Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS): Conceptual Development and Content Validity (original) (raw)

Abstract

The Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS) is introduced as a scale to measure a therapist's fidelity to the EFT model. The rationale and conceptual development of the scale are presented. Members of an EFT electronic mailing list who participated in a survey (n=130) rated all of the items as highly important for the practice providing support for the content validity of the scale. Finally, the 13 items of the EFT-TFS are presented. Future research directions for the EFT-TFS are presented.

Keywords: couples therapy, therapist rating scales, emotion focused therapy, supervision, psychotherapy research

Emotion focused therapy for couples (EFT; Johnson, 2004) is one of the most empirically supported models of couple therapy for relational distress (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Evidence is also emerging to support its use as a treatment for depression (Dessaulles, Johnson, & Denton, 2003), attachment injury survivors (Makinen & Johnson, 2006), and parents of chronically ill children (Walker,Johnson, Manion, & Cloutier, 1996). EFT also may be useful with couples coping with other conditions such as chronic illness (Kowal, Johnson, & Lee, 2003) or hypersexual behavior (Reid & Woolley, 2006).

EFT is a maturing model of couple therapy which already has a published treatment manual (Johnson, 2004) and accompanying workbook (Johnson et al., 2005). To ensure faithfulness of implementation of the EFT model, prior research has relied on methods such as close clinical supervision (e.g., Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000) and adherence checklists (e.g., Dandeneau & Johnson, 1994; Johnson & Talitman, 1997; Makinen & Johnson, 2006). As EFT research continues to develop, a measure of therapist competence is needed to assess skillfulness in implementing the EFT model. To this end, we have developed the Emotional Focused Therapy-Therapist Fidelity Scale (EFT-TFS). The purpose of the present paper is to present the rationale and development of the EFT-TFS items, initial evidence for their content validity, and the items themselves.

Purpose and Proposed Uses of the EFT-TFS

The purpose of the EFT-TFS is to assess therapist fidelity to the EFT model. Fidelity incorporates the concepts of both model adherence and competence where adherence refers to using interventions prescribed by the model while competence refers to executing those interventions skillfully. EFT fidelity is, therefore, defined as implementing interventions delineated in the EFT manual (Johnson, 2004) in a skillful manner that is likely to promote the EFT goal of strengthening the relationship.

Each task in therapy is comprised of more than one therapist behavior and these behaviors have been clustered together in what are referred to here as "skills." It follows that each EFT-TFS item corresponds to an EFT skill. The EFT-TFS has been designed primarily for use in research studies, however, it is anticipated that the scale may also be useful in training settings to assess therapist development and provide feedback to therapists receiving EFT supervision.

Initial Identification of Skills Representing EFT Competence

After identifying the purpose, the second step in scale development is to identify behaviors that represent the construct(s) in question (Crocker & Algina, 1986). The initial development of the EFT-TFS drew from (a) the EFT literature (e.g., Johnson, 2004; Johnson et al., 2005) and (b) the expert judgment of the authors. The authors developed a consensus about skills that comprise the core of EFT practice through an iterative process of generation and revision and items with high face validity were written. Next, the skills (items) were shared with other EFT experts who provided evaluations of the items which were incorporated into the emerging scale.

Survey of EFT Electronic Mailing List Members

Description of Survey

After initial development of the EFT-TFS items, we wanted to have them evaluated by the larger EFT community. There is an electronic mailing list intended for therapists who have completed a five day externship in EFT approved by the Ottawa Couple and Family Institute. At the time of the study the list had approximately 600 members. A survey was constructed on SurveyMonkey.com and the study was approved by the Institutional Review Board of the University of Texas Southwestern Medical Center. A posting was made to the electronic mailing list informing the members of the voluntary survey. The survey was open for responses between June 19 and July 18, 2007. A weekly posting was made to the list during this time reminding members of the opportunity to voluntarily participate in the survey. There were 130 participants who evaluated at least one EFT-TFS item and 97 participants who evaluated all 13 items.

The survey presented the objective for each of the 13 EFT-TFS items (skills) along with brief descriptions of poor, competent, and exemplary demonstration of the skill. Participants were asked to respond to three questions on a 7-point Likert-type scale: 1) How essential is this skill set to EFT?, 2) How important is this skill set to EFT?, and 3) How necessary is this skill set to EFT? Ratings ranged from "Low" (a rating of one), through "Medium" (a rating of four), to "High" (a rating of seven). It was believed that the three questions would assess different aspects of the items although statistical analysis (described below) and feedback from respondents indicated that the three questions were perceived as being essentially the same.

Participants had the opportunity to write in comments for each item as well as general comments at the end of the survey. Optional demographic information was also collected.

Survey Results

Demographic characteristics of sample

Eighty-one participants responded to some or all of the demographic questions. Over half (58.0%) were prepared at the Master's degree level while 33.3% held doctorates (the remainder listed "bachelors" or "other"). Professional licenses held (could list more than one) were marriage and family therapist (42.0%), social work (23.5%), psychologist (18.5%), professional counselor (14.8%), "other" (16.1 %) and "none" (4.9%). Nearly all (93.8%) had completed at least the five day EFT externship (as intended for list-serve membership) while 38.8% had pursued additional formal supervision in EFT and 20.0% were certified EFT therapists. The average number of years of experience was 14.3 and the average age was 51. Participants were from Australia, Canada, and the United States. Nearly three quarters of the participants were female (71.3%) and 90.1% reported their race as White.

Participant ratings of EFT-TFS items

The results of the survey are in Table 1. As noted above, 130 participants made ratings of at least one EFT-TFS item. The number of participants completing the survey tended to decrease with each item until there were 97 participants who completed all of the items.

Table 1.

EFT electronic mailing list member evaluations of EFT-TFS items: Means, Standard Deviations, and Alpha Coefficients for Evaluations of Skill Importance (Sorted bv Mean Importance)

To ascertain whether the three questions used to evaluate each item (essential, important, necessary) yielded similar results, internal consistency analyses (Cronbach's alpha) were conducted for the three items for each of the 13 rated skills. The alpha coefficients ranged from .961 to .989 and averaged .978. In other words, the survey respondents used the three questions in a very similar fashion. Thus, scores were averaged over the three questions; henceforth, this average score will be referred to as the “importance rating”.

All of the items were viewed as important by the survey respondents; mean importance ratings ranged from a "low" of 6.2 to a high of 6.7 (on a 7-point scale where 7 indicates highest level of importance). To ascertain whether some items were viewed as significantly more important than other skills by the survey respondents, a one-way repeated measures analysis of variance (ANOVA) was conducted with the 13 items serving as levels of the repeated measure; this analysis included only the 97 participants that rated all 13 items. Mean importance ratings for each of the 13 items are reported in Table 1. The ANOVA detected a significant effect for item, F (12, 1140) = 7.68,p < .001, Tj2 = .08. A series of pairwise comparisons was conducted to identify the items the respondents viewed as relatively more and less important; the results of these tests are also summarized in Table 1. Items 1, 6, and 5 were regarded as the most important; items 2, 3, and 8 were next most important; then came items 11, 9, 7,4, and 10; and items 13 and 12 were rated as least important (relatively speaking—all items were regarded highly important in absolute terms).

Next, a series of analyses were undertaken to determine if evaluations of the items varied as a function of five respondent individual differences (age, gender, educational level, years of experience as a therapist, and level of EFT training). To facilitate these analyses, a median split was conducted on respondent age, creating groups of younger (under 54; n = 43) and older (54 and older; n = 36) respondents. A median split was also conducted on years of experience as a therapist, creating groups of less experienced (under 14 years of experience; n = 42) and more experienced (14 plus years; n = 36) therapists. Low frequencies for some educational levels led us to compare only those holding the MA (n = 47) with those holding the Ph.D. (n = 26). Finally, low frequencies for some categories of EFT training levels led us to include only three training levels: those who had completed the 5-day externship (n = 28), those who received formal supervision following completion of the externship (n = 31), and those who had received certification as an EFT therapist (n =16). The results of these analyses indicated that evaluations of the 13 EFT-TFS items were not moderated by respondent individual differences: for respondent gender, F (12,936) = 1.60,p > .08; for respondent age, F (12,924) = 1.46,p > .10; for respondent educational level, F (12,864) = 0.80,p > .60; for years of therapist experience, F (12,912) = 0.85,p > .50; and for respondent EFT training level, F (24,864) = 0.63,p > .90.

Participant comments

Participants could, additionally, add their own written comments for each item and for the scale as a whole. In total, there were 237 separate responses entered. Based on critiques offered, further changes were made to the EFT-TFS items and descriptions.

Structure of the EFT-TFS

Each EFT-TFS item is rated on a 5-point Likert-type scale with anchor points to guide the raters at points 1,3, and 5. A rating of "1" is defined as a "poor" or "absent" demonstration of the skill, a rating of "3" is defined as a "competent" demonstration of the skill and a rating of "5" is defined as an "exemplary" demonstration of the skill. The ratings of"2" and "4" are provided for skill demonstrations judged to fall between the anchor points. The anchor points consist of descriptions of each level of competence. The EFT-TFS consists of a scoring sheet and accompanying manual (which may be obtained from the first author). The Cognitive Therapy Scale (Vallis et al., 1986) was used as a model of a successful therapist fidelity rating scale. As with the Cognitive Therapy Scale, a total score of 40 or greater on the EFT-TFS is defined as competent implementation of the EFT model. (A score of 39 would represent an average score of "3" ["competent"] on the EFT-TFS items.)

Making EFT-TFS ratings requires the application of judgment on the part of the rater as to what is considered poor, competent, and exemplary demonstration of the EFT model. The EFT-TFS rater must, therefore, have expert knowledge of EFT. That has been operationalized as an EFT therapist who has been registered by the Ottawa Couple and Family Institute (see www.eft.ca for registradon details). The EFT-TFS is considered applicable to any EFT session except for the first and last as there are many activities in those sessions not sufficiently unique to EFT. Although different skills tend to be exercised to a greater or lesser extent depending on the stage of therapy, each skill should be demonstrated to some extent in each session.

EFT-TFS ratings are made by the rater after observing a video recording of one entire session. Research raters should have no information about the couple or therapist other than the session number. It is important that raters primarily focus their evaluation on the behavior of the therapist rather than the couple. It is inevitable that the couples' behavior may play some role in rating the therapist (e.g., if the couple takes offense to a therapist statement, the therapist's handling of their reaction would be evaluated). However, it would not be uncommon that a therapist may demonstrate competent EFT skills while the couple may not demonstrate a therapeutic response. Raters should take into consideration how "challenging" the couple is in making ratings of the therapist. The 13 EFT-TFS items are now presented.

Skill 1: Alliance Making, Alliance Maintenance, Creating Safety in Session

Objective of Item & Desirable Therapist Behaviors

EFT asks the members of the couple to gradually make themselves more open and vulnerable to each other. This requires that they take risks with each other as well as the therapist. Generally, the behavior of the therapist toward the couple should be warm and supportive. There is little (if any) role for traditional "confrontation" in EFT. For example, an EFT therapist would not say "I don't think you've really gotten serious about working on this relationship. " Partners are challenged but the form this type of "confrontation" takes is specific reflections of ongoing dyadic processes and their consequences. An EFT therapist might say "Can you tell him that it is too hard to believe him, so that you have to leave your wall up? " Therapists establish the desired therapeutic alliance by actively inquiring about each person's experience and validating that experience. Most negative behaviors can be framed in the context of attempting to deal with underlying attachment needs or fears. The therapist should generally not express negative judgments about the patient's behavior and, especially, inner experience.

Therapists should not speak or behave in an authoritative or "expert" manner but, rather, in a manner that allows the couple to teach the therapist about their experience. They should always speak in a respectful tone with the couple. There may be limited use of self-disclosure (which should not, however, detract from the flow or focus of the session).

In general, therapists should spend approximately equal amounts of time with each partner and challenge each partner approximately an equal amount. In a given session, however, it may be that the therapist works more with one partner than the other. In this case, the therapist (a) should make clear to the partner receiving less attention that the therapist is aware more time has been spent with the other partner, (b) should make clear that s/he will want to hear more in a future session from the partner who has received less attention, (c) may offer some explanation for the imbalance, (d) should check with the partner receiving less attention to see if the partner is accepting of the therapist's comments. For example, "I know I have spent more time today with [your partner] and I do want to hear more from you next time - I wanted to focus on this today because it is really important and I thought we all needed to hear it, is that OK? "

If therapists sense that there may be a strain or rupture in the therapeutic alliance, addressing this should be the immediate focus of therapy. Therapists can ask about partners' reactions to what they have just said and encourage the partners to express their feelings if tension is sensed in the therapeutic relationship. Therapists may need to clarify their words or apologize for mistakes or missteps to restore the alliance.

EFT sessions can be emotionally arousing so that it is usually desirable to debrief couples before the session ends. This is part of alliance maintenance and creating safety. For a session of lesser intensity this debriefing might be quite informal, such as asking “How are we doing here? OK? " For a more intense session, it might be more formal, such as "We are getting near the end of our time today – you have both taken a lot of risks and before I want to check in with you and see how this has been for yon? " The therapist might ask questions such as “How are you feeling about leaving and going back to work?, " etc.

Descriptions of Differing Skill Levels

Anchor Point 1

A poor demonstration of this skill would be manifested by a therapist behaving judgmentally or taking sides in a manner that was detrimental. The therapist may seem impatient, aloof, or have difficulty conveying warmth and confidence. Poor interpersonal skills, in general, on the part of the therapist would be part of inadequate performance of this skill.

Anchor Point 3

A desired demonstration of this skill would include a display by the therapist of a satisfactory degree of warmth, concern, and genuineness through words, body language, and tone of voice. The therapist generally maintains a balance between partners. The therapist inquires of each partner if the therapist is correctly understanding them, responds to indications that either of the partners is dissatisfied with the therapist, accepts partner's experience, attempts to engage the couple in a collaborative effort, and debriefs as indicated.

Anchor Point 5

In an exemplary demonstration of this skill the therapist would display optimal levels of warmth, concern, and genuineness and would have created a safe, non-blaming, responsive environment for partners to experience and express feelings. Therapist demonstrates empathic understanding of partners experience. Responds optimally to any expressed strain to the therapeutic alliance. Debriefing, if indicated, becomes part of the therapeutic experience.

Skill 2: Validation of Each Partner

Objective of Item & Desirable Therapist Behaviors

An important assumption in EFT is that partners' basic needs and emotional reactions are normal and healthy. In most cases, the therapist can, at minimum, validate that the partners' behavior was the best solution they could find to deal with their attachment needs and fears. Validation is the process of letting the partners know that the therapist views their needs and reactions as understandable, valid, and normal. In doing so, the partners begin to see the therapist as a safe person. At the same time, they may begin to view their needs as appropriate rather than pathological and they may begin to see their partner's needs as normal rather than pathological. Therapists should not validate one partner in a way that invalidates the other. When in doubt, it is generally therapeutic to validate core attachment needs. For example, in response to a partner's demands for more frequent sex, a therapist might say, "I think I hear you saying, though, that it is important to you to build this relationship - am I right? " Validation may be an active, explicit intervention such as "I think I understand, sometimes you need his reassurance, is that right? " Use of the partners' own words is desirable. Validation is also accomplished by non-verbal behavior and use of language. For example, the therapist may discuss behaviors that the other partner might consider irrational in a "matter-of-fact" tone.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when the therapist: a) makes no validating comments about partners' emotions and interactional position, b) uses judgmental language or non-verbal behavior, c) validates one partner while invalidating the other.

Anchor Point 3

This skill is adequately demonstrated when the therapist validates each partner's reactions and emotions without invalidating the other (e.g., "you fight for him because he is important to you"). Validating comments are made but may not be elaborated.

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist optimally validates each partner's emotions and interactional position without invalidating the other. Validating comments are exceptionally accurate, descriptive and may be connected to partners' emotions. The therapist may make the same validation in different ways - e.g., using partners' own words, using a metaphor, etc.

Skill 3: Continually Reframing the Problem in Terms of the Cycle

Objective of Item & Desirable Therapist Behaviors

In EFT, a goal is to help the couple view their problem as the cycle of negative interaction that they are both caught up in. Making this shift is a challenge for many couples and usually requires the therapist to continually point out the cycle. The therapist should refer to the cycle, refer to the problem as being the cycle, and frame the cycle as the "enemy" throughout treatment. Referring to the cycle once or twice in a session is typically not sufficient. When one of the partners refers to a behavior that is a piece of the cycle the therapist should verbally link that behavior to the emerging cycle. Therapists should make use of "linking" comments, tracking questions, and reflection. For example, "oh, so when she says that, you feel she is treating you like a child and that's when you lash out? "

Descriptions of Differing Skill Levels

Anchor Point 1

Skill Three is poorly manifested when the therapist refers to the cycle insufficiently. The therapist misses significant opportunities for linking questions and comments. The therapist may try to frame the problem as the cycle prematurely (e.g., before both partners feel validated) and, when the reframe is rejected, tries to "force" the reframe on them. The reframe offered may take only one partner's point of view and seem to blame the other partner.

Anchor Point 3

Skill Three is adequately demonstrated when the therapist continually tracks and defines the process of interactions in terms of the cycle. Each partner's emotions and behaviors are linked to the emotions and behaviors of the other partner. The problem and content are reframed in terms of the cycle. There is a frequent use of linking questions, tracking, and reflection. If evidence surfaces that both partners are not yet ready to accept the systemic frame, therapist notices quickly and moves to restore the alliance. There is a balance of respecting the partners' point of view while also encouraging a new systemic view.

Anchor Point 5

The exemplary demonstration of Skill 3 is manifest when the therapist continually tracks and defines the process of interaction in terms of the negative interaction cycle with each partner's emotions and behaviors optimally linked to those of the other partner. Reference to the cycle may be seamlessly interweaved into the session. If evidence surfaces that one or both partners are not yet ready to accept the systemic frame, therapist notices quickly and moves to restore safety, trust and rapport - continuing to validate each partner's version of events without retreating from continuing to gently offer the systemic reframe.

Skill 4: Management of Couple's Interaction

Objective of Item & Desirable Therapist Behaviors

Managing interaction between the two partners is an essential skill in EFT (as for any model of couple therapy). Conflict can occur (with or without loud voices) and may be characterized by one party denigrating, berating, or making fun of the other party. A certain amount of conflict and distress is to be expected and is not necessarily destructive. Particularly early in therapy, it is necessary for the partners to express their secondary emotions and feel that the therapist has validated these feelings. Prematurely cutting off the useful expression of secondary emotions is not good management of couple interaction.

Managing interaction also includes managing "non-interaction. " That is, a withdrawing partner may have little or no interaction. The task of the therapist is to try and draw out the withdrawing partner and manage the session by trying to keep this partner involved. There are other aspects of interaction besides conflict that must be managed. Couples may focus excessively on the content of problems, joke and not speak seriously, focus on how the other's upbringing is the cause of their problems, etc. In general, any couple behavior that derails the focus of the session from the negative interaction cycle, primary emotions, or attachment must be managed. EFT sessions typically consist of the couple veering off track and the therapist trying to restore focus. Therapists must balance keeping the session on focus while not cutting the couple off in such a way as to damage the therapeutic alliance (Skill 1).

Descriptions of Differing Skill Levels

Anchor Point 1

In a poor demonstration of this skill, the couple's interaction derails the focus of the session and the therapist makes no attempt to intervene or makes grossly ineffectual attempts. If the couple is off focus, the therapist may not allow them to speak sufficiently to "feel heard" and interrupts them non-therapeutically. The therapist may cut off prematurely the therapeutic expression of secondary emotions. Poor session management would also be demonstrated if a therapist prematurely cuts off and redirects the couple to a new topic when they are productively discussing relevant aspects of the cycle, primary emotions, or attachment issues. No, or ineffectual, attempts are made to draw out silent partners.

Anchor Point 3

In the desired demonstration of this skill the therapist appropriately intervenes if the couple's interaction derails the focus of the session through conflict, joking, changing the subject, etc. The therapist manages conflict by reflecting the process of the conflict and containing secondary emotions. Redirection is done in a respectful manner. The therapist appropriately allows continuation of interaction when the couple is discussing the cycle, primary emotions, or attachment issues. The' therapist works at drawing out a silent partner.

Anchor Point 5

Exemplary demonstration of this skill would be manifested by the therapist responding in an optimal manner if the couple's interaction derails the focus. The therapist skillfully keeps the session on focus while respecting secondary emotions. If the couple is productively discussing relevant aspects of the cycle, primary emotions, or attachment issues, the therapist skillfully mixes guiding comments with allowing the couple to continue interacting. Therapist is skilled at drawing out a silent partner and/or managing session time well.

Skill 5: Processing Emotion

Objective of Item & Desirable Therapist Behaviors

The ability to help the partners access emotions about which they may not even be aware is a key EFT skill. This accessing of emotions allows for the reorganization of behavior and a change in negative interaction cycles. Therapists must actively help partners explore and put words to their emotions using interventions described in the treatment manual (Step 3 of EFT) (Johnson, 2004). The unfolding of emotions takes time and cannot be rushed. Through the gradual processing of emotions, partners can begin to accept their emotions (Step 5 of EFT) and the other partner can begin to accept them as well (Step 6 of EFT). Although the therapist may occasionally spend too much time with one partner, the more usual problem is that the therapist spends too little time exploring the emotions of a partner. Of course, the therapist will eventually work with the other partner to unfold his or her emotions, thereby restoring equity.

Descriptions of Differing Skill Levels

Anchor Point 1

In a poor demonstration of this skill the therapist does not pursue emotions at all or the therapist begins to explore emotions but does not spend enough time doing so (or the therapist processes emotions but stays too long with one person before bringing in the partner).

Anchor Point 3

In the desired demonstration of this skill the therapist appropriately uses emotion-focused interventions to explore and expand emotions and place them in the context of the negative interactional cycle and attachment. The therapist maintains an appropriate balance of time processing emotion between partners or acknowledges the lack thereof.

Anchor Point 5

In the exemplary manifestation of this skill the therapist expertly helps the partners capture the essence of their emotional experience in a way that helps them engage with their emotion. The therapist will employ a wide variety of the interventions to elicit and process emotion. The therapist demonstrates exemplary timing in terms of how long to pursue emotions with one person before bringing in the partner.

Skill 6: Working with Primary Emotions

Objective of Item & Desirable Therapist Behaviors

Primary emotions are the immediate, direct emotional response to a situation whereas secondary emotions are reactive responses to a primary emotion (see Johnson, 2004). For example, a "cutting" comment might lead to feelings of hurt (the primary emotion) whereas what the partner displays is anger (the secondary emotion). Although secondary emotions are viewed as real and valid experience in EFT, it is the identification, expression, and acceptance of primary emotions that leads to change. Couples typically come to therapy with little awareness of their own primary emotions and even less awareness of the primary emotions of their partners. The primary emotions with the greatest therapeutic import tend to be "vulnerable" emotions and most often are some type of attachment fear (e.g., fear of rejection, fear of inadequacy, etc.). Emotions focused on should be (a) primary, (b) attachment oriented and (c) related to the couple's cycle. Other emotions will come up in a therapy session that are not clearly part of the negative interaction cycle. These emotions may need to be acknowledged and validated but it may not be therapeutic to spend a great deal of time processing them. For example, one partner may experience despair that his or her partner will ever change. Although this is a "real" emotion, it is not part of the cycle and extensive processing of "despair" will only leave them feeling more hopeless. Thus, the EFT therapist should talk about how the hopelessness leads to an action tendency which then becomes part of the cycle. Beginning EFT therapists are sometimes uncertain about which emotions to pursue and process. The simple answer to this is that it is most therapeutic to focus on emotions that are part of the negative interaction cycle. This skill differs from Skill 5 (Processing Emotion). In Skill 5 the emphasis is on the "mechanics" of eliciting and processing emotion (EFT Step 3) while Skill 6 involves deepening and processing of relevant primary emotions (pertinent to EFT Steps 5 and 6).

Evaluating this skill requires the rater to judge the extent to which the therapist is focusing on cycle-relevant primary emotions. The most therapeutic primary emotion to focus on may not be immediately apparent to even skilled EFT therapists, so therapists may begin to go down one path and then need to change direction based on what is being learned in the session. A certain amount of redirecting the focus of therapy is within the limits of competent demonstration of this skill. The exemplary therapist will have less need of this type of redirection. Again, the key element of this skill is that the primary emotion being processed is part of the cycle.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when the therapist does not attempt to identify any attachment oriented primary emotions, focuses on primary emotions that are not part of the cycle, heightens destructive secondary emotions, etc.

Anchor Point 3

This skill is adequately demonstrated when the therapist highlights, elucidates, expands, and/or heightens primary emotions that are part of the cycle, doing so through use of evocative questions, process replays, interpretations, and reflections. The therapist uses "RISSSC" ("repeats, uses images, simple words, slow, soft voice, uses client words") in a satisfactory manner (see Johnson, 2004 for a further description).

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist highlights, elucidates, expands, and heightens primary emotions that are part of the cycle through exemplary use of evocative questions, process replays, interpretations, and reflections. Uses "RISSSC" in an exemplary manner to prepare key enactments and engagement in change events.

Skill 7: Placing Emerging Emotions into the Cycle

Objective of Item & Desirable Therapist Behaviors

In some models of "pure" family systems therapy, the cycle may be dealt with on only a behavioral level. Similarly, in some models of "pure" experiential therapy, emotions may be dealt with in isolation from relational context. A unique aspect of EFT is the placement of emotions into the systemic cycle. Skill 3 (continually reframing the problem in terms of the cycle) involves defining the presenting problem(s) in terms of the cycle. Skill 7 involves placing emerging emotions into the cycle. This may be done simultaneously with Skill 3, although the reframing of the problem (Skill 3) and placing emotions into the cycle may not necessarily occur at the same rate (uncovering of emotions tends to lag behind). The therapist behaviors embodied in this skill help the couple to see how each partner's emotions are reactions linked to the behavior of the other person so that each sees how they pull for the other's negative responses and create the cycle. The cycle is, again, externalized and framed as the enemy.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when the therapist does not place emerging emotions into the cycle at all or inadequately does so.

Anchor Point 3

This skill is adequately demonstrated when the therapist appropriately places emotion into the emerging cycle.

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist regularly and skillfully places emotion into the emerging cycle in an impactful manner.

Skill 8: Therapeutic Use of Enactments

Objective of Item & Desirable Therapist Behaviors

With any type of dyadic problem, the couple must ultimately interact in a different way for the problem to be considered resolved. In EFT such new interaction is "enacted" within therapy sessions, often with direction by the therapist, in what is referred to as an "enactment" or "restructuring interaction." Enactments are one of the most distinctive aspects of EFT. There should usually be an enactment or an attempt to create an enactment in every session. The typical steps of enactment are: a) prepare for the enactment by processing emotions and attachment needs, b) set up the enactment, c) create the enactment, d) follow-through with the enactment, and e) process the enactment.

In an enactment, the therapist asks one partner to talk to the other and usually gives that partner specific directions. The therapist monitors the ensuing interaction and guides the partners in processing their experience of the interaction. The enactment may lead to further spontaneous conversation between the partners which the therapist monitors. Following the request to engage in an enactment, couples will often try to redirect the session. "Gentle persistence" may be required to keep the focus on the experience of the enactment. Enactments should be used or attempted in Stage One as well as Stage Two. Even if the couple is not able to carry through with the enactment in an early session this provides diagnostic information.

Additionally, the couple begins to see what to expect from therapy. Detailed information on enactments is provided in the EFT workbook (Johnson et al., 2005).

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when the therapist: (a) does not make any use of enactments in a session, (b) begins to set up enactment but then does not pursue it if a partner resists or (c) prematurely cuts off or interrupts a couple that is enacting around the cycle, primary emotions, and attachment issues.

Anchor Point 3

This skill is adequately demonstrated when the therapist sets up enactments by adequately synthesizing the emotion first and then creating the enactment, following it, and processing it. The therapist adequately manages partner reluctance. If the couple is interacting around the cycle, primary emotions, and attachment issues, the therapist appropriately allows the interaction to continue - perhaps with some facilitation.

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist sets up enactments by optimally synthesizing the emotion first and then creating the enactment, following it, and processing it. The therapist deals optimally with partner reluctance and is able to use the reluctance therapeutically. If the couple is discussing aspects ofthe cycle, primary emotions, or attachment issues, the therapist skillfully mixes reflecting or guiding comments with allowing the couple to continue interacting on their own.

Skill 9: Managing Defensive Responses

Objective of Item & Desirable Therapist Behaviors

There is a sequence that often occurs in an EFT session in which the therapist works with one partner to process that partner's experience and then, eventually, turns to the other partner to find their response. The second partner typically makes a response that can be characterized as either "accepting" or "defensive." Defensive responses may take the forms of attacks and can be destructive to therapy if not managed appropriately. On the other hand, a defensive response can become a therapeutic experience if managed skillfully by the therapist. The therapist should help defensive partners process their reactions. The therapist should explore and validate the defensive partner's reaction(s). Defensive reactions often include disbelief, feeling attacked, or feeling that their experience is not recognized and validated. The defensive reaction can be an opportunity for the therapist to help the defensive partner become aware of unacknowledged emotions and further elucidate the negative interactional cycle and attachment concerns.

Descriptions of Differing Skill Levels

Anchor Point I

In the poor demonstration of this skill the therapist makes limited attempts to manage defensiveness. Poor mastery of this skill would also be demonstrated by a therapist disavowing secondary emotions of the defensive partner. For example, "what's up, you've said you want him to open up and now that he did you attacked him" would be an invalidation of the defensive partner's secondary emotion (anger) and a poor therapist response.

Anchor Point 3

In the desired demonstration of this skill the therapist acknowledges secondary emotions and is able to help defensive partners process their responses in a productive way that creates safety for the partner who made himself/herself vulnerable. The therapist ties secondary emotions into the negative interactional cycle and attachment needs.

Anchor Point 5

The therapist demonstrates optimal skills in validating secondary emotions of defensive partners and tying these emotions back into the negative interactional cycle and attachment needs. The therapist helps both parties understand the trigger in the discloser's words that resulted in defensiveness, while illuminating the meaning attached to those words by the defensive partner and their resulting response. The therapist helps both partners disentangle the attachment needs illuminated from the defensive behavior that perpetuates the cycle.

Skill 10: Maintaining Session Focus on Emotion, the Cycle, and Attachment Issues

Objective of Item & Desirable Therapist Behaviors

As a relatively brief therapy, the sessions in EFT must remain focused on emotion, the negative interactional cycle, and attachment issues. The emotions addressed initially may be secondary emotions (for example, reactive anger) but, as therapy progresses, there should be more emphasis on primary emotions. One challenge for therapists is to ascertain the relevant emotions and the negative cycle. This is a perceptual skill (Tomm & Wright, 1979) that is reflected by the questions therapists ask and enactments they set up. Some beginning therapists may (erroneously) propose solutions to problems and try to convince the couple to implement these, but when EFT is properly practiced solutions are generated by the couple (Step 8 of EFT).

Content of the couple's problems (as opposed to the process of how the couple interacts around the problems) should only be addressed to the extent necessary that (a) the couple feels the therapist is listening, and (b) a framework is developed for discussing emotion, the negative interactional cycle, and attachment issues. The goal is for the couple to experience emotions and attachment needs as opposed to having an intellectual understanding. Therapists should generally not "lecture" about EFT concepts but, rather, create an experience for the couple.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when: (a) the session has excessive focus on content, (b) the session wanders aimlessly under direction of the couple, (c) there is excessive social conversation, (d) therapists propose and promote "solutions" to the couple's problems, (e) therapists talk excessively about themselves and (t) therapists "lecture" about EFT concepts. There is little focus on emotion, the cycle, or attachment issues.

Anchor Point 3

This skill is demonstrated in a desired manner when the therapist generally maintains a focus on emotion, the negative interactional cycle, and attachment even if the clients derail the focus at times and the session "drifts" off such focus. There is a mix of focus on emotion, the cycle, and attachment issues with times of lack of this focus. There is an appropriate amount and type of social conversation and/or self-revelation in the session.

Anchor Point 5

This skill is demonstrated in an optimal manner when the therapist sets the focus for the session and maintains it. If the couple sidetracks the session, the therapist redirects back to intended focus with minimal "drift" off focus and without alienating the couple. Most of the session is "on focus." The therapist weaves the maintaining of focus seamlessly into the course of the session and with validation of the partners.

Skill 11. Framing Cycle, Problems, and Emotions in Terms of Attachment Needs and Fears

Objective of Item & Desirable Therapist Behaviors

EFT assumes that distressed couple behaviors represent attempts to have attachment needs met. Therefore, it is essential that attachment needs and fears be brought into the open and related to the cycle, the presenting problems, and both the primary and secondary emotions. The therapist should identify attachment needs and fears using the same techniques described above in Skill 5 (Processing Emotion) and then relate these needs and fears to the cycle, presenting problems, and primary emotions.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when the therapist: (a) does not identify any attachment needs and/or fears, (b) does not tie attachment needs and fears back into the negative interaction cycle with the accompanying primary and secondary emotions.

Anchor Point 3

This skill is adequately demonstrated when the therapist, at times during the session, identifies and relates attachment needs and/or fears to the negative interaction cycle, presenting problems, and primary emotions.

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist regularly identifies attachment needs and/or fears and weaves these into the cycle, presenting problems, and primary emotions in an seamless manner.

Skill 12: Following the Steps and Stages of EFT

Objective of Item & Desirable Therapist Behaviors

EFT has an element of circularity in that the steps may be repeated as the couple delves deeper into underlying emotions and attachment fears. Additionally, there may be some back and forth between the stages. EFT, however, also exhibits linearity in that there is a sequence in which key elements of treatment must occur. The usual sequencing in a course of EFT will be: assessment and deescalation (Steps 1–4) (including validating secondary emotions), restructuring the bond (Steps 5–7) (withdrawer first, then helping the partner accept the new responses), and consolidation of gains (Steps 8–9) (development of new narrative and plans for maintenance).

Some elements of the sequence are mandatory. Assessment and deescalation (Steps 1–4) must occur before restructuring of the couple bond (Steps 5–7). To try and accomplish advanced processing of emotions and restructuring of the attachment bond without having identified the problem (Step 1), negative interactional cycle (Step 2), the relevant primary emotions (Step 3), and the attachment issues at play is an error.

There are other aspects of the sequencing that usually occur but are not as invariant. In classic demand-withdraw cycles the withdrawer generally (but not always) moves slightly ahead of the blaming partner in the change process.

Descriptions of Differing Skill Levels

Anchor Point 1

Poor demonstration of this skill would be if the therapists left outsteps/stages and has skipped ahead without proper preparation of the earlier work. For example, trying to elicit vulnerable emotions from one partner while the other partner is demonstrating hostility (which the therapist is not acknowledging) would be a poor demonstration of this skill.

Anchor Point 3

This skill is demonstrated in a desirable fashion when the therapist generally is making efforts to progress through and accomplish the goals of each step/stage in their proper sequence. When couples make a "step backward" in therapy, therapists may display some indecisiveness in guiding the session as they struggle to adjust.

Anchor Point 5

This skill is demonstrated in an optimal fashion when the therapist has optimally progressed through and accomplished the goals of each step/stage and uses the steps as a guide to focus the therapy sessions. While generally moving forward in therapy, the therapist is also alert to times where there is a need to "back up" and re-trace steps worked through previously and does so in a seamless manner.

Skill 13: Consolidation of Change and Development of New Narratives

Objective of Item & Desirable Therapist Behaviors

In successful therapy a point is reached where the negative interaction cycle has been modified and attachment needs are being better met. It is important that the couple develop a new narrative or story about their relationship to help solidify changes. If the couple has not resolved all of their presenting problems, the lack of change can be incorporated into the new narrative as well. Skill 13 is not only utilized at the termination of therapy. As couples report change at any time during the course of treatment, consolidation should generally be employed. The couple may spontaneously talk in any session about the changes that have occurred. If so, the therapist should support the continuation of this discussion. If the couple does not talk about changes on their own, the therapist should initiate such a discussion as sessions are coming to an end. Topics to be included are highlighting new behaviors or responses (or highlighting an impasse), key change events, the new bond between them, etc. If the couple is leading such a discussion in a therapeutic direction the desirable behavior on the part of the therapist is to listen and be supportive without much active intervention.

Descriptions of Differing Skill Levels

Anchor Point 1

This skill is poorly demonstrated when there is no or inadequate discussion Emotion of changes that have occurred and the new relationship between them (or highlighting areas of no change). The partners describe positive changes which have occurred without any acknowledgement on the part of the therapist supporting these changes.

Anchor Point 3

This skill is adequately demonstrated when the therapist satisfactorily highlights positive change and new responses. The therapist satisfactorily helps partners integrate their new view of the relationship, new attributions, and new narratives.

Anchor Point 5

This skill is demonstrated in an exemplary manner when the therapist optimally highlights positive change and new responses. The therapist optimally helps partners integrate their new view of the relationship, new attributions, and new narratives.

Conclusion

In this paper we have made the first presentation of the Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS). The EFT-TFS is a 13 item scale where each item represents a core skill for implementing the EFT model. The initial item development was presented and the results of the first empirical evaluation of the EFT-TFS presented. In a survey of therapists who nearly all have had some formal training in EFT, all items were rated as highly important to the practice of EFT. This is an indication of excellent content validity. Finally, the 13 items/skills were presented for use by researchers, supervisors, and clinicians.

Much work remains to be done on the EFT-TFS. A crucial step will be to assess the ability of different raters to agree on EFT-TFS ratings. While our initial use with the EFT-TFS has been promising, this needs to be evaluated in a systematic manner. Important further evidence for the validity of the scale would be its ability to distinguish expert and beginning EFT therapists and to assess whether EFT-TFS ratings were associated with clinical outcomes for couples. We are undertaking such studies and hope to present additional results for the EFT-TFS in the future.

Acknowledgments

Appreciation is expressed: to Gail Palmer and Douglas Tilley for comments on the EFTTFS items, to Connie Cornwell for comments and for ordering the items in the present sequence, and to Jay Seiff-Haron and all of the other members of the EFT electronic mailing list who participated in the survey and also provided feedback. This work was supported in part by grant 5K23MH063994 from the National Institute of Mental Health (Dr. Denton).

Contributor Information

Wayne H. Denton, Family Studies Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9121. wayne.denton@utsouthwestern.edu.

Susan M. Johnson, Department of Psychology, University of Ottawa and Director of the Ottawa Couple and Family Institute, Vanier 6th Floor, 11 Marie Curie, O ttawa, Ontario, Canada, K1N6N5. soo@magma.ca.

Brant R. Burleson, Department of Communication, Purdue University, 100 N. University Street, Beering Hall 2114, West Lafayette, IN 47907-2098. brantb@purdue.edu.

References

1. Baucom DH, Shoham V, Mueser KT, Daiuto AD, Stickle TR. Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal ofConsulting and Clinical Psychology. 1998;66:53–88. doi: 10.1037//0022-006x.66.1.53. [DOI] [PubMed] [Google Scholar]
2. Crocker L, Algina J. Introduction to classical and modern test theory. Belmont, CA: Wadsworth; 1986. [Google Scholar]
3. Dandeneau ML, Johnson SM. Facilitating intimacy: Interventions and effects. Journal ofMarital and Family Therapy. 1994;20:17–33. [Google Scholar]
4. Denton WH, Burleson BR, Clark TE, Rodriguez CP, Hobbs BV. A randomized trial of emotion-focused therapy for couples in a training clinic. Journal of Marital and Family Therapy. 2000;26:65–78. doi: 10.1111/j.1752-0606.2000.tb00277.x. [DOI] [PubMed] [Google Scholar]
5. Dessaulles A, Johnson SM, Denton WH. Emotion-focused therapy for couples in the treatment of depression: A pilot study. American Journal ofFamily Therapy. 2003;31:345353. [Google Scholar]
6. Johnson SM. The practice of emotionally focused couple therapy: Creating connection. 2nd ed. New York: Brunner-Routledge; 2004. [Google Scholar]
7. Johnson SM, Bradley B, Furrow J, Lee A, Palmer G, Tilley D, et al. Becoming an emotionally focused couple therapist: The workbook. New York: Routledge; 2005. [Google Scholar]
8. Johnson SM, Talitman E. Predictors of success in emotionally focused marital therapy. Journal ofMarital and Family Therapy. 1997;23:135–152. doi: 10.1111/j.1752-0606.1997.tb00239.x. [DOI] [PubMed] [Google Scholar]
9. Kowal J, Johnson SM, Lee A. Chronic illness in couples: A case for emotionally focused therapy. Journal ofMarital and Family Therapy. 2003;29:299–310. doi: 10.1111/j.1752-0606.2003.tb01208.x. [DOI] [PubMed] [Google Scholar]
10. Makinen JA, Johnson SM. Resolving attachment injuries in couples using emotionally focused therapy: steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology. 2006;74:1055–1064. doi: 10.1037/0022-006X.74.6.1055. [DOI] [PubMed] [Google Scholar]
11. Reid RC, Woolley SR. Using emotionally focused therapy for couples to resolve attachment ruptures created by hypersexual behavior. Sexual Addiction & Compulsivity. 2006;13:219–239. [Google Scholar]
12. Tomm KM, Wright LM. Perceptual, conceptual, and executive skills. Family Process. 1979;18:227–250. doi: 10.1111/j.1545-5300.1979.00227.x. [DOI] [PubMed] [Google Scholar]
13. Vallis TM, Shaw BF, Dobson KS. The Cognitive Therapy Scale: Psychometric properties. Journal ofConsulting and Clinical Psychology. 1986;54:381–385. doi: 10.1037//0022-006x.54.3.381. [DOI] [PubMed] [Google Scholar]
14. Walker JG, Johnson S, Manion I, Cloutier P. Emotionally focused marital intervention for couples with chronically ill children. Journal ofConsulting and Clinical Psychology. 1996;64:1029–1036. doi: 10.1037//0022-006x.64.5.1029. [DOI] [PubMed] [Google Scholar]