EFT with Couples facing End-of-Life

1. EFT with Couples facing End-of-Life

2. Find your partner

3. Couples Movie Clip

4. Literature ReviewEnd-of Life Impact Couples who are faced with the upcoming death of a partner experience issues both on an individual level and on a relational level

5. Literature ReviewEnd-of Life Impact: Partner with Illness • Physical • Social • Emotional • Depression • Anxiety • Spiritual (Mohr, Moran, Kohn, Hart, Armstrong, Dias, Bergsland, & Folkman, 2003)

6. Literature ReviewEnd-of Life Impact: Caregiver partner • Need to provide emotional support • Need to provide instrumental support • likely to withdraw emotional support as need for instrumental support increases due to increased distress, resentment, and burnout • Emotional distress is often worse on the caregiving partner than the patient; they are less likely to seek out or accept professional help • Common symptoms: increased fatigue, health problems, and social isolation (Mohr et al., 2003)

7. Literature ReviewEnd-of Life Impact: Relational Communication Adjustment to changes in roles Adjustment to demands of illness Coping strategies (McLean & Jones, 2007; Mohr et al., 2003)

8. Rationale for Couple Therapy at End of Life • Adaptation to a diagnosis of cancer will be altered by the quality of the couple relationship (Hannum, Giese-Davis, Harding, & Hatfield, 1991) • Provide opportunity for relational and personal growth • Caregiving partner usually has the largest impact on the overall well-being of terminally ill partner (Mohr et al., 2003)

9. Case StudyJim and Sue • White, middle-class, professional • Married for 10 years, no children • Sue has been battling a brain tumour for 3 years • Her prognosis was recently deemed terminal • Doctors are unable to estimate how much time she has left • Jim has been withdrawing from Sue

10. Rationale for EFT use • Terminal cancer occurs in the context of relationship • Circular reciprocity (Stiell, Naaman, & Lee, 2007) • Avoidance of emotional expression by male partners of cancer patients perceived as insensitive and rejecting (Sabo, Brown, & Smith, 1986) • EFT creates a positive emotional environment • Helps partners regulate emotional and physical functioning, which reduces overall impact of disease (Steinglass, 2000) • Focus on power of emotional communication and attachment helps build resilience in the face of illness (Stiell et al., 2007) • Useful in highly emotionally charged experiences (textbook ref), such as terminal illness

11. EFT OverviewOrigins EFT is an integration of Experiential/Gestalt approaches and Interactional/Systemic approaches

12. EFT OverviewOrigins: Experiential/Gestalt • Therapeutic alliance itself is healing • Acceptance and validation of client experience • Belief that people are to make healthy choices • Examine how inner and outer realities define each other • People are formed and transformed in relationship with others • Use here-and-now experience of therapy session to foster corrective experiences

13. EFT OverviewOrigins: Systemic Influences • Focus is on interaction between members of system • Problems are due to interactions • Breaking a negative cycle will effect positive change • EFT focuses on using emotion to help break negative cycles and enact new patterns of interaction

14. EFT OverviewOrigins: Experiential-Systemic Synthesis • Focus on present experience, not past • Person is seen as fluid entity • Experiential approaches focused within the person; excluded relational influences • Systemic approaches focused on interactions; excluded individual internal responses and meanings

15. EFT OverviewOrigins: Influence of Attachment Theory • Primary attachments create an internal working model of relationships which is played out in all of our relationships (Bowlby in Engler, 2003; Bowlby in Stiell et al., 2007) • No person is inherently able to regulate their emotions. This develops through relationships. (McWilliams, 2004) • Attachment injuries – traumatic events that damage the bond between partners, such as chronic illness (McWilliams, 2004)

16. EFT Overview Relationship Health A healthy relationship is one in which there is a secure attachment bond • Mutual emotional accessibility and responsiveness • Depathologizes dependency in adults • Allows activation of attachment seeking behaviours • Model of others as dependable and trustworthy, model of self as lovable and entitled to care

17. EFT Overview Relationship Distress • Due to attachment insecurity and separation distress • Sequence of responses to threat against attachment security • Anger • Clinging and seeking • Depression and despair • Mourning and detachment • Rigid interaction patterns such as demand-withdraw can be disastrous

18. EFT OverviewKey Principles • Collaborative alliance provides secure base from which to explore • Therapist is consultant to process • Emotion is primary in forming attachment behaviours, guiding perceptions, motivating attachment responses • Therapist privileges emotional responses • Attachment needs are healthy and adaptive

19. EFT OverviewKey Principles Cont’d • Problems are maintained by interactional organization and by dominant emotions • Therapist deescalates negative patterns and reactive emotions; help shape new, positive interactions • Change occurs through new emotional experience in present interactions • The actual “client” is the relationship, not individual members of couple

20. EFT Overview: Three TasksTask 1 – Create and maintain therapeutic alliance • Four qualities of building alliance: • Empathic attunement • Acceptance • Genuineness • Continuous active alliance monitoring

21. EFT Overview: Three TasksTask 2 – Access and Reformulate Emotions • EFT therapists recognize key universal emotions • anger/rage, fear/anxiety, joy/elation, shame/disgust, sadness/despair, surprise/curiosity • Step-wise process of emotions: • Appraisal • Arousal • Reappraisal • Action Tendency

22. EFT Overview: Three TasksTask 2 – Access and Reformulate Emotions Cont’d • Emotions inform interactions and help in organizing adaptive responses to a person’s environment • Primary emotions • Secondary emotions • Instrumental emotions • 3 key issues in focusing on emotion: • Involvement • Exploration • New emotion

23. EFT Overview: Three TasksTask 2 – Access and Reformulate Emotions Cont’d Skills for Emotional Engagement • RISSC • Validation • Evocative Responding • Heightening • Empathic conjecture and interpretation • Self-disclosure

24. EFT Overview: Three Tasks Task 3 – Restructure Key Interactions • Tracking and reflecting interaction • Simple reflection: when he does this, you do that • Framing and reframing interactions • Example EFT Reframes: • Fighting against the Enemy of the Negative Cycle • Withdrawal as an attempt to Protect the Relationship • Pursuing to Fight for a Connection • Restructuring interactions using enactments • Structured, focused, choreographed

25. EFT OverviewFurther Interventions Resolving attachment injuries • Help injured partner discuss the impact and the significance of the attachment • Other partner then able to better understand how the event has injured their partner in attachment terms. • Aid injured partner in further discussing the injury in terms of expressing grief and fear. • Other partner realizes their role in the injury and expresses their own emotions. • Injured partner is able to ask their partner for support in dealing with emotions • A new narrative of the event has been constructed by the couple and each partner is able to understand the other’s experience of the event.

26. EFT OverviewProcess of Change • Nine treatment steps, organized into three stages • In mildly troubled couple, the partners usually progress through steps at parallel rate • In more highly troubled couple, the more withdrawn or passive partner is invited to progress through the steps slightly ahead of partner • Begin with one or two conjoint sessions, then one with each partner • Typically lasts 8 to 15 weekly sessions

27. EFT OverviewMechanisms of Change Levels of Change: • Expansion of Experience • Engagement of the Partner in a Different Way • New View of the Partner is Offered to His/Her Mate • New Cycle is Initiated • A Bonding Event Occurs in the Session • Shifts in Both Partners’ Sense of Self

28. EFT OverviewStage 1: Cycle De-escalation Goals • Couple to have overarching perspective of their interactions • Each partner’s reality is validated • Partners are encouraged to unite against the negative cycle • Initiate new cycle that promotes attachment security

29. EFT OverviewStage 1: Cycle De-escalation • Step 1: Identify relational conflict issues • Step 2: Identify negative interaction cycle where these issues are expressed • Step 3: Access unacknowledged emotions underlying the interactional position each partner takes in this cycle. • Step 4: Reframe problem in terms of the cycle, accompanying underlying emotions, and attachment needs.

30. Role Play: Stage 1 Scenario #1

31. EFT OverviewStage 2: Changing Interactional Patterns Goals • Have withdrawn partners reengaged in the relationship • Partners are able to confide in and seek comfort from each other • Partners are becoming mutually available and responsive

32. EFT OverviewStage 2: Changing Interactional Patterns • Step 5: Encourage each partner to identify with disowned attachment needs and aspects of self. • Step 6: Promote acceptance by each partner of the other partner's experience • Step 7: Promote expression of needs and wants to restructure the interaction; create bonding events

33. Role Play: Stage 2 Scenario #2

34. EFT OverviewStage 3: Consolidation and Integration Goals • To consolidate new responses and cycles of interaction • If you practice the new cycle enough times it will become the norm

35. EFT OverviewStage 3: Consolidation and Integration • Step 8: Facilitate the emergence of new solutions to old problems • Step 9: Consolidate new positions and cycles of attachment behaviour

36. Role Play: Stage 3 Scenario #3

37. EFT OverviewTermination • During stage three the therapist is less directive • Therapist outlines positive changes that have occurred during therapy • Discuss goals for the future and any feelings about termination • Couples are welcomed to return

38. EFT OverviewPredictors of Success • Positive therapeutic alliance = success • With male partners who have been described by their partners as “inexpressive” • With female partners who feel that their partner still cares for them • Areas that have NOT influenced the success of EFT with couples include: age, education, income, length of marriage, cognitive complexity, or religiosity.

39. EFT OverviewApplicability & Diversity • Used with diverse ages, classes, backgrounds, and sexual orientations • Positive outcomes for males and females • Often used with gay and lesbian couples • Couples with issues of low sexual desire are often difficult to treat in a few sessions • Effective with traumatized partners, depressed partners • Can be used with couples where there is mild and infrequent violence and/or emotional abuse

40. Popular Notions of End-of-Life Issues

41. Resources for Couples

42. Group Member Reactions • Topic: Couple Therapy at End-of-Life • Similarities • Differences • We engaged in much discussion about whether the illness should be chronic (e.g. MS) or something terminal • Approach: EFT • Similarities • We appreciated the importance of focusing on attachment during this difficult time of life, so EFT seemed a great fit • Most of us found that EFT was a very dense and complicated approach • Differences

43. References Engler, B. (2003). Personality theories: An introduction, 6th ed. Houghton Mifflin: New York. Hannum,J. W., Giese-Davis, J., Harding, K., & Hatfield, A. K. (1991). Effects of individual and marital variables on coping with cancer. Journal of Psychosocial Oncology, 9(2), 1-20. McLean, L.M., & Jones, J.M. (2007). A review of distress and it’s management in couples facing end-of-life cancer. Psycho-Oncology, 16, 603-616 McWilliams, A.E. (2004). Couple psychotherapy from an attachment theory perspective: A case study approach to challenging the dual nihilism of being an older person and someone with a terminal illness. European Journal of Cancer Care, 13, 464-472. Mohr, D.C., Moran, P.J., Kohn, C., Hart, S., Armstrong, K., Dias, R., Bergsland, E., & Folkman, S. (2003). Couples therapy at end of life. Psycho-Oncology, 12, 620-627 Sabo, D., Brown, J., & Smith, C. (1986). The male role and mastectomy: Support groups and men’s adjustment. Journal of Psychosocial Oncology 4(1-2), 19-30. Stiell, K., Naaman, S.C., & Lee, A. (2007). Couples and chronic illness: Attachment perspective and emotionally focused therapy interventions. Journal of systemic therapies, 26(4). 59-74. Steinglass, P. (2000). Family processes and chronic illness. In Cancer and the Family, Baider, L., Cooper, C.L., & Kaplan-DeNour, A. (Eds.), pp. 3-15. John Wiley: West Sussex, England.

44. Rationale for Couple Therapy at End of Life optional slide –already covered in video • Reduce psychosocial distress • For ill partner, it can ameliorate the perception of severity of symptoms (Mohr et al., 2003) • For caregiver, it can ease bereavement (McLean & Jones, 2007)

45. Application of Attachment Theory • Dying represents a threat to the attachment and attachment behaviours are activated in times of threat (McWilliams, 2004) • Potential relationship issues • Securely attached relationships show ability to take turns in being caregiver and care receiver (McWilliams, 2004) • Withdraw-pursue or withdraw-withdraw cycles (Stiell, Naaman, & Lee, 2007)

46. Use of Self Important to be comfortable with grief process Issues of countertransference Higher awareness of end of life, become fearful of own life Self care (depression, burn out) Awareness of own philosophy and theoretical base (ensure that it works with group participants)

47. Critical Analysis