is 70; a score of 98 is
the distress cut off point (Spanier, 1976). Couples 1 and 2 reported scores just below and
above the distress cut off point. Couple 3 reported more distressed and lower adjustment thanCouples 1 and 2, but scored above the norm for divorcing couples. All couples generally

42reported higher agreement scores on the Consensus sub-scales and lower disagreement scores
on Affectional Expression and Cohesion sub-scales.
Table 6
Pre-assessment Measures Results
PRE- DAS RTS RAAS
Couple 1
Female 93 173 Fearful/
Avoidant
Male 95 167 Fearful/
Avoidant
Average 94 170
Couple 2
Female 95 154 Preoccupied
Male 108 166 Dismissing
Average 101.5 160
Couple 3
Female 72 136 Preoccupied
Male 80 159 Dismissing
Average 76 147.5
Relationship Trust Scale. In Couple 1, both scored just above the normal range of
trust for couples, indicating an above average trust level. Partner A indicated lower scores onthe Responsiveness of Partner and Dependency subscales. Partner B indicated lower scoreson the Dependency subscale. In Couple 2, both scored above the normal range of trust forcouples, indicating an above average trust level. Partner A scored lower of theResponsiveness of Partner and Faith of Caring subscales, and Partner B scored lower on theConflict Efficacy subscale. Couple 3 scored just below the normal range, indicating a lowmoderate trust level. Partner A scored lower on Responsiveness of Partner,

43Dependability/Reliability, Faith in Partner's Caring , Conflict Effi cacy, and Dependency
Concerns; and Partner B scored lower on Dependability/Reliability, Faith in Partner's Caring,Conflict Efficacy, and Dependency Concerns.
Revised Adult Attachment Scale. The RAAS was designed to measure the amount of
closeness, dependability and fear of abandonment in intimate adult relationships. The pre-
treatment RAAS scores indicated general defensive attachment styles among all couples. Both partners in Couple 1 scored in the moderate Fearful/Avoidant attachment style range. InCouples 2 and 3, Partner A (with the attachment injury) scored in the Preoccupied range andPartner B scored in the Dismissing range.
What were the post-test scores and did the scores result in “successful” resolvers according to
the measures’ norms?
Pre- and post-tests were used to measure overall resolution of the attachment injury.
All couples scored within target “norms” according to each measure and also reported“successful” resolution in the TCDBS. The implementation checklist confirmed that EFTinterventions were used throughout treatment.
Dyadic Adjustment Scale. Couples were expected to score at least above a combined
score of 98 to be considered “successful.” The norm for happily married couples is 114.8
(Spanier, 1976). All couples scored above the “successful” cut off and within close range of114 or the score of happily married couples. All couples, as in the pre-treatment scores,generally reported higher agreement scores on the Consensus sub-scales and showed fewerdisagreement scores on Affectional Expression and Cohesion sub-scales.
Relationship Trust Scale. The RTS was used to measure the amount of trust gained
through treatment. Couples were expected to score above 150 (normal range trust of partner)
to be considered “successful.” Post-treatment average scores on the RTS wereapproximately 180, compared to pre-treatment scores of approximately 160.
Revised Adult Attachment Scale. The RAAS was used to measure the amount of
change is the participants’ perception of attachment style. A change in attachment style wasnot a criterion for whether treatment has been “successful” or the resolution of attachmentinjury. Changes in “low” scores of attachment styles were expected for to become moremoderate. On the pre-treatment RAAS assessment, Couples 1, 2, and 3 scoredfearful/avoidant and preoccupied; preoccupied and dismissing; and preoccupied anddismissing, respectively. Post-treatment scores for Couples 1, 2, and 3 were secure and lowpreoccupied; secure and secure; and low preoccupied and low dismissing, respectively. Dismissing style participants scored higher on Dependency subscales, and preoccupied andfearful/avoidant style participants scored lower on Fear of Abandonment subscales, suggesting“successful” changes in attachment style.

44Attachment Injury Measure. Pre-treatment scores for the AIM indicated a range from
“Very Much a Problem” to “Severe Problem.” The “successful” range for post-treatment was
expected to be below 3 or “Moderately Severe.” Post-treatment scores for all couples wereabout 2, indicating “Slight Problem.”
Table 7
Results of Post-Treatment Measures
POST- DAS RTS RAAS AIM TCDBS PRSQ
Couple 1
Female 98 188 Low
Preoccupied“Slight
Problem”42 5
Male 105 182 Secure “Slight
Problem”4.5 27
Average 101.5 185 “Slight
Problem”4.25 26
Couple 2
Female 108 182 Secure “Slight
Problem”42 8
Male 118 191 Secure “Slight
Problem”43 1
Average 113 186.5 “Slight
Problem”4 29.5
Couple 3
Female 102 172 Low
Preoccupied“Slight
Problem”42 5
Male 106 180 Low
Dismissing“Slight
Problem”42 8
Average 104 176 “Slight
Problem”4 26.5

45Post-treatment AIM interview. The post-treatment interviews extended the
participants’ validation that the attachment injury was satisfactorily resolved. Partners were
interviewed separately and were asked about their written responses on the pre-treatmentAttachment Injury Measure. The purpose of the interviews was to get the participants’perspective on the ”specific negative event” or attachment injury, and for participants toexpand of relationship themes such as trust, intimacy/closeness, and the amount of changesince the beginning of treatment.
Target Complaint Discomfort Box Scale. Post-treatment of the TCDBS asks how
much does the issue brought into therapy presently “bother” each participant. Scores range
from (1) Couldn't be Worse to (5) Not at All. Couples scored approximately 4 or “A Little.”
Post Session Resolution Questionnaire. The PSRQ measured the amount of in-
session change perceived by the couple. “Successful” scores were expected to be above 20.
The average for Couples 1, 2, and 3 was 26, 29.5, and 26.5 respectively.
Implementation Check. The implementation check was used as a guide by the
researcher to ensure that the therapy condition was done according to the EFT model. The
focus was on client change processes and not the client-therapist interaction. The researcherreviewed all therapy sessions of the three couples on audiotape when choosing the “bestsessions” for the process of resolving attachment injuries. An informal check was done toensure that the therapists were following EFT protocol and that the focus of client change wasspecific to EFT criteria. All EFT intervention procedures (1, 3, 5, 7, 9, 11, 13 and 15) for thecategories of Definition of Problematic Event, Attacking Behavior, Process Focus, Resolutionof Problematic Event were used.
What were the results of the Structural Analysis of Social Behavior and Experiencing Scale
process measure scores within each marker or phase of resolution?
One graduate level student/therapist from the Ottawa Civic Hospital and the
researcher rated the change events in each stage of the therapy process. The two raters werepreviously trained in EFT and also received training in the SASB. The training consisted oftwo 2-hour sessions and involved rating practice segments (10 for each session). Theinterrater reliability for the SASB for the in-session process measures was .89, indicating highinter-rater reliab ility (Cohen, 1969). The majority of rater disagreements fell within the
Cluster codes of specific behaviors such as protesting versus sulking. Raters rarely disagreedon the more general category codes of Focus scores such as Self or Other, or Quadrant scoressuch as Affiliative, Distant, Hostile or Friendly. The researcher coded the ES for all phases ofresolution.
Change events fell within the predicted stages of the resolution process. The first
phase emerged in the assessment phase or the first two steps of the EFT model and markedthe attachment injury. The markers were statements of an incident of betrayal or rejection

46such as responsiveness during a miscarriage or accessib ility during a critical discussion
concerning family members. Although other issues and event were discussed in this phase, theattachment injury was nonetheless introduced. The injured partner accused and blamed theirpartner in an angry or critical manner, while the blamed partner withdrew and took a defensivestance.
Couple 1 expressed the following:Sara: I was mad at him. He was just standing there watching and the baby
needed comforting, like he is only five years old and he just stands there. I think, “Dosomething.” I feel mad now thinking about it.
Sam: I was going to. ( Pause)
Therapist: What happened after that?Sara: Well he just went into his shell and I was left to clean up the mess off the floor
and do all the other stuff too. I’m fed up. I just kind of slap him down . . . I have ashort fuse, especially when I have a bad day or a headache. He should just know. Ittakes a lot for me to get really angry and sometimes I have to get really angry just toget a reaction. Sometimes I feel I have to stay and have a fight so I can get a reactionjust so we can communicate about something.
The process measures showed that defensive behaviors such as blaming or withdrawing were
highest at the beginning or the Assessment phase.
Codes in the De-escalation phase showed lower levels of anger or pursuing behaviors
for partner A, and more engagement and affiliative behaviors for partner B. “Secondary”issues to the attachment injury were discussed in the beginning stages of this phase. Couple 1expressed:
Sara: I am glad to hear that I am important to you. Sometimes, I just don’t know
how you feel about me or how you feel about anything. I used to say to him that I wassorry to hurt his feeling ( laughter) because I thought he only had one.
Sam: Well, I have never been a very expressive person, never talked a lot, but she
knows that I do have feelings but I just don’t talk a lot about them. I do want to talkmore about them, but I just don’t want to be criticized.
There was a return to higher anger levels during the de-escalation phase, particularly
when the attachment injury was worked through. However, during the attachment injuryphase, within the de-escalation phase, partners with the attachment injury showed moredifferentiated affectual expression, such as a mix of anger statements followed by more

47vulnerable expressions of needs and self-disclosure. Their partners became less defensive and
more responsive. Although affect expression was more differentiated in this phase than in theAssessment phase, couples continued to interact in the similar rigid interaction cycles.
The following transcript shows the discussion of the attachment injury:
Therapist: What happened after that, after you realized that you had lost the
baby?
Sara: I called for Sam to come down and help me. He came down, but was frozen, like
he didn't know what to do. I just remember thinking that if I go off the deep end here,at what point will he pick up the phone and call. . . at what point will he come over tocomfort me. Well I didn't want him to call anyone. I wanted him to take care of meand I thought . . .
Therapist: Take care of you how?Sara: To. . . (pause) to hold me and do what people do when somebody dies. To me if
somebody I knew died, I would ask if they are ok and say that I am really sorry and ifthey wanted to talk about it, I would listen and if they started to cry, I would comfortthem. You kind of have to say something. Everything just seemed so solid and hedidn't seem upset by it.
The Re-engagement/Resolution phase scores showed high affiliation and re-
engagement and followed predicted scores, indicating both a resolution of therapy and aresolution of the attachment injury. Partner A continued to differentiate affect, expressesvulnerability, and also described the attachment meanings in terms of safety and trust. PartnerB became more engaged, listened more, acknowledged the other partner's pain, and acceptedresponsibility for his/her part in the attachment injury. During this phase, partner A“softens”and became less hostile and more trusting and expressed the need for comfort,safety, and reassurance. Partner B responded to partner A’s pain and offered comfort. Thebehaviors in this phase redefined the bond as engaged.
The following shows the re-engagement/softening marker in Couple 2:Sara: I know that. And I appreciate that he does all that he does for me. I know if
over the years if I hadn’t criticized you so much, you may be more open to me andtrust me more.
Sam: I totally trust you.Sara: I really am seeing you differently. Not for who I want you to be, but who you
are. But not that I expect a totally emotional person all the time, but find differentways for us fit together.

48SASB and ES scores during marker events. The following shows the range of SASB
and ES scores with marker events. All rater codes fell within predicted ranges.
I. Assessment:
1. On the SASB, statements from Partner A (injury partner) were rated as 1-6
(belittling and blaming), 1-7 (attacking and rejecting), or 2-1 (asserting and separating). Statements from Partner B were rated as 2-6 (sulking and appeasing), 2-7 (protesting andwithdrawing ), or 1-1 (freeing and forgetting). Scores were consistent with predicted rangesof scores.
2. On the ES, statements from both partners on average were rated less than 3.
II. De-escalation:
1. On the SASB, statements from Partner A (injury partner) were rated as 2-2
(expressing and disclosing of needs). Statements from Partner B were rated as 1-2 (affirmingand understanding).
2. On the ES, statements from both partners were rated as a level 4.3. On the SASB during the attachment injury phase, statements from Partner A (injury
partner) were rated as 2-2 (expressing and disclosing of needs). Statements from Partner Bwere rated as 1-2 (affirming and understanding).
4. On the ES, statements from both partners were rated as a level 4.
III. Re-engagement/ Softening/Resolution:
1. Sequential responses from both partners were rated as falling in Quadrant I or IV
on the SASB (autonomous/affiliation).
2. Sequential responses from both partners attained a level 4 rating (description of
feelings and personal experiences) on the ES, with at least one of these responses reaching apeak of 5 or 6.
How did clients describe the attachment injury after the resolution phase of treatment?
The post-treatment interviews extended the participants’ validation that the attachment
injury was satisfactorily resolved. Partners were interviewed separately and were asked toread their written responses on the pre-treatment Attachment Injury Measure. The purpose ofthe interviews was to get the participants’ perspective on the ”specific negative event” orattachment injury, and themes such as trust, intimacy/closeness, and the amount of changesince the beginning of treatment.
The following segments showed participants’ views of the attachment injury, change
and intimacy after treatment. Segments of attachment significance, as shown throughattachment language (Bowlby, 1969, and Johnson, 1996), are provided. The first segmentgave the injured and her partner’s perspective of the attachment injury event after resolution. Both showed empathy for the other’s experience.

49Molly: He was very preoccupied with a major project at work and also I think our
emotional baggage got in the way that day. Had we been less distant and lessantagonistic towards each other, he would have been there. I know he would havebeen.
Molly: I am pretty sure that if I had a miscarriage today, he would not react the same
way again. I think he learned a hard lesson from that experience. And I am watchinghim with his mother now in treatment, and he is so there for his mom that I amsurprised and frankly jealous ( laughter).
Mike: Well, I know it was very difficult for her and actually it was very painful for us
both. If that were to happen today, undoubtedly I would drop what I was doing andbe there. We were so tangled up in conflict then and there had been so many falsealarms that I could make that kind of decision then. Now I could not do that.
Another participant expressed that the attachment injury would surface during everyday
conversations, and that the injury had been worked through to her satisfaction. She stated:
Sara: It seemed that every time we had a fight, it was so bizarre, I would always end
up bringing up the miscarriage. We would be fighting about where the knives go, forexample, and all of a sudden I would say, “You just didn’t understand” and “Whydidn’t you see what this was about?” But it never comes to that now. We dealt withit. I did what I needed to do and it seems like a thing of the past now. It is different. It feels so good to have it behind us. I mean, I will never forget it, but it doesn’t havethe impact that it used to.
All participants expressed a sense of positive general change in the relationship. One partner
stated:
I thought we were going to separate as a result of it. It feels different now. I mean,
we haven't gone through major personality overhauls, but we know we can handlethings that used to get us down. And it seems simple now. I stop hiding and talkabout it.
As predicted by the resolution phase of EFT, participants described their post-
treatment using attachment language. The use of attachment language such as “lonely” and implied access to “primary emotions” and a sense of safety to express them interpersonally forboth partners. The partner of an attachment injury participant explained:
Sam: Yes, just agree with her with whatever. I was very lonely though. It took the
manhood out of me. There was a time that I was lonely. I am not a talker and don’tshow my emotions and I know that is a problem and I am trying to do better. I meanwe went through some hard times, especially the miscarriage, and I went through

50some hard times. Had I known more about what was happening to her on a deeper
level, it would have helped.
Table 8
Summary of Post-Treatment Attachment Injury Interviews
AttachmentInjuryPerception of
changeAttachment
SignificanceEffect on
Intimacy
Couple 1
Femaleson’s ongoing
behaviorproblems“It got so
much better”“I need to
show love”more talking,
coping; “We areallies”
Male (AI) child’s ongoing
behaviorproblemspositive
change; “wecan handle it”“I need her
help”; “stay intouch” emotionally
“know” eachother; openedup
Couple 2
Female (AI)miscarriage AI less impact;
give spacetrust; “I know
he cares”;“he’s not un-emotionalmore
encouraging;less reactive
Male “her” control
issueswider range of
possibilities;less controlling“I was very
lonely”talk more; she
listens more
Couple 3
Female (AI)partner backs
out of promise;miscarriage“He would
have beenthere;”tremendousprogress“We can really
be there foreach other”accessible,reliable.more trust;
sense of peace,joy; both actorand director
Male puts him and
family downputs them
down less;supportive withfamily“It was painful
for us” “Beingthere for her istherapy forme”give love and
receive love;talk more; moretrust
Rick: It was severe. And there is no control over a teenager sometimes so I expectproblems to come our way. But as I said, we can handle it . . . Or we can handle

51ourselves as a couple. I have come to realize that I need Rhet’s help sometimes and
can ask her for it and I know not to get in the middle and put her in a place to decidebetween me and her kids.
All participants expressed positive change in levels of felt and expressed intimacy after
treatment.
Mike: Being there for her is a type of therapy for me. It is a reciprocal process and it
I express love and I feel I will get it back. It is a positive sharing. Sometimes comingtogether has caused so much friction and we are showing the good ingredients now. Ireally try to show that I care.
Molly: If you look through the trust scales, you will see the changes in us. In
February, I was in a terrible place, and now I feel a sense of empowerment and I takecare of me and take care of Mike and the family. I trust Mike, I trust that we willwork things through. . .
In what ways did the event pathways of the proposed rational model of attachment injury
resolution differ from those of the empirical model?
The rational and empirical models of the resolution of attachment injuries share similar
pathways. It was proposed that the markers would be statements of an incident of betrayal orrejection from partner A . The injured partner would show hostility, while the other partner
would withdraw and take a defensive stance. Second, in the de-escalation phase, partner A
would begin to articulate the significance of the injury, differentiate affect (e.g., hostility andhurt). Partner B would become less defensive and more responsive, but both interacting in
similar rigid interaction cycles as in the first phase. Third, in the re-engagement phase, partner
A would continue to differentiate affect, express vulnerability, and describe the attachment
meanings in terms of safety and trust. Partner B would become more engaged, acknowledge
the other partner's pain and accept responsib ility for his/her part in the attachment injury.
The difference in the rational and empirical models lies in where the attachment injury
became a significant event in treatment. The rational model proposed that the attachmentinjury would become a significant, workable theme from the beginning of treatment in theassessment phase and continue as such thematically through the de-escalation and re-engagement phases. The empirical, however, model showed that the attachment injury wasindeed brought out as a clinical issue, however, the resolution of the injury did not take placeuntil after de-escalation had taken place. Some couples worked through the injury in underten sessions after the assessment phase; others worked through other issues for up to fifteensessions. What couples had in common, in summary, was that the resolution of theattachment injury came after a period of de-escalation and that the resolution of theattachment injury was a prerequisite event before the Resolution/Softening phase.

52The empirical model proposes that the attachment injury is not necessarily the focus of
treatment until the de-escalation phase of treatment. The injury may appear in the assessmentphase and become a thematic therapy issue. On the other hand, as shown through participantsin the study, the attachment injury can remain an unspoken topic.
The empirical model, as expected, expands the rational model in detail. The following
empirical model follows the similar steps as the rational model. The attachment injury markerevent was renamed as the Assessment Phase due to variations of topics discussed in treatment.
I. Assessment Phase.
1. Pre-assessment session measures are given. Clients report initial content presenting
problem and typically report distress concerning the relationship. Partner A shows secondary
affect behaviors such as blaming, hostility, critical anger and contempt. Partner B shows
secondary affect behaviors such as defensiveness, minimizing, withdrawal and avoidance. Theattachment injury can be mentioned, but not necessarily becomes the core focus of therapy.
2. Relational cycles are identified. Typical patterns are: pursue/distance,
hostility/withdraw, attack/defend, attack/attack and defend/defend.
II. De-escalation Phase.
3. Partners become less defensive. Clients show differentiation of affect and the
expression of needs. Partner A shows less anger and pursuing behaviors, and expresses
vulnerability. Partner B becomes more engaged and listens more empathically. Couples
vacillate between periods of closeness (re-engagement) and periods of anger and distance,especially if the attachment injury or other significant attachment issues are discussed. Otherissues, whether topical, emotional or relational, are worked through. This phase is the bulk oftherapy and can last as few as ten to more than twenty sessions. The attachment injuryemerges in this phase but at different points in the therapy process depending on the couple.
4. Attachment Injury. Partner A expresses the attachment significance of an event that
marks a drastic change in the relationship. Partner A begins to express vulnerability and
articulates lack of trust, accessib ility, responsiveness, emotional security, emotional contact
and engagement, commitment and belonging. Partner A uses attachment language such as “I
was devastated and all alone.” Partner B becomes more engaged, listens more empathically
and is less defensive. The attachment injury can be resolved but does not necessarily serve asthe re-engagement or softening event. The resolution of the attachment injury precedes there-engagement phase of therapy.

53Table 9
The Empirical Attachment Injury Resolution Model
Phase 1: Assessment
Presenting problem;Secondary affect;Cycles of pursue/distanceor attack/defend(Partner A: The Injured)
Shows blaming, hostile,critical anger andcontemptuous behaviors(Partner B)
Defensive, minimizing,withdrawal/avoidancebehaviors
Phase 2: De-Escalation
Differentiation of affectand the expression ofneeds; Attachment Injurydiscussed at any point inthis phase(Partner A)
Express less anger andmore vulnerability; Usesattachment language suchas “I am hurt”(Partner B)
Becomes more engaged;Listens more empathicallyand less defensive
Attachment Injury
Couples can revert toPhase 1: Secondary affect;Cycles of pursue/distanceor attack/defend(Partner A: The Injured)
Shows blaming, hostile,critical anger andexpression of needs(Partner B)
Some defensive, minimizing,avoidance behaviors, butmore engaged
Phase 3: Re-Engagement/ Resolution/Softening
Primary Affect: Expressionof vulnerability andemotional engagement;Mutual expression ofneeds; More empathic (Partner A)
More trusts; Discloses andexpresses needs; Lesshostile; Acceptslimitations(Partner B)
Trust the other more; Moreengaged and empathic;More accessible andresponsive
III. Re-engagement and Softening Phase.
5. Couples express vulnerabilities and show emotional engagement. There is an
emergence of new relational cycles which serve as the biggest shift in the relationshippositions compared to pretest measures. Partner A expresses needs and vulnerabilities, trusts
the other more, feels that the other can be accessible and responsive, and accepts limitations.
Partner A is more empathic, less hostile and is able to ask for comfort from the other.
Partner B also is more engaged and empathic, trusts the other more, and accepts limitations.

54Partner B is more accessible and responsive, and feels that the other more approachable. (See
Table 5 for The Attachment Injury Empirical Model)
Summary
Attachment injuries, according to Johnson (1996), are relationship events that occur in
critical moments of need when a person is vulnerable. The person’s sense of trust, closeness,and general satisfaction feels betrayed. The event may seem inconsequential to an outsideviewer, and even the person’s partner; yet the incident is repeatedly raised without satisfactoryclosure and it later becomes a stuck point to task resolution clinically. This study identifiedcouples with such injuries and proposed a theoretical/empirical model of resolution.
Couples with attachment injuries were identified by an expert clinician and the
researcher. The attachment injuries were resolved using EFT and the model (N = 3) wasdeveloped using task analysis. The empirical map was developed as follows: Pre- and post-tests such as the DAS, RTS, RAAS, and AIM measured overall resolution of the attachmentinjury. All couples scored within proposed ranges and were considered “successful” resolversaccording to all pre- and post-measures. Process measures identified in-session changes. All“best sessions” ratings from the SASB and ES fell within predicted ranges. At the resolutionsession the researcher interviewed couples based on pre-assessment AIM responses to identifychange events from the clients’ point of view. The TCDBS and PSRQ showed the“successful resolution” of the attachment injury.
A rational, conceptual map of expected change was compared to an empirically
developed map. The marker events emerged at the assessment, de-escalation, and resolutionphases of treatment. The attachment injury emerged during the de-escalation phase oftreatment.

55Chapter V
Discussion
Couples often enter therapy under significant emotional distress. They report low
levels of marital satisfaction, trust and intimacy. Many feel emotionally defeated and that theirattempts at restoring intimacy have fallen short. These couples relate to one another in limitedways, often through defensiveness, reactivity, anger, indifference and rigid attack and defendcycles. The therapist may guide these couples through a long de-escalation process and noteimprovements in intimacy and satisfaction, and later find that the couple has reverted back tosimilar rigid cycles, anger and withdrawal as in the initial stages of therapy. The couple feelsstuck; the therapist feels stuck.
Johnson (1996) proposed that distress can frequently be traced to a specific incident
when one partner experiences a strong sense of betrayal by the actions of their partner. Forthe couple, this injurious incident represents a wound in the attachment bond and is marked byconsuming pain and mistrust. In therapy, this incident becomes a recurring theme, wherecouples are seemingly stuck in negative interactional cycles and report a loss of trust,dependability, responsiveness and accessibility.
EFT is a form of couples therapy that offers a systematic means for understanding
relationship distress. Few family therapy models have been empirically tested. EFT, however,has empirically mapped out replicable procedures, specific interventions, and has tested theeffectiveness of interventions on numerous presenting problems, particularly on maritaldistress (Greenberg & Johnson, 1986a). EFT has been shown to create stronger attachmentbonds and higher levels of trust and intimacy in couples (Johnson, Hunsley, Greenberg, &Schindler, 1998).
This study posed several essential questions that have needed examination. First,
there are no references to attachment injuries other than Johnson’s (1996; 1998)conceptualization. This study may further validate Johnson’s (1996) conceptualizationthrough the clients’ points of view. Second, there are no empirical studies in the literature onattachment injuries. This study attempted to build a preliminary model of how attachmentinjuries can be resolved clinically. Third, EFT has shown a high effect size for couples withgeneral distress, but has not addressed couples who relapse to initial distress levels duringtreatment or who terminate treatment as non resolvers. Additionally, EFT theory does notdistinguish between general distress and specific events that hamper resolution. This studyoffered a refinement in EFT theory through the tested concept of attachment injuries.
This study identified the theoretical construct of attachment injuries in couples and
proposed, through task analysis, a preliminary rational/empirical model of resolution of suchinjuries. Couples with attachment injuries were identified by an expert clinician and the

56researcher. Couples described critical “negative events” in a pre-treatment self-report
measure. Pre- and post-tests measured overall resolution of the attachment injury. Attermination, all couples scored within the “successful” range in the Dyadic Adjustment Scale,Relationship Trust Scale, Revised Adult Attachment Scale, Attachment Injury Measure PostSession Resolution Questionnaire, and Target Complaints Discomfort Box Scale. Processmeasures identified in-session changes. All couples scored within “successful” ranges in “bestsessions” in the Structural Analysis of Social Behavior and Experiencing Scale measures. Lastly, couples were interviewed at post-treatment and described a clear impact by the focuson EFT and attachment injuries as shown by their improved empathy, the use of “primaryaffect” and attachment language, and reports of positive change and higher maritalsatisfaction.
A rational, conceptual map of expected change was compared to an empirically
developed map. The data showed significant overlap between rational/empirical models, withone compelling exception. The rational model mapped the attachment injury as the firstmarker event in treatment. The empirical model, however, showed that the attachment injurywas not necessarily the first maker or presenting problem in treatment, and the resolution ofthe attachment injury came after several sessions within the de-escalation phase and was anecessary step that precipitated the re-engagement/resolution phase.
Attachment needs are activated when there is a real or potential threat, danger, loss, or
uncertainty (Bowlby, 1969). The hypothesis of this study was that a relationship event such asfeeling betrayed at a specific time of need could activate innate attachment reactions anddamage the attachment bond. The injured’s sense of trust and the other’s accessib ility and
responsiveness, all vital to secure emotional bonds, seemed lost. These events theoreticallysolidified more rigid emotional positions such as pursue/withdraw or attack/defend. Theattachment injury event became a touchstone for future relationship interactions and stuckpoints in treatment.
The concept of attachment injury helps clinicians identify specific events in
relationships that may have prompted an enormous change in partners’ perceptions andemotional positions towards one another. The clinician may recognize the injury by theamount of charged affect around the issue and, if put into relational cycles and into relationalcontext of needs and vulnerabilities, the couple may avert such stuck points. The results ofthis study have yielded a proposed theoretical model of change for couples who sustain anattachment injury and adds to the validation of the theoretical concept of attachment injuries.
Attachment Injury as a Useful Clinical Concept
Differentiating clinical issues. This study showed that the attachment injuries can
provide a useful clinical tool for differentiating between general distress and specific critical
events. Most couples experience distress in varying degrees, but not all couples experience

57injurious events which unravel the emotional bonds that connect them. In therapy, some
couples resolve their distress without undue complications. Other couples, however, despitetheir efforts, can show improvements but repeatedly fall back into the same anger, criticism,and withdrawal as in the first sessions. Perhaps some of these “relapse” clinical events are dueto attachment injuries.
As shown in this study, couples did not move into the re-engagement phase of
treatment until after the injury had been addressed and placed within a relational attachmentcontext. Couples tended to show markers of re-engagement and resolution only after theattachment injury had been addressed in depth. All couples reported “successful” DAS, RTS,PSRQ, TCDBS scores and verbal confirmation in post-treatment interviews a few sessionsafter the attachment injury resolution. In-session measures confirmed that after couples hadde-escalated, their relational patterns became more rigid during the attachment injury phase,and marked the beginning of the re-engagement phase.
This study presented a way to identify attachment injuries in treatment. Not every
critical relationship event is an attachment injury. Two couples can go through roughly thesame experience with the same interactions, and one has few resulting problems and the othersuffers significant relationship damage. This study showed, through self-report measures, thatcouples who had attachment injuries were particularly emotionally vulnerable at the time ofthe injury. The event, in other words, could be the “straw that broke the camel’s back.” Clinically, there are many types of attachment injuries in terms of content. The process,however, was similar. Couples’ relationship satisfaction and trust was low. Attachment stylessuggested high preoccupation or withdrawal. Couples reported that s imilar events had
happened repeatedly in the time that preceded the injury. In treatment, the attachment injurywas a clinical theme which the couple had attempted to work through, but later came up againwith similar emotional charge, according to the SASB process measure.
Identifying attachment injuries. Pinpointing an attachment injury at times may be
difficult. Some couples specifically identified the attachment injury in the assessment sessions
and had well-formulated meanings surrounding the attachment injury. One participantpinpointed the attachment injury as the event which changed her overall trust toward herpartner and she subsequently felt worse about herself, gained excess weight and “gotdepressed.” The couple repeatedly “argued” about the injury. Other couples, however, maynot be aware of how these critical events block intimacy, accessib ility, responsiveness and
trust. One participant stated that the attachment injury event would come up at “odd times”and “out of the blue” in seemingly unrelated conversations. She was aware that therelationship had changed, but could not identify satisfying reasons for the changes.
The process of working through an attachment injury may take persistence and
patience. Injured participants tended to enter therapy showing restricted emotional

58expression, shown through attacking and defending statements. Interpretively speaking, the
injured showed a feeling of helplessness and overuse of secondary affect through critical orblaming statements and few primary affect expressions of needs and vulnerabilities. Theirpartners also showed high amounts of secondary affect through dismissing or withdrawalstatements. Both partners gave or received little comfort.
This study showed that certain clinical events should happen before an attachment
injury is resolved: there must be emotional engagement and access to underlying “primary”affect. The injured has to be emotionally engaged with his or her partner beyond blame andcriticism, and experience the event more as a primary loss of security. The other has toacknowledge both the pain of the injured and their own. As indicated in re-engagement phaseprocess measures, both have to be emotionally engaged and express their needs,vulnerabilities, and desire for connection.
Once the attachment injury is identified, clients tended to describe the event in detail.
One participant described her thought processes, the sequence of events, what she wasfeeling, what she felt towards her partner, what she said, what he said. Another participantprovided similar descriptions of an attachment injury and also remembered the specific wheatfield in which it happened while driving through Saskatchewan with her husband. Thetherapist should provide a safe “holding environment” during such descriptions throughreflection, validation, slow pacing, and later placing the injury into a relational context.
Qualitative Observations
Further validity. This study mapped change processes of attachment injuries through
pre- and post-test measures and in-session process measures. Qualitative interviews also
validated participant changes. Additional observations of change that offered supportivevalidity can be made. First, vocal quality changed over sessions. During first sessions, toneof voice tended to be more forced and loud by the injured and weaker and more hesitant bythe withdrawer. In later session, particularly after the injury had been resolved, the pursuingparticipants tended to have softer and more relaxed vocal tones, and withdrawers stronger andless hesitant vocal tones. Also, conversation content and process conversations became moreaffiliative in later stages of treatment. At the beginning sessions, participants tended to speakin successive monologues, addressing the therapist. In later sessions participants addressedone another on shared topics.
Roles of the therapist. The therapists in this study used EFT as the treatment.
Generally therapists practicing EFT attempt to create “safety” in the relationship by validating
the experiences of both partners and by accessing underlying feelings. In this study, therapistsin the first steps identified the presenting problems, secondary affect such as critical anger, andrelational cycles. The couples began a de-escalation of negative affect and began to workthrough issues with fewer rigid ways of relating such as expressing a majority of statements

59through criticism. When couples felt more connected in the de-escalation phase, the
attachment injury surfaced and, despite previously “failed” attempts, couples began to resolvethe attachment injury. Therapists asked participants to be as emotionally engaged as possibleand began to put the incident in an attachment framework. Therapists asked the injuredpartner to express underlying feelings directly to their partner through such question as, “Canyou turn to him right now and tell him . . .” or “Will you risk . . .” The therapist usedattachment language to address relational needs with statements such as, “She is scared youwill not be there . . .”
Therapists who work with couples with attachment injury play various roles. In this
study, once the injury was acknowledged, the participant tended to need the therapist to stayfully present with them and guide them through a flood of powerful emotions such as anger,guilt and vulnerability. In addition, the therapist needed to include the withdrawing partner inthe process and validate his or her own difficult experiences as well. The participants,hypothetically, can only go as far as what the therapist can tolerate in terms of “hot” affect.
Length of treatment. An inference from this study is that the length of treatment
depends on the severity of the attachment injury and how the therapist addresses the injury in
treatment. The length of treatment in this study varied among couples. Those with higherinitial DAS scored tended to complete treatment within about 15 sessions. Couple three hadlower DAS and RTS scores and the participant reported 2 attachment injuries. Both were“successfully resolved” according to self-report measures; however, the length of treatmentwas about 25 sessions.
Theoretical Contributions Through the Differences in the Rational and Empirical Models
The data from this study showed strong evidence that EFT in general and attachment
injuries in particular are promising concepts for the field of couples therapy. Differences inthe rational and empirical models were minimal. The “best session” markers in this studyconfirmed the rational model’s stages of de-escalation, re-engagement and resolution. Theempirical model confirmed that “successful”couples went through particular phases oftreatment after the assessment phase such as de-escalation and re-engagement. Furthermore,the empirical model showed that couples may bring up the injury in the assessment sessions,but did not “successfully” deal with it until after several de-escalation sessions.
The findings in this study add to EFT theory by refining the existing EFT process of
change model in light of a more specific presenting problem, an attachment injury. EFT hasshown to be effective in dealing with marital distress; however, this study helped define amore specific type of distress and provided a model of guiding couples and therapists throughthis type of distress.
As in former EFT studies (Johnson, Hunsley, Greenberg, & Schindler, 1998), all
couples in this study followed processes of de-escalation, re-engagement and resolution.

60Within these phases, couples showed a softening of critical statements from injured
participants, more engaged statements from withdrawn participants, and an expansion ofemotional expression from both participants.
EFT interventions (Johnson, 1996) were further validated by their effectiveness in
helping participants access both secondary and primary affect, and the use of an attachmentframework help couples re-engage emotionally, and guide them towards resolution of theattachment injury. Forth, there has been a lack of discussion of non resolving couples in EFT. This study may help clinicians identify potential non resolving couples because an attachmentinjury was not satisfactorily addressed.
Other schools of family therapy. The concept of attachment injuries and EFT can have
utility to other family therapy modalities. Narrative therapy, for example, guides clients in the
“re-telling” (e.g., White & Epston) of relationship distress events. However, process andoutcome research has not shown how Narrative interventions work (Literature Review). Theuse of EFT, however, allowed participants to tell their relationship “stories” from variousemotional positions. In the re-engagement stages of therapy, the re-telling of the injuries wasan integrated narrative of both self and other, and open expression of need and affiliation. Forexample, one participant described the injury as a sense of rejection and betrayal in theassessment stages. He was self-focused. In later stages, the participant, turning to hispartner, re-told the same event as his inability to ask for comfort and affiliation during hardtimes.
This study may also be useful for the forgiveness literature (Coop-Gordon, Baucom, &
Snyder, 2000). Some modalities tend to focus on the event itself and use insight andunderstanding of the negative event as guiding concepts for treatment. This study showed,however, that focusing on the relational attachment bond and re-experiencing the events “inthe present” through his or her partner can be a powerful healing experience that re-engagesthe couple to higher levels of trust, intimacy and satisfaction.
Shortcomings
Audiotapes were used to collect the process data due to logistical complications of
room and video equipment shortages at the Ottawa Civic Hospital. The use of audiotapes toanalyze the force of expression and the reactions of partners likely became less obvious toraters over the course of the therapy sessions. Ideally, the use of videotape would offer abroader view of interactions and perhaps a more exact coding of emotional expression andinteraction sequences.
The task analysis protocol in the first stages of building a rational/empirical model calls
for studying a small sample or “few cases” (Greenberg, Heatherington, & Friedlander, 1996)

61based on an expert clinician’s observations of a particular clinical point of interest. The
question of what is an adequate small sample can be raised. Three couples were chosen as aninterpretation of a “few” and “small sample” due to the duration of data collection. With alarger sample, findings may have shown that attachment injuries can be resolved at variousstages of treatment.
The rational/empirical model highlighted pursue/withdraw cycles. Some couples
clinically may show pursue/pursue, withdraw/withdraw or pursue and withdraw cycles fromboth partners. The empirical pursue/withdraw model highlighted what may be mostpredominant pattern presented clinically. Also, with withdraw/withdraw patterns, couplesmay not express critical anger as the model suggests.
Future Research
Three couples were selected to build the preliminary attachment injury model based on
task analysis protocol (Greenberg, Heatherington, & Friedlander, 1996). The next step in thetask analysis protocol involves using a larger sample, such as 30 to 40 couples, comparingprocess to outcome, and comparing resolvers versus non resolvers. This strategy should beused in future studies, as a preliminary model, to develop a more detailed model of attachmentinjury resolution.
An inference that can be drawn from this study was that attachment injuries happen
during attachment related events. Content examples of attachment injuries can includeinfidelity, miscarriages, a partner’s inaccessib ility during physical illness, or being ignored or
excluded from an important event. Future studies could enumerate various types ofattachment injuries and develop, perhaps through qualitative inquiry, an in-depth analysis ofthe nature of the injury and the specific meaning to the couple. In addition, future studies caninvolve a more specific outline of the nature of the attachment bond that precipitates anattachment injury emphasizing the process of the injury. What were trust and satisfactionlevels and attachment styles before the attachment injury occurred? Can “secure attachment”couples sustain such injuries? If so, what internal and external events of change lead up to theinjury?
Future studies could focus on the “injurer” and possible sustained injuries before the
attachment injury dealt with in treatment. Also, the use of the word injury has broadconnotations. If there is an injured, there usually is one who injures. The author has notimplied a dichotomous distinction of victim/perpetrator. Relationally, partners in this studywere caught in the same quality patterns, with the same amount of distance anddisappointments. Some withdrawers perhaps experienced attachment injuries but ignoredtheir need to process it until treatment. When their partner, later, was in need, they may havefelt resentful and unwilling to be accessible since their partner had not been accessible to them.
Hence results a cycle of injuries.

62The pre- and post-RAAS scores suggested that couples showed adjustments in
attachment style. Dismissing participants scored in higher Dependency ranges andpreoccupied and fearful/avoidant participants showed lower scores in Fear of Abandonmentsubscales. Future studies could find positive correlations in EFT treatment and factors thatsuggest more secure attachment styles.
Future studies can investigate the “opposite” of attachment injuries or what events
strengthen the bond in unusually powerful ways. The study may include when attachmentevent occurs or when one partner is particularly vulnerable, what are ways couples havesuccessfully bypassed injuries and strengthened rather than injured the bond.
Many couples seek treatment when distressed and leave feeling closer and more
satisfied in the relationship. Others, however, may seek treatment to help them throughseemingly insolvable stuck points that hamper their feelings of intimacy and satisfaction. Thefocus of emotional experience and attachment framing of relationship events in therapy maygive couples new ways of relating to one another and provide each other with mutualvalidation, accessib ility, responsiveness, and deeper sense of intimacy and connection. This
study hopefully will help couples find new ways of healing attachment wounds and creating adeeper connection.

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72APPENDIX A
Information and Consent Form
Referrals for Outside Treatment

73INFORMATION AND CONSENT FORM
Title of Project: Resolving Attachment Injuries in Couples Using Emotionally
Focused Therapy: A Process Study.
Principle Investigator: John W. Millikin and Dr. Susan M. JohnsonCouple No.__________Purpose of this Research Project
This research project is designed for distressed couples who wish to improve the level of trust
and security in their relationship. The purpose of this research project is to examinecharacteristics of the interactions between you and your partner and determine if thesecharacteristics are predictive of outcome in a particular form of couples counseling.
Major Procedures
If you agree to participate in this project, both you and your partner will be required to
complete questionnaires in order to assess your suitability for this study. If you do not meetthe inclusion criteria for this study, you will be given feedback on your initial testing andreferred for other counseling if you so desire.
If you meet our criteria for participation, you will be asked to complete questionnaires that are
part of this research study. You will then be assigned to a counselor who will call you toarrange your first appointment. Both you and your partner will be seen for a total of ten (10)one hour sessions with the format being one week for each session. Sessions w ill be
conducted by senior doctoral level interns under the supervision of Dr. Susan Johnson, aregistered clinical psychologist at the Ottawa Civic Hospital. All sessions will be videotapedfor supervision purposes and to ensure that the approach is faithfully implemented. Thecounseling sessions are free of change and will take pl ace at the Centre for Psychological
Services.
At the end of the final session, you will be asked to complete a set of research questionnaires.
Ten to twelve weeks after the termination of the counseling sessions, you will be contacted tocomplete follow-up questionnaires (approximately 30 to 45 minutes). I also understand thatdebriefing on the more detailed procedures of the study will be offered after the completion offollow-up questionnaires, and summaries of the results will be sent to couples if requested.
Counseling Approach Used in This Study
The particular approach of couples counseling that you will be offered is called Emotionally
Focused Couples Therapy. This form of couples counseling has been found to be successfulin helping many distressed couples improve their relationships.

74Benefits and Risks
No benefits will be guaranteed to couples and there will be no monetary compensation
for their participation. Couples will r eceive free couples therapy. Some couples may
experience less distress and more intimacy in the relationship. They may also begin to resolvepast conflicts with more satisfaction.
The risks of the study include experiencing uncomfortable feelings in light of
relationship problems during the therapy process due to the nature of the issues they maydiscuss, and couples may find that therapy does not adequately resolve their presenting issues. If this is the case, couples will be referred to therapy outside of the civic hospital. Confidentiality
Confidentiality of all tape recordings and written responses will be respected according to the
ethical guidelines of the College of Psychologists of Ontario and the American Association ofMarriage and Family Therapy. Your names will be known only to the people who are directlyinvolved in the research. These include the principal investigators, the clinical supervisor, andyour counselor. Anonymity will be assured through the pooling of all data so that thepublished results will be presented in group format and no individual or couple will beidentified. All videotapes and written forms will be securely filed at the Ottawa CivicHospital.
If researchers wish to keep certain recordings such as videotapes or transcriptions for training
purposes, you will be asked to sign a consent form to this effect. All other recordings will becompletely erased after the end of the study. Written responses to questionnaires as well asprogress notes written by the counselors will be kept in a confidential file at the Ottawa CivicHospital.
In some situations, the investigator must break the confidentiality agreement. If child abuse is
known or strongly suspected, investigators are required to notify the appropriate authorities. Is a participant is believed to be a threat to herself/himself or to others, the investigator mayhave to notify the appropriate authorities.
Consent for Services
I, ___________________________, understand that I am being asked to participate in a
study to examine couple characteristics that relate to success in a particular approach tomarital therapy. I consent to the use of tape recordings of counseling sessions and of mywritten responses to the questionnaires for the purposes of this research with theunderstanding that all information gathered will be held in strict confidence within the limits ofthe law and according to the ethical principles of the College of Psychologists of Ontario, andthat this information will be available only to those who are directly involved in this study.

75Freedom to Withdraw
I also understand that my participation in this study is voluntary and I may withdraw from this
project at any time and/or request that tapes be erased without penalty and withoutjeopardizing access to further counseling.
I have received a copy of this information and consent form and I have read and understood it.
I hereby agree to participate in the testing and in this research project if I am selected.
Compensation
There will be no compensation for participation in this study.
Signature:______________________
Witness Signature:________________Telephone No.: (H)______________
(W)______________
Date:__________________________Should I have questions about this research or its conduct, I may contact:
John Millikin ( 562-5800, Ottawa Civic Hospital)
Investigator
Dr. Susan Johnson (562-5800 ext. 4813, Ottawa Civic Hospital)
Faculty Supervisor

76REFERRALS FOR OUTSIDE TREATMENT
If the clients report substance abuse ask if they wish to be referred for treatment
elsewhere:
1. Al-Anon
2. Rideauwood Institute 3. Royal Ottawa Hospital
If the clients ask if they wish to be referred for treatment elsewhere:
1. Centre for Psychological Services
2. Family Service Centre of Ottawa3. Ottawa Academy of Psychology4. Ottawa Civic Hospital5. Catholic Family Services6. Royal Ottawa Hospital

77APPENDIX B
SELF-REPORT MEASURES
Demographic Data Questionnaire
Dyadic Adjustment Scale
Relationship Trust Scale
Attachment Injury Measure
Revised Adult Attachment Scale
Post-Session Resolution Questionnaire
Target Complaint Discomfort Box Scale

78DEMOGRAPHIC DATA QUESTIONNAIRE
Couple No.__________
How many years have you lived together as a couple?__________
How many children do you have?__________Have the two of you had any marital counseling before taking part in this project?
Yes______ No______
What is your gross family income (annual)? __________
Please state your age (in years)__________What is your present occupation?__________________________________Have you had a previous marriage? Yes______ No______Please indicate the highest level of education that you have completed to date:
_____ Grade 10 or less_____ Grade 12 or less_____ 2 years of post-secondary education_____ Community college diploma program_____ Bachelor's degree_____ Master's degree_____ Ph.D. degree

79DYADIC ADJUSTMENT SCALE
Couple No.__________ M____ F____
Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement
or disagreement between you and your partner for each item on the following list. (Please a checkmark to indicateyour answer).
Always
AgreeAlmost
AlwaysAgreeOcca-
sionallyDisagree Frequently
Disagree Almost
AlwaysDisagree Always
Disagree
1 Handling family
finances
2 Matters of recreation
3 Religious matters
4 Demonstrations of
affection
5 Friends
6 Sex relations
7 Conventionality
(correct or properbehavior)
8 Philosophy of life
9 Ways of dealing with
parents or in-laws
10 Aims, goals, and
things believed important
11 Amount of time
spent together
12 Making major
decisions
13 Household tasks
14 Career decisions
15 Leisure interests and
activities

80All the
timeMost of
the timeMore
often thannotOcca-
sionallyRarely Never
16 How often do you
discuss or have youconsidered divorce,separation, orterminating yourrelationship?
17 How often do you or
your mate leave thehouse after a fight?
18 In general, how often
do you think thatthings between youand your partner aregoing well?
19 Do you confide in
your mate?
20 Do you ever regret
that you married (orlived together)?
21 How often do you
and your partnerquarrel?
22 How often do you
and your mate "geton each others'nerves"?
Everyday Almost
everydayOccasionally Rarely Never
23 Do you kiss your mate?
24 Do you and your mate
engage in outsideinterests together?
How often would you say the following events occur between you and your mate?

81Never Less than
once amonthOnce or
twice amonthOnce or
twice aweekOnce a
dayOften
25 Have a stimulating
exchange of ideas
26 Laughter together
27 Calmly discussing
something
28 Work together on a
project
These are some things about which couples sometimes agree and sometimes disagree. Indicate if either item belowcaused differences of opinions or were problems in your relationship during the past few weeks (Check yes or no).
Yes No
29. Being too tired for sex. ___ ___
30. Not showing love. ___ ___
31. The dots on the following line represent different degrees of happiness in your relationship. The middle point,
"happy", represents the degree of happiness of most relationships. Please circle the dot which best describes thedegree of happiness, all things considered, of your relationship.
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
Extremely
UnhappyFairly
UnhappyA Little
UnhappyHappy Very
HappyExtremely
UnhappyPerfect
32. Which of the following statements best describes how you feel about the future of your relationship?
_____ I want desperately for my relationship to su cceed, and would go to almost any
length to see that it does.
_____ I want desperately for my relationship to su cceed, and will do all I can to see that
it does.
_____ I want desperately for my relationship to su cceed, and will do my fair share to see
that it does.
_____ It would be nice if my relationship su cceeded, but I can't do much more than I am doing now to help it
succeed.
_____ It would be nice if it su cceeded, but I refuse to do any more than I am doing now to keep the relationship
going.
_____ My relationship can never su cceed, and there is no more that I can do to keep the relationship going.

82RELATIONSHIP TRUST SCALE
Couple No._________M____ F____InstructionsPlease read each of the following statements carefully and decide whether or not you agree
that it is true for your relationship with your partner. Indicate how strongly you agree ordisagree by circling the appropriate number on the scale beside each statement. Please answeras accurately and honestly as you can.
1 = STRONGLY DISAGREE
2 = MODERATELY DISAGREE3 = MILDLY DISAGREE4 = NEUTRAL5 = MILDLY AGREE6 = MODERATELY AGREE
7 = STRONGLY AGREE
1 My partner has always been responsive to my needs
and feelings.1234567
2 I sometimes have concerns that my personal identity
must be compromised to make our relationship work.1234567
3 Resolving conflicts in our relationship is a give-and-
take procedure. Though neither of us may becompletely happy with any given solution, I'm usuallysatisfied that any action we take is in the best interestsof our relationship as a whole.1234567
4 I f e e l t h a t m y p a r t n e r c a n b e c o u n t e d o n t o h e l p m e . 1234567
5 My partner is not someone who can always be relied
on to keep a promise.1234567
6 I f e e l e x t r e m e l y c o n f i d e n t t h a t m y p a r t n e r l o v e s m e . 1234567
7 When we are dealing with an issue that is important to
me, I feel confident that my partner will put myfeelings first.1234567

838 If a better alternative were to come along, there is the
possibility that my partner would at least considerleaving our relationship.1234567
9 M y p a r t n e r i s t r u l y s i n c e r e i n h i s / h e r p r o m i s e s . 1234567
10 Even when my partner and I are very angry, with each
other, we still know that we love each other fully and
unconditionally.1234567
1 1 M y p a r t n e r i s p e r f e c t l y h o n e s t a n d t r u t h f u l w i t h m e . 1234567
12 Through our concerted efforts at problem solving, we
have managed to cope with the stresses on ourrelationship very efficiently.1234567
13 Our marriage could easily be explained in terms of
"(s)he contributes this" and "I contribute that". Attimes it doesn't feel like we're in it together.1234567
14 It is sometimes for me to be absolutely certain that my
partner will always care for me. Too many things canchange in our relationships time goes on.1234567
15 My partner and I are compatible enough that my
personal needs can be realized in our relationship.1234567
16 At times I am uncomfortable when I think about how
much I have invested in my relationship with mypartner.1234567
17 In our day-to-day interactions, my partner consistently
acts in ways that are positive.1234567
1 8 T h e r e a r e t i m e s t h a t m y p a r t n e r c a n n o t b e t r u s t e d . 1234567
19 I am never concerned that conflicts and serious
tensions can damage our relationship because I knowwe can weather any storm.1234567
20 My partner is not necessarily someone others consider
to be reliable. (S)he can't always be counted on.1234567
2 1 M y p a r t n e r i s d e e p l y c o m m i t t e d t o o u r r e l a t i o n s h i p . 1234567

8422 Problems in our relationship don't seem to sort
themselves out over time. They seem to build up,mushrooming into concerns that are out of proportionto the problem at hand.1234567
2 3 M y p a r t n e r t r e a t s m e f a i r l y a n d j u s t l y . 1234567
24 My partner has proven to be a faithful person. (S)he
would never be unfaithful, even if there was absolutelyno chance of being caught.1234567
25 I feel that my partner does not show me enough
consideration.1234567
26 When problems have surfaced in our relationship, we
have shown considerable ability to work through themsuccessfully.1234567
2 7 M y p a r t n e r i s a t h o r o u g h l y d e p e n d a b l e p e r s o n . 1234567
2 8 I f e e l t h a t I c a n t r u s t m y p a r t n e r c o m p l e t e l y . 1234567
29 Our two styles of dealing with conflicts make me
concerned about our capacity to confront problemsthat arise in our relationship.1234567
30 My partner typically behaves in ways that are very
rewarding to me.1234567
3 1 A t t h e p r e s e n t t i m e , d o y o u t r u s t y o u r p a r t n e r ? 1234567

85The Revised Adult Attachment Scale
Please read each of the following statements and rate the extent to which it describes your
feelings about romantic relationships. Please think about all your relationships (past and
present) and respond in terms of how you generally feel in these relationships. If you havenever been involved in a romantic relationship, answer in terms of how you think you wouldfeel.
Please use the scale below by placing a number between 1 and 5 in the space provided to the
right of each statement.
1–––––2–––––3–––––4–––––5
Not at all Very
characteristic characteristic
of me of me
1) I find it relatively easy to get close to people. ________
2) I find it difficult to allow myself to depend on others. ________
3) I often worry that romantic partners don't really love me. ________
4) I find that others are reluctant to get as close as I would like. ________
5) I am comfortable depending on others. ________
6) I don’t worry about people getting too close to me. ________
7) I find that people are never there when you need them. ________
8) I am somewhat uncomfortable being close to others. ________
9) I often worry that romantic partners won’t want to stay with me. ________
10) When I show my feelings for others, I'm afraid they w ill not feel the ________
same about me.
11) I often wonder whether romantic partners really care about me. ________
12) I am comfortable developing close relationships with others. ________
13) I am uncomfortable when anyone gets too emotionally close to me. ________
14) I know that people will be there when I need them. ________
15) I want to get close to people, but I worry about being hurt. ________
16) I find it difficult to trust others completely. ________
17) Romantic partners often want me to be emotionally closer than I feel ________
comfortable being.
18) I am not sure that I can always depend on people to be there when I need them. ________

86PRE-TREATMENT ATTACHMENT INJURY MEASURE
Please describe as thoroughly as possible the nature of the attachment injury from your
point of view. Include a description of the injury, how you dealt with the injury when it occurred,how you dealt with the injury generally until treatment at the Ottawa Civic Hospital. Also includehow the injury affected the a) level of trust between you and your partner and b) the level ofintimacy between you and your partner.
On a scale of 1 to 7, how do you rate the injury:
1 Not a Problem
2 Slight Problem3 Moderate Problem4 Very Much a Problem5 Very Serious Problem6 Severe Problem7 Extremely Severe Problem
POST-TREATMENT ATTACHMENT INJURY MEASURE
Now that you have completed therapy, how do you rate how the injury affects you now:
1 Not a Problem
2 Slight Problem3 Moderate Problem4 Very Much a Problem5 Very Serious Problem6 Severe Problem7 Extremely Severe Problem

87POST-SESSION RESOLUTION QUESTIONNAIRE
Couple No.__________ Session No.__________1. Was the issue that brought you and your partner worked on today the same or related to
the issue which you brought into counseling ? Please circle one of the following:
1……………………..2……………………..3……………………..4……………………..5
Very Different Different Related Similar Same
2. How much progress do you feel you and your partner made in dealing with your issues in
the session you have just completed? Please circle one of the following:
1……………………..2……………………..3……………………..4……………………..5
A Great Deal Considerable Moderate Some No Progressof Progress Progress
3. Are you and your partner any closer to resolving your relationship issues than you were
when you came to the session today? Please circle one of the following:
1……………………..2……………………..3……………………..4……………………..5
Very Much Considerably Moderately Somewhat Not at all
4. How resolved do you feel right now in regard to the concerns you brought into
counseling? Please place a tick in the appropriate box.
1…………..2………………3……………..4……………..5…………….6…………….7
Totally Resolved Somewhat Resolved Not at all

88TARGET COMPLAINT DISCOMFORT BOX SCALE
Couple No.__________ Session No.__________
Keeping in mind the issue that you and your partner selected as the focus of counseling, in
general how much does this issue bother you now?
Please answer the question by placing an 'X' in the box that best describes the amount of
disturbance you feel now because of the problem.
1
Couldn't be Worse2
Very Much3
Quite a Bit4
A Little5
Not at All

89APPENDIX C
PROCESS MEASURES
The Structural Analysis of Social Behavior
The Experiencing Scale
Implementation Checklist

90THE EXPERIENCING SCALE (ES)
General description of the seven stages:
Stage 1: The chief characteristic of this stage is that the content or manner of expression is
impersonal. In some cases the content is intrinsically impersonal, being a very abstract,general, superficial, or journalistic account of events or ideas with no personal referentestablished. In other cases, despite the personal nature of the content, the speaker'sinvolvement is impersonal, so that he or she reveals nothing important about the self and theremarks could as well be about a stranger or an object. As a result feelings are avoided andpersonal involvement is absent from communication.
Stage 2: The association between the speaker and the content is explicit. Either the speaker
is the central character in the narrative or his or her interest is clear. The speaker'sinvolvement, however, does not go beyond the specific situation of content. All comments,associations, reactions, and remarks serve to get the story or idea across but do not refer to ordefine the speaker's feelings. Thus the personal perspective emerges somewhat to indicate anintellectual interest or general, but superficial, involvement.
Stage 3: The content is a narrative or a description of the speaker in external or behavioral
terms with added comments on feelings or private experiences. These remarks are limited tothe events or situations described, giving the narrative a personal touch without describing thespeaker more generally. Self-descriptions restricted to specific situations or roles are also partof Stage 3. Thus feelings and personal reactions come into clear but limited perspective.
They are "owned" but bypassed or rooted in external circumstances.
Stage 4: At Stage 4 the quality of involvement or "set" shifts to the speaker's attention to the
subjective felt flow of experience as referent, rather than to events or abstractions. Thecontent is a clear presentation of the speaker's feelings, giving a personal, internal perspectiveor account of feelings about the self. Feelings or the experience of events, rather than theevents themselves, are the subject of the discourse, requiring this experiencing, the speakercommunicates what it is like to be him or her. These interior views are presented, listed, ordescribed, but are not the focus for purposeful self-examination or elaboration.
Stage 5: The content is a purposeful elaboration or exploration of the speaker's feelings and
experiencing. There are two necessary components: First, the speaker must pose or define aproblem, proposition, or question, about the self explicitly in terms of feelings. The problemor proposition may involve the origin, sequence, or implications of feelings or relate feelingsto other private processes. Second, the speaker must explore or work with the problem in apersonal way. The exploration or elaboration must be clearly related to the initial propositionand must contain inner references that have the potential to expand the speaker's awareness ofexperiencing.

91Stage 6: At Stage 6 the way the person senses the inner referent is different. There is a felt
sense of the there-and-yet-to-be-fully-discovered, that is, of an unclear inner referent that has
a life of its own. It is a sense of potentially more than can be immediately thought or named. This felt sense is more than recognizable feelings such as anger, joy, fear, sadness, or "thatfeeling of helplessness." If familiar or known feelings are present, there is also a sense of"more" that comes along with the identified feelings.
Stage 7: The content reveals the speaker's steady and expanding awareness of immediately
present feelings and internal processes. He or she clearly demonstrates the ability to movefrom one inner referent to another, linking and integrating each immediately felt nuance as it
occurs in the present experiential moment, so that each new sensing functions as aspringboard for further exploration and elaboration.
Short Form of Experiencing ScaleStage Content Treatment
1 External events; refusal to participate Impersonal, detached2 External events; behavioral or Interested, personal, self-participation
intellectual self-description
3 Personal reactions to external events; Reactive, emotionally involved
limited self-descriptions; behavioraldescriptions of feelings
4 Descriptions of feelings and personal Self-descriptive; associative
experiences
5 Problems or propositions about feelings Exploratory, elaborative, hypothetical
and personal experiences
6 Felt sense of an inner referent Focused on there being more about "it"7 A series of felt senses connecting Evolving, emergent
the content
Note. Reprinted from M.H. Klein, P. Mathieu-Coughlan & D. J. Kiesler, The experiencing scales, in L. G.
Greenberg & W. M. Pinsof (Eds.), The psychotherapy process: A research handbook (pp. 22-23). New York:
Guilford Press. Copyright 1970 by The Regents of the University of Wisconsin, Revised, 1983.

92STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOR (SASB)
Focus:
1=other, 2=self
Quadrant:
1=Affiliative2=Distant3=Hostile4=Friendly

Cluster:
Other
1=freeing and forgetting 2=affirming and understanding 3=loving and approaching 4= nurturing and protecting 5=watching and controlling 6=belittling and blaming7=attacking and rejecting8=ignoring and neglecting
Self
1=asserting and separating2=disclosing and expressing3=joyfully connecting4=trusting and relying5=deferring and submitting6=sulking and scurrying7=protesting and recoiling8=walling off and distancing

93IMPLEMENTATION CHECKLIST
Couple No. _____ Session No._____ Rater_____
Instructions to raters: Place one check mark on the rating form beside an intervention each
time that intervention is noted. An intervention is defined as a therapist statement.
Intervention ChecklistDefinition of Problematic Event
1. ____The problematic event is defined/redefined in terms of the emotions and needs
underlying the positions taken in the relationship.
2. ____The therapist elicits the couple's ideas/theories/beliefs about why the problematic
event has developed.
3. ____The therapist clarifies and elaborated the basic positions taken by the partners in the
relationship.
4. ____The therapist asks the couple to disclose biographical data that may be relevant to
explaining why the relationship is the way it is, such as how the parents' marriage influencedtheir own.
Attacking Behavior
5. ____The therapist validates or develops the positions implied by negative behavior such as
name calling; such behavior is interpreted in terms of underlying needs and feelings.
6. ____Negative behavior such as blaming or name ca lling is immediately stopped with
authority on the part of the therapist and/or is defused by asking the blamer's theory on howhe/she was attracted to and got involved with such a person.
Process Focus
7. ____The therapist probes for and heighten emotional experience, especially fears and
vulnerabilities, clarifying emotional triggers and responses and focusing upon inner awareness.
8. ____The therapist avoids and suppresses affective interchange, and/or behavioral
interpretation, or confrontation. No feeling or behavior is accessed, confronted or interpreted.

949. ____The interacting sensitivities underlying behavior are clarified and the meaning of
individual emotional experience is interpreted in terms of the other partner and therelationship.
10. ____The therapist invites the couple to speculate about general explanations they might
consider for couples with similar problems and/or offers a possible theory to trigger thepartners' thinking.
11. ____Therapist keeps a focus on what is occurring in the present between partners.12. ____Therapist takes what is happening in the present and brings it back to the past, to
their parents' relationship, to their background and upbringing.
Resolution of Problematic Event
13. ____Therapist fac ilitates expression of affectively based needs and wants to the partner.
14. ____Therapist helps each partner identifying and express to the therapist his/her
expectations from the other partner without basing them in feelings.
15. ____Therapist helps clients to share their new perspective of each other and/or of the
relationship, and to explore their new feelings in response to this new perspective.
16. ____Therapist asks each partner to disclose opinions/thoughts/theories about what
throughout the sessions has led to improvement.

95APPENDIX D
Attachment Injury Measure Self-Report Descriptions

96Attachment Injury Measure Self-Report Descriptions
Couple 1: Male reporting an attachment injury.
The event that has had the most significant effect on our relationship is one that has
existed for the sum total of our relationship. All three children in our family unit havepresented us with challenges, hurt, and disappointments far beyond what I believe tobe the norm. There have been several events which have stopped me in my tracks, leftme wondering if I can stay afloat. I cannot believe what we have been subjected tothrough the years, culminating with the youngest child, Kip. He is a bright kid withsevere ADHD, ODD, and a substance abuse problem. The last “event” has put him indrug rehab in another city. His disruptive behaviour had lead to our seriouslyconsidering splitting up at least twice. In fact, we have both taken private breaks fromthe situation to recharge our batteries, and try to gain a sense of normality again. These have also been used as small “trial separation.” My feelings have been stompedon time and again. Hurt, anger, pain, hopelessness, and grief are common, everydayfeelings. Personal, mental and physical health has suffered accordingly. Depressionrules the day.
Since we’ve spent all or most of our energies with these “battles,” we’ve had little time
to develop our own relationship to what we envision, in our “golden years.” We’ve norole models from our own families to follow, and I’m afraid of being with Rhet, aloneat last, yet afraid, and still alone, b ecause we don’t know how to be a loving,
nurturing, healthy, fun-loving couple. I trust Rhet explicitly. We do not know how tobe intimate with each other (or forgot).
Couple 1: Female scored a 3 or “very serious problem” and wrote:
My children have put a strain on our marriage from the beginning. We have had to
deal with different challenges with all three of them. However, Kip has by far been themost difficult challenge. Problems with his behaviour have escalated over the last fewyears. He finally was placed in a group home this June. Before this happened, wewere at a point in our relationship when I was put into a position where I felt I had tochoose between my son or my husband. We were at a point where we wereconsidering separating. How could I make such a choice? I could not turn my backon my son no matter what. Since Kip has been in the group home, there still has beena fair amount of stress, but not quite as constant. For a while I felt I felt like Ishouldn’t show love towards my son. However, I have resolved that. I felt resentfultowards Rick for putting me in that position of choosing, I am afraid this situation maycome up again.

97Couple 2: Female scored a 2 or “severe problem” and reported an attachment injury:
It’s difficult to name one event but I guess an underlying problem has always been that
Sam is unemotional. This became glaringly obvious after my miscarriages. He justdidn’t seem to know what to do. It hurts me that can’t show me his feelings. I stilltrust him but I know that I can’t depend on him for emotional support. Themiscarriages themselves decreased the level of intimacy between us but I don’t thinkthat Sam’s lack of feeling did.
Couple 2: Male scored a 4 or “very much a problem” and wrote:
The problem which affects me the most in this relationship is that I feel that Sara has
to be in control. She will imply or make remarks that make you feel inferior. Thereare times when we are discussing a small simple problem and it turns into a bigargument. I feel most of the time the right way has to be Sara’s way–this would befine if her way is the better way but sometimes it is not.There are times when I give into her and agree with her even tough I think I am rightbut I do this just to avoid a heated extended discussion that goes nowhere!!
Couple 3: Female scored 1 or “Extremely Severe Problem”and reported an attachment injury:
One year into our marriage, Mike was supposed to honour a promise a promise he
made upon our marriage to support my career. If I didn’t find work in my career inOttawa after one year of searching, we would move to another city with betteropportunities for me, i.e., Toronto. Not being fully bilingual was a serious handicapfor my career choice in Ottawa. I had expressed concerns about finding work inOttawa even while we courted. When the year was up, Mike refused to considermoving away. He was quite comfortable and secure in his position with a smallcomputer software company. I was devastated that he was backing out on a veryimportant promise. I had told him that I would never marry someone who didn’tsupport my goal of being a career woman and mother. He had said that was the typeof woman he wanted. I thought we were perfectly clear on this issue, even beforemarriage. I had financed my way through school on loans.
Therefore, I had a large student debt to pay off. He totally justified not moving by
saying that we could not afford to have him leave a good job for the “bog unknown.” I couldn’t see how we could afford to keep me out of work, due to our large debt-load. I went into a deep depression, developed a chronic health condition from thestress, and tried to get professional help without success. I was clinically depressedfor over 4 years. I felt trapped. I was too depressed to leave the relationship,although I felt like leaving many times. My trust in him was completely destroyedalong with my self-esteem. I gained over 30 pounds of extra weight and felt terrible. Ifelt I had no place, or money, or self-esteem to go anywhere or do anything. We

98started fighting regularly after this event. I also lost a lot of respect for him as a
person, and became quite bitter and critical. Many days I don’t feel like I even likehim. The is very little if any intimacy for me in this relationship. I don’t feel like I cantrust Mike to be there for me, or support my dreams and goals. Other incidents havehappened since this event which confirm my doubts that Mike can be there for me,even in a crisis. Mike talks about how he wants to support me emotionally and withattaining my goals, but I don’t think he has a clue how to do it. And when I reallyneed his support, he backs out on me. About 1 ½ years ago, I had my secondmiscarriage in 3 months. I called Mike at work to tell him to come home because Iwas hemorrhaging and was really scared. He refused to come home because he wasworking late on an important project with a deadline. I begged him to come home, buthe refused to come. He even called me to tell me he was taking his c-workers out fordinner and he would be home late. I had called a girlfriend to come over with me. She took me and my 3 year old son over to her house for the weekend. I didn’t wantto go home, but I felt I had no choice. I had no where else to go and had no money. This situation compounded my distance of Mike being there for me even in a crisis.
Couple 3: Male scored 4 or “Very Much A Problem.”
A little less than a year ago, Molly has a major falling out with a long-time friend (they
have not spoken since). Within a few weeks of that event, Molly had a major fallingout with my mother and my sister. These events weighed heavily on Molly’s mind andmuch time was spent talking about them. Although I recognized that Molly has astrong need to “talk it out”, I found that these conversations were emotionallyexhausting. At times, these intense talks could last a couple of hours. Molly wouldspend much time putting down my family. When I tried to put ground rules fordiscussing her hurts (namely to stop putting down my family), she responded byaccusing me of siding with my fa mily and not s upporting my wife.
It was during this time that my grandmother died. I was close to my grandmother andfelt fortunate to be at her bedside when she passed away. A couple of days after herdeath, Molly resumed talking about her unresolved hurts. I explained that I wasemotionally unable to deal with her issues at that time. She continued on with herunresolved issues, and I responded by raising my voice to get the message across. Molly was very angry at me for taking the position I did and accused me of beingselfish and uncaring about her. In spite of my attempts to identify to Molly that Ineeded a break from her issues so I could have time to mourn the death of mygrandmother, Molly kept bringing up her issues. I felt that my needs were beingignored. I felt she was stalking me with her issues at a time when I wanted to come toterms with the death of a loved one.

99APPENDIX E
“Best Session” Transcripts for Markers of Change

100“Best Session” Transcripts for Markers of Change
Couple # 1Assessment Phase
Sam: I feel that I am here to defend myself. The way she talks to me, she asks a question
and she uses this harsh tone with me. She gets short with me.
Therapist: What is the tone like that she uses?Sam: It is short. . . abrupt. She will tell me a lot of the time, “That was a stupid question.”Sara: I just get exasperated with him.Therapist: I get a sense that you get angry with him, disapproving with him and then he shuts
down and withdrawals?
Sara: Yes. I get angry with him, but I always have a good reason.Sam: Like last night, the baby puked on the floor and she came up to me and shouted, “Don’t
just stand there. Don’t just look at him.” I was in shock.
Sara: I was mad at him. He was just standing there watching and the baby needed
comforting, like he is only five years old and he just stands there. I think, “Dosomething.” I feel mad now thinking about it. [1]
Sam: I was going to. ( Pause) [2]
Therapist: What happened after that?Sara: Well he just went into his shell and I was left to clean up the mess off the floor and do
all the other stuff too. I’m fed up. I just kind of slap him down….I have a short fuse,especially when I have a bad day or a headache. He should just know. It takes a lotfor me to get really angry and sometimes I have to get really angry just to get areaction. [3] Sometimes I feel I have to stay and have a fight so I can get a reactionjust so we can communicate about something. And I am running out of energy. Fighting is getting pointless now. If I just gathered my things and left, he would let mewalk out the door and be just fine.
Therapist: Do you feel you are not fighting for the relationship?

101Sam: I just feel that if she really doesn’t want to be with me, then just go, if that is how you
feel, I don’t want you to stay around. [4]
Sara: Well I want to be able to rant and rave once and a while and say, “If you don’t do this,
I’m leaving” and have him say back to me, “Please don’t leave me.” But I know hewouldn’t say that. He needs to put more effort into this. [5] I just don’t matter to him,that’s what I feel like. I tell him how I feel and he doesn’t say anything.
Sam: I don’t want her ranting and raving about everything that comes up. She does it all the
time. And I tell her, if she has problems, go find someone, one of your friends to talkto. [6] I mean, I don’t mind if she has a problem and needs to say something, but shegets upset all the time and tries to make me feel stupid.
Sara: Well like with Bobby last night, you should know that that was a problem and I needed
help and when you just stand there, I can’t help but try you to have a reaction and dosomething. [7] He needed help.
De-escalation Phase
Therapist: What is it that you want from him? What do you need from him?Sara: On a day-to-day basis, affection. I said this to him so many years ago that I want him
to see no further than me and he said, “Excuse me? That will never happen.” And Itold him that so not that he can’t look at other people, but I want to be the center ofhis life and the most important thing in his life.
Therapist: That’s how you feel. You want to be the center, the focus and what I hear from
you is that when you don’t get that, you make a lot of noise, you get angry and youstart picking at the smaller, less significant things and. . .
Sara: He sees that as controlling.Therapist: Yes. And what I also hear from you, Sam, is that you do care and you try to do
things to lighten up her load.
Sam: She wants me to make her feel cherished, like when she says I can’t see anyone else but
her, but it’s hard for me to do that and deep down I am feeling angry at her and then Iend up feeling stupid when the anger wears off. [8]
Therapist: Can you talk a little more about your anger?

102Sam: Well, when she picks at me for every little thing, I feel resentful and feel she is laying all
her frustration on me. And I feel she is just trying to control me when a lot of timesshe is out of control. So when she says, “Don’t look at anybody except me,” I feel sheis still trying to control me and then I get upset. [9] I mean, I am not out looking atpeople and she knows that. I really like helping her and I do, but I don’t want to becontrolled.
Therapist: My sense is that your intentions are good.Sam: Yes. I have them up in mind, but then I get stuck. . . Should I do it or shouldn’t I do it.Therapist: So you know what is right but. . .Sam: If I don’t do what she wants, I am shot down. If I do what I think is right but she
disagrees, then I am shot down again. I want to help her because she is important tome, but when we get in these ruts and I feel she is picking on me, it’s hard to do. Anyway, she by no means makes me feel like I am the center of her life.
Sara: I am glad to hear that I am important to you. Sometimes, I just don’t know how you
feel about me or how you feel about anything. [10] I used to say to him that I wassorry to hurt his feeling ( laughter) because I thought he only had one.
Sam: Well, I have never been a very expressive person, never talked a lot, but she knows that
I do have feelings but I just don’t talk a lot about them. I do want to talk more aboutthem, but I just don’t want to be criticized. My parents didn’t have a good marriageand were mad a lot, so I just don’t want to go through that again.
Therapist: What happens for you when she is critical towards you?Sam: Well, it hurts. When I come into the house and she says I just got a headache, I feel she
is saying something to me, that it is about me, and that hurts to hear. She may seethem as passing comments, but they aren’t to me.
Sara: I didn’t know that. . .Sam: So I just pass it off or just deal with it. [11]

103Attachment Injury Phase
Sara: After I had the miscarriage in the bathroom, I remember blood was all over the place
and I realized that I had just lost this baby. I was ok at that time. I thought I was ableto handle this and that when I saw Bob everything would be ok and we would go tothe hospital and take care of everything.
Therapist: What happened after that, after you realized that you had lost the baby?Sara: I called for Sam to come down and help me. He came down, but was frozen, like he
didn't know what to do. [12] I just remember thinking that if I go off the deep endhere, at what point will he pick up the phone and call. . . at what point will he comeover to comfort me. Well I didn't want him to call anyone. I wanted him to take careof me and I thought . . .
Therapist: Take care of you how?Sara: To. . . (pause) to hold me and do what people do when somebody dies. To me if
somebody I knew died, I would ask if they are ok and say that I am really sorry and ifthey wanted to talk about it, I would listen and if they started to cry, I would comfortthem. [13] You kind of have to say something. Everything just seemed so solid andhe didn't seem upset by it.
Therapist: So, you really needed him to be there and to hold you.Sara: Yes.Therapist: And he didn't even have to say anything, just be there for you.Sara: Yes. But he shut down and then went away and I just remember being alone. And then
my sister came in and gathered us up and we got into the car and drove to the hospital.I remember that she didn't really say anything either. She was just trying to rush us offand when I was in the car, I was there feeling totally alone staring down at a buttercontainer filled with my baby. I just wanted them to be there, really be there for me soI could cry.[14] After that I just knew I would have to deal with this on my own.
Therapist: Deal with this on your own? Sara: Yes, I knew right then that I was alone in this and realized that is how it has been for a
while now. And for us things kind of fell apart from there….

104Re-engagement Phase
Sara: I just think that old habits die hard sometimes thinking that if he wanted to, he would
say things. I try to remember that I have to see him a whole new way.
Therapist: Which is what?Sara: Which is that he wants to say things but he is afraid of the way I will r eact to him, like
which way am I going to slap him down this time for saying something (laughter). [15]And it makes me feel really bad to know he is afraid of how I’m going to react to him.. . I feel bad that I put him in that position and I don’t think about that because I knowif he were to treat me that way, I would feel the same way and respond the same way. If I thought about that, I would be more perceptive to him.
Therapist: So you don’t want to be as critical or come across as being critical?Sara: Right, and I’m not even thinking how I might sound to you and how I make you feel.Sam: Well over time I have just learned that you will have your good days and your bad days
and I know you think I don’t feel anything, but I do and I try hard to make you happy. You may not know what I am feeling, but I feel and I want to be practical at the sametime. . . to take care of as much as I can.[16] ( Slowly) Well, like when you had the
miscarriage, I came home and I knew something was wrong and I felt a shock becauseI could see it on your face. I wanted to help you, so I decided to keep my headtogether and be as practical as I could about it. [17] Then when I found out whatreally happened, I ran in ten different directions to make sure everything was okaybefore we went to hospital.
Therapist: Did you know this is how Sam was feeling at the time? That he was in shock and
tried to take care of things?
Sara: No, I didn’t know. And I guess I never gave you a chance. I never knew and I wish I
did now. Had I known all of that, the whole thing would have been different. I canaccept now that Sam feels a lot but just doesn’t talk a lot about them. [18] I feel goodknowing that he cared that day and that I wasn’t really alone like I thought.
Sam: No, I was definitely there for you. I will try to do things differently. I was very
concerned about you. I was very scared for you. [19]
Therapist: You were concerned for her and you didn’t want to put extra pressure on her
because you knew she was in shock. I pick up on a lot of care and concern from you.

105Sam: Yes, I a lot of concern.
Sara: I know that. And I appreciate that he does all that he does for me. I know if over the
years if I hadn’t criticized you so much, you may be more open to me and trust memore. [20]
Sam: I totally trust you. [21]Sara: I really am seeing you differently. Not for who I want you to be, but who you are. But
not that I expect a totally emotional person all the time, but find different ways for usfit together.
Couple #2Assessment Phase
Rick: For the longest time I have tried to get Rhet to see that Kip was walking all over her.
She was becoming a doormat and he rubs his feet all over her time after time. And allI could do now was sit there and watch. I had a role in parenting, I know, but Icouldn’t take all the responsibility of this kid with all the drugs and dealing and troublehe was getting into. That was her responsibility and she was muting herself. Why?[22]
Therapist: What was it like for you to sit there and watch, watch Rhet be walked on by Kip?Rick: I got angry. I just wanted to scream and yell sometimes and say, “Why do you put up
with this crap from him?” I took over for her so many times and took a stand on hisdrug use and disobedience, but he doesn’t listen to me. I am not his Dad and he justbrushes me off. [23]
Therapist: Can you talk to Rhet about that anger you felt, the anger you may feel now?Rick: Well, it is frustrating to see you deal with Kip. I know you want to be nice to him, but
there are limits to nice. You let him get away with murder time after time and I nowyou have been through a lot with him and the other kids too, but you just sit there andlet the daemons take over and I wish you would take a stand once in a while. [24]
Rhet: I know. ( Pause)
Therapist: What happens for you, Rhet, when Rick is upset with you?

106Rhet: Well, I understand why he gets mad. I guess I feel stuck in between a rock and a hard
place. I have Rick over here and Kip over there and it’s like I have to make sure I dothe right thing for both.
Therapist: And what does doing the right thing look like?Rhet: I just freeze. . .Don’t really know what to think, what to do. I know that I don’t do
enough. ( Pause) [25]
Therapist: Will you talk to Rick about how hard it is?Rhet: I think he knows. I do the best I can, but it is not enough.Rick: I know you do your best, but you take a road of inaction so much that I, well. . . I used
to get so mad and now, recently, I have been thinking that it would be easier if Iwasn’t in the picture. You could just deal with him and I wouldn’t have all thisconstant conflict. I thought we would have a peaceful marriage, but since day one, wehave had crap hit the fan nonstop. I am tired of it. That’s enough. [26]
De-escalation Phase
Rick: We have been spending less and less time together especially during the past year and a
half. My computer business is going well, so I spend evening time planning the nextsteps for the business. I will just go downstairs and work.
Rhet: Yes, you will disappear for hours down there and I wonder if you are still alive or not.
(laughs)
Therapist: Is it just for work reasons that you go downstairs, or are their other reasons too?Rick: Well, there is some truth to that. I do have work on my mind and have a lot to do. But
some of it can wait for the next day. To tell the truth, I go downstairs in my littlecovey-whole to stay away from all the conflict between Rhet and Kip. [27] I just blockit out of my mind. I wish I didn’t have to go to my private space, but I feel I have noother choice.
Therapist: Rhet, what is it like for you to have Rick downstairs? Where are you? What are
you doing?

107Rhet: Well I usually sit upstairs and watch TV and wait for Rick to come up. Kip is out so
much that we don’t even spend much time together. And of course over the past fewmonths, Kip has been in the rehab home, so he is not even there.
Therapist: And what is it like for you when Rick is downstairs?Rhet: I would like to spend time with him. Sometimes I go to the basement door and peek
down to see what he is doing and wonder when he will finish.
Therapist: You have a desire to see him, connect with him?Rhet: Yes. I will stand by the door.Rick: I didn’t know you stood by the door and I didn’t know you were waiting for me. I
always thought you were absorbed in your TV shows or when Kip is there that youspend time with him and if I’m not getting in the middle, you and he can have a morerelaxed time. Come to think of it, I am waiting sometimes for you to knock on thedoor and say hello and ask if I want to come upstairs to watch TV or even betterescape to bed sometimes. [28]
Therapist: So it sounds like even though there has been conflict at home over the past years,
at the same time you both desire to spend time together and you are both waiting forthe other to initiate the contact.
Rick: Yes. It seems kind of silly to think we are both waiting for the other and nobody says
anything. When we don’t have problems with Kip, we get along fine. I guess myworry too is that sometimes I don’t know what to say. . . I just have computer stuff onmy mind and that must be boring for her. [29]
Rhet: It’s not boring to me. Well, I can’t talk about computers all day, but it’s not boring. I
guess we end up talking about Kip and his problems and we just stop talking becausethe conversation goes the same way every time.
Attachment Injury Phase
Therapist: Can you talk a little more about the night you got into [the fight] with Rhet?Rick: This was about a month before Kip went to the rehab home after he was arrested. I
noticed that my wallet had been moved on the dresser and I looked in it and all mymoney was gone except a five-dollar bill. He must have stolen 40 dollars at leastbecause I had been to the bank earlier.

108Therapist: Did you talk to him about it? To Rhet?
Rick: Well, yes and no. Well, I talked to Rhet about it first. I told her that Kip had stolen
money out of my wallet and probably went straight out to buy dope.
Therapist: And then what happened?Rick: So told Rhet that Kip had stolen the money and she really had no reaction. It seemed
like she was either frozen in her tracks or didn’t give a damn one or the other.
Therapist: How did you feel at that time?Rick: God, I get pissed now just thinking about it. First, this crap had been going on for
years. First with Janice, then with Judy, and now with Kip. I told her that he wouldhear it from me when he got home and she needed to do something about it too. Thiswas the FINAL showdown with all this. And you know what her comment was tome? She said that he was her kid and you are not his Dad. Well I hit the roof. [30] Ofcourse he is her kid and I am not his Dad, but I support him and he steals from me toget high. I can barely understand his behaviour, but I don’t understand Rhet’sdoormat role in this family. I was more pissed at her than at Kip then.
Therapist: What did you say to her then? Did you tell her what was going through your mind?Rick: I was so enraged. . .devastated. I thought to myself, “I have no ally in this house.” I
didn’t tell her this, but I thought it would be better if I weren’t here. . . that it would bebetter if she just dealt with this alone. I knew I would just walk out right then, but Iknew I would go to my corner and she goes to hers and there would be a wall betweenus. I can just focus on my work and let the house go straight to hell. No more hasslewith Kip. No more rides for the others. Just stay away from all of them like I am aborder renting a room. [31]
Therapist: Is this a part.? . .Rick: And then Kip comes home stoned. . . I could see it in his eyes and smell it on his
clothes.
Therapist: So, part of the devastation for you was that you knew there was a wall between
you and Rhet and there was no coming together on what to do.

109Rick: Yes, I knew right then that I had to change everything. If I wanted peace of mind, I
would have to cut the ties, whether I stayed there or not. And that is what I did. I’mout of the ring and gloves off. [32] I can’t deal with her passivity. I can’t change her.And will not try. If it means putting her out of the picture, okay. I’ve been depressedrecently and have to keep things moving at work.
Therapist: Rhet, What was this like for you? Did you know Rick had such a strong reaction
to this situation?
Rhet: I knew he was really upset. I didn’t know that it was this much. [33]Therapist: What was happening for you during all this?Re-Engagement Phase
Rick: Kip came home for a week last Friday and I have been surprised that everybody has
gotten along. I have tried to stay calm when he starts to manipulate Rhet or gets upsetwith her and I also try to stay around for her.
Therapist: Stay around?Rick: Yes, well over the past weeks we have made efforts to spend time with each other. I
still go down to the basement to work, but we make dates for later to watch TV or totake a walk. So if we have a problem, I try not to either get too anxious, and youknow how anxious I can get, and I try not to disappear off the face of the earth. [34]
Therapist: How is that for you Rhet, spending more time with each other and making. . .
strategies for conflict?
Rhet: I have loved the times together.Therapist: Can you tell Rick that now?Rhet: Yes. Well, I love the times together when we walk. We both need to exercise and the
walks help because we can work out and talk at the same time. I’m not sure if wehave a lot of strategies ( laugh), but we see things differently now. [35]
Therapist: Differently, how so?Rhet: As we talked about before, I am trying to be more assertive and stick to the rules. I
really need Rick’s help with that because. . .

110Rick: Well I need help with it too! I am Mr. Social Phobia and can barely initiate a
conversation. Sorry ( to Rhet). . . [36]
Rhet: I need help with that because you know I try to please everybody and end up no where
with everybody. When you’re around like that, I feel a lot more confident laying downthe law.
Rick: I appreciate that. Your laying down the law so to speak ironically keeps me from
getting so upset. ( Pause)
Therapist: And for you Rick, how are those times for you, when you get together?Rick: They help a lot. We actually look foward to doing things togetherTherapist: To her.Rick: I look foward to doing these things together and what is most important is that we are
building, you know, all the things we have talked here, trust and a sense of teamwork. That’s what it feels like, a sense of teamwork like we are in this thing together and(pause) I really appreciate that. [37]
Therapist: How is that for you to hear that from Rick?Rhet: It feels really good. I know we have a lot of things to work through, but I feel we have
a path and we just need to keep moving. [38]
Couple # 3
Assessment Phase
Molly: When we got married, I told him specifically that I did not want to come to Ottawa to
live. I don’t have family here like he does, and I can’t find a job in my field like hecan. I came here with the agreement that we would stay for a year or so and thenmove to Toronto where I could have a job and be in a more exciting city. But it neverturned out that way, he always seems to arrange things so they come out his way and Iam left with zero. [39]
Therapist: So you had an agreement to. . .

111Molly: Yes, an agreement that was soon ignored.
Therapist: Right, a life plan that you feel left out of and now you are left feeling. . .?
Molly: I am feeling cheated out of my part of the agreement. And then we had our first child
and I always wanted children and love them, but this is not how I wanted it to happen,you know, raising kids alone at home with no life outside. I went to university too,you know. [40]
Therapist: You feel he has taken something away from you, cheated you out of something
you wanted. What is that like for you?
Molly: I resent him for it. Wouldn’t you? I put my trust in him to help me the same way I
help him day after day. . .
Mike: Can I say something here? What Molly doesn’t understand is the amount of sacrifice
and effort I put into the family [41] so that we can live comfortably and so that she canhave what she needs. And she doesn’t understand that I can’t drop this job, my job isa very good one, and move to another city in hopes that another will give us the samelifestyle that we have now. We have a sizable mortgage to pay and quite a fewexpenses and we are saving for the kids education and our retirement.
Molly: But Mike, you can get another job anywhere. I have to speak French to work around
here. (Pause) This is where we end up every time, right here, stalemate.
Mike: I think we need to learn a more effective way to problem solve and communicate in a
way that facilitates a better understanding of our problems.
Molly: Yes, I would problem solve with you if you didn’t just state your position as if it were
facts for us both. I communicate pretty well. You are just so wound up in your worldthat you can hear anything anyone else says.
Therapist: Mike, I see your hands are going up into the air. Are you hands expressing the
stalemate?
Mike: Yes, partly the stalemate in the actual conversations about where to live and partly
because she digs and digs into them so that the hole is so deep, it’s difficult to get outof them.
Therapist: Can you go into what digs and digs means?

112Mike: Well she won’t let up. She will take a problem and grind it until there is nothing left,
like all the stuff with where to live and stuff with my family, especially my mother, andshe won’t let up.
Therapist: She will grind it until there is nothing left. . . of the topic or. . . . ?Mike: She grinds me and will criticize me, my job, my family, everything. . .Therapist: And what do you do when that happens?Mike: I try to talk things out for a while, then I know where the conversation is going, so I
just wait until the storm passes and stay out her way. [42]
De-escalation Phase
Molly: I have been so depressed and so unhappy for the past few years now with everything,
the marriage, my life. I am just happy about the kids and that is about all.
Therapist: So, over the past few years, you have been depressed as you say and unhappy.
How has that impacted you? How has that been for you?
Molly: Well actually over the past year especially, I have been overwhelmed with the kids,
with the newborn and our four-year old, and when I get a chance to be alone, I justfeel (pause) so mad at Mike because he seems to be in his own little happy world
doing exactly what he wants to do and getting his way all the time. He has his career,me and the kids and everything is great for him. Mike is the kind of person who is verymethodical and unemotional and I am free and emotional and say what is on my mind.
Therapist: You say he is methodical and unemotional. How does his being unemotional
affect you?
Molly: I just what to scream and tell him to stop hiding behind his walls and his job and his
being so cognitive about everything. He is like a computer sometimes, well, it makessense because he programs them all day, so he comes home like that.
Therapist: So you get very frustrated with him because you feel he is hiding behind something
and hiding from you in times when you want to be with him or be close to him. Am Igetting a sense of how it is?
Molly: Yes.

113Mike: Well, she assumes that I am unemotional, but she is so stuck in her problems that I
think sometimes she can’t even see what I offer.
Molly: Well, I know. . . I know. It’s just when all I see is you giving me a lecture or going
out on the deck to smoke a cigar during a talk, it just seems like you don’t feelanything at all and don’t really care what happens or care what is going on for me.
(Minutes later in session)Molly: Sometimes I really need him to listen to my point of view and at least take it in as a
part of his thinking. . . [43]
Therapist: What would that mean to you, if he took your point of view in?Molly: I would at least know he cares and isn’t so far away from me. [44]Therapist: Is that something you need, for him to be closer to you?Molly: Yes I need that. It would take a lot of work and a lot of settling old wounds, but it
really would change so much for me.
Therapist: Like what would it change?Molly: I would feel closer to him and wouldn’t get like I had to scream to be heard or to be
taken seriously. It hurts to be ignored all the time. I know myself well and I know Iwant my independence, but at the same time I need some support there. I need apartner there.
Therapist: Mike, how is it to hear Molly say when she is trying to talk to you that it hurts to
be ignored?
Mike: I have no intention to hurt Molly. . . I don’t sit there during conversations and devise
ways to undercut her efforts. If she came to me in a pleasant mood when I got homeand attempted to understand my efforts and, many days, my exhaustion, I wouldappreciate interacting with her and generally feel better about being around her in theevenings. [45]
Molly: (Laughter) And maybe we could both sleep in the same room once in a while and give
the couch a break. [46]

114Attachment Injury Phase
Molly: Everything seemed to happen all at one time a few years ago. We had been going
back and forth about whether to live here or moved to another town where we bothcould get good jobs. One night in particular, I approached Mike about a graduateprogram in Toronto and it seemed like I was going to my dad to ask him if I could go,but I broached the subject with him after I had done pretty careful research on theirreputation and had called to talk to one of the professors, and his response was. . .well he just tightened his face and gave me a cold stare and said, “No well in hell” andstormed off. I knew right them that it was over. [47]
Therapist: You had been cut off and you knew that it was over?Molly: Yes, our marriage was failing miserably and I knew that I had a choice, either put up
with this life or leave and have the life I wanted. But we had Stevie then, he was atwo year-old boy, and I don’t see my self as a divorced parent. A kid needs both hismom and dad. I knew I would have to just stay quiet and for the matter stay as faraway as possible.
Therapist: So you were ready to make a sacrifice in one way, but you also had decided in that
moment to distance yourself from Mike and live separate lives.
Molly: Right.Therapist: And what was that distance like, deciding to shut off from him?Molly: I felt a sense of freedom, like I was just retreating from the war and I wasn’t going to
fight any more and perhaps I could put my energy somewhere else, something where Icould feel a sense of peace.
Therapist: What else did you feel about it?Molly: And it also was devastating. ( Pause) That I (crying) knew that our relationship was
two people living together without love or respect. I needed you, Mike, and youtreated me like dirt, like I was your worst enemy. [48]
(Later in session)Molly: And a week after his decision to stay in Ottawa, I was about 10 weeks pregnant at the
time and I know that I was under a lot of stress. I got up off the couch and knewsomething was wrong. I won’t go into now, but I was about to miscarry the baby.

115And this was the second in one year and I was terrified that I was losing this baby and
terrified that we wouldn’t be able to have kids again.
Therapist: What happened when you realized that you were about to miscarry the baby? Did
you call for help or. . . . ?
Molly: (Pause) I call Mike at work and asked him to come home, that I was about to
miscarry and needed him there to help me. I couldn’t handle this all alone. And hetold me, “No, I can’t come home right now. I have a huge deadline later today” andthat he has told me and I needed to call his mother or someone else to help. So Icalled a friend to help. Mike didn’t come home until 9 P.M. or so, and I found outthat he and his co-workers had gone out for dinner to celebrate their project.
Therapist: So you had this terrifying thing happen to you and you felt like Mike had left you
totally on your own to take care of everything and you needed him there with you.
Molly: And I really needed him that time. I had nothing left in me. I mean, he gave me two
huge blows like that in one week. I didn’t even have the energy at that point, I just feltso demolished. [49] I walked around stunned like the world had crashed, that myworld was not like it used to be and I had to deal with it. Did you have any idea whatI went through?
Mike: (pause) Yes, I do know. I have apologized profusely for it, but I can’t seem to get
that through to her. And from my point of view, she had called several times thatweek saying that she was miscarrying and the first few times, I got off work and ranhome and it was a false alarm. It was like crying wolf five times in one week and thenthat time, I decided to stay at work. It would have been so difficult to leave at thatpoint in the day considering the circumstances. [50]
Re-engagement Phase
Mike: My mother has been diagnosed with cancer this week and I realize how much I need
Molly. You have helped me so much with taking care of things at home and staying intouch with my family and I know how hard it is for you to put aside all the things thathave happened with them. I just need. . . (pause, crying) [51]
Molly: Mike, I love you so much. ( crying, couple hold each other ) We can get through this.
[52]
(Minutes later in session)

116Molly: I have realized that I have been angry at you for so many things and I know that I
have put myself in these situations. I see that. I needed you and I know I was puttingso much pressure on you to help me work through my things.
Mike: Thank you.Molly: I have my friends at church who have been so helpful to me and I will start the
education program this Fall and I think that having these things in place helps me seethat I was relying on you to fill in the gaps that I needed to take care of. We still havethings to work out and I know I will get frustrated, but I am ready to stop the analysisand just go on with things and show as much love as I can when I can. [53]
Mike: I need a break from the analysis of our problems too and try to get things normal. I
was going to say get them back to normal, but I think they never were normal. (laughter) I feel a definite change with both of us. With our working through your
going back to school and our working on the financial programs at home at night, Iknow we will start working together on things. It may be slow, but I feel differentabout it now. [54]
Therapist: Hearing you both talk, it sounds like both of you see each other differently now
and have a sense of trust that you have not had for a long time.
Molly: Well, I know we will re-build our trust. I mean Mike is very trustworthy when it
comes to the family and planning our future and our own sense of trust will get betterover time. This is a beginning. [55]
Therapist: And you Mike, do you feel a sense of trust like Molly?Mike: I feel a change in her and I agree with her that it will take some time, but it certainly is a
lot different.
Therapist: What change do you feel in her?Mike: She is less focused on my faults and more focused on what she wants and I can feel a
relief, like a ton of brick have been taken off my back. And we have a tough timecoming up now with my mother and I really have needed her to just be there and notgo into her frustrations when we talk about it, and she has been there and given mespace when I need it. [56]
Therapist: You can count on her?Mike: Yes, like I hope she can count on me.

117APPENDIX F
Post-Treatment AIM Interviews

118Post-Treatment AIM Interviews
1. Couple 1
Male reporting attachment injury
Researcher: In your assessment statement, you write about events that happened that you felt
distress about. You write: The last “event” has put him in drug rehab in another city. His disruptive behavior had lead to our seriously considering splitting up at leasttwice." How do you feel about that now?
Rick: A lot has changed since we began therapy last September. Kip has gone through the
rehab home, and not without slips and falls, but he is moving in a better direction now. We have had times alone and he was quite charming and some of those times Iactually forgot about all the turmoil just last year.
Researcher: And what about you and Rhet, how have things changed since September?Rick: We have gone through so many changes, both personally and as a couple. I can say
changes for the positive. We spend a lot more time together now and when we do, weare on the same page. She and I have dealt with my social phobia problem quoteunquote and we go out now and I don't feel so uncomfortable.
Researcher: How did you two deal with it?Rick: We talked about it sessions, of course, and I think we just know more about each other
on an emotional level, so it helps when she knows what I am going through. We takelong walks now and that gives us time to debrief and get back in touch.
Researcher: You also say, "Hurt, anger, pain, hopelessness, and grief are common, everyday
feelings. Personal, mental and physical health has suffered accordingly. Depressionrules the day." How do you see that now?
Rick: Well I don't feel depressed now. I don't think I ever was depressed in a significant way.
I think that our situation was depressing me and I was down a lot. Now that we havenew understandings and have really opened up to each other, I don't think thatanymore. And that goes for the hurt, hopelessness. . . What were the rest (laughter)?
Researcher: Let's see, anger pain and grief.Rick: (Laughter) I was in a state then. Of course I feel anger from time to time. I think they
all came together when we had the big blow up and I thought we were going toseparate as a result of it. It feels different now. I mean, we haven't gone through

119major personality overhauls, but we know we can handle things that used to get us
down. And it seems simple now. I stop hiding and talk about it.
Researcher: You said that the event with Rhet and Kip was a “severe problem." Do you still
see it that way?
Rick: It was severe. And there is no control over a teenager sometimes so I expect problems
to come our way. But as I said, we can handle it. . . Or we can handle ourselves as acouple. I have come to realize that I need Rhet’s help sometimes and can ask her for itand I know not to get in the middle and put her in a place to decide between me andher kids.
Researcher: You write in your assessment that I gave you at the beginning that, you said,
"Before this happened, we were at a point in our relationship when I was put into aposition where I felt I had to choose between my son or my husband." Where are younow on that issue?
Rhet: I don't feel that I have to choose between Kip and Rick like I felt last year. I see now
that Rick was also put into a difficult position and had to make a lot of decisions that Ineeded to make. I was trying to please everybody and ended up not pleasing anyone.
Researcher: What decisions did you need to make? How do you see it now?Rhet: I felt I was putting a lot of the disciplining on Rick's shoulders where he wasn't in a
position to make a lot of the parenting decisions. He was trying to help, I know.
Researcher: And trying to please everyone, you said you ended up not pleasing anyone?Rhet: Yes, it was my low self-esteem. I try to make everyone happy and it doesn't turn out
that way. I know now that I am responsible for myself and I also know that Rick willhelp me. We are not against each other it feels like now. It is more like we areworking together and we are allies.
Researcher: So you can be responsible for yourself and go to him at the same time?Rhet: Yes. That has made a difference.Researcher: You also say in the assessment, "Since Kip has been in the group home, there still
has been a fair amount of stress, but not quite as constant." How is the stress levelnow?

120Rhet: It got so much better, especially the past two months. Kip being away helped us get
closer and the stress was nothing like it was. We still have conflicts like with workand my other two kids, but we cope with it better now. Kip is coming back soon, andwe are a little worried about the adjustment and I know things won't be perfect all thetime.
Researcher: And do you feel more comfortable showing love towards Kip? Rhet: Yes I do. I know he needs it and I need it. And now that Rick and I are closer, I think
we have an understanding that I need to be close to Kip too and not decide betweenthem.
Researcher: You also say, "I felt resentful towards Rick for putting me in that position of
choosing, I am afraid this situation may come up again."
Rhet: It may come up again, but the difference now is that Rick and I can talk about it
without getting so upset with each other.
2. Couple 2:
Female reporting attachment injury
Researcher: In the assessment statement, you mentioned that Sam is unemotional. How do
you hear that statement now?
Sara: Well, I certainly wouldn’t say he is unemotional. I would say that he has a hard time
expressing his emotions. I used to take it personally. I figured that if he loved me, hewouldn’t be like that. If he cared about me, he wouldn’t want me to feel that way.
Researcher: Have you found that he loves you and he is quite too?Sara: Yes. And that is a break through for me. I think that in time he will express a lot more
to me and I know that it is up to him. I can’t make him talk and I can’t make himlisten. I will try to encourage him, but it is who he is and I can’t make him.
Researcher: You say also that you cannot depend on him for emotional support. Has that
changed?
Sara: I think that I have changed the way I feel more than I cannot depend on him. I have
changed myself a lot and how I think about this. He tries to do things for me, I know.

121 It just wasn’t the way that I thought they should be, so it felt like he was not trying.
He didn’t know what it was.
Researcher: Can you tell him that?Sara: It is hard for me and I don’t just come out and day it, but I try more now.Researcher: You have changed. How do you know that?Sara: I thought that when we started therapy that I was always reaching out and he was
pushing me away. But I see now that I have been throwing myself at him and he justdidn’t know how to deal with me. So I have learned that he does have feelings and Ineed to back off a little bit and let him deal with his feelings and later I can deal withmy feelings. I know it is not my fault that he is not jumping in to save me. I used toblame him and blame myself.
Researcher: It sounds like you are giving each other more space and have become less
reactive to one another.
Sara: Yes we do. We are much less reactive now. Sometimes I st ill wonder whether he really
wants to be with me or he will just get fed up and leave. I am more comfortablesaying it and he can say, “I am not leaving” and I am ok with that. I feel morecomfortable backing off a little. Like when we are in a fight, I can back off and thinkthat maybe I am not doing the right thing here. Like now when we talk aboutsomething and I still don’t do what we agreed on, I will very quickly say now, “Youare absolutely right.”
Researcher: You also say that he didn’t know what to do after you miscarried and that was a
big issue between you.
Sara: Yes, big, big, big, big issue.Researcher: How do you put that into perspective now?Sara: I think it was because he didn’t know how to help me. I think I always knew that he did
know how to help me, like I knew that it wasn’t because he didn’t care about me anddidn’t want to do anything, but he just didn’t know what to do. For a long time, Iblamed him for not knowing what to do. I thought that if he loved me, he should haveknown what to do. I feel now that had he known what to do, he would have done it. And had I said what I needed, he would have known. ( Laughter)
It seemed that every time we had a fight, it was so bizarre, I would always end upbringing up the miscarriage. We would be fighting about where the knives go, for

122example, and all of a sudden I would say, “You just didn’t understand” and “Why
didn’t you see what this was about?” But it never comes to that now. We dealt withit. I did what I needed to do and it seems like a thing of the past now. It is different. It feels so good to have it behind us. I mean, I will never forget it, but it doesn’t havethe impact that it used to. I know what I would do, but I don’t know what othersshould do. He took care for me in his own way. He thought I was upset and I neededto be left alone and I know he was trying to help. I was upset that he left me alone. And I feel a lot more trust now than before.
Male
Sam: She is more open-minded now.Researcher: How so, she is listening more?Sam: Yes, listening more and trying to listen to my point of view and understand my point of
view instead of just her going with her point of view. This is the first time I have seenher include other ways of seeing things.
Researcher: What is the effect on you that fact she has changed like that?Sam: It makes me feel a lot better because I knew I was right and I would give in just to give
in. But now, we can talk about this and we can decide the fair thing to do.
Researcher: Has your concept of right changed? The way you both describe it, it seems like
there has been a right and a wrong. Has that changed?
Sam: Yes. Three is a wider range of possibilities, and there is a lot more gray area. We are
communicating better. We have a ways to go, but we are getting along a lot betterand being a lot more patient with each other.
Researcher: You also said at one point in your assessment statement that she always makes
you feel inferior. How do you hear that statement now?
Sam: I felt inferior because I was always wrong and she was always right. That was the way
we set things up. She was always in control it seemed. Even if I had a point or wasright.
Researcher: And your strategy was to avoid problems?Sam: Yes, just agree with her with whatever. It was very lonely though. It took the
manhood out of me. There was a time that I was lonely. I am not a talker and don’t

123show my emotions and I know that is a problem and I am trying to do better. I mean
we went through some hard times, especially the miscarriage, and I went throughsome hard times. Had I known more about what was happening to her on a deeperlevel, it would have helped. And it would have helped if she had understood what wasgoing on with me. I didn’t tell her much, so there was no reason for her to know. And I think I have a lot going on inside. I just don’t make it public. I don’t think thesame thing would happen again if we went through a crisis like that now. We know toask each other what is going on and help each other.
3. Couple 3:
Female reporting attachment injury
Researcher: When you wrote on the assessment measure about the miscarriage, you said it
was a pivotal event. How do you look back on that event now?
Molly: I think I understand where he (Mike) was at then at that time, although it was very
painful for me.
Researcher: Where was he at that time?Molly: He was very preoccupied with a major project at work and also I think our emotional
baggage got in the way that day. Had we been less distant and less antagonistictowards each other, he would have been there. I know he would have been.
Researcher: And what about today, if that were to happen?Molly: I am pretty sure that if I had a miscarriage today, he would not react the same way
again. I think he learned a hard lesson from that experience. And I am watching himwith his mother now in treatment, and he is so there for his mom that I am surprisedand frankly jealous ( laughter). But I am pretty sure he would be there for me like
that. I trust that he would be there for me. Like when I hurt my back this summer andcouldn’t move around for a few weeks, he just jumped right in and was there for methe whole time. And that is tremendous progress.
Researcher: How do you feel about the miscarriage now?Molly: Wow. Big question. Things have been tough. We considered separation and have
been in crisis mode for such a long time. But I am determined to be ok with things .And it is time to focus and be positive. I want to be positive and set the example. Doit for myself and for Mike and for my family. We used to get so down. When he was

124down, I was down too. I will not be pulled down anymore. I feel that this is a new
start for me. I have surrounded my self with loving friends and have made new ones,will be starting school soon. I feel sturdy now. And as things have changed so muchin the past few months, I know that if we put our minds to it, we can really be therefor each other when things like a miscarriage happen. I am doing my part and that is ahuge change. I am ready to take whatever comes I am ready to take a role. I am notjust an actor in this play of our relationship, but actor director. And Mike is actordirector also.
Researcher: What else has changed for you?Molly: If you look through the trust scales, you will see the changes in us. In February, I was
in a terrible place, and now I feel a sense of empowerment and I take care of me andtake care of Mike and the family. I trust Mike, I trust that we will work thingsthrough, but I still feel the weight of some of the problems sometimes. I still not stickmy neck out at all costs and stay in a relationship that is incredibly unhealthy, but I willdo everything I can possibly do. I feel really good about myself. From this therapy, Ihave gotten such a sense of peace and confidence, that I feel a sense of joy andempowerment that I can take care of things.
Male
Mike: Over the past few weeks, I have experienced a great deal of blueness because of my
mom. And so it is hard to make an assessment right now.
Researcher: In terms of how you feel now, do you feel she is there for you?Mike: From my perspective, she desires to be there and tried with success, but she may feel
threatened because the challenges we have, and I feel very vulnerable right now. There is such a culmination of events now, the sickness, layoffs in my company, ourdiscussing separating a few months ago. It is threatening.
Researcher: Are you there for one another during these times?Mike: Being there for her is a type of therapy for me. It is a reciprocal process and it I
express love and I feel I will get it back. It is a positive sharing. Sometimes comingtogether has caused so much friction and we are showing the good ingredients now. Ireally try to show that I care.
Researcher: What do you need from her now?

125Mike: I just want to use fewer words sometimes and use a few, more powerful words when
we talk. I think that her ears are more open to what I say now. I need to ask forroom sometimes.
Researcher: How can she be there for you?Mike: She tries. ( Client cries ). I feel so vulnerable now. I really hope Molly can be a part of
this. I hope we can continue to lay off fighting every time we sit down and talk aboutsomething significant. We have started to set time aside to talk, and I really need thatmore.
Researcher: ( Later in interview ) Do you trust Molly more now?
Mike: Well, I trusted her in the past with many things. She is a trustworthy person. What has
caused problems is her wanting to fight and put me and my family down. She has notdone that so much recently and especially the past few days with my mom, she hasbeen supportive and has given me space, even when I know that it is hard for her. Soour trust is much better and little by little, I am hopeful that it will be strong and not anissue at all.
Researcher: Part of therapy has concerned the miscarriage that Molly had a few years back.
How do you see that event now?
Mike: Well, I know it was very difficult for her and actually it was very painful for us both. If
that were to happen today, undoubtedly I would drop what I was doing and be there. We were so tangled up in conflict then and there had been so many false alarms that Icould make that kind of decision then. Now I could not do that.

126VITA
John W. Millikin was born in Greensboro, North Carolina. After graduating from an
all-boys boarding school, he attended the University of North Carolina at Chapel Hill. Duringhis junior year, he attended the University of Seville, Spain, and also taught high schoolEnglish at a local academy. He studied fa mily therapy at Appalachian State University. He
entered the family therapy program at Virginia Tech in 1997 and did his clinical internship
with Dr. Susan Johnson at the Ottawa Civic Hospital.