Early on in our careers as marriage and family therapists, still learning our psychosocial ABCs — in diapers, as it were — we’re introduced to those so-called “foundational models” with which we’re expected to have at least a passing familiarity. Our professors and preceptors encourage us to find a model that jibes with us and explore it more deeply, yet most of us will end up practicing in the United States, where managed care is as inescapable as death and taxes, and so, as a practical matter, we pay close attention to approaches with strong empirical support: CBT, ACT, Gottman method. (Not to say there’s anything wrong with that; I’m not about to argue that evidence-based practice is something undesirable.) Emotionally focused couples therapy (EFCT) is often cited as a model with rigorous research support, and for good reason. It is, at its heart, a reasonable outgrowth of attachment theory, which in turn enjoys solid empirical support for both children and adults, and has been considered as a candidate for a “grand unified theory” of psychotherapy, if such a thing exists. Research also indicates that emotional engagement — that is, a secure attachment bond — is critical for relationship stability, so EFCT’s focus on facilitating emotional safety and responsiveness in a relationship just makes good sense. And EFCT seems to be at least somewhat generalizable across sexual, racial, ethnic, and gender minority couples, possibly because attachment needs, and a desire for secure attachment bonds, are near-universals.
From that argument, it seems reasonable that an EFT-trained therapist should be able to hang out a shingle and start treating any and every couple, no ifs, ands, or buts; no adaptation of theory or practice beyond the adjustments we’d make for any couple: updating our hypotheses based on what the clients tell us in the course of questioning.
Right?
As with most issues in this field, the answer seems to be: it depends on the client.
Take, for example, the case of interracial couples in my own specialty, medical family therapy (MedFT). Research has shown us that, statistically speaking, people in interracial relationships have a higher propensity to develop issues with psychological distress, sleep quality, and chronic conditions such as malignancy, diabetes, arthritis, hypertension, ulcers, heart disease, and emphysema — possibly due to acculturation pressures, exposure to vicarious discrimination, stigmatization by friends, family, and community, and the cumulative effects of the resulting stress. Once conditions develop, more privileged partners may form coalitions with a physician against their partner, inadvertently reinforcing a power differential and appropriating some of the partner’s agency, and, in relationships lacking in social support — due to immigration status, social isolation, or familial ostracism — that differential, and the emotional pain it cultivates, gets compounded through insularity. Here again, EFCT can be a powerful tool for the MedFT practitioner, but that efficacy is contingent not only upon the therapist’s cultural competency and prior self-of-the-therapist work, but also on their willingness to skillfully adapt their interventions for the couple at hand. Emotional language may need to be adapted to account for cultural differences in emotional expression or meanings — reframing caregiving gestures, for example, as “nice things to do” for a partner, rather than a matter of the caregiver’s skills and the care recipient’s dependency.
Of course, interracial couples face challenges beyond the medical setting. We, as therapists, and even our clients, may have a tendency to minimize the influence of racial or cultural differences on relationship issues. As some authors have pointed out, there’s a risk of assuming that every problem has its roots in identity, privilege, or marginalization; yet denying the possibility that these phenomena have at least some influence on personal and relational issues also does our clients a disservice. Even “typical” relationship issues such as gender roles, affection, and extended family involvement may be nuanced by each partner’s respective experiences of race, culture, power, and privilege. All couples are subject to individual, relational, social, and physical influences and constraints; identities, values, and belief systems are part and parcel of all four. Partner disagreements and inadvertent attachment injuries often stem from unconscious assumptions about fidelity, priorities, individualism and collectivism, problem solving, and emotional expression carried over from the family of origin, and these, in turn, from their parents’ families of origin, on and on, contextualized by histories of privilege and oppression, social class, economic hardships and opportunity, and religious beliefs and cultural norms. So it’s crucial for the EFCT therapist to validate each partner’s experiences and beliefs — just as we validate expressed emotion — but also reflect and reframe on how those experiences and beliefs contribute to the couple’s negative cycle.
So, all these facts in hand: do we, as EFCT therapists, need to adapt our approach for interracial couples — or, for that matter, hail from different religious backgrounds or nationalities — any more than we adapt it for any other couple? To put it another way: are partners’ differences in race and ethnicity really that different than if they were, say, of two different denominations within the same religion, or grew up in two different states in the U.S.? My personal view is that race and ethnicity, in the United States and in many other countries, has historically been associated with pervasive differences in socioeconomic status, opportunities, beliefs, and values that they bear at least some exploration from a standpoint of curiosity — to do otherwise would be to lose an important tool for demolishing clients’ superficial experience of self and other, and erecting a new one on a more secure foundation — which is, in my mind, the crux of EFCT.
References & Further Reading
Beasley, C. C., & Ager, R. (2019). Emotionally focused couples therapy: A systematic review of its effectiveness over the past 19 years. Journal of Evidence-Based Social Work, 16(2), 144-159.
Briere, J., & Jordan, C. E. (2009). Childhood maltreatment, intervening variables, and adult psychological difficulties in women: An overview. Trauma, Violence, & Abuse, 10(4), 375-388. https://doi.org/10.1177/1524838009339757
Budge, S. L., Sinnard, M. T., & Hoyt, W. T. (2021). Longitudinal effects of psychotherapy with transgender and nonbinary clients: A randomized controlled pilot trial. Psychotherapy, 58(1), 1. https://doi.org/10.1037/pst0000310
Compton, E., & Morgan, G. (2022). The experiences of psychological therapy amongst people who identify as transgender or gender non-conforming: A systematic review of qualitative research. Journal of Feminist Family Therapy, 34(3-4), 225-248.
Dansby Olufowote, R. A., Samman, S. K., & Frick, H. (2022). Medical family therapy with diverse populations part II: Understanding & treating interracial & international couples with chronic illness using emotionally focused MedFT. International Journal of Systemic Therapy, 33(4), 250-275.
Girard, A., Connor, J. J., & Woolley, S. R. (2020). An exploratory study of the role of infidelity typologies in predicting attachment anxiety and avoidance. Journal of Marital and Family Therapy, 46(1), 124-134. https://doi.org/10.1111/jmft.12371
Girme, Y. U., Jones, R. E., Fleck, C., Simpson, J. A., & Overall, N. C. (2021). Infants’ attachment insecurity predicts attachment-relevant emotion regulation strategies in adulthood. Emotion, 21(2), 260-272. https://doi.org/10.1037/emo0000721
Gottman, J. M. (2014). What predicts divorce?: The relationship between marital processes and marital outcomes. Psychology Press.
Gouveia, T., Schulz, M. S., & Costa, M. E. (2016). Authenticity in relationships: Predicting caregiving and attachment in adult romantic relationships. Journal of Counseling Psychology, 63(6), 736-744. https://doi.org/10.1037/cou0000128
Greenman, P. S., Young, M. Y., & Johnson, S. M. (2009). Emotionally focused therapy with intercultural couples. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 143-166). SAGE Publications, Inc. https://doi.org/10.4135/9781452275000
Gullett, L., & West, T. V. (2016). Understanding racial color blindness and multiculturalism in interracial relationships: Cognitive and emotional tensions and their implications.
Hardtke, K. K., Armstrong, M. S., & Johnson, S. (2010). Emotionally focused couple therapy: A full-treatment model well-suited to the specific needs of lesbian couples. Journal of Couple & Relationship Therapy, 9(4), 312-326. https://doi.org/10.1080/15332691.2010.515532
Heiden‐Rootes, K. M., Addison, S. M., & Pettinelli, J. D. (2020). Working with queer couples. The Handbook of Systemic Family Therapy, 3, 123-153.
Jacobson, N. S., & Addis, M. E. (1993). Research on couples and couple therapy: What do we know? Where are we going? Journal of Consulting and Clinical Psychology, 61(1), 85.
Johnson, S., & Whiffen, V. E. (2003). Attachment processes in couple and family therapy. The Guilford Press.
Johnson, S. M. (2012). The practice of emotionally focused couple therapy: Creating connection. Routledge.
Johnson, S. M., & Campbell, T. L. (2021). A primer for emotionally focused individual therapy (Efit): Cultivating fitness and growth in every client. Routledge.
Louie, P., Brown, H. R. H., Cobb, R. J., & Sheehan, C. (2024). Are Interracial Couples at Higher Risk of Multiple Chronic Conditions? Evidence from a Nationally Representative Sample [Original Paper]. Journal of Racial and Ethnic Health Disparities, 1-11. https://doi.org/10.1007/s40615-024-01952-y
Maynigo, P. M. (2015). Cultural differences in attachment and emotion: Emotionally focused therapy with intercultural couples. Rutgers The State University of New Jersey, Graduate School of Applied and ….
Paetzold, R. L., Rholes, W. S., & Kohn, J. L. (2015). Disorganized attachment in adulthood: Theory, measurement, and implications for romantic relationships. Review of General Psychology, 19(2), 146-156.
Parra-Cardona, J., Cordova, D., Holtrop, K., Escobar-Chew, A. R., & Horsford, S. (2009). Culturally informed emotionally focused therapy with Latino/a immigrant couples In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 345-368). SAGE Publications, Inc. https://doi.org/10.4135/9781452275000
Rholes, W. S., Paetzold, R. L., & Kohn, J. L. (2016). Disorganized attachment mediates the link from early trauma to externalizing behavior in adult relationships. Personality and Individual Differences, 90, 61-65.
Rosati, F., Lorusso, M. M., Pistella, J., Giovanardi, G., Di Giannantonio, B., Mirabella, M., Williams, R., Lingiardi, V., & Baiocco, R. (2022). Non-binary clients’ experiences of psychotherapy: Uncomfortable and affirmative approaches. International journal of environmental research and public health, 19(22), 15339. https://doi.org/10.3390/ijerph192215339
Stricker, G., & Gold, J. R. (2013). Comprehensive handbook of psychotherapy integration. Springer Science & Business Media.
Vatcher, C.-A., & Bogo, M. (2001). The feminist/emotionally focused therapy practice model: An integrated approach for couple therapy. Journal of Marital and Family Therapy, 27(1), 69-83. https://doi.org/10.1111/j.1752-0606.2001.tb01140.x
Wachtel, P. L. (2014). Cyclical psychodynamics and the contextual self: The inner world, the intimate world, and the world of culture and society. Routledge.
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