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The
Use
of
Emotionally-ffocused
Couples
Therapy
(EFT)
for
Survivors
of
Acquired
Brain
Injury
With
Social
Cognition
and
Executive
Functioning
Impairments,
and
Their
Partners:
a
Case
Ser
ies
Analysis
Giles Yeates*, Adrian Edwards,
Clara Murray, Nicola Zapiain Creamer, and
Mythreyi Mahadevan
Abstract
A breakdown of intimacy and familiarity in close romantic relationships is
common and characteristic of life following acquired brain injury (ABI), yet is
not commonly addressed in neuro-rehabilitation services. Recent conceptual,
qualitative, and quantitative studies highlight the role of emotional and inten-
tional misattunement in relationship breakdown and associated psychological
distress of both partners, alongside the emotional withdrawal and/or critical
responses of the non-injured partner. Emotionally-focused couples therapy (EFT)
is an evidenced-based couples therapy that is widely used around the world for
similar themes in couples’ relationships unaffected by brain injury. Its use in ABI
has only been reported anecdotally to date. This paper presents four couples’
cases post-ABI, with both qualitative therapy process description and single case
quantitative pre-post therapy comparison on a range of relationship and indi-
vidual psychological distress measures. Every survivor of ABI was eighteen
months post-injury or more, and identified to have an enduring mixture of social
cognition and executive functioning impairments upon neuropsychological
assessment, among other difficulties. The couples are presented as three
therapeutic successes, contrasted with a case characterised by mixed outcomes.
The applications, contributions, and limitations of EFT in brain injury services is
considered.
Key words
: Brain injury; stroke; social cognition; executive functioning; relation-
ships; couples therapy.
Neuro-Disability & Psychotherapy
1(2)
151–197 (2013)
151
*Address for correspondence: Giles Yeates, Community Head Injury Service,
Buckinghamshire Healthcare NHS Trust, Camborne Centre, Jansel Square, Bedgrove,
Aylesbury, Bucks. HP21 7ET. Giles.Yeates@buckspct.nhs.uk
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Introduction
Characterising intimate relationships following brain injury
Distress and disconnection commonly characterises intimate relation-
ships following acquired brain injury (ABI). This was initially highlighted
by Rosenbaum and Najenson (1976) as unique for couples following
neurological injuries, in comparison with other conditions (supported by
Peters, Stambrook, Moore, & Esses, 1990). However, subsequent efforts
to characterise what is unique to these relationships have yielded mixed
and contradictory findings. Some studies of relationship outcomes
(divorce, separation, remaining together) have failed to find differences
between ABI samples and both other long-term conditions (Bracy &
Douglas, 2005; Frank, Haut, Smick, Haut, & Chaney, 1990; Kreutzer
et al., 1998; Testa, Malec, Moessner, & Browt, 2006) and national popu-
lation trends for such outcomes (Kreutzer, Marwitz, Hsu, Williams, &
Riddick, 2007; Wood & Yurdakul, 1997). Variability in outcomes is
noted across ABI couples studies, however, irrespective of sample size
and methodology. Godwin, Kreutzer, Arango-Lasprilla, and Lehan
(2011) highlight a range of identified separation and divorce rates, from
fifteen to seventy-eight per cent.
Investigations focused on other dimensions of experience and func-
tioning in those couples who do remain together post-injury, do converge
to highlight high levels of marital dissatisfaction, dyadic maladjustment,
sexual dysfunction, and progressive social isolation for both partners (e.g.,
Elsass & Kinsella, 1987; Peters, Stambrook, Moore, & Esses, 1990;
Ponsford, 2003). Outcomes for non-injured partners include increased
burden, strain, stress, and clinical anxiety and depression (Perlesz,
Kinsella, & Crowe, 2000; Thomsen, 1974). Many of these outcomes have
been shown to increase over time post-injury (for comprehensive reviews
of this literature, see Bowen, Yeates, & Palmer, 2010; Godwin, Kreutzer,
Arango-Lasprilla, & Lehan, 2011).
Intersubjective experience in relationships
Moving away from standardised questionnaire measures to subjective
and experiential accounts of relationships and intimacy following ABI, the
depth of relational disconnection and disturbance is revealed. Pre-
dominantly female partners disclose their feelings of “living with a
monster”, analogous to living with Jekyll and Hyde (Wood, 2005). Others
describe being “married to a stranger” (Wood, 2005), “married without a
husband” (Mauss-Clum & Ryan, 1981), wanting their real husband back
(Wood, 2005). Intimacy “feels wrong” to some partners (Gosling & Oddy,
1999), with the emotional side feeling “badly damaged” (Oddy, 2001),
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and some partners report a dislike of physical contact (Rosenbaum &
Najenson, 1976). Connecting these quotes are themes of both an absence
of something once familiar and a presence of something alien and intru-
sive into the relationship (Yeates, Whitehouse-Hart, & Balfour, in press).
Two recent qualitative studies of intimacy following ABI have tried to
take these isolated quotes further and explore these issues in more depth.
Gill, Sander, Robins, Mazzei, and Struchen (2011) used a thematic
analysis to identify both barriers to intimacy in couple relationships fol-
lowing traumatic brain injury (TBI) (physical, cognitive, and emotional
changes, emotional reactions to changes, altered personhood of the
survivor, sexual strains and incompatibilities, role changes/conflicts,
communication difficulties, family factors, isolation) and dimensions of
relationship strength that supported the quality and longevity of the rela-
tionship post-injury (unconditional, unselfish love, being there, commit-
ment to staying and working on the relationship, being understanding,
pre-injury relationship foundation, gratitude for survival, spending time
together/friendship, social support, family bonds, spirituality, prior ex-
perience, coping skills).
Yeates, Whitehouse-Hart, and Balfour (in press) focused on elements
that were disturbing and hard for respondents to articulate. Post-injury
changes in survivor interpersonal functioning were experienced as intru-
sive for both partners and survivors, who also reported themes of lost
familiarity, distance, and alienation within the relationship. Judgements
of personality change in the other partner were made both by relatives
and survivors within these experiences, highlighting disturbed affective
recognition of the other as a critical factor in relationships post-injury.
This was both bidirectional and oscillating in quality, with moments of
old selves re-appearing interspersed by more common moments of not
knowing each other and each other’s intentions. The non-injured part-
ners’ experiences were private: the disturbing extent of these changes
post-injury were not witnessed to the same degree by friends or other
family members. Both pre-injury vulnerabilities in the relationship and
earlier experiences of loss and abandonment for non-injured partners
were seen to be re-activated and exacerbated by a common post-injury
dimension of misattunement in the relationship. Emotions and intentions
were frequently not recognised or responded to within the relationship,
and things did not feel right fundamentally for either survivors or part-
ners, exemplified by one couple; “it’s like there’s a piece of grit in our
relationship, wearing away our hearts from the inside.”
Staying attuned to the ebb and flow of evolving interpersonal
sequences, be they conversation or making love, has been shown to be
undermined by difficulties in attentional switching (“there can’t be any
unplanned time sharing with each other. I have to mentally know when
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it’s going to happen so I can prepare because I can’t switch gears any-
more,” Gill, Sander, Robins, Mazzei, and Struchen., 2011, p. 60) and
interoception (“when we’re kissing and cuddling I feel quite strange I
guess I feel that
way
when I get
lost
in umm . . . the development of our
arousal . . . it’s a weird sensation, I suppose ummm, my stomach as well
as anything else around my stomach, and around my heart areas it
doesn’t feel right.” Yeates, Whitehouse-Hart, & Balfour, in press).
Personality change, neuropsychology, and relational
processes
Much has been written about personality change following brain injury
(see Yeates, Gracey, & Collicutt-McGrath, 2008) but the relational dimen-
sion of these judgements has been neglected. The clinical literature rarely
discusses the possibility of simultaneous and two-way personality change
for couples, as a product of a breakdown in a relational process (excep-
tions to this are provided by both a professional and spouse of ABI
survivor, Feigelson, 1993, and Crimmins, 2000, respectively). In the
stroke literature, Shadden (2005) describes aphasia post-stroke as “iden-
tity theft” for both survivor and non-injured partner. Similarly, the oscil-
lating dynamic of familiar self and stranger as experienced by partners is
not explored within the literature, despite the distress caused by this
dynamic nature (“when I feel the old him is back in the room, I know it
will not last long,” Yeates, Whitehouse-Hart, & Balfour, in press).
The person who is making personality change judgements of the
survivor is most commonly the partner. They are often referring to an
essential sense that the person whom they used to know (and be known
by) so well is no longer recognisable in that way, the interpersonal con-
nection between them has been lost. The particular influences of the
brain injury in this phenomenon has come to be more fully elucidated
and understood, as those acquired neuropsychological impairments
affecting interpersonal connection and social relationships have been
increasingly identified.
This literature has been reviewed by Yeates (in press) who highlights
the role of both traditionally defined cognitive impairments (attention,
memory, language, and particularly executive functioning deficits) and
social cognition deficits (mentalizing, emotional recognition, autonomic
responsivity, and social responding/decision-making congruent with
social and moral norms) in over-determining forms of misattunement in
couple relationships. Such misattunement can be misidentification of
the other’s intentions and emotional states, confusion of self and other
perspective, failed embodied resonance to respond empathically to
another’s emotional communication, a lack of initiation to either
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communicate a point of view or attend and respond to another in distress
(also compromised by problem-solving difficulties). Affect dysregulation
is also a significant dimension (either too much or too little emotion in a
given interpersonal sequence), along with responses to another’s distress
that may be hurtful, inappropriate, selfish, and/or exacerbating. Such
forms of misattunement and resultant distress in the other call for
increased social cognition skills to repair, but these are not present.
While some survivors of brain injury are also presented in experimental
settings as lacking empathy and autonomic responsivity to social cues in
a fixed, absolute ways (e.g., Bechara, Damasio, Damasio, & Anderson,
1994; Blair & Cipolotti, 2000), other tentative evidence suggests that for
other survivors such responses are not absent, but can only be triggered
at a higher threshold following injury, and so open to therapeutic manip-
ulation (Evans, Bowman, & Turnbull., 2005; Yeates, in press).
Negative interactional patterns
Both quantitative and qualitative data point to the possible interrelation-
ship between neuropsychological impairments and negative inter-
personal processes in couples relationships. Using a correlational cross-
sectional design and bootstrapping analysis, Yeates and colleagues
(2012; Yeates, unpublished) studied seventy couples where one partner
has an acquired brain injury and found a range of predictive relation-
ships between neuropsychological impairments and relationship out-
comes. These included a direct positive relationship between survivors’
emotion recognition ability and partners’ rated interconnectedness in
the relationship. Alongside this there was an indirect predictive path: a
combination of survivors’ ability in mentalizing (correctly inferring the
mental perspectives and intentions of others) and detection of violations
to social norms (e.g., a stranger touching a woman’s baby without her
knowledge) inversely predicted the level of strain in burden experienced
by non-injured partners, which in turn directly predicted their ratings of
overall relationship satisfaction and physical intimacy in the relationship.
This path also predicted the tendency for the non-injured partner to be
engaged in a mixture of critical or emotionally withdrawing responses in
the relationship. This data triangulates with the qualitative findings of
Yeates, Whitehouse-Hart, and Balfour (in press) who outlined a vicious
cycle of interpersonal misattunement in twenty couples where the sur-
vivor demonstrated social cognition deficits on testing. Increased criti-
cism and/or emotional disconnection by non-injured partners over time
was acknowledged, as they could not cope with emotional rejection and
abandonment in the face of the survivor’s struggle to attune to their
needs. The disconnection evolved as a coping strategy to prevent the
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more acute emotional distress in attempted but failed moves to re-
connect, it being safer not to try in the end. Unfortunately this trend
created a vicious cycle where it became harder for a survivor with such
difficulties to attune to/be cued by a withdrawn or criticising partner, or
formulate and implement a helping/reconciliatory response, thereby
perpetuating the interactive pattern. This kind of sequence, requiring
verification in future studies, may be one parameter for the oscillation of
personality change judgments described above. In a similar vein, Stiell
and Gailey (2011) note the presence of “withdraw–withdraw” cycles
between partners as time progresses following post-stroke aphasia. The
survivor is in an “imposed withdrawn” position as a result of communi-
cation difficulties, while their partner has also progressively moved into a
withdrawn position over time, under conditions of attachment threat,
which may involve the non-use of communication-facilitation strategies
despite knowledge of such.
Candidates for intervention?
Given the profound nature of these experiences and difficulties, it is sur-
prising that these issues are not priorities for brain injury services and that
couples interventions are not routinely offered. These remain the “ele-
phants in the room” in rehabilitation conversations. A common experi-
ence for services can be a mixture of hopelessness at the enduring and
overwhelming nature of such difficulties, together with a sense of impo-
tence at not possessing the therapeutic skills to work with these issues.
Couples may be referred to generic couple therapy agencies, who can
feel in parallel that they do not possess the brain-injury and neuropsy-
chological knowledge to make sense of some of the issues unique to
post-injury relational life.
In considering the literature above, these issues can be conceived in
neuropsychological and social-relational terms. With regards to the for-
mer, the field of social neuroscience has recently evolved concepts rele-
vant to couples’ experiences post-injury so that links between
neurological damage and relationships can be conceptualised (Yeates, in
press). Intervention strategies based on this same literature, however,
have their limitations in their extension to couples work. The rehabilita-
tion of executive functioning difficulties has rarely informed couples
work. Social cognition deficits have been addressed via skills-training
approaches (e.g., packages of mentalizing, emotion-recognition and
social behavioural skills, e.g., Boake et al., 1986; McDonald et al.,
2008). These very deliberate, explicit learning approaches may have
value in structured, formal environments (e.g., in a work role) but may be
insufficient for a shared re-experiencing of profound romantic emotional
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connection. This has been shown by Bartels and Zeki (2000) to be
characterised by a deactivation of cortical mentalizing areas alongside
activation of midbrain attachment-focused neural systems that are highly
automatic in nature.
Inspired by contemporary theories of mirror neurons and their em-
bodied, automatic operationalisation, McDonald, Bornhofen, and Hunt
(2009) attempted to improve emotion-recognition ability in survivors by
instructing them to approximate their facial musculature to resemble the
cue visual image of a certain emotional expression (in an effort to pro-
vide a visceral feedback mechanism). This approach was not found to be
successful, nor was an alternative attention-focussing strategy. More
recently, this group noted that increased attention to emotional stimuli
did affect autonomic arousal of survivors, but all of this was independent
from emotion recognition ability (McDonald et al., 2011). In addition to
methodological limitations of the studies, these approaches may have
also placed too much emphasis on an intentional, deliberate act of
embodied mimicry and social comprehension. In terms of neuropsycho-
logical needs for couple work, developing survivor abilities in identifying
and responding to intentional and emotional states of others may be
dependent in turn on finding ways to stimulate and regulate autonomic
arousal of survivors, conducive to felt, attuned empathic responses to
close others (Yeates, in press; Yeates et al., 2012).
In contrast there has been a long but insufficiently-developed tradition
of systemic and family therapy work within neuro-rehabilitation, focusing
on relationships and communication between survivors and relatives (for
overview see Bowen, Yeates, & Palmer, 2010; Yeates, 2009). This has
explored the complexity of such, situated within wider social processes,
meanings, and contexts. These ideas have evolved a range of useful strate-
gies to work with brain injury-specific issues (for examples, see Bowen,
Yeates & Palmer, 2010) and the value of its orientation is in its focus on
relationships between people, allowing both survivors and relatives to
approach an understanding of what happens differently between them
since the injury, without an exclusionary barrier of personal blame.
However, it is the first author’s experience that while these approaches
are fantastic in improving communication, reducing psychological
distress, and getting groups of people “unstuck”, they do not reliably help
people fundamentally deepen their emotional connection with one
another, and rarely to the point of “falling back in love again”. They have
much to offer in the relational understanding and therapeutic response to
problems in empathy, but arguably do not fully exploit the immediate,
intimate emotional dimension between people. Sexual therapy and
education approaches are a vital and much underused component of
couples work (e.g., Masters & Johnson, 1976; Simpson, 2001), but there
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is also a concurrent need to respond to the breakdown of broader psy-
chological intimacy and intersubjective safety that may influence sexual
relations, that is, make a possible sexual encounter feel comfortable and
emotionally safe (Bowen, Yeates, & Palmer, 2010).
Based on the research studies mentioned above, Yeates (in press;
Yeates et al., 2012) has suggested the essential components for a cou-
ples’ intervention in response to the aforementioned difficulties are:
(i) clarification of each partner’s intentions and perspectives
(ii) the orchestration of socio-emotional attunement (intentional or
affective) between the couples
(iii) increasing emotional intensity of the non-injured partner’s emotional
expression, sufficient to trigger the autonomic responsivity in the
survivor conducive to an empathic response, while also regulating
affect in the interactions between the couple
(iv) supporting the non-injured partner’s distress and their move out of a
critical/and or withdrawn position
(v) the systemic focus on the relationship between partners, all to
enhance connection and intimacy.
A strong experiential impression for the first author when starting couples
work in ABI services, was of an interpersonal “knot” for many couples,
where the possibility of enhanced connection was present, perhaps
glimpsed rarely, but unreliably accessed and available to the couple,
leading to frustration, confusion, and disappointment for them and the
therapist.
Emotionally-focused couples therapy (EFT)
EFT (Johnson, 2004) offers an intensification of both partner’s emotional
experience plus orchestration and regulation of affective and commu-
nicative processes within the couple, and as such is a candidate for the
requirements mentioned above. A systemic therapy that uses an attach-
ment (Bowlby, 1969) frame in particular, couples’ distress is formulated
as differing forms of negative cycles involving attempts to seek proximity
of a significant other (attachment figure; the partner) while regulating
affect (both surface feelings and less consciously-accessible fears and
longings within attachment relationships) through defensive strategies.
These cycles can comprise different combinations of pursuing and with-
drawing interpersonal sequences, and the relevance of such formulations
for the aforementioned ABI couples research is clear. Panksepp (1998)
has demarcated the neurobiological basis of attachment-based inter-
personal sequences and affects in mammals, and it follows that damage
to these underlying systems will have an interpersonal, intersubjective
reality for couples intertwined within a close relationship.
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EFT proceeds through three stages:
(i) engagement and conflict de-escalation (following the creation of a
secure therapeutic base for the couple, the cycle is identified and
formulated with the couple, externalised as their shared enemy or
adversary
(ii) changing the interactional patterns and partner’s subjective positions
within these, building in nurturing, reconciliatory, and secure attach-
ment sequences, and finally
(iii) integration and consolidation of therapeutic gains.
It is a brief therapy (eight to twenty sessions, although may be longer
when working with trauma survivors (Johnson, 2002)) and evidence-
based, used around the world for both couples in non-clinical settings
and also applied across a range of clinical groups (see Johnson, 2004).
These include couples coping with the impact of physical illness, which
is conceived as a traumatising influence, in some cases exacerbating pre-
existing vulnerabilities in the couple relationship (Johnson, 2002; Kowal,
Johnson, & Lee, 2003; MacIntosh & Johnson,, 2008; Mikail, 2003;
Naaman, Johnson, & Radwan, in press; Naaman, Radman, & Johnson,
2011; Stiell, Naaman, & Lee, 2007). Fears of rejection, abandonment, and
loss are arguably universal (Bowlby, 1969) and attachment styles devel-
oped early in life have been shown to shift later on, including moves from
secure to insecure styles in the face of adverse life events or prolonged
abusive or neglectful relationships (Crittenden, 2000).
Four papers have described the application of EFT with acquired brain
injury specifically. Stiell, Naaman, and Lee (2007) describe a case of a
husband with post-stroke aphasia and the impact of such on the couple.
The couple were formulated as stuck within a “withdraw–withdraw”
cycle, where both partner’s fears of abandonment and rejection by the
other stimulated a mutual distancing, both spatially as each person occu-
pied different parts of the house and interactionally, as less meaningful
and emotional communication was shared. As with the combination of
executive functioning and/or social cognition difficulties and partner
withdrawal mentioned above, the withdraw–withdraw cycle in this case
deprived the aphasic stroke survivor of facilitated communication and
rendered him inaccessible as a recognisable partner to his wife. The
authors used the EFT process plus speech therapy interventions to clarify
the cycle and engage both partners in a positive cycle of increasing
psychological intimacy and connection.
Recently, Stiell and Gailey (2011) devoted a book chapter to the EFT
work of the Ottawa Aphasia Centre, noting the prevalence of with-
draw–withdraw cycles post-stroke. They describe their co-therapy
approach (couples therapist plus speech and language therapist) that
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initially creates a “communication platform”, a shared space that both
facilitates functional communication and forms a safe, secure emotional
base for the couple, consistent with Stage 1 of EFT. Augmented commu-
nication strategies are interwoven with EFT strategies such as RISSSC
(Repeat what has just been said, use Imagery, Slow down, Keep it
Simple, Soft intonation use Clients’ words (Johnson, 2004)) and enact-
ments of positive attachment sequences. The withdrawn non-injured
partner is gradually supported to come back into contact and interaction
with the survivor, who in turn is supported to express in a richer way
their feelings and desire to connect with their partner. This group
have also published a model of multi-disciplinary working where EFT is
situated alongside physiotherapy and speech and language therapy
strategies to improve family shared activities and engagement with wider
community resources (Ryan, Stiell, Gailey, & Makinen, 2008).
A recent article by Chawla and Kafescioglu (2012) followed the format
of Stiell, Naaman, and Lee (2007) by also presenting two cases of chronic
physical illness, one of which was a traumatic brain injury. In this case,
the negative cycle identified between the couple was one of pursue–
withdraw—the wife or the TBI survivor would be irritated and demand
that her husband would complete a particular task around the house, and
he would feel overwhelmed in response and retreat to the bedroom or
computer to get away from it all. This would escalate to anger and scream-
ing between the both of them and her husband would eventually leave
the house and go missing. Using EFT, the couple were able to identify the
cycle and then subsequently express their attachment needs to each other
(the wife’s need to feel loved through her husband’s sharing of tasks and
his need to be accepted for all his post-injury difficulties).
Developing the evidence-base for EFT following brain injury
These articles provide rich vignettes of how EFT can offer a useful
process for couples following brain injury and are an important first step
in developing the practice of EFT in brain injury services. To develop this
work a more systematic exploration of EFT in ABI is required. Prior to
investment in large scale trials and comparisons with control conditions
and other forms of therapy, it would be useful to identify any suggestive,
tentative evidence for both indications and contra-indications for EFT in
differing ABI subgroups, or across differing presenting problems (e.g.,
injury severity, predominance of one category of neuropsychological
impairment or form of psychological distress between a couple). Given
the remit of this journal, neuropsychological difference is an undevel-
oped but critical issue in the EFT literature. While some aspects of EFT
may fortuitously present a natural fit with ABI-orientated, compensatory
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family work practice (Bowen, Yeates, & Palmer, 2010), it is unlikely to be
a panacea for all post-injury An important future development will be the
identification of essential modifications and adjuncts to EFT practice for
differing presenting needs across survivors of ABI. Stiell and Gailey
(2011) note that where aphasia is also accompanied by difficulties in
initiation or emotional lability, couples are challenged to a greater extent
and the therapists’ approaches in sessions need to adjust accordingly.
Additionally, differences in pre-injury attachment and relational histories
within and across couples may be pertinent. They have been shown to
interact with cognitive impairments post-injury in complex ways (Yeates,
Whitehouse-Hart, & Balfour, in press) and have been suggested to in-
fluence the responsiveness of differing couples to EFT intervention
post-injury (Stiell & Gailey, 2011).
In addition there is an underdeveloped but critical conceptual issue
within the EFT brain injury papers to date. Within two papers, stroke
(Stiell, Naaman, & Lee, 2007) and traumatic brain injury (Chawla &
Kafescioglu, 2012) are subsumed into the generic term of chronic physi-
cal illness. As such, the unique impact of neurological injuries on inti-
macy and interpersonal connection is masked, as are the potentially
profound challenges that such injuries raise to the assumed therapeutic
mechanism of EFT. Stiell and Gailey (2011) rightly elaborate on the
additional strategies that are required in response to communications
and initiation difficulties post-stroke. Therapeutic modifications are sug-
gested by the authors to be necessary for an EFT approach to engage with
core underlying attachment insecurities, negative withdraw–withdraw
cycles and foster the development of positive attachment interactions
and closeness in the relationship. However, for their couples, these
authors assume the underlying potential for attachment-based motiva-
tions and needs and the possibility of connection were the cognitive
difficulties and negative interpersonal cycles addressed.
For the sake of all couples who seek help in brain injury services, this
assumption should be held wherever possible, but some ABI’s under-
mines the very neurobiological basis of attachment itself (Panskepp,
1998; Yeates, in press) and have the direct potential, perhaps unlike any
other disability, to either open up a pre-existing attachment insecurity
within a couples’ relationship, or even plunge a securely-attached
couple into an predominantly insecure, disorganised shared state of
mind and emotion. Following the conceptual heritage of Hegel, psycho-
analytic thinkers, attachment theory, and more recently mentalization-
based therapists (Fonagy, Target, Gerherly, Allen, & Bateman, 2003), the
parameters of affect regulation and self-organisation formed in the inter-
subjective attunement of an attachment (couples) relationship can be
considered to unfold if the neurobiological basis is undermined. Both
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partners, organised along an axis of connection and resonance, will be
affected.
A logical question that follows is that if the underlying neurological
basis of attachment is compromised within at least one half of the rela-
tionship, does the action of a therapy designed to exploit attachment
process still work? In the same way that the EFT work of Kathy Stiell and
colleagues improves verbal communication following aphasia, the in-
gredients of EFT may also improve socio-emotional communication
between survivors of ABI and partners. As noted above, adaptations to
standard practice may be required in response to alterations to differing
functions post-injury, and the emotional, embodied experience of one
partner in a connection with another is no exception. In taking forward
this essential question, some initial optimism can be based on the essen-
tial characteristics of EFT itself. Intensification of communicated affect
and clarification and orchestration of emotional and intentional attune-
ment all chime with the aforementioned experimental procedures, and
suggest that post-injury impairments in social cognition and emotional
experience are not static and absolute, and may respond to EFT uniquely.
However, it is unlikely that all post-injury changes will respond in the
same way or to the same degree. Such variation will presumably present
an associated range of suitability for EFT couples work, and this critically
requires future empirical investigation.
To provide a next step to the four existing studies, this paper presents
three EFT couples cases post-injury, each completing pre-post standard-
ised questionnaire measures of individual psychological distress and
relationship functioning. Changes in questionnaire scores are subjected
to a quantitative analysis of statistical and clinically significant change,
alongside nuanced-observations of the therapeutic progress. Three cases
(A, B. C) are presented as a therapeutic success, contrasted with one cou-
ple (D) demonstrating a mixed response to the approach. All survivors in
this case series have received full neuropsychological assessments, the
results of which are reported here. They are common in that they are all
eighteenth months or more post-injury and on testing demonstrated
impaired social cognition
and
executive functioning in some form post-
injury. These are assumed to be stable, enduring difficulties on a gross
level given the time post-injury, as indicated from the studies of
Ietswaart, Milders, Crawford, Currie, and Scott (2008) and Milders,
Ietswaart, Currie, and Crawford (2006), who reported no improvements
in social cognition difficulties across a year post-injury. At the same time,
the couples also differ in many ways, in terms of type of injury and
broader pattern of neuropsychological difficulties for the survivor, time
post-injury, length of the couples’ relationship, and the attachment
histories of each partner.
162 GILES YEATES ET AL.
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Service
setting
All therapy reported care was conducted at the Community Head Injury
Service, Aylesbury, part of the UK’s National Health Service. As such, all
treatment is provided free on delivery to a local geographical population.
This service is fairly unique both nationally and internationally, in that it
offers long-term support across the lifespan post-injury and has a family
and couples service embedded within its core structure (Tyerman &
Barton, 2008; Tyerman & Booth, 2001). The first author is a clinical
neuropsychologist and has completed core skills training and supervi-
sion in EFT. The other authors have varying levels of formal EFT training
and were either lead or co-therapists for the work described. Mythreyi
Mahadevan provided data collection support.
All four survivors of injury had already engaged in the service, pursu-
ing rehabilitation or vocational goals and working with other members of
the multi-disciplinary team (occupational therapy, vocational consultant,
or receiving individual psychological therapy from a clinical neuropsy-
chologist). All couples were in active involvement with the service and
couples therapy was signposted within the service. In the community
head injury service nearly every survivor of ABI receives a full neuro-
psychological assessment with a big focus on social cognition (mentaliz-
ing, emotion recognition, social inference, social judgement-making,
emotion-based decision-making) prior to commencing couples or family
work. All couples were seen on a fortnightly basis unless other factors
necessitated longer between-session intervals. These four couples were
selected from the caseload of couples receiving EFT from the service
from 2010 to the present. Fifteen cases have been seen by this service so
far, and the four presented here have been selected because a) they have
been seen to completion with follow-up review, b) they consented to
release of data in anonymised form, and c) illustrate the particular aims
of this article by serving as example for differing negative cycle types and
highlighting both the successes and challenges of applying EFT in brain
injury services.
Methodology
Each case will be presented in a uniform manner: a) pre-injury attach-
ment and relational themes, b) injury data and results of neuropsy-
chological assessment and mood/relationship questionnaires, c) reported
relationship difficulties by both partners, d) a narrative account of
the therapy process, and e) evaluation of therapeutic change for each
couple. The latter is achieved using both quantitative and qualitative
information.
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Identification of neuropsychological impairments
The precise nature of post-injury neuropsychological impairments for
survivors was ascertained using standardised neuropsychological tests as
part of the service’s routine clinical assessment. In addition to widely
used tests of intellectual functioning, language, attention, memory, exec-
utive functioning and visuospatial cognition, the following tests of social
cognition were used:
The Benton Facial Recognition Test, for face perception (Benton,
Sivan, Hamsher, Varney, & Spreen, 1994)
Reading the Mind in the Eyes Test, for mentalizing (Baron-Cohen,
Wheelwright, Hill, Raste, & Plumb, 2001)
Recognition of Faux Pas Test, for mentalizing (Stone, Baron-Cohen, &
Knight, 1998)
The Awareness of Social Inference Test, TASIT, for emotion recogni-
tion and social inference (Macdonald, Flanagan, Rollins, & Kinch,
2003)
Bangor Gambling Task, BGT, for emotion-based decision-making
(Bowman & Turnbull, 2004)
Social Situations Task, for social judgement making (Dewey, 1991).
Questionnaire measures of psychological distress and
relationship functioning pre- & post-therapy
Anxiety and depression for survivors of ABI was measures using the
Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith,
1983), noted for its sensitivity to mood difficulties following ABI inde-
pendent of non-mood related post-injury changes. For partners, the Beck
Depression Inventory-Second Edition (BDI-II) (Beck, 1991) and the Beck
Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988) were used.
The degree of care-giver burden experienced by partners was assessed
using a version of the Carer Strain Index (CSI) (Robinson, 1983), modified
for ABI (a sixteen item scale, scores ranging from 0 to 160).Relationship
functioning was assessed using the Dyadic Adjustment Scale (DAS)
(Spanier, 1976), which both survivors and their partners completed. This
yields an overall measure of dyadic adjustment or relationship quality
(total score ranging from 0 to 131, generated from thirty-two items, com-
binations of Likert and dichotomous scales). In addition we have used
two subscales to track changes in relationship functioning highlighted by
Yeates and colleagues (2012; Yeates, unpublished) to be pertinent out-
comes following brain injury. These are the Dyadic Cohesion subscale,
measuring the degree of interpersonal connection and responsiveness in
the relationship (six items, with scores ranging from 0 to 26) and the
164 GILES YEATES ET AL.
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Affective Expression subscale, reflecting physical intimacy in the rela-
tionship (four items, with scores ranging from 0 to 10). In the case reports
below, questionnaire scores are only reported if either partner’s scores
were within the clinical range/at cut-off pre-therapy, or moved into the
clinical range/cut-off as a negative outcome from therapy.
Determining statistical reliability and clinical significance of
therapeutic change
Statistical reliability and clinical significance of change in scores on psy-
chological measures pre-post intervention was determined following the
application of test theory as suggested by Jacobson and Truax (1991).
Statistical reliability of change in scores was calculated via their Reliable
Change Index (RCI), which moderates change in scores against the error
of measurement of the relevant instrument. RCI is calculated using the
following equation:
RC=X2 – X1
Sdiff
Where X2 represents the post-treatment score and X1 the pre-treatment
score, and Sdiff is the standard error of difference between the two
scores. Sdiff can be computed like this:
Sdiff = √2(SE)
2
SE=standard deviation of the normative sample
√1—test–retest reliability of the measure
Sdiff reflects the distribution of change scores should no actual change
have actually occurred. An RC of 1.96 or more is highly unlikely (
P
<
0.05) should no change have actually occurred.
The clinical significance of any statistically significant, reliable change
is indicated by an improved score passing a cut-off threshold for healthy
functioning as specified in the literature. Where this is not available, and
where the clinical and functional populations overlap (as is the case in all
of the measures used in our therapy evaluations below), Jacobson and
Truax advise a cut-off point that lies halfway between two standard
deviations from the mean of the clinical sample (in the direction of func-
tionality) and two standard deviations from the mean of the functional
population (in the direction of dysfunctionality). Normative data for each
measure is reported in Table 1 below, plus a generic ABI sample recruited
by Yeates and colleagues (2012; Yeates, unpublished). In comparing
the individual couples’ pre-intervention scores (Tables 2 to 5 in case
studies section below) with both normative and generic ABI sample data,
it is clear that in the four couples described below, where post-injury
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difficulties in social cognition and executive functioning are shared fac-
tors, there were increased levels of personal psychological distress and
relationship difficulties.
166 GILES YEATES ET AL.
TTaabbllee 11:
Normative
and
ABI
sample
data
for
each
outcome
measure
Measure Normative sample ABI sample
Reference for (Yeates et al., 2012;
normative data Yeates, unpublished)
DAS total Survivor
Mean 114.8 Mean 84.21
SD 17.4 SD 15.65
Cut-off point ≥ 96.5 Partner
Spanier (1976) Mean 83.83
SD 16.85
DAS coherence Survivor
Mean 13.4 Mean 14.62
SD 4.2 SD 3.96
Cut-off point ≥ 11.4 Partner
Spanier (1976) Mean 14.48
SD 4.58
DAS affective expression Survivor
Mean 9.0 Mean 5.94
SD 2.4 SD 2.36
Cut-off point ≥ 7.6 Partner
Spanier (1976) Mean 6.23
SD 2.38
HADS anxiety Mean 5.1 Mean 8.22
(Survivors) SD 3.3 SD 4.52
Cut-off point ≤ 8
Spinhoven et al (1997)
HADS depression Mean 3.4 Mean 6.12
(Survivors) SD 3.6 SD 3.66
Cut-off point ≤ 8
Spinhoven et al (1997)
BDI-II Mean 7.65 Mean 12.48
(Partner) SD 5.9 SD 10.6
Cut-off point ≤ 3
Beck et al. (1990)
BAI Mean 6.7 Mean 8.8
(Partner) SD 5.6 SD 9.6
Cut-off point ≤ 13
Beck et al. (1990)
CSI Mean 12.4 Mean 66.7
(Partner) SD 6.6 SD 42.4
Cut-off point ≤ 27.3
Fitzpatrick et al. (2010)
Q5
Q9
Q10
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These quantitative analyses will be situated within qualitative obser-
vations of the therapeutic process itself, with conceptual links made
between initial presenting problems, formulation, and final outcome.
Case
studies
Case A: Jack (fifty-six) and Harriet (fifty-two)
Pre-injury attachment and relationship themes
Jack described a difficult childhood in an inner-city context, with an
alcoholic father, whose intermittent physical and verbal abuse of all of
his three sons was punctuated by equally sadistic attacks between the
boys, with Jack as the youngest, the most common victim. His mother
was described as an absent figure to her children, preoccupied with
managing the needs of her husband. When not at school, Jack’s refuge
was the local public library, where from an early age he would immerse
himself in books from opening to closing hours. He spent his early-
middle adulthood progressing through the ranks of a financial institution,
from counter clerk to consultant, and educating himself to degree level in
the evenings. He was heroically hailed as a company success story and
later head-hunted by a multi-international firm.
He met Harriet at the beginning of this ascension, and she later nar-
rates her awe and respect of her husband’s accomplishments. She
became pregnant a year after they met, and went on to have three chil-
dren (aged eight, ten, and fourteen at the time of the injury). She assumed
the role of mother and housewife as Jack’s career progressed and the
family enjoyed greater and greater affluence after modest beginnings.
Harriet has experienced a great deal of loss in her life. Her parents both
died from illness during her late teens and early twenties, and her elder
brother, with whom she was very close, died just before the birth of her
first child. Harriet described herself as a “coper, just getting on with it” in
an unfair life, but invested in being present for her children as they grew
up. At the point of Jack’s injury, the family spent the week with Jack
largely absent, commuting long hours into the city to week. They would
regroup at the weekends, however, when the couple would experience
closeness and the family connected.
Details of brain injury
In 2007 Jack sustained an ischaemic stroke secondary to a left carotid
artery occlusion. This involved infarctions of both left and right middle
cerebral arteries, with damage to both left and right fronto-parietal areas.
Enduring cognitive difficulties post-injury were identified on neuro-
psychological assessment, in the areas of attentional switching (which
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affected prospective memory together with planning and organising) and
the recognition of disgust. The synthesis of multi-model social informa-
tion in rich social encounters would often be incomplete, due to the
aforementioned attentional difficulties resulting in the ineffective prioriti-
sation of the most pertinent social information for any given encounter.
Experiences post-injury
Jack was initially referred to our vocational rehabilitation service six
months post-stroke, as part of a large flurry to return to work as soon as
possible. Our service’s focus was organised by this initially, with no
wider family difficulties reported on initial assessment. However, a year
later, eighteen months post-injury, alongside considerable gains in
returning to work, he and his wife approached our service for family
support. This was initially, on the one hand, a request presented by the
couple to support their children in understanding and adjusting to their
father’s injury, and on the other, Jack’s disclosure of feelings of anxiety
and worry about both work and home.
Two initial large family meetings revealed a good understanding of the
stroke on the children’s part, but also Jack’s experience of being at the
bottom of the pile in the family pecking-order post-injury, changing places
with the dog as the recipient of scorn and irritation from other family mem-
bers. Harriet was vehemently joined by her children in despairing over
Jack’s withdrawal from family life as part of his attempts to return to work.
While at home he would be oblivious to the needs and perspectives of his
children, staying in his study for the most part, or when venturing out,
obliviously stepping through the middle of the children’s shared activities
in a preoccupied manner to access his laptop or phone in connection with
a work errand. Family commitments were frequently forgotten and de-
prioritised. Jack felt overwhelmed with managing a successful return to
work, ever fearful of making a catastrophic mistake from an attentional
slip that may cost his reputation and career, while at the same time feel-
ing like a constant failure at home, as a father and as a husband.
He was able to articulate a constant sense of rejection by people close
to him at home, initially so supportive during the acute phase post-
stroke, now experienced by Jack as constantly turning on him. When the
children were not present Jack described how this feeling of rejection
was at its most acute when his sexual advances were rejected by Harriet.
She acknowledged her intentional distancing from him to cope with the
stranger he had become to her—once assertive and strong, the public
face of the family (with her at his side), now scared, confused, and uncer-
tain. She describe moments when Jack had a “rabbit in the headlights”
expression on his face when confused or overwhelmed, and how she felt
disgusted by this, this was not the Jack she knew and fell in love with. On
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the other hand, she felt so isolated and lonely now, and missed the com-
panionship and shared strength that she used to experience with Jack.
These discussions led the couple to pursue support via couples therapy
sessions, to strengthen their family from within.
Course of therapy (twenty sessions)
The themes above were very present in the room from the beginning of
the EFT sessions. Jack would appear in his own world of overwhelmed
anxiety, experiencing much of the early discussions as entirely criticism
of his failings, which served to stimulate a deeper level of emotional
withdrawal from both Harriet and the two therapists in the room. For her
part, Harriet would attempt to share her disappointments with their
family life at home, in a tentative, uncertain manner, fearful of her hus-
band’s new fragility. In response to his withdrawal, she would end
abruptly, angry and exasperated, and then withdraw herself, muttering
how hopeless the situation was becoming. The therapy session was left
with uncomfortable silences, and it was difficult for the therapists to think
and offer new directions of inquiry at these moments.
These moments were eventually used by the therapists to track a
withdraw–withdraw cycle in the room, and in their relationships gener-
ally. Focusing initially on Jack, the therapists’ evocative questioning and
slicing the pre-withdrawal moments thinner were effective in expanding
his emotional experience. Jack progressively opened up and engaged
with the therapists initially, describing how his fear of doing the wrong
thing and failing constantly at home and work served to freeze him, for
fear of making things worse and losing Harriet to a greater degree. He
knew how disappointed in him she had become, but felt confused as to
how to make things right and when he did try to attempt solutions, would
be let down by his memory.
Harriet was surprised at these details, assuming that Jack’s progressive
psychological absence was a result of a core disinterest in her and the
family. She found this disconnection so painful, particularly in the con-
text of all of the other powerful losses in her life, and it became easier
over time to busy herself in her own activities and while maintaining her
role as a supportive wife in practical terms, minimising her meaningful
contact with her husband. However, the painful nature of these experi-
ences over the year, potent as they were given previous losses, made it
difficult for her to risk reaching out to Jack during sessions, even after
hearing his expanded emotional communication. Her withdrawal provi-
ded few clues for Jack to go on in attuning to her needs, and assumed
that unspoken criticism of him was a silent but constant factor on her
part. This negative cycle between them was framed by the therapist as
“staying in our bunkers”, drawing on a description from Jack in an early
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session, to capture the withdraw–withdraw dynamic. When Harriet’s
feelings did spill over and she would suddenly berate him at infrequent
moments, Jack described this as resurfacing into the middle of “enemy
fire”, causing him to drop back again into a withdrawn position that felt
safer. This formulation is represented in Figure 1 below.
170 GILES YEATES ET AL.
Figure 1: Jack and Harriet EFT formulation
1-Yeates.qxp 10/09/2013 16:22 Page 170
Jack’s neuropsychological impairments were located as an additional
influence, with both social cognition difficulties making it difficult for
Jack to read subtle social cues, and Harriet’s withdrawn position mean-
ing that other cues and content had greater capture for Jack on a moment
by moment basis in their busy family home, thereby her feeling “off the
radar”.
Across the twenty sessions of therapy, both partners were encouraged
progressively to come out from their respective bunkers and reach out to
each other from positions of vulnerability. Given the importance to
Harriet of knowing that she was being thought about by Jack, the thera-
pist started the expansion of emotional expression with Jack first. He was
encouraged to expand more on his position of wanting to do the right
thing to support and be there for Harriet, but feeling so absolutely afraid
that he will get things wrong again and let her and himself down. His
only default was to privately think about his return to work instead—
bringing in money to the family again would sort everything out, undo all
the wrongs, and it was a path that felt more in his control and a more
encouraging arena of previous triumphs in contrast to the confusion sur-
rounding his romantic relationship.
As this narrative was being developed, the therapists checked in with
Harriet constantly to understand the impact on her of hearing Jack’s
wishes and fears—did it allow her to feel safer in knowing that she was
on Jack’s radar more than she thought? If so, was she more inclined to
want to reach out to him? This process led to an enactment where Jack
was supported to powerfully say:
I feel like such a failure to you as a husband and father of our children.
I really want to be closer to you and support you more, I see how you
struggle doing so much for all of us at home. But I am so scared of
getting more things wrong, adding more to your plate and you becom-
ing even more disappointed in me. When I’m quiet it’s because I’m
confused and stuck, not because I don’t care.
Harriet, moved by this disclosure, was able to respond;
If I know that I’m thought about, that I’m not on my own, that’s
enough. I want to be let in to help you and us be a team again. When
you go into your own world, worrying about work, it feels like there’s
three of us in the relationship.
Jack was progressively able to hear Harriet’s needs not as criticisms, but
as invitations to be closer when she needed, despite him not having all
the answers at those times.
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These conversations allowed a regular checking-in between the cou-
ple to emerge as a repeating feature of their communication. This was
supported by mobile phone alerts prompting Jack to stop work-related
activities at pre-agreed times and prioritised the relationship for those
moments. Harriet developed renewed confidence to express what she
needed from him (in terms of childcare, domestic activities, but also
ideas to renew the romance in their lives, or a need in the moment for a
hug or a listening ear), and enjoy Jack’s increased responsiveness and
attention to her needs, from his new position of struggling but available,
out of the bunker. During this course of therapy their relationship deep-
ened, physical intimacy became a more prominent feature of their rela-
tionship, and their children reported an increased sense of the “old dad”
coming back again.
The attentional difficulties remained a constant challenge to the
couple’s intended plans of action for sharing and closeness. As therapy
sessions decreased from fortnightly to monthly towards the end, there
were increasing instances where Jack’s agreed and intended activities to
support Harriet were not realised, overwritten in his mind by work com-
mitments. This would trigger a retreat for both partners back into their
withdrawn positions. The consolidation phase of therapy aimed to pro-
vide additional cognitive supports (e.g., more clearly defined routines at
home, making the phone reminders for couples’ contact more potent
through the use of idiosyncratic musical melodies, marking them out
from work-related concerns) to help Jack manage his intended plans in
the face of distractors. Alongside this Harriet was supported to more
responsively signal her feelings of falling off the radar to Jack, as it was
happening, rather than sinking into her bunker and offering fewer cues
for Jack to make use of.
Those self-report measures for both Jack and Harriet that were scored
within the clinical range pre-therapy are listed in Table 2, alongside their
scores for those measures post-therapy.
Levels of physical intimacy were rated by both partners as problematic
pre-therapy. Both partners’ scores on measures of depression were
within the clinical range, as was Harriet’s level of care-giver burden.
Following the criteria set by Jacobson and Truax (1991), post-therapy
measures identified as now reliably lying within the functional range
were Jack’s ratings of physical intimacy and both partner’s self-ratings of
depressive symptomatology. Harriet’s ratings of physical intimacy fell
just below the cut-off score for a confident assertion of a movement to
functionality. Her ratings of care-giver burden had halved but still lay
outside the range of normative samples. Both partner’s scores of overall
relationship functioning improved by more than two standard deviations,
but did not reach the threshold score for a confident assertion of a move
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into functionality. Ratings of relationship cohesion for both partners did
not change significantly following therapy.
Reflections
This piece of work was identified as meaningful and helpful by both part-
ners who could track the improvement they made together during the
course of therapy, in increasing closeness and stopping the onward drift
of an insidious process of disconnection and distance between them.
These gains were reflected in the reliable positive changes in all of the
pre-post therapy scores, although some changes did not reach clinical
significance as operationalised by psychometric conventions. Those
scores, the care-giver burden, and overall relationship functioning
ratings, seem to reflect the enduring presence of neuro-disability in this
couple’s lives, be it at a significantly reduced level of impact on personal
distress and relationship connection and intimacy following couples
therapy (these post-therapy scores do now lay close to, or exceeding the
means of the community brain injury sample).
Case B: Terry and Daisy
Pre-injury attachment and relationship themes
Terry (sixty-four) and Daisy (sixty-five) have three adult children, all of
whom have left home and started families of their own. Both grew up
in the north of England. Terry has one sister and recalls that while his
parents were both very instrumentally supportive, his father did not often
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TTaabbllee 22:
Pre-
and
post-ttherapy
scores
for
Jack
and
Harriet
Measure Pre- Post- Reliable Nature of Clinically
therapy therapy change change significant?
score score index
DAS total
Survivor 73 88 2.98 Improvement No
Partner 63 76 2.58 Improvement No
DAS coherence
Survivor 15 15 0 No change No
Partner 11 11 0 No change No
DAS affective expression
Survivor 2 7 2.9 Improvement Yes
Partner 1 6 2.94 Improvement No
HADS depression 15 8 –4.02 Improvement Yes
BDI-II 13 0 –5.88 Improvement Yes
M-CSI 88 49 –8.90 Improvement No
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demonstrate physical affection towards them. Seeing his father provide
such to his grandchildren was both encouraging and saddening to Terry,
who wondered why his father was not able to do this for him. Daisy
described a very difficult childhood. She was raised mostly by her mater-
nal grandparents, interspersed with periods with her mother who was
remembered as critical, deceiving, and unpredictable. Daisy remembers
entrusting sensitive information to her in confidence only to then be pub-
lically shamed by her mother using that information. Her father left when
she was very young. Terry and Daisy met when they were in their early
twenties, married, and began to raise a family soon after. Terry was suc-
cessful at his work in insurance and was promoted regularly. However,
these promotions meant relocating to different parts of the country each
time. Daisy took up a role as a housewife, and accepted the challenges
of relocation (for her social isolation at times, not being able to develop
and maintain any social networks; managing the bulk of childcare as
Terry would often leave the house early in the morning and return late in
the night), seeing this as her way of supporting Terry and the family, and
assuming that Terry would not chose these kind of working conditions if
he had any choice throughout his working life.
Details of brain injury
Terry sustained a haemorrhagic cerebro-vascular accident ten years prior
to our couples therapy intervention. An aneurysm ruptured, resulting in
damage to the left dorsal frontal cortex. Neurosurgery was performed to
evacuate the haematoma and embolise the aneurysm. Neuropsychol-
ogical testing was completed at the beginning of the couples therapy,
and found ten years post-injury evidence of enduring cognitive difficul-
ties in auditory-verbal working memory, executive functioning affecting
planning, organising, and expressive verbal communication (e.g., initia-
tion and word-finding), together with recognition of disgust, mentalizing,
and emotion-based decision-making.
Experiences post-injury
Following his injury and initial period of rehabilitation, Terry attempted
an unsuccessful return to his former work role. After finding the cognitive
difficulties and post-injury fatigue to be insurmountable barriers to over-
come, Terry instead took up a part-time role in a local supermarket to
keep himself busy, alongside leisure interests. During a ten year period
post-injury, dissatisfactions grew in the couple’s relationship. Daisy grew
increasingly distressed that in their life post-retirement, where there was
no clear need to de-prioritise their time together as a couple under any
work commitments, Terry was still choosing to spend time away at work.
This led Daisy to wonder if during their whole married life together,
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Terry really did need to prioritise work and its disruptions the way he had
done, or if Terry had really chosen this lifestyle because he never really
cared that much for Daisy or the family. The implications of this possibil-
ity for Daisy left her once again, as with her mother, in a situation where
all of a sudden an attachment figure reveals their deceit and lack of care
for her.
On a day to day basis the couple’s experience of each other became
increasingly marked by cold periods of silence interspersed with argu-
ments and spiteful comments to each other. Daisy would experience
Terry as emotionally withdrawn, unavailable to her (either spending time
asleep during the day or engrossed in his own activities). She felt
unthought about and off Terry’s radar much of the time. When she would
try to reach out to him to express her sadness about this, or in response to
frequent faux pas that Terry would make in social company (e.g., saying
things in a direct way and unintentionally embarrassing or offending one
of their friends), she would then find that Terry would respond angrily,
snapping back at her. She found this response the most difficult post-
injury aspect to deal with, experiencing Terry as a horrible stranger in
their marriage at these moments. At the same time Terry experienced
Daisy as increasingly complaining, judging, criticising, or confusing and
bewildering. He experienced himself as constantly doing the wrong
thing by Daisy, letting her down, but finding this is out too late and feel-
ing ill-equipped to know how to make amends or do things differently in
the future. At the beginning of couples therapy, Daisy had accessed the
UK’s IAPT (Improving Access to Psychological Therapies) primary care
psychological therapies programme, and had completed a block of CBT
(cognitive behavioural therapy) for depression, but had judged this to
have been of limited value.
Course of therapy (twenty-five sessions)
The pattern of interaction (a oscillating pursue–withdraw/withdraw–
withdraw cycle) that held both partner’s positions in reciprocation to
each other became clear during the early sessions of therapy. A cycle
was outlined (Figure 2) where Terry’s sense of confusion and criticism
(from self and Daisy) led to withdrawal, over-determined by a combina-
tion of social cognition and executive impairments that made it harder
for Terry to encode subtle social cues from Daisy and also problem-solve
a response to her communicated dissatisfactions.
Terry’s withdrawal would lead Daisy to feel off the radar, lonely, and
abandoned, in response to which she would either pursue Terry with
questions, prompts, and accusations (creating a dilemma that even if
Terry did what she wanted after her prompts, he did not do it sponta-
neously, so his love and care for her could not be assured or trusted).
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176 GILES YEATES ET AL.
Figure 2: Terry and Daisy EFT formulation
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When questioning and prompting him in this way, Daisy would focus on
what Terry was doing wrong or the effect on her, but never stated what
she wanted or needed from him instead (which would be too emotion-
ally risky, leaving Terry the option of rejecting her emotional needs if
stated so directly, as her mother did). At other times, burnt out from this
pursuing, Daisy would also step away and emotionally withdraw from
the relationship, remaining quiet, sad, and hopeless about the relation-
ship. Terry felt trapped, judged, or confused in response to Daisy’s alter-
nating pursuing or withdrawal, and the dearth of clear social cues
characteristic of both Daisy’s responses kept Terry in a confused, uncer-
tain position. At times, feeling frustrated with the confusion and sense of
failure, Terry acknowledged he would act angrily in response to Daisy.
As such, the cycle between them was self-maintaining.
After identifying and sharing the cycle with the couples, the initial
focus was with Terry as the withdrawer, expanding his emotional experi-
ence and communication so Daisy could feel more thought about and
considered. Terry’s experience of confusion and uncertainty was opened
up using the RISSSC questioning approach, and he was able to progres-
sively articulate how he longed to do the right thing by Daisy, would
spend a great deal of private time trying to get things right before he
would overtly present the results to her. The vulnerability of this experi-
ence, the “work in progress” was taken up by the therapist, and Terry
was supported to describe how privately fraught his internal attempts to
get things right were for him, how feeling a failure has been a constant
quality of his subjective experience. Terry became tearful and increased
his eye-gaze towards Daisy during the evocative responding by the ther-
apist, who repeated his words and imagery while emphasising the vul-
nerable and confusing aspects of Terry’s subjectivity. At other times in
the therapy, Terry had a tendency to respond to Daisy’s emotional dis-
tress in an intellectual and practical way, missing the dimension of emo-
tional attunement. The idea of responding on the wrong wavelength was
developed with Terry, so highlighting the benevolent intention to reduce
Daisy’s distress alongside an unintended consequence of her feeling
unsupported emotionally. Daisy was deeply moved by this, realising that
the very times she felt “off the radar” Terry was privately anguished in his
consideration of her and longing to support her and for her approval. In
addition she felt compelled to reach out to Terry, comfort and feel close
to him in his vulnerable experience. She described “feeling something of
him again, getting the old Terry back” during these communications.
With Daisy now more hopeful following Terry’s expanded emotional
communication, the therapist spent more time elaborating the ambiva-
lence of her position now in the relationship. On the one hand the afore-
mentioned moments in therapy have given her hope that she can get
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more of the old Terry back. On the other hand stepping back into a con-
nected position with Terry risked being disappointed and hurt again (as
would still happen mid-therapy when Terry’s openness in sessions was
contrasted with a return to withdrawn, unresponsive positions back
home between sessions), and feeling “off the radar” for Daisy was always
a deeply painful experience, with its re-activation of earlier attachment
crises. Given the hypothesis stated in the introduction that the emotional
withdrawal of the non-injured partner may over-determine an organising
influence of the survivor’s social cognition difficulties on the couple rela-
tionship (in fact this idea was as influenced by this particular couple as
the research data discussed previously), Daisy’s increased emotional
engagement in the relationship was considered to be pivotal. Using
evocative responding and RISSSC questioning, Daisy’s emotional
dilemma was articulated and amplified (while preventing her expression
of this turning into critical attacks on Terry, instead stating her competing
needs of longing for closeness with him yet fearing being hurt and left on
her own again). She became very tearful as she was encouraged to
express these needs to him in this way, her eyes looking longingly but
apprehensively at him. During session twelve, with this amplified emo-
tional signal at its most potent, Terry was overcome with compassion and
embraced Daisy passionately, kissing her, apologising. This was the first
physical contact of this kind in the ten years since the injury.
The consolidation phase of the therapy lasted ten sessions, over a
six month period. Daisy was encouraged to progressively risk initiating
a communication of emotional needs between them more and more,
giving up a cherished wish that Terry will spontaneously know and
respond to her needs. However, she began to find that these risky com-
munications would lead to more frequent emotionally attuned responses
from Terry. For his part, it seemed to be a constant revelation to him that
to express vulnerability and disclose his struggles (“work in progress”)
would result in Daisy feeling thought about and closer to him. He found
her modified expressions of need when things had gone wrong, to be
opportunities to get things right again and be closer. The couple devel-
oped a visual symbol, a key, to show to each other to express a vulnera-
ble need for closeness during a building argument (in an immediately
recognisable way that was complementary to Terry’s post-injury neuro-
psychological profile) which was extremely helpful in triggering repara-
tive moments more frequently.
A comparison of pre- and post-questionnaire scores reflected the posi-
tive changes observed during therapy. Reliable and clinically significant
improvements in scores were identified for Daisy’s ratings of her depres-
sion and relationship cohesion. Reliable changes were observed in her
ratings of overall relationship adjustment (not sufficient to fall within the
178 GILES YEATES ET AL.
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normative range but favourably comparable with the community ABI
sample), relationship cohesion, physical intimacy in the relationship and
care-giver burden (decreasing from the upper extremes of the scoring
range to just outside the normative range on the M-CSI, and favourably
comparable with the community ABI sample). Terry’s post-therapy scores
did move into the normative range on measures of physical intimacy and
depression. However, the pre-therapy scores were just the other side of
the cut-off point on these measures and the magnitude of resultant change
was not statistically reliable. His ratings of overall relationship adjustment
and relationship cohesion did not change as a result of therapy (Table 3).
Reflections
Of all the couples reported here, Terry and Daisy demonstrated the most
dramatic changes in their expression of intimacy and emotional connec-
tion across sessions. This intervention could also be seen retrospectively
as a more potent treatment of Daisy’s mild depression than her individual
cognitive-behavioural therapy. This makes sense given EFT’s targeting of
the attachment crisis in which survivors and couples find themselves post-
injury, and which the individual mood difficulties of each partner may
reflect (Bowlby, 1969). This case mostly clearly illustrates the hypothe-
sised critical post-injury relationship changes hypothesised to affect many
couples following ABI—neuropsychological difficulties that undermine
emotional attunement in the relationship plus the emotional withdrawal
of the non-injured partner. In the same way this case demonstrates the
THE USE OF EMOTIONALLY-FOCUSED COUPLES THERAPY (EFT)
179
TTaabbllee 33:
Pre-
and
post-ttherapy
scores
for
Terry
and
Daisy
Measure Pre- Post- Reliable Nature of Clinically
therapy therapy change change significant?
score score index
DAS total
Survivor 88 83 1.78 No change No
Partner 71 84 2.58 Improvement No
DAS coherence
Survivor 17 15 –0,9 No change No
Partner 8 14 2.70 Improvement No
DAS affective expression
Survivor 6 8 1.18 No change Yes
Partner 0 6 3.53 Improvement No
HADS depression 7 5 1.15 No change Yes
BDI-I 13 0 5.88 Improvement Yes
M-CSI 143 32 25.34 Improvement No
1-Yeates.qxp 10/09/2013 16:22 Page 179
path to relationship change that can occur when the non-injured partner
makes the commitment to move out of the withdrawn position and
take responsibility for initiating sequences of emotional closeness in the
couple, as risky and saddening as this can be experienced initially.
Case C: Bill and Kelly
Pre-injury attachment and relationship themes
Bill (sixty-one) and Kelly (fifty-eight) had been together forty-one years at
the point of seeking help with their relationship, six years post-stroke.
They have two adult children who have their own families elsewhere in
the UK. Both partners followed a life philosophy of working hard (doing
their respective bits in the workplace and at home) and getting on with it.
Neither felt they were emotionally open people. From an expanded posi-
tion mid-therapy, Kelly looked back on her life with an increased aware-
ness that she had always been putting others’ needs before her own in
her life. As a daughter she was encouraged less by her parents and
enjoyed fewer life opportunities than her brother. After meeting and
marrying Bill she settled quickly into the roles of mother and housewife,
supporting the educational and vocational success of their children
alongside Bill’s determined progression in his career as an engineer. Bill
spent his whole adult life working long hours to financially support his
family, while spending little free time with them.
Details of brain injury
Bill sustained an ischaemic CVA in the right medulla in 2004, following
a history of ischaemic heart disease. Neuropsychological assessment in
2010 identified enduring difficulties in the areas of planning and organis-
ing, visual selective attention, and the recognition of sadness, disgust,
and sarcasm in others. In addition he had been left with left-sided weak-
ness affecting his mobility and upper limb dexterity.
Experiences post-injury
In the six years of rehabilitation post-stroke, the majority of professional
input (within stroke services) had been to support Bill’s physical recov-
ery, with his cognitive and emotional needs beginning to be addressed in
the year preceding the first couples session, following contact with our
service. Both Bill and Kelly attended educational groups which covered
the cognitive and emotional sequelae of brain injury and both identified
in these groups post-injury changes that they had been struggling with,
but about which had been unable to have a shared conversation with a
professional up to that point in time, nor even have a vocabulary with
which to describe and make sense of such changes. One year into their
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contact with our service, Kelly rang up one day in an acute state of dis-
tress. She tearfully poured out her frustrations about Bill’s behaviour and
disclosed that if nothing was done she might actually attempt to kill him,
such was the level of rage that was triggered by her interactions with
him. This intensity of feeling had been building for a while but at its cur-
rent point was very distressing and she felt she had little control to avoid
causing him harm. She agreed by the end of the phone call to come in
with Bill for a series of couples sessions.
In the initial couples session, Kelly described her frustration, anger, and
rage in response to Bill’s mood and behaviour. She narrated how in the
first year post-stroke Bill was upbeat and his usual determined self in his
physical recovery. However, his return to work process was a disaster—
he found out belatedly that he did not possess the cognitive abilities to do
his pre-injury job, made some critical mistakes, and was medically retired
from work. This plunged him into a deep depression for a year, and while
subsequently resurfacing for the most part, had remained in a withdrawn
but controlling position in their relationship ever since. She would often
express her frustrations at something he has forgotten or done wrong, to
which he would go quiet and unresponsive. This would infuriate Kelly,
who would persist in her complaints, shout louder, and become abusive.
She experienced herself as “a mad woman, a horror”. Bill would quieten
even more. Kelly noted that money had become a contentious issue for
them both. While the couple used to use a joint account alongside their
individual ones, Bill had started to redirect money to his own account,
preventing Kelly from accessing it when she needed it. When she had
resolved organisational problems for Bill, often at great stress and hard-
ship to herself, she had felt unappreciated and ignored.
Bill described how he would feel attacked during these time, felt like a
failure, letting everyone down, feeling out of control, and just wanting it
all to go away. Since the difficulties with returning to work, a domain in
which he previously experienced himself as competent and successful, he
had felt less and less in control of his life. The changing around of money
across bank accounts was understood as one way in which he has wres-
tled some form of control back in an area of life (he always used to man-
age money in the family), but on his terms in isolation, finding the business
of a shared interaction/joint bank account to be overwhelming and unpre-
dictable. When feeling out of control this way, he acknowledged he was
more likely to either go quiet or criticise and devalue the additional roles
and tasks that Kelly had been undertaking since the stroke.
Course of therapy (six sessions)
In the initial three sessions Bill and Kelly’s respective positions were con-
nected through the description of a pursue–withdraw cycle (Figure 3).
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182 GILES YEATES ET AL.
Figure 3: Bill and Kelly EFT formulation
1-Yeates.qxp 10/09/2013 16:22 Page 182
Bill’s withdrawal was seen to leave Kelly feeling unappreciated,
ignored, devalued, shut out, and subsequently enraged. In trying to get a
response out of Bill, with her communications escalating higher and
higher as Bill withdrew more and more, Kelly’s actions were reframed as
an attachment protest—she would not let her contact with Bill and rela-
tionship disappear and drift away. This would leave Bill feeling criti-
cised, confused (influenced by the social cognition and executive
difficulties), overwhelmed, failing Kelly, and so trigger further with-
drawal, perpetuate and escalate the cycle and lead to more extreme
manifestations of the cycle between them.
The couple found the initial outline of the cycle to be extremely help-
ful, left them feeling less blaming of themselves or each other, and were
able in the fourth and fifth sessions, via the evocative responding and
RISSSC questioning of the therapist, to access more complex feelings and
fundamental attachment fears. Kelly was able to explore the huge sense
of resentment that she had been feeling all of her adult life about her own
needs never being put first, how she was waiting desperately for this in
their retirement, and how robbed of this she felt by the stroke and Bill’s
ever-increasing emotional close-down. She felt the loss of a thoughtful,
considerate gaze on her needs more than ever, and felt fundamentally
abandoned and alone. She described this tearfully, while Bill was able to
explore his crisis of self-identity in a life post-stroke with no work role
and opportunity to contribute and feel worthwhile. In these two sessions
each partner was encourage to acknowledge the distress of the other,
and reach out for and to provide support. Kelly was able to articulate
how she needed Bill to let her and notice her needs and wants, so she
can feel connected. Bill was able to see how this was a way of feeling
useful and worthwhile again, and get comfort himself at low points, the
mutual benefits of a joint account.
On the sixth session the couple announced their mutual valuing of the
couples session thus far and the wish not to attend any further sessions.
This was a surprise to the therapists, who while acknowledging the
progress made thus far had anticipated more work to be undertaken in
future sessions to cement a positive nurturing cycle in the place of the
negative loop. We wondered if this departure was premature and if we
would see the couple again soon in crisis and disappointment. A thera-
peutic letter was written to the couple to outline the formulation of the
cycle, included elaborated aspects of self-experience, plus the key
aspects of communication that the couple had used to exit out of this
cycle and develop more nurturing interactions with each other. General
neuro-rehabilitation service reviews with the couple at six and twelve-
months post-therapy indicated that the therapeutic gains were main-
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tained and the couple continued to enjoy a new closeness with each
other. They had even completed a DIY refurbishment of their kitchen, as
a team, without the prolonged appearance of the negative cycle in the
process.
The couple did re-complete the measures as part of a research study
eight weeks following their last session (Table 4 below). Kelly’s ratings of
the overall relationship adjustment had improved to just below the lower
boundary of the normative sample for the Dyadic Adjustment Total Scale
(and favourably comparable with the community ABI sample). ratings of
relationship cohesion increased significantly, falling within the norma-
tive range post-therapy. Their ratings of physical intimacy did increase by
a couple of points to just pass into the normative range, but the magni-
tude of this movement was not of a reliable degree statistically. Kelly’s
ratings of depression and anxiety both decreased in the direction of func-
tionality, the former being reliable and clinically significant. In contrast,
her scores of care-giver burden increased, perhaps reflecting a new
understanding of the enduring aspects of the brain injury influencing
their relationship (but without ongoing couple’s work to support this
understanding). While Bill’s ratings of relationship cohesion significantly
improved post-therapy, his score for overall relationship functioning
decreased significantly. The reasons for this were unclear, and may have
reflected some outstanding work for him within couples therapy that was
not completed within the six sessions held.
184 GILES YEATES ET AL.
TTaabbllee 44:
Pre-
and
post-ttherapy
scores
for
Bill
and
Kelly
Measure Pre- Post- Reliable Nature of Clinically
therapy therapy change change significant?
score score index
DAS total
Survivor 82 69 –2.58 Negative No
Partner 69 90 4.17 Improvement No
DAS coherence
Survivor 14 19 2.25 Improvement Yes
Partner 6 19 3.15 Improvement Yes
DAS affective expression
Survivor 7 9 1.18 No change Yes
Partner 8 9 0.6 No change Yes
BDI-II 13 7 –2.17 Improvement Yes
BAI 9 2 –1.8 No change Yes
M-CSI 65 81 4.17 Negative No
1-Yeates.qxp 10/09/2013 16:22 Page 184
Reflections
This couple appear to have experienced a meaningful change in their
relationship over six sessions (three months), following several years of
relationship and psychological distress post-stroke. The therapists would
have like to have persisted in the EFT process to deepen the couples’
exploration of their respective constructions of self and attachment fears,
to orchestrate deeper reconciliatory, positive interactional cycles. How-
ever, the couple decided their work was done following the six sessions,
and their self-report several months later did bear this judgement out,
even if the psychometric data indicated outstanding areas of individual
needs and relationship difficulties.
Case D: Jeff and Tammy
Pre-injury attachment and relationship themes
Jeff (forty-two) and Tammy (fifty-eight) formed a relationship following
Jeff’s injury. Jeff was brought up in Scotland but moved down to England
when seventeen to take advantage of greater work opportunities in
London. He was in an abusive relationship with a female partner for sev-
eral years and sustained a traumatic injury from an assault, suspected to
have been perpetrated by her, in 2008. Jeff does not like to think about
this time and has remained cautious and uncertain in relationships since.
Tammy disclosed a very abusive childhood, involving repeated sexual
abuse from her siblings alongside neglect interspersed with violence
from both parents. She moved away and distanced herself from her fam-
ily as soon as she was old enough to leave. Her adult life to date included
a chronic history of bulimia nervosa and a succession of failed relation-
ships. She has been a victim of domestic violence from previous partners,
and has been cheated on by others. She has an adult daughter who has
ostracised her, Tammy was not able to explore why this has happened.
Details of brain injury
An MRI scan (magnetic resonance imaging scan) highlighted damage to
the right frontal pole and inferior right frontal cortex. Neuropsychol-
ogical assessment eighteen months post-injury identified acquired,
enduring difficulties in executive functioning (initiation plus the formula-
tion and implementation of plans in response to multiple goals), visual
selective attention, speed of information processing, working memory,
and the encoding and retrieval of information secondary to the executive
difficulties. This appears to have extended into the semantic domain, as
Jeff’s access of verbal meanings and knowledge was problematic and
unreliable. Social cognition assessment highlighted difficulties in face
perception, recognition of others’ happiness, anger, anxiety, disgust
(with an intact ability to recognise sadness), inference of sarcasm in
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others’ communication, mentalizing when using contextual and verbal
descriptive information alone, detecting violations of social norms, and
emotion-based decision making.
Experiences post-injury
Jeff and Tammy met while working as support workers in a community
youth project, Jeff’s first paid role, four years post-injury. The couple had
been together twelve months when they requested support from the ser-
vice, two years post-injury. While Tammy rented a room in a shared
house elsewhere, the couple had essentially been cohabiting at Jeff’s flat
for six months at this point. Difficulties developed in two areas: shared
activities together, and sexual intimacy. When both partners were not
working, Tammy grew increasingly dissatisfied that they would spend all
of their time in Jeff’s flat, with him mostly playing on the games console.
She would end up doing all the cleaning and cooking for him. Jeff’s
experience during these times was a mixture of fatigue (a significant post-
injury feature in his life since he began part-time work) and inertia, with
his initiation difficulties making it hard for him to spontaneously generate
ideas for things to do together. Tammy felt unthought about and a servant
to Jeff, as she did in the bedroom. They had developed a pattern of sex-
ual contact were she would please Jeff while feeling neglected by him,
putting up with this but growing in resentment. Jeff described constant
uncertainty in the bedroom, not knowing what to do differently to please
Tammy, and worrying about doing the wrong thing. Tammy’s growing
feeling in the relationship as a whole was that Jeff did not really love or
care about her, was keeping secrets and withholding things from her.
This was a familiar position for Tammy in relationships, and portended a
bleak future for them together.
Course of therapy (thirteen sessions)
The sessions of EFT were held over a period of a year. The initial eight
sessions were held fortnightly over four month and the last four were at
infrequent intervals, interspersed with cancellations from the couple.
During the latter eight month period, the couple broke up on two sepa-
rate occasions, each lasting around four weeks, and later contacted the
service to resume sessions about four to six weeks after getting back
together. The couple did separate for a third time and have not resumed
sessions to date, although have been back together for around three
months to the authors’ knowledge.
Following a standard EFT process a negative cycle was outlined in early
sessions, describing Jeff’s sense of being “in a fog”, accompanied by
Tammy’s need to build a protective brick wall around herself (Figure 4),
a withdraw–withdraw cycle.
186 GILES YEATES ET AL.
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THE USE OF EMOTIONALLY-FOCUSED COUPLES THERAPY (EFT)
187
Figure 4: Jeff and Tammy EFT formulation
1-Yeates.qxp 10/09/2013 16:23 Page 187
Tracking the cycle through, Tammy would raise an issue of discon-
tentment with Jeff (mostly around time together or sex), which would leave
Jeff frozen and confused. He had a sense that he had done something
wrong again, that Tammy’s unhappiness was growing and it was his fault,
but did not know what to do to fix it. At this point initiation difficulties
made it difficult to generate a response, interacting with re-activation of
his early relationship trauma—when a partner would raise discontent-
ment, in his experience, the situation would become dangerous. All Jeff
knew for certain was that any attempted solution typically was not what
was required, and made things worse. So Jeff typically did nothing, apol-
ogises, but then would say little, withdrawing into himself, and turning
away to play on a computer game. Tammy experienced this withdrawn
lack of response as something to be suspicious about. She felt that Jeff’s
head was swimming with thoughts and information that he was with-
holding from her. She noted that at times she wondered if Jeff’s sisters and
wider family all knew about aspects of his life that she did not, and had
fun and enriched relationships together to her exclusion. She came to
understand these moments in the cycle as re-activation of previous trau-
matic feelings of shame, humiliation, abandonment, and rejection from
earlier experiences of abuse and infidelity. Tammy felt out of control in
this place and relied on a tried and trusted only remaining option when
feeling like this throughout her life—to withdraw and retreat into herself.
She described this as building up a brick circular wall to protect herself
from the repeating cruelty that life seemed to throw at her. In this place,
while Tammy felt safer, Jeff had less cues to read from her on how to reach
out to her (compounded by his array of emotion recognition and emo-
tion-based decision-making difficulties) and felt in an even thicker fog, so
escalating the cycle.
Given the complex, post-trauma aspects of this work, the guidance of
Johnson (2002) was followed to move through the therapy at a very slow
pace, attempting to establish a secure base in the therapy sessions to
allow both partners to start reaching out to one another. The therapists
focused on Jeff first, expanding his sense of being in the fog at critical
moments, including in the sessions when Tammy did express her discon-
tent. The disorientating and destabilising qualities of this experience was
elaborated (“It feels like the world is falling away from me and I don’t
know which way to turn next”) as Tammy listened, and clear links were
made both to previous relationship trauma (a shared aspect of experi-
ence for them both) and to the brain injury, with education around exec-
utive functioning difficulties and problems in initiation (“Jeff the brain
injury seems to have left you stuck ‘on pause’ at certain moments, unable
to ‘press play’ and get your thoughts going again”).
188 GILES YEATES ET AL.
1-Yeates.qxp 10/09/2013 16:23 Page 188
Tammy’s experienced was explored simultaneously in these discus-
sions, seeing what was happening with her brick wall the more she was
hearing about Jeff’s sense of being in a fog. Hearing that there were no
secrets, just confusion, did that lead her to take a risk and remove one or
two bricks from her wall? Could she dare to reach a hand out from the
hole in her wall and express her need for closeness and connection and
help Jeff in knowing how best to meet those needs? This was particularly
pertinent in discussing sexual intimacy, as Tammy acknowledged that
she always ended up pleasing her partners while feeling neglected, but
feared bringing this up in a relationship in case the partner would leave
her. Tammy started to take risks in guiding Jeff to help him attune to her
physically (following exercises from Sensate Focus psychosexual ther-
apy, Masters & Johnson, 1976). Given the uncertainty and anxiety of
both partners in elaborating their fears and needs, the therapists
expanded Jeff and Tammy’s articulated experience through one to one
exchanges between client and therapist first (allowing the other partner
to hear the emerging, different conversation and checking in on their
responses), later building to enacted expressions of fears and needs to
each other.
The couple initially responded to these ideas well, and charted a pro-
gression of increased closeness and openness in their relationship, feel-
ing that their reaching out to each other to express their vulnerabilities
and uncertainties were met safely and responded to by the other. Tammy
found the psycho-education around initiation difficulties helpful, further
supported by the local brain injury specialist nurse outside of the cou-
ples’ sessions. However, when a misattunement eventually occurred,
when Jeff was particularly tired or did not have the right cues to respond
to Tammy, she would be immediately plunged back into a unsafe, dis-
trusting position, and needed to build the brick wall around her once
again. The previous information about post-injury cognitive difficulties,
once meaningful when she felt emotionally safer, were no longer acces-
sible to her in those unsafe moments. Her withdrawal during these times
would include the couples therapy sessions themselves, as it would be
her who wished to cancel these sessions and the once again risk oppor-
tunities to share vulnerable feelings. Jeff would be back in the fog in
these times, without sufficient cues and prompts, and the withdraw–
withdraw cycle re-established itself with vigour once more.
The couple did complete a re-administration of the questionnaires for
research purposes in the same week as their last appointment, permitting
a comparisons of scores with those derived at the beginning of therapy,
in Table 5 below.
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At the beginning of therapy, both partners rated the overall adjustment,
cohesion, and physical intimacy in their relationship within the dysfunc-
tional range on the various Dyadic scales (although Jeff’s rating of inter-
connectedness was within the functional range). Jeff’s self-ratings of
anxiety and depression were within the borderline range for the former
and in the clinical range for the latter. Tammy’s self-report scores were
within the clinical range for depression (severe range), anxiety (moderate
range), and care-giver burden. After the thirteen sessions, Tammy’s rating
of care-giver burden did decrease, but did not reach the normative range.
This was understood to reflect the increasing time she had been taking
away from the relationship at the point of post-therapy questionnaire
completion. While Tammy’s ratings of overall relationship quality did
significantly increase post-therapy, both partner’s ratings of relationship
cohesion, physical intimacy, depression, and anxiety either remained
stable within the clinical range or significantly worsened to more
extreme levels of distress.
Reflections
It seems that EFT, while helpful for this couple initially, did not lead to
changes in relationship for this couple as it did for the other three
couples. While the brain injury service’s link with Jeff remained from a
190 GILES YEATES ET AL.
TTaabbllee 55:
Pre-
and
post-ttherapy
scores
for
Jeff
and
Tammy
Measure Pre- Post- Reliable Nature of Clinically
therapy therapy change change significant?
score score index
DAS total
Survivor 58 58 0 No change No
Partner 55 68 2.58 Improvement No
DAS coherence
Survivor 16 8 –2.7 Negative No
Partner 5 8 1.35 No change No
DAS affective expression
Survivor 3 3 0 No change No
Partner 7 6 –0.6 No change No
HADS anxiety 8 17 5.36 Negative Yes
HADS depression 12 11 –0.57 No change No
BDI-II 29 39 4.52 Negative Yes
BAI 26 25 –0.25 No change No
M-CSI 56 37 –4.34 Improvement No
1-Yeates.qxp 10/09/2013 16:23 Page 190
community neuro-rehabilitation perspective, it has become clear that the
couple have moved forward in their relationship following their last sep-
aration, without the need for couples therapy. It may be that it is emo-
tionally safer for both of them at the current time to carry on with a
dissatisfactory, but predictable and safer status-quo. Indeed it may be the
practical supported provided by occupational therapy and community
nursing within the team, in relation to planning leisure and daily activi-
ties, that has provided the most enduring support for the couple in their
ongoing but fragile and changeable connection with each other.
It is unclear which specific factors within the complexities of this cou-
ple case are responsible for the limited efficacy of EFT. Jeff is the only sur-
vivor of traumatic brain injury in these cases. He did sustain an array of
social cognition impairments, although this was also the case for the ABI
survivors in the previous cases. His initiation difficulties were more pro-
nounced than the other survivors, which may have over-determined a
greater likelihood of withdraw–withdraw cycle activation on a weekly
basis. Unique to this couple are the fact that they met post-injury and
have no children together, so a lack of a historical constellation of mean-
ings and shared relationships may be a vulnerability factor in their rela-
tionship (as suggested by Kreutzer, Marwitz, Hsu, Williams, & Riddick,
2007). An additional distinguishing factor is the pre-injury psychological
trauma history of both partners, situated as it was within close relation-
ships. For Jeff this may have interacted with and compounded the effects
of the cognitive difficulties in influencing a withdrawn position within
relationships, while for Tammy her relationship history clearly influ-
enced how she experienced the manifestation of Jeff’s cognitive difficul-
ties (despite psycho-education on an intellectual, factual level), and her
ability to initiate an exit out of the negative cycle for both of them.
Without the dynamic work and cues of the therapist in the session to
help the couples move out of their positions in the cycle and take risks in
expanding their emotional communication of vulnerability and reach out
to each other, the relationship between and beyond sessions seems to
have returned to an organisation of withdrawal and avoidance of emo-
tional risks.
Discussion
and
conclusions
Four EFT couples therapy cases have been presented. In each case these
couples include a survivor of ABI (eighteen months post-injury or more),
coping with enduring difficulties in social cognition and executive func-
tioning (a common neuropsychological profile across many forms of ABI,
(Yeates, in press)), in addition to psychological distress and challenges to
self-identity. Their romantic partners were also emotionally distressed,
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suffering clinical levels of depression, anxiety, anger, or burden) at the
beginning of therapy. The relationship in every case was characterised
by disconnection prior to therapy, some involving conflict, others involv-
ing cold, lifeless withdrawal. As a result of EFT in three of the cases, the
psychological distress of individual partners was reduced and gains were
made in the couple relationship, often involving increased interconnect-
edness/cohesion, physical intimacy, or overall relationship satisfaction.
While comparing very favourably with a community brain injury sample
(Yeates, unpublished; Yeates et al., 2012), in many cases aspects of the
relationship were not improved to the scoring range of non-distressed
marital couples who have not experienced a brain injury. However, in
the first three cases many aspects of the relationship, as rated by both
partners was improved significantly and on occasion moved to close to
the lower boundaries of a normal sample. Given the enduring and dev-
astating features of ABI as it is often portrayed in both scientific and lay
literatures, such empirically demonstrated achievements are important.
However, it is the qualitative process gains made in therapy by the first
three couples that are the real encouragement to the clinicians reporting
this work here. These often occurred in a short period of time following
many years post-injury, and after many years of relational and individual
distress. We have been honoured to witness profound moments of re-
connection during the EFT process, often after long period of drought and
inertia in emotional closeness.
The fourth couple are presented as a contrast. Given the limited in-
therapy progress made by the couple and their ultimate disengagement,
we were surprised that some positive relational changes were evident in
the post-therapy DAS scores. However, most of the measures did bear
out the therapists’ impressions in the room—the EFT process, with its
requirement for partners to take progressive risks in sharing attachment
fears and needs with each other, was too great an ongoing demand. The
particular combination of psychological trauma histories, withdrawal
attachment strategies, and initiation cognitive difficulties, was an insidi-
ous organising influence in this couple.
The comparison of the three successful and one unsuccessful cases
hints at the therapeutic mechanism of EFT for this clinical population,
both in terms of its potential value and limitations across different cou-
ples. Where social cognition and executive difficulties have over-deter-
mined emotional disconnection between a couple post-injury, often
exploiting pre-injury vulnerabilities in the relationship, EFT can facilitate
the clarification of emotional states, needs and perspectives, and subse-
quent orchestration of these and attunement between partners. The
evocative responding and RISSSC techniques of EFT serve to amplify
emotional experience and communication, and may serve to breach a
192 GILES YEATES ET AL.
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raised threshold for the survivor post-injury (Yeates, 2013) to be moved
into a compassionate, nurturing response to their non-injured partner. In
this way, EFT can be seen to directly target neuropsychological threats to
attachment and social connection. These neuropsychological influences
are considered to be enduring, however, and without a moderating influ-
ence in relationship dynamics, are always potential threats to closeness
within a couple’s relationship. As such, the authors believe that success-
ful EFT following brain injury requires the non-injured partner to take
ongoing responsibility to step out of a conflictual or withdrawn position
to cue/initiate an attuned response from the survivor. Many partners are
willing to take this role on after experiencing meaningful positive
changes in their relationship during EFT sessions. For other couples,
however, perhaps like Jeff and Tammy, the level of interacting complex
psychological and neuropsychological needs would not permit the pro-
longed acquisition of this role-arrangement and communication pattern.
The four cases here, however, are not a substantial basis for generali-
sations about the efficacy of EFT following brain injury. Instead, the
detailed observations and single-case evaluations reported here support
a rationale to test the efficacy of this therapy through controlled group
studies, and determine with greater certainty the proportion of distressed
couples that may or may not benefit from this approach in brain injury
services. Group therapy process research may also identify survivor-
and/or partner-related variables that are predictive of therapy outcome.
Until such studies are reported, further case study reports of EFT with dif-
ferent ABI subgroups (in terms of injury type and/or differing profiles of
neuropsychological, psychological, and relational needs) would be wel-
come to develop couples therapy practice in brain injury services.
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