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Emotionally focused individual therapy for the treatment of trauma- related symptoms of the self


Abstract and Figures

Emotionally Focused Individual Therapy (EFIT) is an evidence-based and empirically supported therapy (Wiebe & Johnson, 2016). Although there is significant research on EFT for couples with trauma, there is limited research on the effect of the treatment for trauma of individuals. The study models change in trauma-related symptoms and emotional dysregulation over the course of 12-15 sessions of EFIT treatment with 40 individuals. HLM results confirmed a significant change demonstrating a decrease in trauma-related symptoms of depression, attachment difficulties, and impaired self-reference. The findings did not show any significant decrease in emotional dysregulation across therapy sessions. It should be noted that the Covid-19 pandemic impacted the study results and lead to limitations, such as incomplete data. The findings support the theoretic assumption that EFIT helps alleviate symptoms of trauma for individuals engaged in therapy. Keywords: attachment theory, emotionally-focused, emotional dysregulation, and trauma
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RUNNING HEAD: Emotionally focused individual therapy for the treatment of trauma-
related symptoms of the self
Thesis submitted to Saint Paul University in partial fulfillment of the requirements of the
Master of Arts in Counselling and Spirituality
School of Counselling and Spirituality
Saint Paul University
Ottawa, Ontario, Canada
© Meghan Billings, Ottawa, Canada, 2021
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Emotionally Focused Individual Therapy (EFIT) is an evidence-based and empirically supported
therapy (Wiebe & Johnson, 2016). Although there is significant research on EFT for couples with
trauma, there is limited research on the effect of the treatment for trauma of individuals. The study
models change in trauma-related symptoms and emotional dysregulation over the course of 12-15
sessions of EFIT treatment with 40 individuals. HLM results confirmed a significant change
demonstrating a decrease in trauma-related symptoms of depression, attachment difficulties, and
impaired self-reference. The findings did not show any significant decrease in emotional
dysregulation across therapy sessions. It should be noted that the Covid-19 pandemic impacted the
study results and lead to limitations, such as incomplete data. The findings support the theoretic
assumption that EFIT helps alleviate symptoms of trauma for individuals engaged in therapy.
Keywords: attachment theory, emotionally-focused, emotional dysregulation, and trauma
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
This thesis is dedicated to the survivors of trauma.
To my family who continues to survive it.
And to my beloved dog, Wilson, whom I tragically lost while writing.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
First and foremost, I would like to extend my deepest gratitude to my thesis supervisor Stephanie
Wiebe for her tremendous patience and guidance over the last few years, and to whom I am
I would also like to thank my father who proofreads all of my written work and keeps me
Finally, I would like to thank my committee members, Stephanie Yamin and Yuanyuan Jiang,
for their brilliance and for serving on my board.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Table of Contents
Abstract ii
Dedication iii
Acknowledgements iv
Table of Contents v
Table of Figures vi
Introduction 1
1 Literature Review 4
1.1 The Nature of Trauma 4
1.2 Trauma and Attachment Theory 6
1.2.1 Self-disturbance symptoms 6
1.2.2 Insecure attachment symptoms 7
1.2.3 Mood dysregulation symptoms 8
1.3 Depression, anxiety, and PTSD 9
1.4 Trauma and Emotion Regulation 11
2 Emotionally Focused Therapy for Individuals (EFIT) 12
2.1 EFT and Emotion 12
2.2 EFIT in practice 14
2.2.1 EFIT stages 15 Stabilization 16 Restructuring 16 Consolidation 16
2.2.2 Mechanisms of change 16
2.2.3 The EFIT Tango 18
2.3 EFT and Trauma 19
2.3.1 EFT for couples 20
2.3.2 Emotionally Focused Individual Therapy (EFIT) 21
3 Purpose of Thesis 24
4 The Present Study 26
4.1 Research Questions, Hypothesis, and Rationale 26
5 Method 28
5.1 Research Design 28
5.2 Participants 29
5.3 Procedures 29
5.4 Measurements 30
5.4.1 DERS-36 30 Emotional dysregulation reliability scores 31
5.4.2. TSI-II 32 Trauma-related reliability scores 32
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
vi SELF scale 32 IA subscale 32 ISR subscale 32 D subscale 32
5.4.3 ADIS-5 33
5.5 Plan of Statistical Analysis 33
5.5.1 The Residual Change Scores 33
5.5.2 Missing Data 33
5.5.3 Hierarchical Linear Modelling (HLM) 34
6 Results 35
6.1 Data Screening and Cleaning 35
6.1.1 SPSS 35
6.2 Missing Data 35
6.3 Statistical Analysis 35
6.3.1 HLM 35
6.3.2 Changes across EFIT sessions 36 Emotion Dysregulation Linear Slope 36 TSI SELF Linear Slope 36 Depression Linear Slope 36 Insecure Attachment Linear Slope 37 Impaired Self-Reference Linear Slope 37
6.3.3 TSI-SELF predicting change in DERS across EFIT sessions 37
7 Discussion 39
7.1 Changes in EFIT of trauma symptoms related to the self 40
7.2 Limitations 42
7.3 Implications 44
7.4 Future research directions 45
8 Conclusion 46
9 References 47
Table of Figures
Figure 1: TSI Scores over Time 37
Figure 2: TSI SELF Subscale Scores over Time 38
Table of Tables
Table 1: Means and Standard Deviations of Treatment Variables over Time 39
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Emotionally Focused Individual Therapy for the Treatment of
Trauma-related Symptoms of the Self
According to the Canadian Psychological Association, it is estimated that 76% of
Canadians have experienced trauma in their lifetime (Ameringen, Mancini & Boyle, 2008). After
experiencing trauma many individuals are plagued with memories of the event and experience
symptoms that impact normal functioning. The amygdala is one part of an individual’s brain that
could show changes in functioning as a result of trauma. The amygdala forms emotional memories
based on experiences (Johnson, 2005). When traumatic memories are formed, an individual is
more likely to experience activations in their nervous system, which leads to frequent responses to
real or perceived threats. The individual in this situation experiences constant emotional flooding.
When an individual’s nervous system is constantly activated, it leads to symptoms of emotional
dysregulation in clients that have experienced trauma (Briere, Hodges, & Godbout, 2010). Trauma
has a powerful negative impact on an individual’s life and relationships (Johnson, 2005).
The nature of trauma is multidimensional and survivors of trauma report feeling helpless
with their complex symptoms (Johnson, 2005). Instances that could impact normal functioning
through emotional dysregulation are, for example, being confronted with physical danger,
significant loss, or another distressing situation (Briere et al, 2010). Trauma is a painful emotional
experience; therefore, an argument can be made that treatments focused on emotion may be more
likely to be effective over cognitive-based therapies. Ultimately, emotionally-focused therapy
targets emotions in areas of the brain, such as the amygdala, to treat emotional processes which
are beyond cognitive control (Johnson, 2019).
In psychotherapy, one of the major challenges for therapists is how to work on helping
clients transform their dysfunctional emotional responses when these are no longer serving their
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
needs towards healthier emotional responses. As a result of learned responses, clients with
emotional dysregulation feel reminded of painful experiences whenever they are faced with
emotionally activating cues, such as a trauma trigger (Briere et al, 2010). One of the effects of
trauma on emotional regulation is the loss of the ability to regulate anxiety, so individuals develop
coping strategies to try and lessen feelings that they cannot control (Johnson, 2005).
It is also likely that depressive symptoms will arise for an individual who experiences
trauma because of arousal de-activation that has formed to deal with the hyperarousal symptoms
(Johnson, 2005). Major depression is one of the most prevalent psychiatric disorders world-wide
(Nelson et al, 2017). Individuals who seek treatment for depression often have experienced some
form of childhood trauma in their lifetime. Disengagement, avoidance, and numbing strategies are
common coping mechanisms for trauma survivors, such as appearing absent in their relationships
(Burgess et al, 2016). The avoidance of trauma triggers a natural response when an individual is
feeling overwhelmed with symptoms related to their experience (Johnson, 2005).
Healthy adaptive orientations to these experiences are normally processed emotions and
based on primitive human survival mechanisms. Emotional responses could become problematic,
however, for individuals who perceive that they are under constant threat because of the memories
that have shaped them (Briere et al, 2010). Dysfunction occurs when a client’s normal adaptive
responses affect their ability to process emotional information even in times where there is no real
threat (Greenberg, 2004).
Trauma survivors often blame themselves for what happened and experience damages to
their sense of self such as feelings of shame and helplessness (Johnson, 2005).
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Therapy that focuses on emotions works on building emotional resilience, which ultimately
helps individuals cope with traumatic experiences and emotional injuries (Pascual-Leone,
Yeryomenko, Sawashima, & Warwar, 2019).
Emotionally Focused Individual Therapy (EFIT) focuses on the present process and
explores a client’s patterns and ways of processing (Johnson, 2019). This attachment-based
individualized approach focuses on a client’s emotional injuries and pain through compassion and
exploration (Johnson, 2019). The process of EFIT involves discovering with a client how they
experience depression and anxiety. Through the development of secure attachments, a client can
foster resilience and confidence with their sense of self. EFIT works to help an individual uncover
how their symptoms perpetuate responses and behaviours that shape their sense of self and
emotional worlds. As these emotional experiences evolve throughout therapy, new meanings and
responses are formed (Johnson, 2019).
EFIT offers a safe haven in the therapeutic relationship in which an individual is guided
through a process of learning about their emotions and attachment needs, which helps them explore
ways to create safety and connection in relationships, including a more integrated sense of self in
the process (Wiebe et al, 2017). A secure connection is pertinent in the face of danger or threat for
trauma survivors. Trauma leaves an individual with negative assumptions about themselves and
insecure perceptions in their relationships (Johnson, 2005). Treatments like EFIT are constructivist
and focus on creating meaning in relation to an individual’s sense of self, which is particularly
relevant for those who have experienced trauma (Johnson, 2005).
This thesis will present a literature review that will cover the gaps in trauma research
findings, future directions, and effectiveness of EFIT treatment for clients. It will pose definitive
research questions that lead to the working hypothesis that EFIT is effective in helping clients
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
reduce trauma-related emotion dysregulation and symptoms related to sense of self. The
methodology section will outline the research design, procedures, measurements, data analysis,
and findings. The thesis concludes with a discussion of potential limitations and implications for
future research on effective treatment methods for trauma.
Literature Review
The Nature of Trauma
Trauma is the disturbance as a result of an unexpected event or repeated exposure to events
that cause helplessness, intense fear, horror, and/or tremendous distress (Mlotek & Pavivio, 2017).
For example, childhood maltreatment, including physical, emotional, sexual abuse, and neglect
are considered traumatic events. Trauma also includes events of real or perceived threat of sexual
violence or physical harm (American Psychological Association (APA), 2013). A traumatic event
could be a singular event learned or witnessed by an individual or repeated exposure to an event.
In particular, childhood maltreatment is associated with adult interpersonal difficulties and issues
with emotional regulation because of repeated exposure to trauma over a period of time and usually
impacts the brain at an early age of development (Mlotek & Pavivio, 2017).
According to Harte, Strmeli, and Theiler (2020) emotional pain is caused by both “large
T” and “small T” trauma (p.43). “Large T” traumas are events like, assault, accident, abuse, or
interpersonal violence, while “small T” traumas are stressful interpersonal experiences (Harte,
Strmelj, & Theiler, 2020, p. 43). Traumatic emotional injuries in relationships could benefit from
treatment methods that focus on resolving, healing, and rewriting emotional responses such as
those offered by attachment-based interventions (Greenberg, Warwar, & Malcolm, 2008).
On some occasions, trauma is associated with symptoms of Post-Traumatic Stress Disorder
(PTSD) that includes symptoms of hyperarousal, intrusive thoughts, avoidance, mood
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
disturbances, and cognitive issues (APA, 2013). For example, an individual in a chronic state of
hyperarousal as a result of feeling unsafe and insecure within their relationships is more likely to
have difficulty regulating emotions and responding in constructive ways (Johnson, 2019).
Emotional dysregulation in individuals with childhood trauma may have one or more symptoms,
such as self-destructive behaviour, self-harm, beliefs they deserved abuse, lack of self-awareness,
and an unclear sense of self (Mlotek & Pavivio. 2017).
Complex trauma refers to a type of trauma that is intricate and occurs repeatedly within
relationships over a period of time (Courtois, 2004), which has come to light in recent research.
For example, there is evidence that attachment trauma and forms of domestic violence have a deep
impact on interpersonal relationships and an individual’s sense of self. Some of the more severe
symptoms developed from complex traumas that have been discovered are, alterations in self
perceptions, alterations in perceptions of the perpetrator or abuser, alterations in relationships to
others, somatizations of these symptoms or comorbid medical illnesses, and alterations in systems
of meaning (Courtois, 2004).
According to Courtois (2004), prolonged exposure to trauma is more likely to lead to severe
symptoms in adulthood and throughout an individual’s lifespan. Specifically, alterations in
perceptions of oneself is the most complex symptom to treat. An individual may feel a chronic
sense of guilt, shame, and blame associated with their experience and these symptoms could be
on-going, which impacts sense of self and feelings of self-worth. Some of the findings in the
Courtois (2004) study discovered that the most common symptoms with complex trauma were
lack of self-awareness in their symptoms, difficulties with trusting others, and challenges with
emotional dysregulation. A noted realization and gap found in the study, however, was that when
treatments focused on affect regulation alone, fears of abandonment and feelings of loss related to
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
safety of their relationships were often left unresolved. These unresolved attachment-related
symptoms made it more likely that individuals would eventually return to treatment (Courtois,
Trauma and Attachment Theory
Trauma survivors often feel like they cannot count on being able to trust others, regulate
their bodies, or rely on their emotions for safety. A survivor of trauma often feels a sense of being
out of control and there is no firm sense of self (Johnson, 2005). Individuals rely on attachment
styles that protect them from psychological pain and rejection (Rependa et al, 2018). Dismissive
and avoidant styles, in particular, are common among trauma survivors who tend to avoid getting
to close or going emotionally deep within their relationships and feel threatened if someone was
to gain closeness to them. Avoidant styles rely on developed coping mechanisms to protect
themselves from painful experiences (Rependa, at al, 2018).
Attachment theory suggests that individuals need to maintain closeness with others during
times of real or perceived threat in order to feel safe and secure (Bowlby, 1979). According to this
theory, it makes sense that individuals who avoid emotional connections as a result of their
traumatic experiences can lead to individual and interpersonal dysfunctions throughout one’s life
(Muller, 2010).
Self-disturbance symptoms. According to attachment theory, healthy adaptations are a
result of positive connections with others, which fosters emotional experiences that impact
emotional regulation and perceptions of self (Johnson, 2019). In addition, the theory proposes that
developmentally traumatic events such as experiencing childhood maltreatment, significantly
effects a child’s self-perception and perception of others through negative interaction cycles and
experiences. In addition to developmental trauma, event trauma, such as exposure to war or a car
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
accident can also impact an individual’s sense of self (Briere, 2004). These beliefs significantly
impact interpersonal relationships and emotion regulation throughout one’s lifespan (Bowlby,
Self-disturbance symptoms are primarily constructed of three core impaired self-
capacities: 1) identity disturbances, which includes problems with accessing and maintaining a
sense of self; 2) emotional dysregulation and/or inabilities to regulate negative emotions; and 3)
relational disturbances, such as problems with forming and sustaining meaningful relationships
due to feelings of insecure attachment (Briere & Rickards, 2007). Individuals with self-
impairments may be more likely to lack self-awareness in terms of their needs and feelings. A lack
of self-awareness puts an individual at risk for problems that include mood instability and
difficulties with expressing themselves. An absent sense of self-reference may also lead to
alternative learned responses for dealing with internal distress (Briere & Rickards, 2007).
Insecure attachment symptoms. Individuals with impaired sense of self may experience
relational problems and have problems forming secure adult relationships. An individual with fears
of abandonment, for example, may find themselves in chaotic relationships (Briere & Rickard,
2007). Emotional experiences that contribute to the development of avoidant and dismissing
coping patterns occur throughout close interpersonal interactions. Children observe and experience
emotional events with primary caregivers. These patterns can manifest into adulthood within
intimate relationships (Johnson, 2019).
An adult’s history of complex trauma can also be present in their parenting style through
avoidant and dismissive attachment patterns (Foroughe, 2018). An individual who experiences a
traumatic event in adulthood may also develop insecurity in their relationships (Johnson, 2005).
EFT conceptualizes these experiences as negative interactions that impact emotional affect and
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
continue to perpetuate patterns of insecure attachment, disconnection from others, and distress
within relationships (Wiebe & Johnson, 2016).
Attachment-related trauma symptoms are linked to identity disturbances and are associated
with dysfunctional behaviours (Briere & Rickard, 2007). Compulsive self-reliance in relationships
as a way of protecting oneself from threat or stress is one symptom which leads to distance in
relationships and lack of intimacy (Mikulincer & Shaver, 2018). Problems with relatedness and
unstable self-image sometimes leads to a Borderline Personality Disorder (BPD) diagnosis.
Characteristics of BPD include disturbed object relations and childhood trauma as central risk
factors to this diagnosis (APA, 2013). Attachment theory suggests that children need secure
relationships with parents who are emotionally stable to help with the development of a positive
sense of self (Bowlby, 1979).
Mood dysregulation symptoms. Symptoms of trauma are biopsychosocial in the sense
that individuals experience somatic, behavioural, and interpersonal responses (Dalton et al, 2013).
Childhood abuse, for instance, is linked to the development of insecure attachments, fears of
abandonment and mistrust in others, avoiding intimacy and closeness, and other fears or
developments of hypervigilance related to fears of harm (Dalton et al, 2013). Dysfunctional coping
behaviours that could occur as a result of dealing with unstable moods, for example, include self-
destructive behaviours like substance use, self-harming, and disordered eating (Briere & Rickard,
Later in life mood dysregulation symptoms manifest in relationship challenges, such as in
the development of emotional bonds that are satisfying and when an individual is learning to assert
their needs within a partnership (Johnson, 2005). Insecure attachment that develops in the context
of trauma has negative impacts on mood, but more importantly may lead to symptoms of
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
depression (Ventimiglia, 2020). Insecure attachments present itself in interpersonal feelings of
helplessness and loneliness, and fears of abandonment that perpetuate in an individual’s future
relationships (Johnson, 2014). Ultimately, difficulties with regulating emotions in adulthood
related to childhood abuse has been found to lead to higher divorce rates in couples and impact the
quality of relationships as an adult survivor (Whisman, 2006).
Researchers have found that attachment figures are immediately activated when an
individual experiences threatening stimuli, which further suggests that attachment styles are an
important factor to consider in the treatment for trauma (Mikulincer & Shaver, 2018). The early
attachment experiences lead to difficulties in emotional dysregulation and interferes with the
development of inner capacities for dealing with stress. Exposure to trauma at any point in an
individual’s lifetime requires treatment that actively seeks to confront the attachment symptoms
(Mikulincer & Shaver, 2018).
Depression, anxiety, and PTSD
Trauma exposure is associated with the development of mood disorders (Ventimiglia,
2020). In a study by Ventimiglia et al (2020) of 107 participants, it was found that the manifestation
of depressive symptoms as adults and emotional dysregulation is directly associated with an
individual’s history of trauma. In addition, Ventimiglia (2020) found that the severity of trauma
exposure or whether it occurred in childhood or throughout a lifetime did not influence fluctuations
in symptom severity. A key finding from this study was that an individual has a higher risk of
depression if they experienced higher levels of stress, had a history of trauma, and reported
negative feelings towards their sense of self (Ventimiglia et al, 2020). According to Bowlby (1979)
regarding attachment theory, these risk factors shape interpersonal behaviours, which in turn,
perpetuates depressive symptoms.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Mental health issues, such as, depression and anxiety disorders develop as a result of
attachment insecurities and emotional dysregulation (Johnson, 2019). Bowlby (1979) suggests that
the experience of loss, in particular, leads to feelings of hopelessness and other depressive
symptoms. Individuals experiencing depression view themselves as failures and report having low
self-worth. Experiences of loss and failure lead to feelings of self-criticism, which perpetuates
depression and impaired self-references (Bowlby, 1979).
Individual experiences of trauma and threat lead to rejection sensitivities, as found in
anxious and avoidant attachment styles (Bowlby, 1979). The function of anxiety is to warn an
individual of a potential threat and when these systems are overactive or chronically triggered it
can lead to self-defeating symptoms and perpetuate depressive symptoms (Johnson, 2019). The
key factors of anxiety include frequent negative self-perception, vigilance associated with
uncertainty, avoidant behaviours for coping with emotions, and fears. Sensitivities, as a result of
heightened senses of threat, are a risk factor that contributes to the onset of anxiety and depression
(Johnson, 2019).
Moreover, literature on Post-traumatic Stress Disorder (PTSD) and attachment found that
children who were sexually abused are more likely to experience symptoms of traumatic stress
because of the development of insecure attachments (Johnson, 2005). In addition, long-term
studies on military veterans and sexual abuse survivors have shown that there is a relationship
between attachment styles and symptoms of trauma. For instance, an individual with insecure
attachments may be more at risk for PTSD and emotional dysregulation (Dalton et al, 2013).
Individuals who experience trauma face the prospect of developing symptoms of affect
dysregulation, which shows up within their relationships and further causes distress (Johnson,
2005). Furthermore, individuals who have symptoms of depression, anxiety, and stress have
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
usually experienced traumatic events during development or throughout their lifespan (Johnson,
According to Nelson et al (2017), in a meta-analysis of 184 studies exploring the impact
of childhood maltreatment on the development of depression, found that childhood trauma is a
major risk factor for the development of depression in adulthood. In the meta-analysis, it was found
that 46% of individuals with depression in the studies reported experiencing a traumatic event in
their lifetime (Nelson et al, 2017). Since depression is the most prevalent psychiatric disorder
world-wide, it is theorised that almost half of individuals with depressive symptoms have
experienced some form of trauma, either in childhood or at some point in their lifetime (Nelson et
al, 2017).
Trauma and Emotion Regulation
Emotional regulation is an individual’s ability to manage and respond to an emotional
experience (McRae, Dalgleish, Johnson, Burgess-Moser, & Killian, 2014). Emotional
dysregulation is when an individual has difficulty using healthy coping strategies to defuse or
control emotions. Interpersonal distress within intimate partner relationships has been found to
impact individual wellbeing within the relationship (McRae et al., 2014). According to Johnson
(2019) emotional regulation is the ability to access, identify, modify, and use emotions as a guide
for how we act, think, and respond to situations.
Research suggests that significant or long-term traumatic stress is connected to symptoms
of affect dysregulation and identity disturbances (Briere et al, 2010). In addition, chronic traumatic
stress such as extended interpersonal abuse or violence is associated with symptoms of mood
changes and dysregulation, such as dissociation and suicidality. The Diagnostic Statistical Manual
of Mental Disorders 5 (DSM-V) characterises trauma as symptoms of hyperarousal and emotional
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
numbing, or avoidance (American Psychiatric Association, 2013). Prolonged exposure to trauma
overwhelms the emotional regulation system, which theorists suggest leads to avoidance
behaviours to escape or cope with these distressing states (Briere, 2004).
Low affect regulation capacities are related to extreme affective experiences. According to
research by Briere (2004) focusing on trauma-avoidance symptoms, the treatment methods that
were determined to be most effective concentrated on emotional processing of trauma-related
events that encouraged a growth in emotional regulation capacities. Healthy emotions, for
example, were joy, surprise, and anger, which are emotions that educe actions towards goals,
curiosity, and openness. Avoidance emotions, for instance, were shame, fear, and sadness that tend
to conjure withdrawal responses, fight or freeze, and hiding (Johnson, 2019).
EFT uses practices that regulate and process emotions through creating bonds and
developing an emotional equilibrium (Johnson, 2019, p. 26). In previous EFT studies, it was found
that sessions with deep emotional experiencing exhibited the best results and the most progress in
expanding emotional self-awareness and lowering emotional control related to insecure
attachments (McRae et al, 2014).
Emotionally Focused Therapy for Individuals (EFIT)
EFT and Emotion
In EFT, emotion is considered a foundational construct of a person’s orientation to the
world. Emotions are a key element in human functioning that help people understand themselves
and their environment (Johnson, 2019). The main concept of EFT is to assist clients in organizing
their emotional experiences, thoughts, and feelings for optimal awareness and functioning
(MacIntosh & Johnson, 2008). EFT utilizes emotional experiencing in the treatment of
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
maladaptive functioning for distress by enhancing a client’s understanding of their responses to
experiences (MacIntosh & Johnson, 2008).
In general, EFT is recognised for focusing on the transformation of emotional experiences
from dysfunctional or maladaptive emotions to more healthy responses with couples (Johnson,
2005). It has been found in recent research, for example, that EFT may be an effective form of
psychotherapy for childhood sexual abuse survivors within couples (MacIntosh & Johnson, 2008).
In treatment, trauma survivors use their emotional experiences in session to formulate new
responses in a safe space with their partners (MacIntosh & Johnson, 2008). More recently,
however, there has been interest in how EFT may encourage positive change in individual
responses to trauma, largely as a result of success in couple’s therapy that has shown positive
outcomes for reducing symptoms of distress (Johnson, 2005).
Emotional regulation is the ability to lessen or control the intensity of a given emotion,
depending on the situation, while making decisions on how to respond (Greenberg & Pos, 2006).
The goal of EFT is to transform maladaptive emotions, such as fear and shame, to adaptive ones
such as anger and sadness (MacIntosh & Johnson, 2008). From the perspective of EFT, therapeutic
change means developing a sense of self-awareness and transformation occurring throughout the
course of therapy (Johnson, 2005). Throughout EFT treatment, clients learn to identify their
emotional experiences and make reflections on how their feelings impact themselves internally,
which in turn supports the transformation of maladaptive emotions to adaptive ones for healthier
functioning and secure relationships (Johnson, 2014).
In 2019, Johnson developed “Emotionally-Focused Therapy for Individuals” abbreviated
as “EFIT” which is based on Johnson’s EFT for couples. EFIT and EFT for couples have similar
components with the major difference being that the secure relationship is modelled between the
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
therapist and the client rather than between the two partners in therapy. Although Greenburg’s
EFT was also modelled on EFT for couples, it is not attachment-based and focuses primarily on
emotion processes and changing emotions. Although emotionally-focused and emotion-focused
are similar, there is a key difference in in the nature of these two therapeutic realms. Emotionally-
focused therapy uses an attachment-based perspective in understanding relationships (Johnson,
2005). In attachment theory, emotional connections are pivotal in the healing and treatment process
in terms of creating a secure bond (Johnson, 2005, p.11).
EFT theory suggests that emotional injuries impact an individual’s sense of self, safety in
relationships, and fear responses. Attachment theory suggests that trauma results from attachment
wounds leads to fears of abandonment and isolation, among other mental health issues (Johnson,
2005). Emotionally-focused interventions and therapeutic processes work on developing
connections with others that, “…fosters emotional balance and regulation” that, ultimately,
encourages healthy relationship patterns and responses as a result of feeling safe and secure in
relationships (Johnson, 2019, p. 26).
EFIT in practice
The practice of EFIT focuses on emotional regulation and processing. EFIT is based on
Bowlby’s (1979) attachment theory, which states that human emotions are organized by and
regulated within bonding experiences with significant others. The process of EFIT involves
identifying an individual’s attachment orientation through exploration of their experiences. The
individual reformulates these experiences through validation and acceptance. In this process, the
individual takes part in forming new emotional and interpersonal interactions. The goal in this
process is to support the individual in formulating and understanding a sense of self and that in
relation to others (Johnson, 2019).
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
The role of the therapist in EFIT is to engage in a safe therapeutic relationship. An EFIT
therapist helps the client track steps in their internal and relational conflicts and tracks these
dialogues. The therapist is a moment-by-moment co-regulator of emotions and helps a client
translate these experiences. Typically, clients with PTSD or severely distressing trauma symptoms
take longer in couple’s therapy to alleviate relationship distress because of their complex
symptoms (Johnson, 2005). EFIT focuses on developing a sense of safety that promotes healing
these complex symptoms by taking a slower approach and practicing containment (Johnson, 2005).
On work with EFT for couples, two components in therapy for dealing with trauma-related
symptoms are screening for violence between partners and evaluating safety at every stage to
ensure a safe therapeutic environment for treatment (Johnson, 2005). Within couple’s therapy for
trauma, part of the treatment is for the client to share their traumatic experience to the non-
traumatized partner. In individual therapy, however this experience is shared with the therapist.
The general practice when dealing with trauma-related and emotional dysregulation symptoms is
to take a slower step-by-step approach (Johnson, 2005).
EFIT Stages. EFIT consists of nine steps carried out over three stages. The three EFIT
stages are stabilization, restructuring, and consolidation. The stabilization stage relates to
discovering a client’s strengths and vulnerabilities. The restructuring stage involves restructuring
interactions, fostering withdrawer reengagement, and blamer softening. The final and third stage
of consolidation involves problem solving, the consolidation of new positions and more flexible
interaction patterns (Johnson, 2019).
Stabilization. In the first stage of stabilization individuals explore strengths and
vulnerabilities. Step one in this process is identifying a client’s presenting issues and creating a
therapeutic alliance (Johnson, 2019). Step one includes exploring a client’s stressors, supports,
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
coping, and safety. Step two involves identifying interpersonal and intrapersonal patterns of how
a client relates to their own emotions and sense of self. In step three, the client explores self-
awareness of their unacknowledged emotions within their relationships. Finally, the fourth step of
stage one is reframing the problem in terms of underlying emotions and attachment needs. As these
new emotional experiences form, the therapist validates and reinforces the experience. During this
stage, a client may be more accepting of their emotions and become less numb or avoidant
(Johnson, 2019).
Restructuring. In the second stage of EFIT, emotional experiencing is deepened, and more
complex emotions are explored in imaginary encounters with the self and others. In step five, the
client’s awareness expands through dialogue with the therapist and imagining contact with others.
In step six, attachment needs are accepted, and validation occurs between the therapist and client
in reference to the self and with others. Finally, in step seven of this stage, positive cycles of a
secure relationship are conditioned through the expression of needs. During this stage, a client may
become more attune to their needs and responses, while experiencing a decrease in depression and
emotional dysregulation symptoms (Johnson, 2019).
Consolidation. In the third and final stage of EFIT, the therapist collaborates with the client
in translating their emotional discoveries and underscoring a client’s new sense of confidence. Step
eight requires a facilitation of new solutions to interpersonal and intrapersonal experiences outside
of therapy. In step nine, new narratives are created with these new solutions and consolidated
through the creation of positive interaction cycles in the client’s world. The therapist in this stage,
reviews the client’s progress with specific emphasis on their emotional regulation, changes in
avoidance responses, and connections with their self and others. The therapist reinforces the sense
of security and safety the client experienced in therapy for future use after therapy (Johnson, 2019).
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Mechanisms of Change. There are six components that are identified as mechanisms of
change within EFIT. In one mechanism of change, an individual engages with their emotions
through perception, sensations, motivations, actions, and meanings (Johnson, 2019). Once an
individual’s understanding and relationship of their emotions has changed, they take part in
creating new experiences with this knowledge. Through these recognized mechanisms of change,
an individual is equipped with newfound ways of regulating their emotions and shaping their
experiences. The individual integrates these new emotional skills to develop a more positive sense
of self (Johnson, 2019).
Another component of change in treatment occurs throughout the creation of a safe place
in therapy for the exploration and processing of emotional experiences and injuries. The therapist
alliance is a key part of therapy since it helps the client feel safe, seen, accepted, and heard
(Johnson, 2019). The therapist’s qualities in EFIT consists of compassion, nonjudgement,
unconditional positive regard, and respect. Validation is the forefront of the alliance created which
helps the therapist meet the client where they are at emotionally and ultimately, fosters self-
awareness (Johnson, 2019).
A pivotal mechanism of change related to the self is achieved through focusing on the
integration of the self and the individual’s constructed reality the dancer and the dance itself,
Johnson states (2019). In attachment theory and EFIT, the self is a process and developed from a
set of interactions with others. The individual engages in relational cycles with the therapist, who
helps model healthy interactions and find meaning. These cycles help develop new affect
regulation patterns that eventually become habitual for the individual (Johnson, 2019).
In addition, through the creation of healthy adaptations and understanding a mechanism of
change can be identified. EFIT theory is that individuals with emotional regulation strategies are
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
more equipped to accept feelings and assert their needs with vulnerability and ultimately feel more
emotionally attuned to oneself (Johnson, 2019). At this point, an individual has experienced
compassion and validation, and therefore, may develop healthier emotional adaptations. The
secure attachments developed from these experiences foster growth and lessens an individual’s
symptoms of self-impairment and emotional dysfunction (Johnson, 2019). The therapist role in
this mechanism of change is to model a secure attachment through emotional presence and by
offering manageable challenges for the individual to process within the session (Johnson, 2019).
A fifth mechanism of change is the acknowledgment of a client’s past learned experiences
while staying present. The therapist recognizes the individuals experience of trauma and response
to threat, which are brought into awareness. EFIT mechanisms of change theorize that past learned
experiences return with self-interactions and with others. The therapist uses a moment-by-moment
process of validation with the client that focuses on the emotional experience of the individual by
asking questions that deepen their understanding of themselves. These changes are observable by
the therapist in their interactions throughout the sessions (Johnson, 2019).
A final mechanism of change occurs in the deepening of the therapeutic experience that
involves the client’s commitment of these new interactions to be continued outside of therapy.
EFIT theorizes that these pivotal moments and interactions in therapy are remembered because of
their adaptive nature and empiricism (Johnson, 2019). To deepen the therapeutic experience, EFIT
therapists engage in themes of trauma, abandonment, hope, fear, hopelessness, anxiety, isolation,
and inadequacy. These experiences are explored and brought forth in therapy to realize the
individual’s responses to emotional injury and depth. Ultimately, an EFIT therapist follows an
emotional map of an individual’s life using core aspects of human nature and survival strategies
to encourage change (Johnson, 2019).
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
The EFIT Tango
The EFIT tango refers to the dance between the therapist and the client, which occurs
throughout all of the stages and steps of therapy. The first tango move in EFIT is mirroring the
present process. The second EFIT tango move is affect assembly and deepening. The third tango
move involves choreographing engaged encounters with significant attachment figures in the
person’s life. Move four embraces processing the encounter. Finally, the fifth tango move is to
integrate and validate the experience. These five moves are repeated to help develop emotional
safety and security (Johnson, 2019).
EFT and Trauma
Emotion in its nature, is a “…high-level system that integrates a person’s awareness of
innate needs and goals with feedback from the environment and the predicted consequences of
actions” (Johnson 2019, p. 34). According to Johnson (2014), the function of emotion is that it
orients, engages, shapes meaning, motivates, communicates, and sets up a response from others.
Trauma and insecure attachments greatly influence an individual’s ability to regulate emotions
(Johnson, 2014). Chronic activation of the nervous system due to unsafety or distress increases
an individual’s likelihood to experience depression, an impaired sense of self, and emotional
dysregulation, such as aggression (Ventimiglia et al, 2020).
EFIT offers promising results for clients with deep emotional wounds. One of the theories
that recognizes the potential in attachment-based treatment options for individuals with trauma, is
EFT for couples (Brubacher, 2017). Attachment theory is a foundational philosophy of EFT for
couples (Johnson, 2019). Attachment fears of abandonment, responses to rejection, and feelings
of trust and safety are all factors that are associated with clients that have insecure, anxious, or
avoidant attachment styles. Attachment styles effect how an individual reacts and responds to the
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
world (Bowlby, 1976). Hyperactivation and deactivation of emotions are specific emotional
dysregulation issues experienced by trauma survivors because of early attachment bonds
(Brubacher, 2017).
Other therapeutic interventions focused on client emotion related to EFIT, such as emotion-
focused therapy as developed by Greenberg and colleagues, in many ways have been found to help
treat symptoms of complex trauma related specifically to early childhood abuse or neglect (Paovio
& Nieuwenhuis, 2001). A specific study by Paovio and Nieuwenhius (2001) uses a quasi-
experimental design of 46 participants between the ages 24-49, where the goal of the study was to
evaluate the effectiveness of emotion-focused therapy on emotional change among people with
complex trauma (Paivio and Nieuwenhuis. 2001). The participants engaged in 1-hour weekly
emotion-focused sessions over approximately 28 weeks. The participants disclosed experiences
that ranged from chronic verbal assault, repeated threats of harm, and family violence (witnessed
and experienced) in their childhood.
The study found that most of their participants (66%) made significant improvements in
emotional regulation and that just over half (54%) of participants indicated they had reduced
feelings of distress in comparison to how they felt pre-therapy. The researchers determined from
results on measurements of distress, pre- and post-therapy, that EFT was successful in addressing
emotional dysregulation as a result of trauma associated with child abuse (Paivio & Nieuwenhuis,
2001). Moreover, they found “…no evidence that the type of abuse was a predictor of treatment
response” (p. 130).
EFT for couples. EFT has been widely studied in the treatment of couples with a trauma-
history (MacIntosh & Johnson, 2008). There is significant research on couples that were sexual
abuse survivors, for instance, to help partners reconnect. Often, survivors of sexual abuse have
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
symptoms of hyperarousal and emotional dysregulation as a result of their childhood experiences.
Many survivors continue to seek out intimate connections later in life; therefore, much of the
research evidence supports the use of EFT for unresolved trauma in adult relationships (MacIntosh
& Johnson, 2008).
More specifically, MacIntosh and Johnson’s (2008) study found that 5 of the 10 couples
demonstrated an increase in relationship satisfaction, 5 couples recorded significant improvements
in trauma symptoms, and 5 couples demonstrated a decrease in hyperarousal symptoms
(MacIntosh & Johnson, 2008). This key finding indicates a gap in research on whether or not
emotional dysregulation symptoms, such as hyperarousal symptoms, could predict the efficacy of
EFT for the treatment of individuals with trauma. For example, research on changes in emotional
regulation and the prediction of changes in trauma-related symptoms of the self could prove to be
beneficial to the overall understanding of individual treatments (MacIntosh & Johnson, 2008).
Research in EFT reveals through exploration of attachment-based approaches finds that
emotional injuries related to complex trauma are often manifested in adult interpersonal issues
(Dalton et al, 2013). Trauma impacts the development of healthy intimate partner relationships
because symptoms manifest in avoidance and withdrawal responses from partners with untreated
emotional injuries. In a randomized control trial of 32 couples, researchers Dalton et al (2013)
found that female partners disclosing a history of child abuse/neglect had improved marital
functioning scores following EFT (Dalton et al, 2013). These results suggest that EFT for couples
is an effective treatment for relationship distress in individuals who have experienced childhood
One theory for the effectiveness of EFT is that it addresses individual fears and insecurity
commonly expressed by trauma survivors, such as feelings that they may never be able to connect
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
or feel close to their spouses, and this translates to improvements in marital functioning of these
couples (Dalton et al, 2013). Based on attachment theory, fears within relationships are related to
insecure attachments and feeling a sense of unsafety (Bowlby, 1979). Trauma-related symptoms
within a couple’s present symptoms of an impaired sense of self related to the other means that
these clients are likely experiencing symptoms of depression and emotional dysregulation
(Johnson, 2019). EFT addresses insecure attachment through developing a safe therapeutic
relationship and practicing new relational experiences within the therapy room (Johnson, 2019).
Emotionally Focused Individual Therapy (EFIT). There has not yet been any research
conducted on the process and outcomes of EFIT of individuals for the treatment of trauma-related
symptoms (Johnson, 2019). There is one approach, however, that shows promising results for
treatment methods focused on emotion for trauma survivors, called Emotion-Focused Therapy
(Greenberg, 2006). The main difference in emotion-focused versus emotionally focused treatments
is that EFIT uses an attachment-based approach. In a randomized control trial by Paivio et al
(2010), two emotion-focused interventions for the treatment of trauma were compared in order to
explore changes in trauma-symptoms related to childhood sexual abuse. The interventions focused
on client experiences and expression of feelings and needs. The researchers discovered from the
comparison data that both emotion-focused interventions were equally successful treatment
options. They concluded that the specific emotion-focused interventions used in therapy have no
impact on the success of treatment, as long as the focus was on emotional and experiential
processing (Paivio et al, 2010). One of the key discoveries in this study was that participants
identified their developmental needs related to their attachment figures. Specifically, participants
identified attachment figures and realized their impact on the development of adaptive emotions
for survival at an early age. The identification and processing of these attachment discoveries were
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
reported to be key elements in treatment success (Paivio et al, 2010). This study finds that gaging
emotional experience is the pivotal part of emotion-focused therapy in reducing symptoms of
distress and developing healthy relationships outside the therapy room; however, it is ultimately
the identification of attachment-related trauma symptoms that lead to improvements throughout
treatment (Paivio et al, 2010).
A case study by Greenberg (2006) documents emotion-focused therapy with a client who
experienced childhood emotional abuse. The client was experiencing low self-worth, had fears
about vulnerability, and was not open to new interpersonal relationships. Greenberg (2006) used
Rogerian methods of building rapport with the client over time and then worked on accessing
primary adaptive emotions. The purpose of emotion-focused therapy in this case study was to
replace feelings of fear with anger to empower the client. Therapy appeared to help this client feel
more open to new relationships and demonstrate improvements in self-worth. One gap in this
research, was the exploration of changes with insecure attachment styles in adulthood related to
the emotional processing of their traumatic experiences. This case study validated Greenberg’s
(2006) previous studies that explored the efficacy of emotion-focused therapy for individuals with
Greenberg, Warwar, and Malcom (2008) conducted a study of 46 individuals with
emotional injuries that ranged from feelings of abandonment, betrayal, neglect, and physical and
sexual abuse. Approximately half of the clients underwent 1-hour of emotion-focused individual
treatment while the control group received group psychoeducation sessions for the 12 weeks
(Greenberg et al, 2008). The outcome of the study was that the clients in the emotion focused
therapy group achieved significantly higher scores on the forgiveness scales and symptom
reduction (Greenberg et al, 2008). One of the limitations Greenberg et al (2008) documented was
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
that the treatment methods (group psychoeducation and individual emotion-focused therapy) were
too different to make any significant comparisons on effective individual treatment options. One
mitigation strategy in this study could be to identify specific attachment-related symptoms of
trauma and their changes over the course of treatment with an attachment-based orientation like
found in EFT.
Pascual-Leone, Yeryomenjo, Sawashima, and Warwar (2019) have recently made
headway in examining of emotion-focused therapy in fostering emotion resilience. The team used
two separate longitudinal single case designs. Both cases exhibited instances of childhood trauma
(abuse) and had positive treatment outcomes, which meant that the individuals were able to
“…bounce back” quickly following emotional activation (Pascual-Leone et al, 2019). The
micropatterns found in this recent study indicated future directions for researchers in terms of
discovering how these patterns impact individuals’ long term and whether the continuous
emotional activation contributed to the client’s ability to self-regulate emotions.
EFIT and emotion-focused therapy are similar in terms of their view of emotion as a
primary mechanism of change; however, the key difference between the therapies is in how they
recognize the process of emotional change. EFIT uses an attachment-based approach as an
orientation of treatment, which makes this option more effective at addressing the impacts of
trauma on an individual’s sense of self, insecure attachment, and symptoms of depression
(Johnson, 2014). Considerable evidence on EFT for couples suggests that it could be an effective
evidence-based treatment for individuals dealing with traumatic circumstances related to issues of
childhood physical, emotional and sexual abuse (Holowaty & Paivio, 2012). Ultimately,
attachment-based approaches like EFIT could lead to improvement of trauma-related symptoms
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
over the course of therapy because of the gaps found in research on emotion-focused therapy and
treatment results of EFT for couples with trauma.
Purpose of Thesis
The purpose of the thesis is to explore the effectiveness of EFIT for alleviating trauma-
related symptoms and emotional dysregulation for individuals seeking treatment for depression
and anxiety. Individuals who have experienced trauma in their lifetime often seek treatment for
depression and anxiety later in life (Wiersma et al, 2009). Moreover, depression is the most
prevalent psychiatric disorder world-wide with almost half of individuals with depressive
symptoms having experienced some form of trauma in their lifetime (Nelson et al, 2017).
Specifically, treatment that focuses on impaired sense of self as a result of trauma could lead to
improvements in symptoms of depression (Wiersma et al, 2009). To address this gap in research,
this study engaged participants that self-reported symptoms of depression and/or anxiety and that
agreed to undergo EFIT treatment.
According to the findings in each of the individual studies, focusing on the activation of a
client’s affective experience throughout therapy promotes resilience and decreases dysfunctional
arousal responses (Pascual-Leone et al, (2019), Greenberg et al, (2008), and Paivio et al (2010)).
Moreover, some of the studies that utilized an attachment-based approach concluded that
emotionally-focused therapies in couples with trauma was an effective treatment for emotional
processing and the development of healthy intimate relationships and improved sense of self
(MacIntosh & Johnson’s (2008), Dalton et al, (2013), and Johnson (2014 & 2019).
One of the frequently occurring limitations in the literature is that the studies conducting
individual therapy report gaps in explorations of changes in trauma-related symptoms using
attachment-based approaches. These studies focused primarily on emotional processing and
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
dysregulation symptoms of trauma. While the studies found significant evidence that emotion-
focused therapies decrease trauma-related symptoms, the studies did not address underlying
symptoms of trauma related to an individual’s sense of self and insecure attachment style. The
research on trauma indicates that frequency in exposure to traumatic events impacts an individual’s
sense of self through the development of insecure attachment, depression, and impaired sense of
self symptoms (Briere et al, 2010).
This study explores changes in trauma-related symptoms involving sense of self.
Participants seeking therapy for depression and anxiety participated in 15 sessions of EFIT, an
attachment-based experiential psychotherapeutic approach that aims to alleviate a range of
symptoms of emotional distress. Trauma symptoms related to the self were measured using the
Trauma Symptom Inventory (TSI-II), which was developed to capture a broader range of trauma-
symptoms, including a range of symptoms commonly found in complex PTSD responses and
clinically relevant symptoms that may not meet criteria for a diagnosis of PTSD. The presentation
of complex trauma symptoms and sub-diagnostic trauma symptomatology is common among
individuals seeking treatment for depression or anxiety (Briere, 1995). The TSI-II subscale for
self-disturbance (SELF) has three parts that focus on insecure attachment, depression, and
impaired self-reference. This study on EFIT will afford more research data and more analysis on
the effectiveness of treatment for trauma symptoms.
The Present Study
This study aims to examine the effects of EFIT on individuals’ trauma-related symptoms
pertaining to the self and emotional dysregulation over the course of 15 EFIT sessions. More
specifically, the research focuses on measuring participants’ trauma-related emotional regulation
and trauma-symptoms related to the self over the course of therapy at the following timepoints:
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
baseline, midpoint 1 (session 5 of therapy), midpoint 2 (session 7 of therapy), and post-therapy. It
examines changes in self-related trauma symptoms early in therapy as a predictor of emotion
regulation across therapy sessions. The foundations of this study follow the EFIT theory that
improvements in self-related symptoms leads to increases in trauma-related emotion dysregulation
symptoms (Johnson, 2019). The basic theory is that an individual with a self-reported secure sense
of self will experience decreases in trauma-related symptoms for the treatment of depression
(Wiersma et al, 2009).
The rationale for the study is based on attachment theory and EFIT treatment processes,
which theorize that an individual develops emotional regulation skills within the first step of
therapy. By step two, the treatment will have impacted an individual’s sense of self through various
interventions and the use of the EFIT Tango. By the final phase of treatment, it is predicted that
these changes will be integrated and fortified resulting in improved symptom scores.
Research Questions, Hypothesis and Rationale
Based on the literature review, the working hypotheses of this study are as follows:
1. Participants receiving EFIT will demonstrate significant linear decreases in trauma-
related symptoms pertaining to the self and emotion dysregulation symptoms across
baseline to session 7.
2. Greater reductions in trauma-related emotion dysregulation will be significantly
associated with changes in self-disturbance symptoms.
The first hypothesis predicts that trauma scores, including emotional dysregulation, will
decrease over time. Based on this hypothesis, self-related symptoms of impaired self-reference,
depression, and insecure attachment will also decrease over the course of treatment. Specifically,
the hypothesis predicts that participants will encounter improved perceptions of self through
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
insight and contextual meanings of self. As a corollary outcome, participants may report feeling
more secure in their attachments through bonding and re-experiencing. Based on results of the
second hypothesis, participants may report decreased symptoms of depression, and decreased
symptoms of emotional dysregulation because of emotional processing in EFIT.
The goal of this study is to investigate the predictive value of key therapeutic change factors
on trauma symptoms measured across therapy. These key factors include change in insecure
attachment, self-disturbance, impaired self-reference, and depression scores as a result of
emotional experiencing in EFIT. The Difficulties in Emotional Regulation Scale (DERS-36) is
used to explore linear change in emotional dysregulation indicators from EFIT. The Trauma
Symptom Inventory (TSI-2) is used to explore linear change in insecure attachment, self-
disturbance, impaired self-reference, and depression reported symptoms. Since emotional
dysregulation is a symptom of trauma, it is hypothesized that DERS scores will decrease and that
TSI-2 scores will also decrease as a result of emotionally focused treatment overtime. The DERS
scores will predict changes in TSI-II scores. These scales explore changes in trauma symptoms
through a linear change model of DERS overtime and a linear change model of TSI over time, as
well as whether or not the DERS predicts changes in the TSI-II.
Research Design
This study examined EFIT across four time points through 15 sessions of therapy with
participants recruited from three cities: Ottawa (Ontario), Victoria (British Columbia), and Denver
(Colorado). There were two study groups, treatment (n=40) and wait-list control (n=40). A total
of 15 sessions of EFIT treatment were given by experienced therapists with EFIT training and each
therapist worked with approximately 2-3 clients. It should be noted, however, that due to the
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Covid-19 pandemic treatment began as in-person therapy and transitioned to an online format at
various timepoints for each participant. The sites where therapy took place were the Ottawa
Institute of Couple and Family Therapy in Ottawa, Centre for EFIT Vancouver Island in Victoria,
and Colorado Centre for EFT in Denver. For the scope of this study, only the EFIT treatment group
of n=40 was used.
Participants were recruited through posters, university email, and social media accounts
inviting people seeking treatment for symptoms of depression and/or anxiety. Those interested in
participating in the study were encouraged to contact the research coordinator for more
information. Participants, who reach out, were assessed for potential eligibility via a telephone
screening process. Those selected had a second assessment to determine final eligibility for the
The inclusion criteria for the study were two-fold: participants were at least 18 years old
and met a primary diagnosis of Major Depressive Disorder with co-morbid symptoms of anxiety.
One exclusion criterion for the study was any changes in the participants’ psychotropic medication
6 weeks prior to enrollment or anticipated during the study period because of potential impact on
emotional regulation results. Another exclusion criterion was the client meeting DSM V criteria
for bipolar disorder, schizophrenia-spectrum disorder, PTSD, substance abuse or dependence.
These exclusion criteria protected against clients exhibiting symptoms of another disorder
throughout the course of therapy.
Study procedures included telephone screening to determine initial eligibility for the study
and signing a consent form agreeing to further assessment. The diagnostic test used in the study
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
was the Anxiety and Related Disorders Interview Schedule for DSM‑V (ADIS-5) to assess
participant inclusion and exclusion criteria related to diagnosis (Barlow & Brown, 2014). The
assessment tests for symptom severity used were the Beck Depression Inventory (BDI-II) to assess
depression symptom severity (Beck, Steer & Brown, 1996); and the Beck Anxiety Inventory (BAI-
II) to assess anxiety severity criteria (Beck & Steer, 1990).
The DERS scale is a measure of emotional regulation capacities. One of the popular
features of the DERS is that it has test-retest reliability, validity, and internal consistency (Fowler
et al, 2014). Research by Fowler et al (2014) measured the psychometric validated of the scale on
592 subjects with severe mental health symptoms. It was found that DERS was a strong measure
with good construct validity. Specifically, the validity was demonstrated with symptoms related
to impairments in emotion regulation that are common in individuals with depression (Fowler et
al, 2014).
The DERS scale consists of 36 items. Negative changes or a decrease in scores on the
DERS scale is indicative of improvement of emotional dysregulation symptoms. Alternatively,
positive changes in DERS scores of an increase in scores indicates a worsening of emotional
dysregulation symptoms (Gratz & Roemer, 2004). Likert scales with a 5-point system were used
to calculate the means with the sum of the scores at each timepoint.
Emotional dysregulation reliability scores. The reliability scores for DERS is found at
pre-, midpoint 1, midpoint 2, and post-therapy are found with N=37. The Cronbach alpha for pre-
therapy = 0.84, midpoint 1 = 0.89, midpoint 2 = 0.87, and posttherapy = 0.71. The Cronbach alpha
scores range from good to excellent for the DERS scores and are reliable for analysis.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
The TSI-II is an empirically validated scale for investigating trauma-related symptoms
(Runtz et al, 2008). The scale used to measure trauma symptoms is the TSI-2 (Briere, 1995). This
scale is designed to explore a broad range of trauma symptoms, in particular, focuses on
symptomology related to self-disturbances (Runtz et al, 2008). Research by Godbout et al (2016)
collected data from 679 adults in the general population with a broad range of traumatic symptoms.
It was found in this study that the assessment factors in the TSI-II significantly recognized
symptomology and predictors of trauma which further supports the use of this particular scale in
the investigation of trauma-related symptoms of self.
The TSI-II consists of 12 types of trauma-related symptoms and 6 of these have subscales.
The scale consists of 136 items, where 4-5 items make up a factor. Each item is rated from 0-3,
where 0 is a lower symptom experience. This study uses one scale, and three subscales that consist
of the items to make up a full factor. The TSI-2 scale is used to determine trauma-related symptoms
before and throughout treatment. For the scope of this study, the TSI-2 Self-Disturbance subscale
(SELF) was used to determine changes in Insecure Attachment (IA), Impaired Self-Reference
(ISR), and Depression (D).
Trauma-related reliability scores. The reliability score results for TSI-II pre-therapy
N=37 offers Cronbach’s alpha scores for depression, insecure attachment, and impaired self-
reference. The scores were rounded to the nearest tenth for readability. The pre-therapy scores for
depression finds a Cronbach alpha of 0.86. The insecure attachment scores find a pre-therapy
Cronbach alpha of 0.77 and impaired self-reference has 0.81. On the Cronbach alpha scale, these
scores ranging from good to excellent and were, therefore, determined to be reliable for analysis.
Also, the midpoint scores were calculated to confirm the reliability. The Cronbach alpha scores
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
were the following for the midpoint TSI-II D, IA, and ISR scores: 0.92 (D), 0.78 (IA), and 0.84
(ISR). The midpoint scores are reliable according to the Cronbach alpha scale.
SELF scale. The self-disturbance factor is a sum of IA, ISR, and D subscales which
ultimately measures disturbed and altered senses and perceptions of self. This combination, in
particular, factors feelings of insecurity and ambivalence which can lead to a lack of self or identity
and being easily influenced by others. This state of being can lead to depression and emotional
dysregulation. In total, the SELF scale consists of 30 items in total. A high score in SELF may
report difficulties in accessing a stable sense of self (Briere, 1995).
IA subscale. The IA subscale consists of 10 items on the assessment form and two factors.
The IA indicator includes Insecure Attachment-Relational Avoidance (IA-RA) and Insecure
Attachment-Rejection Sensitivity (IA-RS) scores. The IA scale measures early experiences of
parental maltreatment, childhood abuse/neglect, and witnessing or experiencing frightening
behaviour (Briere. 1995). The IA scale is made up of two parts. The first part is a participant
experience of insecure attachment related to symptoms of intimacy avoidance. The second part
records a participant’s preoccupations with fears of rejection and abandonment.
ISR subscale. The ISR subscale consists of 10 items on the assessment form and two
factors. The ISR subscale includes scores from the Impaired Self-Reference-Reduced Self-
Awareness Scale (ISR-RSA) and the Impaired Self-Reference-Other-Directedness (ISR-OD). The
ISR subscale explores a participant’s lack of self-knowledge and sense of self and their personal
beliefs. The two pars of this subscale tap into how influenced an individual is by others and if they
are not valuing their own thoughts and feelings.
D subscale. The D subscale consists of 10 items on the assessment form. Moreover, the D
subscale includes factors related to depressed mood and cognitions (D1 and D2). Negative changes
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
or decreases in TSI raw scores indicate an improvement of symptoms while positive changes or
increases in raw scores indicate a worsening of symptoms (Briere, 1995). High scores on this scale
reflects more frequent feelings of unhappiness and perceptions of worthlessness.
The ADIS-5 screening interviews were administered to predict the inclusion criteria and
need for treatment. This screening tool examines a broad range of psychiatric symptoms and
therefore, can screen out comorbid disorders or diagnostic criteria that would impact the study
(Brown & Barlow, 2014).
Plan of Statistical Analysis
SPSS creates a reliability score using Cronbach’s alpha to test the results. Using SPSS, the
scores were examined for missing information and screened for entry errors. SPSS was used for
all descriptive and psychometric analyses. In addition, HLM was used to test the hypotheses.
The Residual Change Scores
The residual change score was used to estimate degree of change between the baseline and
session 7 measurements. The residual change score accounts for the amount of change from
baseline to session 7 while accounting for baseline scores. Therefore, it is a more reliable estimate
of the degree of change from baseline to session 7 than a difference score. The residual change
score is a reliable estimate of the amount of change that has occurred from baseline to session 7
taking into account the variance in session 7 scores that can be accounted for based on baseline
scores. These scores were used to examine change in self-related trauma symptoms in the first half
of therapy as a predictor of change in emotion dysregulation across the course of therapy. The
residual change scores were used to predict change in trauma-related symptoms found pre- and
mid EFIT therapy.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Missing Data
Hierarchical Linear Modeling (HLM) was used investigate any patterns in the missing data
across treatment periods of pre-, midpoint one, midpoint two, and post-therapy timepoints for the
DERS, TSI SELF, and TSI subscales. A pattern-mixture model was conducted to examine whether
missing data was related to linear trajectories of the dependent variables, SELF, D, IA, and ISR.
Hierarchical Linear Modeling (HLM)
HLM was used to test change in emotion dysregulation and trauma-related symptoms of
self-disturbance across four timepoints over the course of EFIT (baseline, session 5, session 7 and
post-therapy), and to examine the relationship between change in emotion dysregulation over the
course of therapy and change in self-disturbance (i.e., insecure attachment (IA), Depression (D),
and Impaired Self-Reference (ISR)) in the first half of therapy.
The analysis determines whether or not there are changes with the treatment variables,
including finding standard deviations (SD) from the mean to determine if there is a significant
change in trauma-related emotional regulation scores. The statistical analysis also takes into
consideration any potential outliers by completing a data analysis to determine the homogeneity
of the variance, including a linear analysis of the independent variables (EFIT over time) and the
dependent variables (emotion regulation and trauma scores). Level one data is the measurement of
TSI-II and DERS scores over time. In level one, the DERS scores are compared to the TSI-II level
2 data in order to explore any correlations between emotional dysregulation symptoms and trauma-
related symptoms throughout EFIT.
Level two data takes into account the individual participant variables nested within the
data. Level two data for trauma-related symptoms is the measurement of TSI-II scores for the
subscales D, IA, and ISR across time with respect to individual participant scores. The individual
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
variables in the SELF scale are explored across time in order to observe any self-disturbance
patterns over the course of therapy. In both levels, HLM also takes into account the missing data
in the study which is particularly important in respect to the study limitations.
The findings are presented in the results section of the report below. Analysis of data
determines whether the hypotheses are supported and will potentially point to any gaps,
limitations, and opportunities for future research.
Data Screening and Cleaning
SPSS screening results indicate 100% participation at pre-therapy timepoint, and the
participation decreases at the midpoints and post therapy because the study is on-going. The
participation for the DERS decreases from 100% to 45.9% at midpoints 1 and 2, to 32.4% post-
therapy. The DERS scores required a reverse scoring method for questions 1, 4, and 6. Mean scores
are calculated for DERS pre-therapy point, midpoint 1, midpoint 2, and post-therapy point. In
addition, TSI-II scores are combined to calculate IA, D, and ISR, and totalled to determine SELF
scores for each of the four timepoints.
Missing Data
The pattern-mixture models could not be examined because the models would not converge
due to lack of variance in the dichotomous variable representing presence or absence of missing
Statistical Analysis
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
HLM was used to examine the rate of change from pre-therapy through midpoints one and
two, to post-therapy.
Changes across EFIT sessions
Emotion Dysregulation Linear Slope. DERS scores did not demonstrate statistically
significantly change, β10 = 2.6 (36), t=-0.09, p<0.17. The coefficient was negative -0.09 so the
scores were reducing from the starting point coefficient of 2.6; however, the amount was not a
significant change. This model yielded a deviance score of 124.64, which was lower than the base
model, indicating that adding the linear slope scores to the model appears to explain more of the
variance in DERS scores as compared to the simpler model in which the linear slope variable was
not included, which demonstrated a deviance score of 135.42.
TSI SELF Linear Slope. The TSI SELF model for exploring change in self-disturbance
symptoms demonstrates a significant negative linear slope across the four treatment timepoints,
β10 = -6.90 (36), t=-3.9, p<0.001, demonstrating that participants reported significant decreases in
self-disturbance symptoms across the four timepoints from pre to post treatment (see figure 1),
representing average decreases of -6.90 in the TSI-self score at each time point. The linear model
for TSI-SELF demonstrates a deviance score of 589.73, which is lower than the TSI SELF baseline
model which has a deviance score of 634.50. Based on the deviance scores, it is evident that this
model takes into account more of the variance in the data. The TSI SELF baseline model shows a
deviance score of 634.50. The TSI SELF baseline model includes the total variables from the three
subscales. The baseline models are used to compare data to more complex models.
Depression Linear Slope. The data is organized into three sections to show the subscale
data for each of the subscales over time. The depression subscale model demonstrates a significant
linear slope across the timepoints, β10 = - 2.67, t(36) = - 3.78, p<0.001. The coefficient shows a
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
decrease in symptoms by - 2.67 at each timepoint, which is evident in the negative slope of the
indicator D (see Figure 2).
Insecure Attachment Linear Slope. The insecure attachment subscale model
demonstrates a significant linear slope across the time points, β10 = -2.26, t(36) = -3.12, p<0.004.
The coefficient displays a decrease in insecure attachment symptom indicators by - 2.26 at each
timepoint, which is visible in the negative slope of the indicator IA (see Figure 2).
Impaired Self-Reference Linear Slope. In addition to the previous subscales, the
impaired self-reference subscale model also demonstrates a significant linear slope across the
timepoints, β10 = -1.96, t(36) = -4.12, p<0.001. The coefficient exhibits a decrease in impaired self-
reference symptom indicators by 1.96 at each timepoint which is visible in the negative slope of
the indicator ISR (see Figure 2).
Figure 1
TSI SELF Scores Over Time: Decreases in self-disturbance symptoms modeled from pre to post
Pre Mid 1 Mid 2 Post
Time Points
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Early change in TSI-SELF predicting change in DERS across EFIT sessions
The TSI-SELF residual change scores did not significantly predict linear changes in the
DERS scores across baseline, session 5, session 7 and post-therapy over the course of 15 EFIT
sessions, β11 = 0.01, t(17) = 2.04, p=0.06. The deviance score of this model was 80.19, which is
lower as compared to the deviance score of the DERS linear model (124.64). Although the
predictive model did not reach statistical significance, it appears to explain more variance in the
data as compared to the linear model.
Figure 2
TSI SELF Subscale Scores Over Time: Decreases in depression, insecure attachment, and
impaired self-reference from pre to post therapy.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Table 1
Means and Standard Deviations of Treatment Variables over Time
Mid-Therapy 1
Mid-Therapy 2
M (SD)
M (SD)
M (SD)
M (SD)
This study investigated changes in trauma symptoms related to the self over the course of
EFIT. The results demonstrated significant changes in trauma symptoms related to self over the
course of therapy. Symptoms of insecure attachment, impaired self-reference, and depression
display a significant gradual decrease over the four timepoints, which also signify improvements
over the course of treatment. Though there were statistically significant changes in scores for the
TSI-II scales, the findings present no statistically significant changes in emotional dysregulation.
Emotional dysregulation reductions scores changed over the first few sessions of therapy;
however, did predict reductions in self-related trauma symptoms across EFIT sessions.
Based on analysis, reductions in trauma symptoms related to the self in the first few
sessions of therapy do not appear to significantly predict reductions in emotional dysregulation
symptoms across EFIT sessions, however, is approaching significance. More data is needed to
show whether the results could become significant. With this current data set it could be theorized
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
that improvements in self-related trauma symptoms in the first part of EFIT may play a role in
reductions in emotion dysregulation across therapy sessions. Though these results are tentative and
dependent on more data collection, the value is approaching significance at the preliminary
findings level.
Changes in EFIT of trauma symptoms related to the self
The study’s results provide support for the assumption that when individuals participate in
EFIT they cultivate feelings of safety in their relationships, which ultimately improves
attachments. EFIT helps an individual develop long lasting changes in attachment bonds which
formulate into secure attachments with others (Wiebe et al, 2017). EFIT theory suggests that as
individuals engage in more secure patterns, they experience less distress and increased self-
awareness (Johnson, 2014). Attachment theory suggests that individuals with symptoms of
insecure attachments with others need treatment that focuses on the client-therapist relationship to
cultivate healthy attachment bonds (Bowlby, 1979). A decrease in insecure attachment symptoms
as found in this study supports the theory that attachment-based approaches cultivate
improvements in self-reported feelings of safety in relationships and secure connections to others
(Johnson, 2019).
Moreover, feelings of safety and security in relationships correspond with sense of self in
relation to the other (Briere et al, 2010). The current study provides evidence that throughout EFIT
the participants self-reported decreases in symptoms, which maintains the assumption that key
bonding experiences and self-awareness are fundamental components in improving attachment
insecurity and avoidance (Johnson & Wiebe, 2016).
The findings in this study provide preliminary evidence to support the assumption that
trauma-related symptoms may decrease when therapy is emotionally-focused and oriented with
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
attachment-based approaches. According to trauma theory, individuals who have experienced
trauma may exhibit symptoms of depression, hopelessness, impaired sense of self, insecure
attachments, and low self-worth (Johnson, 2005; Ventimiglia et al, 2020; & Briere, 2010). The
self-disturbance symptoms in this study examined changes in self-reported symptoms of mood and
impaired self-reference. The results of the study provide evidence that EFIT decreases symptoms
of trauma related to the self may decrease over the course of EFIT sessions.
According to attachment theory, attachment bonds greatly impact an individual’s sense of
self and leads to symptoms of depression and anxiety (Bowlby, 1979). Specifically, attachment
theory suggests that individuals who have experienced trauma develop symptoms of depression
and anxiety related to feelings of insecurity in relationships (Briere, 2004). The study found that
self-disturbances, such as, symptoms of depression, insecure attachment, and impaired self-
reference decreased over the course of EFIT. The assumption that decreases in symptoms of self-
disturbances coincide with decreases in symptoms of depression is shown in these results.
In addition, the results further support research by Briere (2004) and Johnson (2009) which
suggest individuals who seek treatment for depression experience symptoms of impaired sense of
self associated with their experience of trauma in their life. In addition, Bowlby (1979) theorized
that depression was an inherent part of attachment difficulties and considered it a part of mourning
the loss of attachment. The assumption that attachment-based approaches, such as emotionally
focused therapies, increase symptoms related to an individual’s sense of self is found in these
results through decreases in these self-reported symptoms (Johnson, 2004).
EFIT is thought to improve perceptions of self through insight and contextual meanings of
self in treatment (Johnson, 2019). The study further provides evidence that EFIT leads to greater
reductions in self-impairments and depression.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
The study found no changes in the emotional dysregulation scores throughout treatment.
In addition, it is found that emotional dysregulation symptoms are not predictors of changes in
self-related trauma-related symptoms. Theory suggests that emotional dysregulation generally
decreases over the course of EFIT (Johnson, 2019). One theory as to why these symptoms did not
decrease over the course of therapy is because the treatment was impacted by an external problem
unrelated to the study itself. The results suggest that more research is needed to determine whether
emotional dysregulation is a predictor of outcomes in EFIT.
The study exhibits a few limitations worth noting for future studies, such as small sample
size, delays in treatment, and participant emotional impacts related to the Covid-19 pandemic. The
first limitation is the small sample size which is homogenous and, therefore, the results are not
able to be generalized for the broader population.
An unexpected limitation of this study was the effect of the world-wide Covid-19 pandemic
that caused a delay in the study and resulted in missing data and delays in participants completing
the study. The study began its course in September of 2019. The possibility of a pandemic was an
unexpected impact and occurred by March of 2020. In March, all treatments were paused and
awaiting public health confirmations of safety regulations. One of the mitigating factors is that
participants did not all begin and end therapy at the same time. For instance, when the pandemic
occurred some participants were nearing the end of therapy. Other participants were at the midway
point of treatment and some participants had not yet started treatment. Participants were stalled at
various points of their EFIT treatment course; therefore, there is a possibility this incident impacted
participation, missing data, and affected emotional-dysregulation/trauma-related scores.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
There was a pivotal change in the way treatment was administered during this time and is
another limitation. EFIT treatment was originally administered to be an in-person and changed to
an online format. EFIT is an in-person psychotherapy treatment and more research is needed on
its efficacy in a virtual or online format.
The pattern of missing data could not be examined; therefore, it cannot be assumed that
missing scores have no relationship to the results. Ultimately, participants with missing data at
particular time points may potentially differ from those who did complete the questionnaires at
those time points. Therefore, the results must be interpreted with caution.
The potential impact of the pandemic on participant scores may have resulted in changes
observed in the data, which could be related partly because of this world event as opposed to
individual experiences within the EFIT study. Stress related to the pandemic may have
significantly influenced the study results by impacting the mental health and wellbeing of the
participants. One theory is that participants may have experienced increases in mental illness
symptoms as a result of uncertainty and fear associated with the lockdown safety measures and
health anxiety.
Theories on trauma, as exhibited in the literature review above, might propose that
participants who have previously experienced traumatic events or have trauma-related symptoms
are more likely to experience heightened state of arousal following a traumatic event (Briere et al,
2015). The emotional toll of a pandemic on an individual could lead to symptoms of emotional
dysregulation as a result of feeling unsafe in one’s environment. Feeling unsafe, as the research
has shown, perpetuates symptoms of insecure attachment and emotional dysregulation (Briere,
2004). Another emotional impact could be that individual’s may experience symptoms of
depression and hopelessness related to worries about the future state of their individual life and/or
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
the long-term impact of the disease on the global population. These experiences are likely to impact
the trauma-related and emotional dysregulation scores presented in the results.
As per the literature review, EFT has been used increasingly over the last decade for
treating couples with trauma (Johnson, 2014). EFIT is a relatively new treatment in terms of
individual therapy; however, the evidence found in couples therapy support EFT as one of the
more empirically supported treatment plans for psychotherapists (Johnson, 2019). By nature,
trauma is a deep emotional injury that creates wounds that have profound effects on an individual’s
well-being and orientation to the world (Harte, Strmelj, & Theiler, 2020). The emotional depth of
trauma makes it one of the more challenging issues for psychotherapists to treat. The results
presented in this paper could aid therapists in navigating the effects of trauma and encouraging
exploration of evidence-based treatment options.
The current study reveals that trauma-related symptoms decreased over the course of EFIT
despite the limitations involved over the course of therapy. One major clinical implication of the
study is that clients are presented with a potentially effective treatment option for their trauma-
related symptoms. The clinical implications related specifically to the use of the TSI-II subscales
used are that this method did not account for individuals with PTSD and a broader range of trauma
symptoms. Individuals with PTSD meet more criteria and could utilize the full TSI-II scale for
investigation of treatment results.
One implication of the study is that it is unknown whether or not emotional dysregulation
symptoms predict changes in trauma-related symptoms. Although theory on emotional
dysregulation in EFIT suggests that emotional dysregulation symptoms improve over the course
of therapy (Johnson, 2005), the lack of data in this study could suggest further research is needed
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
in this area in terms of predicting changes in symptoms related to trauma. Future research could
explore this implication through longitudinal data using DERS as a predictor and investigating
changes in TSI-II over the course of therapy.
Future research directions
The findings of this study hold a broader implication for future research on trauma-related
emotional dysregulation symptoms in terms of exploring these concepts empirically and
longitudinally for evidence-based practices and trauma-informed therapy. For example, future
research could explore the predictability of emotional dysregulation symptoms on treatments for
trauma-related symptoms.
In the final analysis, EFIT is a relatively new treatment that deserves recognition in the
field of trauma-informed therapy because of these findings; however, substantial research is still
needed to yield a broader understanding and knowledge base. Future studies could propose to
investigate the correlation of emotionally focused treatments for trauma symptoms longitudinally
and post-pandemic. Future studies could test the hypothesis that EFIT is an effective treatment for
trauma-related symptoms and emotional dysregulation long-term, after following the course of
therapy. This could be explored by including follow-up assessments to measure the treatment
effect and whether or not participants experience a decrease in trauma-related symptoms related
to self-awareness and self-disturbances. From the literature review, a high prevalence of
individuals report that they have experienced a traumatic event in their lifetime. This finding
signifies the need for future studies on the effectiveness of treatment methods and the further
discovery and development of evidence-based psychotherapy practices, such as EFIT, that elicit
long-lasting results. Ultimately, the intention of this study is to continue to broaden potential
research avenues for future research on EFIT.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
The current study provides evidence for the theoretical assumption that EFIT helps clients
change trauma-related attachment security, depression, and self-disturbance symptoms that occur
over the course of treatment. Specifically, decreases in trauma-related depression, insecure
attachment, and impaired self-reference were found. Based on the results of the study, the
assumption that emotional dysregulation decreases over EFIT therapy is not supported. This result
could be explained by the limitation on the impact of the world-wide pandemic that occurred in
March 2020 and is on-going. The scope of this study focused on the EFIT treatment group and
trauma-related symptoms, however, the larger EFIT attachment-based project is still on-going and
plans to provide more insights and findings on the effect of treatment for individuals. Ultimately,
the study supports previous EFIT theories that attachment-based approaches improve symptoms
of self-disturbance, insecure attachment, sense of self, and depression.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: Author.
Ameringen, M., Mancini. C., Patterson, B., & Boyle, M. H. (2008). Posttraumatic stress disorder
in Canada. CNS Neuroscience & Therapeutics, 14, 171-181.
Beck, A. T., & Steer, R. A. (1990). Manual for the Beck Anxiety Inventory (BAI-II) [Measurement
Instrument]. San Antonio, TX: Psychological Corporation.
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II
(BDI-II) [Measurement Instrument]. San Antonio, TX: Psychological Corporation.
Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock. Courtois,
C. A., & Ford, J. D. (2015). Treatment of complex trauma. Guildford Press: New York.
Briere, J. (1995). Trauma Symptom Inventory (TSI-II) professional manual [Measurement
Instrument]. Psychological Assessment Resources.
Briere, J. (2004). Dissociative symptoms and trauma exposure: specificity, affect dysregulation,
and posttraumatic stress. Journal of Nervous and Mental Disease, 194 (2), 78-82.
Briere, J., Godbout, N., & Dias, C. (2015). Cumulative trauma, hyperarousal, and suicidality in
the general population: A path analysis. Journal of Trauma and Dissociation, 16, 153-169.
Briere, J., Hodges, M., & Godbout, N. (2010). Traumatic stress, affect dysregulation, and
dysfunctional avoidance: A structural equation model. Journal of Traumatic Stress, 23,
Briere, J., & Rickards, S. (2007). Self-awareness, affect regulation, and relatedness: Differential
sequels of childhood versus adult victimization experiences. Journal of Nervous and
Mental Disease, 195, 497-503.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Brown, T. A., & Barlow, D. H. (2014). Anxiety and related disorders interview schedule for
DSM-5 (ADIS-5L): Client interview schedule [Measurement Instrument].
Brubacher, L. (2017). Emotionally focused individual therapy: An attachment-based
experiential/systemic perspective. Person-Centred and Experiential Psychotherapies,
16(1), 50-67.
Burgess Moser, M., Dalgleish, T. L., Johnson, S. M., Lafontaine, M., Wiebe, S. A., & Tasca, G.
(2016). Changes in relationship-specific romantic attachment in Emotionally Focused
Couple Therapy. Journal of Marital and Family Therapy, 42(2), 231245.
Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and treatment.
Psychotherapy: Theory, Research, Practice, Training, 41(4), 412425.
Dalton, E. J., Greenman, P. S., Classen, C. C., & Johnson, S. M. (2013). Nurturing connections in
the aftermath of childhood trauma: A randomized controlled trial of emotionally focused
couple therapy for female survivors of childhood abuse. Couple and Family Psychology:
Research and Practice, 2(3), 209-221.
Fowler, J. C., Charak, R., Elhai, J. D., Allen, J. G., Frueh, B. C., & Oldham, J. M. (2014). Construct
validity and factor structure of the difficulties in Emotion Regulation Scale among adults
with severe mental illness. Journal of psychiatric research, 58, 175180.
Godbout, N., Hodges, M., Briere, J., & Runtz, M. (2016) Structural Analysis of the Trauma
Symptom Inventory2, Journal of Aggression, Maltreatment & Trauma, 25(3). 333-346.
Gratz, K. L. & Roemer, L. (2004). Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the Difficulties in
Emotion Regulation Scale [Measurement Instrument]. Journal of Psychopathology and
Behavioral Assessment, 26, 41-54.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Greenberg, L. S. (2004). Emotion-focused therapy. Clinical Psychology and Psychotherapy,
11(3), 3-16.
Greenberg, L. S. (2006). Emotion-focused therapy: A synopsis. Journal of Contemporary
Psychotherapy, 36, 87-93.
Greenberg, L. S., Warwar, S. H., & Malcom, W. M. (2008). Differential effects of emotion
focused therapy and psychoeducation in facilitating forgiveness and letting go of
emotional injuries. Journal of Counselling Psychology, 55(2), 185-196.
Harte, M. Strmelj, B., & Theiler, S. (2020). Expanding the emotion-focused therapy task of
focusing to process emotional injury. Person-Centered and Experiential Psychotherapies,
19(1), 38-65.
Holowaty, K. A. M., Paivio, S. C. (2012). Characteristics of client-identified helpful events in
emotion-focused therapy for child abuse trauma. Psychotherapy Research, 22(1), 56-66.
Johnson, S. (2005). Emotionally focused couple therapy with trauma survivors: Strengthening of
attachment bonds. The Guilford Press.
Johnson, S. (2014). Hold me tight: Seven conversations for a lifetime of love. Little, Brown, and
Johnson, S. (2019). Attachment theory in practice: Emotionally focused therapy with individuals,
couples, and families. The Guilford Press.
Johnson, S. M. & Wiebe, S. A. (2016). A review of the research in emotional focused therapy for
couples. Family Process, 55, 390-407.
MacIntosh, H. B. & Johnson, S. (2008). Emotionally focused therapy for couples and childhood
sexual abuse survivors. Journal of Martial and Family Therapy, 34(3), 289-315.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
McRae, T. R., Dalgleish, T. L., Johnson, S. M., Burgess-Moser, M., & Killian, K.
D. (2014). Emotion Regulation and Key Change Events in Emotionally Focused Couple
Therapy. Journal of Couple & Relationship Therapy, 13(1), 1-24.
Mikulincer, M., & Shaver, P. R. (2018). Attachment theory as a framework for studying
relationship dynamics and functioning. In A. L. Vangelisti & D. Perlman (Eds.), The
Cambridge handbook of personal relationships (p. 175185). Cambridge University Press.
Mlotek, A. E. & Paivio, S. C. (2017). Emotion-focused therapy for complex trauma. Person
Centred and Experiential Psychotherapies, 16(3), 198-214.
Muller, R. T. (2010). Trauma and the avoidant client: Attachment-based strategies for healing.
New York, NY: W.W. Norton.
Nelson, J., Klumparendt, A., Doebler, P., & Ehring, T. (2017). Childhood maltreatment and
characteristics of adult depression: meta-analysis. Br. J. Psychiatry, 210, 96104.
Paivio, S. C., Jarry, J. L. Chagigiorgis, H., Hall, I., & Ralston, M. (2010). Efficacy of two
versions of emotion-focused therapy for resolving childhood trauma. Psychotherapy
Research, 20(3), 353-366.
Paivio, S. C. & Nieuwenhuis, J. A. (2001). Efficacy of emotion focused therapy for adult
survivors of child abuse: A preliminary study. Journal of Traumatic Stress, 14(1), 115-
Pascual-Leone, A., Yeryomenko, N., Sawashima, T., & Warwar, S. (2019). Building resilience
over 14 sessions of emotion focused therapy: Micro-longitudinal analyses of productive
emotional patterns. Psychotherapy Research, 29(2), 171-185.
Pos, A. E. & Greenberg, L. S. (2007). Emotion-focused therapy: The transforming power of
affect. Journal of Contemporary Psychotherapy, 37, 25-31.
Emotionally focused individual therapy for the treatment of trauma-related symptoms of the
Rependa, S. L., Muller, R. T, & Foroughe, M. (2018). EFFT and Trauma. In Foroughe, M. (Ed.),
Emotion focused family therapy with children and caregivers: A trauma-informed
approach (pp. 99-119). Routledge: New York.
Runtz, M., Godbout, N., Eadie, E., & Briere, J. (2008). Validation of the revised Trauma
Symptom Inventory (TSI-2). Paper presented at the 116th Annual Convention of the
American Psychological Association, Boston, MA.
Ventimiglia, I., Van der Watt, A. S. J., Kidd, M., & Seedat, S. (2020). Association between trauma
exposure and mood trajectories in patients with mood disorders. Journal of Affective
Disorders, 262, 237-246.
Whisman, M. A. (2006). Childhood trauma and marital outcomes in adulthood. Personal
Relationships, 13, 375386. doi:10.1111/j.1475-6811.2006 .00124.x
Wiebe, S. A., Johnson, S. M., Lafontaine, M. F., Moser, M. B., Dalgleish, T. L., & Tasca, G. A.
(2017). Two-year follow-up outcomes in emotionally-focused couples therapy: An
investigation of relationship satisfaction and attachment trajectories. Journal or Marital
and Family Therapy, 43(2), 227-244.
Wiersma, J. E., Hovens, J. G., van Oppen, P., Giltay, E. J., van Schaik, D. J., Beekman, A. T., &
Penninx, B. W. (2009). The importance of childhood trauma and childhood life events for
chronicity of depression in adults. The Journal of Clinical Psychiatry, 70(7), 983989.
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
This research investigated the processing and integration of past painful/traumatic events using an expanded model of the Emotion Focused Therapy (EFT) task of Focusing. In previous research Harte proposed that processing emotional injuries by bringing previously incomplete memories back into awareness through activating felt sense, followed a particular sequence. The discovery phase of task analysis, a theory building research methodology, was used to develop a detailed model that revealed the steps of client change. Two sets of client participants were recruited. (1) Clients who reported they had experienced an emotional injury that resulted in emotional pain and had been engaged in therapy for some time and (2) trainee therapists in the role of client (bringing their own experiences) working with another trainee. A total of nine EFT trained therapists (26–57 years, mean = 44.25 years, five females and four males) worked with 11 clients (26–53 years, mean = 38.50 years, eight females and three males). Twelve single sessions were visually recorded, transcribed, and rigorously analyzed. A sequential three stage empirical model emerged from the discovery phase of the task analysis. The resultant empirical model describes a newly identified EFT task for processing emotional injuries in response to a felt sense of emotional pain (the marker).
Full-text available
Emotionally Focused Couple Therapy (EFT; The practice of emotionally focused couple therapy: Creating connection. New York, NY: Brunner-Routledge) is an evidence-based couple therapy that aims to create lasting change for couples (Clinical Psychology: Science and Practice, 6(1), 67–79). Although studies have demonstrated strong results in follow-up (Journal of Marital and Family Therapy, 28(4), 391–398), less is known about relationship functioning across time after therapy has ended. We modelled change in relationship satisfaction and attachment from pre-therapy through 24 months follow-up in 32 couples. HLM results confirmed a significant growth pattern demonstrating increases in relationship satisfaction and secure base behaviour and decreases in relationship specific attachment anxiety over the course of therapy and across follow-up at a decelerated rate. These findings support the theoretical assumption that EFT helps couples engaged in therapy create lasting relationship satisfaction and attachment change.
Background: Trauma exposure is associated with the development of mood disorders and their phenotypic presentation. Cross-sectional associations between trauma exposure and mood disorders are well documented. Data on the association of trauma with longitudinal mood trajectories are lacking. We investigated the association between trauma exposure and weekly mood trajectories. Method: Mood disorder patients (N = 107; female = 81; mean age = 37.04 years), assessed for trauma exposure at baseline using the Childhood Trauma Questionnaire (CTQ) and Life Events Checklist (LEC), completed weekly telephonic mood assessments using the Quick Inventory of Depressive Symptomatology (QIDS) and Altman Self-Rating Mania scale (ASRM) over a 16 week period commencing at one week post-discharge from hospital. Associations between trauma exposure, severity of mood symptoms and mood trajectories were analysed using Pearson's correlations, LS Mean scores, F-statistics, and RMANOVA. Results: Trauma exposure was persistently associated, albeit with some fluctuation in the strength of the association, with depressive symptomatology. Emotional abuse showed the most persistent association over time. Sexual abuse was minimally associated with depressive symptomatology. The severity of childhood trauma exposure was positively correlated with the severity of depressive symptoms. Lifetime traumatic events were significantly associated with mania scores, however there was no association between childhood trauma exposure and mania symptoms. Conclusion: Identification of both a history of childhood abuse and neglect and lifetime traumatic event exposure is important in the assessment and management of patients with mood disorders, as trauma can exert a persistent impact on depression trajectories and on symptom severity.
Given recent attention to emotion regulation as a potentially unifying function of diverse symptom presentations, there is a need for comprehensive measures that adequately assess difficulties in emotion regulation among adults. This paper (a) proposes an integrative conceptualization of emotion regulation as involving not just the modulation of emotional arousal, but also the awareness, understanding, and acceptance of emotions, and the ability to act in desired ways regardless of emotional state; and (b) begins to explore the factor structure and psychometric properties of a new measure, the Difficulties in Emotion Regulation Scale (DERS). Two samples of undergraduate students completed questionnaire packets. Preliminary findings suggest that the DERS has high internal consistency, good test–retest reliability, and adequate construct and predictive validity.
This article describes emotion-focused therapy for complex trauma (EFTT ). EFTT is an evidence-based, short-term treatment for childhood abuse and neglect that posits the therapeutic relationship and emotional processing of trauma material as key mechanisms of change . This paper outlines sources of disturbance and long-term effects of complex trauma. It reviews the theoretical framework on which EFTT is based, mechanisms of change and phases of treatment, as well as supporting research. Primary interventions are demonstrated using a case example from a published video of a single session .
Objective: Pascual-Leone and Greenberg's sequential model of emotional processing has been used to explore process in over 24 studies. This line of research shows emotional processing in good psychotherapy often follows a sequential order, supporting a saw-toothed pattern of change within individual sessions (progressing "2-steps-forward, 1-step-back"). However, one cannot assume that local in-session patterns are scalable across an entire course of therapy. Thus, the primary objective of this exploratory study was to consider how the sequential patterns identified by Pascual-Leone, may apply across entire courses of treatment. Method: Intensive emotion coding in two separate single-case designs were submitted for quantitative analyses of longitudinal patterns. Comprehensive coding in these cases involved recording observations for every emotional event in an entire course of treatment (using the Classification of Affective-Meaning States), which were then treated as a 9-point ordinal scale. Results: Applying multilevel modeling to each of the two cases showed significant patterns of change over a large number of sessions, and those patterns were either nested at the within-session level or observed at the broader session-by-session level of change. Discussion: Examining successful treatment cases showed several theoretically coherent kinds of temporal patterns, although not always in the same case. Clinical or methodological significance of this article: This is the first paper to demonstrate systematic temporal patterns of emotion over the course of an entire treatment. (1) The study offers a proof of concept that longitudinal patterns in the micro-processes of emotion can be objectively derived and quantified. (2) It also shows that patterns in emotion may be identified on the within-session level, as well as the session-by-session level of analysis. (3) Finally, observed processes over time support the ordered pattern of emotional states hypothesized in Pascual-Leone and Greenberg's ( 2007 ) model of emotional processing.
Attachment theory as a theory of adult love and emotion regulation can provide a humanistic paradigm for therapeutic change that is relevant to a broad range of presenting problems. I advocate emotionally focused individual therapy, an attachment-based experiential/systemic integration that targets concerns common across various models of individual psychotherapy: creating secure attachment, resolving negative interpersonal and intrapsychic interactive patterns, and developing effective emotion regulation strategies. I suggest that attachment theory sets the stage from which to consider individual therapy as a process of love (developing secure connections) between therapist and client, between client and past and present relationships, and within the client’s internal processes. I present principles of attachment, discuss how these principles can fruitfully shape the therapeutic relationship, define the destination for change, offer guidance for working with emotion and shape interventions and change processes. The change processes which I present and illustrate with a case example are as follows: (1) identifying patterns of emotion regulation and deepening the underlying emotion and (2) creating corrective emotional experiences that can transform these patterns into secure bonds interpersonally and intrapsychically.
How to effectively engage traumatized clients, who avoid attachment, closeness, and painful feelings. A large segment of the therapy population consist of those who are in denial or retreat from their traumatic experiences. Here, drawing on attachment-based research, the author provides clinical techniques, specific intervention strategies, and practical advice for successfully addressing the often intractable issues of trauma. Trauma and the Avoidant Client will enhance the skills of all mental health practitioners and trauma workers, and will serve as a valuable, useful resource to facilitate change and progress in psychotherapy. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Over 11,000 English language copies distributed to date; in its third printing. German Translation: Muller, R. T. (2013). Wenn patienten keine nahe zulassen: Strategien fur eine bindungsbasierte traumatherapie [When patients do not allow closeness: Strategies for an attachment-based trauma therapy], translated by Elisabeth Vorspohl. Stuttgart, Germany: Klett-Cotta. ISBN: 978-3608947861. Italian Translation: Muller, R. T. (2014). Il trauma e il cliente evitante. Strategie di guarigione basate sull’attaccamento, translated by Corrado Zaccagnini. Rome, Italy: Giovanni Fioriti Editore. ISBN: 978-88-95930-82-4.
Background: Childhood maltreatment has been discussed as a risk factor for the development and maintenance of depression. Aims: To examine the relationship between childhood maltreatment and adult depression with regard to depression incidence, severity, age at onset, course of illness and treatment response. Method: We conducted meta-analyses of original articles reporting an association between childhood maltreatment and depression outcomes in adult populations. Results: In total, 184 studies met inclusion criteria. Nearly half of patients with depression reported a history of childhood maltreatment. Maltreated individuals were 2.66 (95% CI 2.38-2.98) to 3.73 (95% CI 2.88-4.83) times more likely to develop depression in adulthood, had an earlier depression onset and were twice as likely to develop chronic or treatment-resistant depression. Depression severity was most prominently linked to childhood emotional maltreatment. Conclusions: Childhood maltreatment, especially emotional abuse and neglect, represents a risk factor for severe, early-onset, treatment-resistant depression with a chronic course.