Short-term and Long-term Effects of Training in Emotionally Focused Couple Therapy - Professional...

SHORT-TERM AND LONG-TERM EFFECTS OFTRAINING IN EMOTIONALLY FOCUSED COUPLE

THERAPY: PROFESSIONAL AND PERSONALASPECTS

Michelle Montagno, Mira Svatovic, and Hanna LevensonWright Institute

This study investigated the immediate and long-term personal and professional e!ects ofa 4-day externship training in emotionally focused couple therapy (EFT). EFT externshiptraining uses lecture, discussion, video vignettes, live demonstrations, and role-plays toconvey an attachment-based approach to working with couples. The two samples includedclinicians (N = 76) who completed surveys immediately before and after training, and asubset of these clinicians (N = 29) who completed measures an average of 8 monthslater. Results indicate that following training, participants increased in their EFT knowl-edge and competence, became more open to their feelings, were more self-compassionate,were less likely to use avoidant attachment behaviors, and improved their own personalrelationships.

The purpose of this study is to explore the short-term and long-term effects of a 4-dayemotionally focused therapy (EFT) externship training. In particular, this study asks whetherthis experiential and attachment-based training has the potential to increase self-reported levelsof knowledge and competence in EFT. It also examines whether such training impacts the lear-ner personally—changing levels of self-compassion, emotional processing, attachment style, andpersonal relationships.

EFT TRAINING AND THE POTENTIAL FOR PROFESSIONAL GROWTH

Despite decades of research, there are limited data on the professional effects of psycho-therapy training. There is an even greater gap in the field’s understanding of the long-term con-sequences of training. Researchers have most frequently sought to measure traininge!ectiveness by examining trainee satisfaction, increase in content knowledge (Miller & Mount,2001; O’Donovan & Dawe, 2002; O’Donovan, Bain, & Dyck, 2005; Tori, 1989), or improve-ment in clinical skills (Buckley, Conte, Plutchik, Karashu, & Wild, 1982; Henry, Schacht,Strupp, Butler, & Binder, 1993; Hilsenroth, Defife, Blagys, & Ackerman, 2006; O’Donovan &Dyck, 2005; Sholomskas et al., 2005). Many training studies report optimistic findings regard-ing therapists’ skill acquisition (Burlingame, Fuhriman, Paul, & Ogles, 1989; Henry et al., 1993;Hilsenroth et al., 2006; Multon, Kivlighan, & Gold, 1996), but some conclude there are little tono e!ects (or even negative e!ects) with training (Bein et al., 2000, Miller & Mount, 2001;Svartberg & Stiles, 1994).

Even less is empirically known about training in EFT. Developed in the early 1980s as anattachment-based model used for couples therapy, EFT strives to understand partners’ underly-ing emotions and core attachment issues that lead to negative interactional cycles and preventcouples from forming a secure bond (Johnson, 2004). Empirical evidence supports the e!ective-ness of EFT as a treatment modality (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998;Johnson, Hunsley, Greenberg, & Schlinder, 1999; Naaman, Pappas, Makinen, Zuccarini, &Johnson-Douglas, 2005), but this study is the first to examine prospectively what happens inlearning how to apply this model.

Michelle Montagno, PsyD; Mira Svatovic, PsyD, and Hanna Levenson, PhD, Wright Institute.

Address correspondence to Hanna Levenson, Wright Institute, 2728 Durant Avenue, Berkeley, California

94704; E-mail: hannalevenson@aol.com

Journal of Marital and Family Therapydoi: 10.1111/j.1752-0606.2011.00250.xOctober 2011, Vol. 37, No. 4, 380–392

380 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

EFT TRAINING AND THE POTENTIAL FOR PERSONAL GROWTH

To date, there is very little documentation about the effects of training on therapists’ per-sonal lives (e.g., Guttman, Feldman, Engelsmann, Spector, & Buonvino, 1999; Sandberg &Knestel, 2009). With regard to personal factors and training in EFT, Palmer and Johnson dis-cussed how therapists ‘‘who know themselves well, including their inner strengths, conflicts, andissues, that activate countertransference will be more able to e!ectively implement EFT’’ (2002,p. 18). Nonetheless, Palmer-Olsen (2007) found that for more than 50% of her sample of certi-fied EFT therapists (N = 17), ‘‘self-of-the-therapist’’ issues were not addressed during any oftheir EFT supervision or training.

Duplassie, MacKnee, and William (2008) examined factors that helped and hindered learn-ing EFT. Through interviews with EFT practitioners (N = 14), they found that all participantssaid they were personally a!ected by the EFT training. Sandberg and Knestel (2009) received 124responses to a questionnaire they posted on an EFT listserv. Consistent with Duplassie et al.’sfindings, respondents reported that they experienced improved relationships and personal func-tioning, as a consequence of learning EFT. And Wittenborn (2009) found that therapists’ attach-ment style is related to one’s capacity to identify and intervene at the level of primary emotionswhen doing EFT couple therapy. However, her findings were based on a small sample (N = 8).

When one thinks of particular personal attributes that might be important in learning howto do EFT, self-compassion and characteristics linked to it, such as the ability to attend toone’s own emotional well-being, come to mind (Gilbert & Proctor, 2006; Jennings & Skovholt,1999). Self-compassion is not only linked to psychological health and well-being, it is also asso-ciated with openness, curiosity, and exploration (Ne!, Rude, & Kirkpatrick, 2007)—importanttraits for therapists seeking connection with their clients.

Researchers also assert that the more compassion people have for themselves, the morethey will have for others (Brach, 2003; Ne! et al., 2007). In turn, greater therapist compassionhas the potential to strengthen the therapeutic alliance with clients, which is one of the strong-est and most robust predictors for therapy outcome (Lambert & Barley, 2001; Norcross, 2002).In addition, self-compassion has been linked to other positive traits, such as self-esteem. In fact,it has been endorsed as a healthier alternative to self-esteem, as bolstering self-compassion doesnot appear to have some of the negative consequences associated with increases in self-esteem,such as developing unrealistic views of the self and tendencies toward narcissism (Ne!, Hsieh,& Dejitthirat, 2005). Research also suggests that the therapeutic alliance grows the more thetherapist is securely attached (e.g., Black, Hardy, Turpin, & Parry, 2005).

FOCUS OF THE PRESENT STUDY

We believe EFT training has the potential to create changes in therapists professionally andpersonally, both in the short term and the long term. We, therefore, undertook this study toexamine immediate and long-term shifts in the therapists’ knowledge, competency, and emo-tional experience (i.e., self-compassion, emotional processing, and attachment style) as a functionof a specific EFT training experience. We reasoned that training that not only improves thera-pists’ skill levels but also their personal capacities that will result in more effective treatments.We have six main hypotheses. Specifically, following training in EFT, therapists will report(a) increases in EFT knowledge and (b) increases in EFT competence, as well as (c) decreases inanxious and avoidant attachment behaviors. The study also proposes that (d) increases in EFTcompetence will correlate with increases in self-compassion and emotional processing and(e) increases in emotional processing will correlate with increases in self-compassion. Lastly, wepredict that (f) the EFT training experience will impact the therapists’ personal lives.

METHOD

This research is comprised of two related studies. Study 1 asks trainees about changes thatoccur immediately posttraining. Study 2 attempts to evaluate long-term changes that occur upto 8 months (average) after the original training.

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 381

Participants and ProceduresThe participants were clinicians and graduate students who attended a 4-day EFT extern-

ship training in San Francisco, Houston, Los Angeles, Salt Lake City, or Ottawa in 2008. Par-ticipants were recruited on the first day of training and asked to complete surveys assessingdemographic information and level of EFT knowledge, skills, and relationship to self and oth-ers, both before and after training. All attendees read an informed consent outlining the pur-pose of the studies and were informed that confidentiality would be protected throughanonymity. To match baseline, posttest, and follow-up data, participants were asked to identifythemselves on all questionnaires using the last three digits of their drivers’ licenses. They werealso asked to provide a self-addressed mailing label for the follow-up study. This label wasturned in separately from their questionnaire data at the time of testing, so that they could becontacted by mail approximately 6 months after training. All participants were informed that ifthey filled out a label or made a request (whether or not they completed a questionnaire), thenthey would receive a copy of the results at the end of the study. Both studies were approved bythe Use of Human Subjects Review Board of the Wright Institute.

Of the total attendees, 110 responded to all measures on the first day of training. Of these,81 (74%) took the posttests on the afternoon of Day 4. The 76 attendees with complete datasets (pre and post) form the subject pool for Study 1. Three to ten months later (an average of8 months following the EFT externship), the 81 original participants were mailed the measuresagain, plus an additional questionnaire regarding the effects of training on the therapists’ ownrelationships with self and others. After two mailings, 40 participants (49% response rate)returned the questionnaires. Twenty-nine participants had complete data for all three time peri-ods; they form the subject pool for Study 2.

Description of the Emotionally Focused Therapy Externship TrainingThe 4-day externship training was comprised of experiential and didactic components and

was open to any mental health professional or student. Participants learned about the theory ofattachment, as it relates to the EFT model, as well as about specific clinical techniques used toimplement the model. The format consisted of lecture, didactic presentations, skill training exer-cises, observation of both taped and live EFT therapy, discussion of specific cases, role-plays,and on-site consultation. The stated goals of the training include learning to (a) understandpartner distress from an attachment perspective, (b) help partners reprocess emotionalresponses that maintain partner distress, (c) shape new interactions and bonding events, and(d) overcome therapeutic impasses (International Centre for Excellence in Emotionally FocusedTherapy, 2009).

MeasuresThe Demographic Survey used in baseline testing asked for personal information such as

age, gender, and relationship status. It also asked about the participants’ professional degree,theoretical orientation, and level of experience doing therapy in general and EFT in particular.

The EFT Knowledge and Competency Scale1 (EFT-KACS; Levenson & Svatovic, 2009) is a12-item measure constructed for this study based on the EFT-Therapist Fidelity Scale (EFT-TFS; Denton, Johnson, & Burleson, 2009)—a checklist that raters watching therapy sessionscan use to assess therapist fidelity (adherence and competency) to the EFT model. Denton andcolleagues derived their scale by doing a content analysis of EFT skills and submitting theseitems to raters (N = 97) trained in EFT. Raters felt that all items were ‘‘essential, important,and necessary’’ (Denton et al., 2009, p. 229) to doing EFT. Levenson and Svatovic (2009) re-formatted this rater version for use as a self-report instrument. Each item on the EFT-KACSrepresents a major EFT skill (e.g., continually reframing the problem in terms of the cycle)from the EFT-TFS and is accompanied by two 7-point Likert scales—one asking about per-ceived knowledge of the skill and the other for perceived competence in executing that skill,ranging from 1 (not at all) to 7 (quite a bit). Participants in the EFT trainings responded to theEFT-KACS at all the three time periods (baseline, posttest, and follow-up).

Because the EFT-KACS is a new measure, a principal axis factor analysis with varimaxrotation on the items for the entire baseline sample (N = 81) was conducted (Montagno,

382 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

2009). Items loading at 0.40 or above in the rotated factor matrix were considered to haveloaded on a factor. It was predicted that two separate factors would emerge. This was con-firmed, with 10 of the 12 knowledge items loading on one factor, and 10 of the 12 competenceitems loading on a second factor. In addition, two knowledge items and the two parallel com-petency items loaded on a third factor. Specifically, these items asked about ‘‘creating safety inthe session and maintaining a positive alliance,’’ and ‘‘validating one partner’s emotions with-out invalidating the other partner’s emotions.’’ We called this third factor Alliance. Together,the three factors accounted for 72% of the variance. A factor analysis of posttest EFT-KACSitems yielded similar factors, which accounted for 73% of the variance. Three scales (Knowl-edge, Competence, and Alliance) were constructed based on the three factors; each scale hashigh internal consistency (Cronbach’s alphas range from .92 to .96; Levenson, Svatovic, &Montagno, 2009).

The Experiences in Close Relationships-Revised Scale (ECR-R; Fraley, Waller, & Brennan,2000) is a 36-item, self-report measure (scored 1 = strongly disagree; 7 = strongly agree) withhalf of the statements addressing romantic attachment anxiety (e.g., ‘‘I often worry that mypartner will not want to stay with me’’) and the other half attachment avoidance (e.g., ‘‘I prefernot to be too close to romantic partners’’). Previous research has indicated that ECR-R scalescores are stable over 3–6 weeks with test–retest reliabilities above 0.90 (Fraley et al., 2000;Sibley & Liu, 2004). Discriminant and convergent validity has also been demonstrated, estab-lishing the ECR-R as a measure of romantic relationship attachment versus familial or platonicattachment (Sibley, Fischer, & Liu, 2005).

The Emotional Processing Inventory (EPI; Reid & Harper, 2008) is a 26-item, self-reportmeasure assessing how often one identifies, communicates, and regulates his or her own feelings(scored 1 = never; 5 = very often). Research (Reid & Harper, 2008) supports the separationof the items into three subscales: Appraisal (e.g., ‘‘I am in tune with the things I feel’’), Expres-sion (e.g., ‘‘It is challenging to talk about how I feel with others, even those who know mewell’’), and Stability of emotions (e.g., ‘‘I feel emotionally unstable’’). Test–retest reliabilitiesare high (rs = .78 to .82) for the EPI as a whole and for each subscale. The scale has also dem-onstrated high overall internal consistency (Cronbach’s alpha = .91), with subscale alphasranging from 0.88 to 0.92.

The Self-Compassion Scale (SCS; Ne!, 2003) is a 26-item self-report measure (scored1 = almost never; 5 = almost always) divided into six subscales that are summed to createa total score. Ne! (2003) reported test–retest reliabilities of 0.93 for the overall SCS.Construct validity has also been demonstrated, with practicing Buddhists reporting higherself-compassion than college students (Ne!, 2003). In the same study, Ne! provided evidencefor convergent and discriminant validity; the SCS correlated significantly with a measure ofsocial connectedness, negatively with a measure of self-criticism, and only moderately withself-esteem.

Finally, participants in this study responded to four questions at follow-up (scored1 = strongly disagree; 7 = strongly agree) about the perceived effect of EFT training on theirpersonal lives; the questions also had qualitative components. For example, participants wereinstructed to indicate how strongly they agreed with the statement, ‘‘EFT training has changedthe way I approach romantic relationship(s)’’ and then to explain their rating in an open-ended,narrative format.

RESULTS

Preliminary AnalysesPrior to examining the main hypotheses, statistical analyses were performed to assess how

representative the sample was of those who chose to complete all of the testing compared withthose who did not—assessing the impact of a possible self-selection factor. Cross-tabulationswith chi-squares and analyses of variance (ANOVAs) were run to compare demographic andbackground characteristics of participants who responded to the instruments at all three timepoints compared with those who only completed the baseline measures. Analyses show thatthe groups did not differ significantly on any demographic or background measures. This

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 383

demonstrates the likelihood that the smaller sample that completed the measures at all threetime points is representative of the total sample.

To ensure that additional postexternship trainings did not affect the Knowledge or Compe-tency Scale scores in Study 2, repeated measures ANOVAS were run examining these potentialrelationships. Results indicate that there were no significant between-subjects effects for postex-ternship training or any significant interactions of postexternship training with time. Given thatadditional postexternship training is not significantly related to EFT-KACS scores, this variablewas not statistically controlled for in the analyses that follow.

Further analyses also indicate that there were no significant associations among Length ofTime until follow-up data were collected (from 3 to 10 months) and Knowledge or Competencescores. Thus, Length of Time until follow-up was not controlled for in subsequent analyses.

To control for potential differences among the five EFT externship training sites, ANOVAswere run to identify trainer or site effects (i.e., whether certain workshop leaders or parts of thecountry more conducive to learning EFT). In Studies 1 and 2, findings reveal that there wereno significant changes in Knowledge or Competency Scale scores over time associated with trai-ner or training sites. Finally, preliminary analyses were run to assess for any baseline differ-ences or changes over time owing to the respondents’ gender, age, professional discipline, andeducational level. No main effects for these were found.

Demographic characteristics of the subjects in Study 1 and Study 2 are shown in Table 1.On average, the majority of participants were middle age, Caucasian, female Marriage andFamily Therapist (MFT). Most described themselves as in a relationship with a significantother and had been in practice longer than 10 years, where they saw an average of five couples

Table 1Demographic Characteristics of the Samples in Study 1 (Pre–Post) and Study 2 (Fol-low-up)

Demographicvariables

Study 1N = 76 (%)

Study 2N = 29 (%)

GenderMale 26 (35) 11 (39)Female 48 (65) 18 (61)

Relationship statusSingle 10 (13) 4 (14)Partnered 53 (70) 20 (69)Didn’t state 13 (17) 5 (17)

EducationStudent 6 (8) 2 (7)MFT 30 (40) 11 (38)LCSW 7 (9) 1 (3)PhD ⁄PsyD 17 (23) 8 (27)Other 15 (20) 7 (24)

OrientationIntegrative ⁄ eclectic 35 (47) 14 (48)Psychodynamic 8 (11) 4 (14)Humanistic 8 (11) 3 (10)Systems 7 (10) 3 (10)Cognitive behavioral 4 (5) 1 (3)Existential 3 (4) 1 (3)Narrative 2 (3) 1 (3)Other 7 (10) 2 (7)

384 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

per week. Additional data indicate that, prior to training, over 90% had read at least one bookon EFT, and two-thirds had seen with at least one EFT video or DVD. Most identified them-selves as having an eclectic–integrative theoretical orientation.

HYPOTHESES

Hypothesis 1Participants self-reported knowledge of EFT will increase with training.A repeated measures ANCOVA was run to examine changes in EFT Knowledge Scale

scores over time (comparing baseline and posttest data for Study 1, and baseline, posttest, andfollow-up data for Study 2). Table 2 shows that participants significantly increased their knowl-edge following the externship. Using Denton et al.’s (2009) guideline, which scores superiorfidelity (adherence to the EFT model) as at or above the 80th percentile, 17% of the currentsample had superior baseline scores prior to training, with an increase to 54% following theexternship. Additional analyses reveal that attendees who had read the fewest books reportedthe most change in knowledge (accounting for 76% of the variance), compared with partici-pants who had read two books (60%) or three or more books (48%).

Study 2 results show the same significant main effect for time with increases in knowledgefrom pretest to posttest; however, post hoc contrasts revealed there was a significant decreasein knowledge from posttest to follow-up. Nonetheless, the long-term follow-up Knowledgescore was still significantly higher than scores prior to training (see Table 2). Thus, Hypothesis1 was confirmed; participants tended to report increases in the amount learned after training,although there was a decrease in self-reported knowledge as time increased.

Hypothesis 2Participants’ self-reported competence in EFT will increase with training, but to a lesser

extent than their increases in knowledge.

Table 2Repeated Measures ANCOVAs for Outcome Variables: Significant Time E!ects

BaselineM (SD)

PosttestM (SD)

Follow-upM (SD) Source df F

Study 1 (N = 71)EFT-KACS knowledge1 4.02 (1.37) 5.47 (1.02) Time (T) 1 18.62**EFT-KACS competence1 3.39 (1.11) 4.50 (1.07) Time (T) 1 15.15**

Study 2 (N = 27)EFT-KACS knowledge1 3.91 (1.36)a e 5.41 (0.88)c e 4.94 (1.08)b e Time (T) 2 15.83**EFT-KACS competence1 3.25 (1.12)a d 4.33 (0.90)b d 4.33 (0.95)b d Time (T) 2 10.53**Anxious attachment2 2.60 (1.08) – 2.43 (0.96) Time (T) 1 0.87Avoidant attachment2 2.44 (1.03) – 2.15 (0.15) Time (T) 1 9.71**<8 years practice(n = 9)

3.11 (1.33) – 2.56 (1.11) Yearspractice

1 5.16*

8+ years practice(n = 18)

2.10 (0.66) – 1.90 (0.80) Years · T 1 2.92

Note. Scales scored 11 = not at all, 7 = quite a bit, 21 = strongly disagree, 7 = stronglyagree. Analyses for Knowledge and Competence control for Years of practice (<8, 8 ormore) and Number of EFT books read at pretest; analyses for Competence in Study 1control for training site. In post hoc tests, means marked a are significantly lower than meansmarked b, which are significantly lower than means marked c and means marked d aresignificantly lower than those marked e. **p < .01, *p < .05.

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 385

A repeated measures ANCOVA (using Competency Scale scores as the dependent variable)was used with baseline and posttest data for Study 1, and with baseline, posttest, and follow-updata for Study 2. Study 1 results indicated that there were significant effects for time confirmingHypothesis 2 that those who attended the externship increased in their competency. Further-more, at baseline, only 3% of the participants reported they already had superior CompetenceScale scores (80th percentile or higher); this increased to 15% at posttest. Additional analysesshow that effects for time accounted for 44% of the variance in the Knowledge Scale scorescompared with only 13% of the variance in the Competence Scale scores. This finding confirmsthe latter part of Hypothesis 2, which predicts that it is easier to improve one’s knowledge thancompetency. It should also be noted that, as expected, the attendees entered and left trainingwith significantly more knowledge than the skill to practice what they knew (i.e., in both Stud-ies 1 and 2 attendees’ Knowledge Scale scores were significantly higher than their CompetencyScale scores).

Analyses for Study 2 also found a main effect for time. Post hoc comparisons showed thatcompetence increased from baseline to posttest and then remained constant from posttest tofollow-up (See Table 2). In the second study, Knowledge Scale scores were also significantlyhigher than Competency Scale scores at all three time periods.

Hypothesis 3At follow-up, participants will have decreased in their attachment-related anxiety and

avoidance.The first part of this hypothesis was not confirmed, using a repeated measures ANCOVA

design (controlling for baseline levels of attachment anxiety and avoidance). Participants inStudy 2 did not change significantly in their Anxiety Scale scores on the ECR-R over time (SeeTable 2). However, it should be noted that this may have been because of floor e!ects, as thesubjects’ reported anxiety, as measured on the 7-point scale, was already quite low comparedwith national norms: 2.5 vs. 3.6 (Fraley, 2005).

Although attendees also reported very low degrees of avoidant attachment compared withnational norms (2.4 vs. 3.6; Fraley, 2005), Avoidance Scale scores did significantly decreasefrom baseline to follow-up (see Table 2), confirming the latter part of Hypothesis 3.

Hypothesis 4As participants become more competent, they will increase in self-compassion and ability

to process emotion.Regressions testing this hypothesis controlled for years of practice, as it was positively

associated with the SCS at pretest, r(62) = .35, p < .01 and posttest, r(71) = .42, p < .01.(That is, clinicians with more experience reported more compassionate attitudes toward them-selves than those with less experience.) Increases in Competence (as represented by posttestscores, controlling for pretest scores) were not significantly associated with increases in self-compassion. The first part of Hypothesis 4 was, therefore, not confirmed.

With regard to the relationship between competency and processing of emotions, resultsfrom a hierarchical regression predicting EPI posttest scores found a significant and positiveassociation with Competence (b = .38, p < .01), after controlling for baseline EPI scores(b = .27, p < .02) and baseline Competence Scale scores (b = ).03, ns). This suggests that asparticipants’ competence increased, so did their emotional processing (EPI scores), supportingthe second part of Hypothesis 4.

Hypothesis 5As participants improve in their emotional processing, they increase in their self-compassion.A hierarchical regression (controlling for baseline SCS scores) found that changes in the

EPI were significantly and positively associated with changes in the SCS (b = .46, p < .01),supporting Hypothesis 5.

Hypothesis 6Participants will report that the EFT training had an effect on their personal lives.

386 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

Participants in Study 2 reported the greatest impact occurred with their romantic relation-ships (M = 5.89 of 7, SD = 0.92), followed by understanding life experiences (M = 5.79,SD = 1.18) and relationships with others (M = 5.65, SD = 1.74); participants reported lessimpact on self-compassion (M = 5.02, SD = 1.35). These four items were highly intercorrelat-ed (Cronbach’s alpha = .82). Respondents were also asked to explain their ratings for eachitem. See Table 3 for a sampling of their responses.

DISCUSSION

The Professional Effects of EFT TrainingAs anticipated, attendees entered the training with more knowledge about EFT than com-

petence in practicing it. Looking at changes over time, the results of this research support ourhypotheses that an intensive training experience in EFT increases one’s self-rated knowledgeand competence. Specifically, results from Study 1 show that participants achieve significantgains in knowledge and competence, immediately following the 4-day EFT externship. Not onlyare these differences statistically reliable they are also clinically significant (Jacobson & Truax,1991) with attendees increasing their self-rated superior scores over three times as much by theend of training (17% vs. 54% for knowledge; 3% vs.15% for competence). As predicted,Knowledge scores increased more than Competence. The results of Study 1 are consistent withprevious findings on the immediate outcomes of trainee satisfaction and increases in knowledge(Miller & Mount, 2001; O’Donovan et al., 2005) as well as competence (Bennett-Levy &Beedie, 2007; Milne, Baker, Blackburn, James, & Reichet, 1999). At follow-up, participantscontinued to rate themselves as more knowledgeable and competent than they were beforetraining. This suggests that participants not only made immediate gains but also retained them.As one participant noted, ‘‘I feel more competent in my work with couples and individuals inhelping them with relationships.’’

Additional findings reveal that while participants markedly increased in their Knowledgescores during the externship, at follow-up, these dropped, while their more modest gains in skilllevel held firm. While effects of regression toward the mean cannot be overlooked, it is reason-able to consider that experiential learning may have more long-lasting effects than book learn-ing (Schon, 1983). It is important to note that the training methods used in the EFT externshipcapitalize on experiential approaches such as skill training exercises and role-plays, viewingrecorded and live therapy, and on-going feedback and on-site consultation (Alliant Interna-tional University, 2008).

A remarkable finding, with major training implications, is that there were no trainer effectsfor either Study 1 or Study 2, demonstrating that comparable learning was achieved regardlessof who was conducting the training. This consistency among trainers may stem from the factthat the core elements of EFT are well articulated. Furthermore, therapists undergo rigorous,

Table 3Examples of how emotionally focused couple therapy (EFT) Training PersonallyImpacted Respondents

I have been reflective of my attachment relationships and attachment style across time. Iam much more thoughtful about my attachment needs as well as others

I’ve had more compassion toward myself in regards to my past and current behavior inmy relationship with my partner

I have been much more grateful and happy in my marriage for our good bondI am much more gentle with myself and willing to reframe an experience to see the primaryemotion that has gotten triggered

Overall, EFT has helped me link my own internal dynamics to an understanding of myearly attachment experiences. These understandings have helped me in my marriage andother relationships!

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 387

standardized training to become designated EFT trainers, including passing several certificationsteps requiring a demonstration of content mastery and teaching skill.

It should also be mentioned that none of the demographic variables (e.g., gender, age, edu-cation) were significantly related to knowledge or competence, perhaps challenging the clichethat women are more suited than men to do emotionally based therapy.

Personal Effects of EFT TrainingThe results from these studies demonstrate that not only are there significant increases

in professional aspects (i.e., knowledge and competency) posttraining, but there are alsoimmediate and long-term personal changes. With regard to the attachment styles of the par-ticipants, findings suggest that for less experienced clinicians, there are significant drops inavoidant behavior over time. The finding that attachment security can change is consistent withBowlby’s (1979) contention that working models both accommodate as well as filter incominginformation. These findings about shifts in avoidance are particularly important, because theyare a departure from existing research that has found that attachment avoidance is resistant tochange over the lifespan (Klohnen & Bera, 1998).

EFT training may provide unique opportunities for more avoidantly oriented participantsto relate to others in emotionally connected, yet structured (e.g., safe) ways. Hence, they mayhave had opportunities to disconfirm their working models of the dangers of attachment (Fraley& Shaver, 2000). An experiential and attachment-based training, such as EFT, might activatethe attachment system of more avoidantly oriented participants by turning their attentiontoward attachment relationships. The training is designed and conducted to create a safe placefor clinicians to explore the emotional facets of connecting to themselves and others. Trainersmodel emotional immersion and encourage participants to empathically engage during role-plays. This environment may provide more avoidantly oriented participants the opportunity tounderstand their attachment longings and behaviors, as well as to engage with their emotionsin new ways—in a sense providing a new attachment experience for them. However, it shouldbe noted that, overall, this sample is a relatively securely attached group—having both low anx-iety and low avoidance scores compared with normative data. Therefore, generalizations toother more heterogeneous samples cannot be made.

Contrary to expectation, attendees’ attachment scores on the anxiety subscale did notchange significantly over time. As anxious individuals’ attachment manifests in relationship-seeking behaviors, perhaps they are already accustomed to being in relationships and havingopportunities to test out and challenge their working models.

Results from Study 1 also show that as participants’ competence increased, so did theirability to process emotions. This finding is entirely consistent with the emotional focus of themodel. In EFT, therapists need to help couples deepen and express their primary emotions. Inso doing, they use their own emotions to reflect, intensify, and attune to their clients’ feelings.Such a reverberating resonance between clients and therapists may have a neurological basis(i.e., the role of mirror neurons; Iacoboni, 2005; Schore, 2003). As a consequence, an increasedawareness of one’s own sensations and feelings is likely to occur. Furthermore, the experientiallearning strategies used to teach EFT in the externship (e.g., role plays) are also likely toheighten the attendees’ emotional responsiveness.

With regard to self-compassion, results indicate that as participants’ emotional processingincreases, their levels of self-compassion increase as well. Participants’ increase in self-compassion,as a function of more emotional engagement, makes sense given the intimate connection betweenself-compassion and attention to and acceptance of one’s feelings (Germer, 2009). We speculatethat the ability to process emotions may be a prerequisite to self-compassion, because one must beaware of his or her feelings first, before assuming a compassionate stance toward them. However,this is a relatively unexamined topic; these results are merely suggestive and need more explora-tion. While previous research has found changes in self-compassion because of training (Gilbert &Proctor, 2006; Moore, 2008; Shapiro, Brown, & Biegel, 2007), the studies were geared towarddirectly teaching principles of self-compassion (i.e., mindfulness). EFT trainers might consider‘‘more mindfully’’ incorporating mindfulness-based strategies as part of future trainings, as thismight help trainees become better attuned to and accepting of their own emotions.2

388 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

At follow-up, participants shared insights about how the training affected them personally,‘‘I am gentler with my partner. I am gentler with myself. I can cut to the chase and talk aboutunderlying vulnerabilities.’’ These quotes illustrate that the effects of training were both impact-ful and long lasting. Overall, the findings suggest that there are personal effects that result fromparticipation in the EFT training.

Strengths, Limitations, and Directions for Future ResearchOne of the unique aspects of this study is the comparatively large sample size. Most

training studies have used a sample smaller than 25 participants (Buckley et al., 1982; Crits-Christoph et al., 2006; Duplassie et al., 2008; Henry et al., 1993; Hilsenroth et al., 2006; Miller& Mount, 2001). In fact, small sample sizes are one area of criticism in the training research(Fauth, Gates, Vinca, Boles, & Hayes, 2007; Hill & Lent, 2006). In addition, several analyseswere performed to assess whether those completing the measures were representative of thetotal sample and to statistically control for pre- and posttest scale scores where appropriate.We also assessed for trainer e!ects.

This study adds to the literature on the professional effects of training and is one of ahandful of studies looking at the long-term effects of such training. Examining knowledge andcompetency separately facilitates our understanding of how learning takes place. In addition,this study is one of the few empirical efforts to examine the personal effects of training on thetherapist. Furthermore, our research introduces a self-report measure, the EFT-KACS, thatoffers promising reliability and validity. Such a self-report measure could be valuable in futureEFT process and outcome studies. (For more information about the EFT-KACS, see Levenson& Svatovic, 2009; Levenson et al., 2009.)

The present research, however, is limited in several ways. The lack of a control group limitsthe generalizability of the findings. Future studies could include a group that received no train-ing, or a group that received only EFT reading materials, to better determine the impact ofexperiential training versus more general exposure to the theory. This study does not directlyassess what contributes to the success of the EFT training—whether it is the subject matteritself, or the use of particular training methods, or a combination of the two. Such informationcould be useful to improve future training.

Another option to strengthen validity would be to compare the reports of people whoreceived training in EFT with the reports of people who received training in a less emotionallybased therapeutic modality, such as CBT. It would be expected that if EFT training were com-pared with CBT training, then participants in both groups would increase in knowledge andcompetence, but there would likely be differences in personal effects. For example, CBT train-ees might show more increases in their abilities to use logic, whereas EFT trainees would beexpected to demonstrate increases in emotional processing.

Another limitation is the comparatively small number of subjects in Study 2. Increasingthe N would allow for more refined statistical analyses. Lastly, the use of self-report measurescreates a major shortcoming. Self-report measures always involve response errors, because ofdemand characteristics (Orne, 1962). Respondents could have been pulled to report that theybenefitted from the training, because they expended a significant amount of time and financialresources on it. Future research could improve this by obtaining external validation of anyself-reported changes. This could be accomplished, for example, by using raters to assessattendees’ pretraining therapies versus posttraining therapies using Denton et al.’s (2009)scale.

CONCLUSION

The present research provides some preliminary evidence about the positive personal andprofessional effects of learning EFT. These studies suggest that formal training in EFT is effec-tive in helping therapists learn how to do this empirically supported treatment. Furthermore, itpresents novel findings on the link between learning and personal growth, both in the shortand long term. Thus, learning EFT may not only improve one’s clinical skills but it may alsoactually improve the life of the therapist.

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 389

REFERENCES

Alliant International University. (2008). Emotionally focused therapy for couples: 4-day externship, San

Francisco. Retrieved February 10, 2009, from http://www.ce-psychology.com/product161.html

Baucom, D. H., Shoham, V., Mueser, K., Daiuto, A. D., & Stickle, T. R. (1998). Empirically supported couple

and family interventions for marital distress and adult mental health problems. Journal of Consulting and

Clinical Psychology, 66, 226–244.

Bein, E., Anderson, T., Strupp, H. H., Henry, W. P., Schacht, T. E., Binder, J. L., et al. (2000). The e!ects of

training in time-limited dynamic psychotherapy: Changes in therapeutic outcome. Psychotherapy Research,

10, 119–132.

Bennett-Levy, J., & Beedie, A. (2007). The ups and downs of cognitive therapy training: What happens to train-

ees’ perception of their competence during a cognitive therapy training course? Behavioural and Cognitive

Psychotherapy, 35, 61–75.

Black, S., Hardy, G., Turpin, G., & Parry, G. (2005). Self-reported attachment styles and therapeutic orientation

of therapists and their relationship with reported general alliance quality and problems in therapy. Psychol-

ogy and Psychotherapy: Theory, Research and Practice, 78, 363–377.

Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.

Brach, T. (2003). Radical acceptance: Embracing your life with the heart of a Buddha. New York: Bantam Books.

Buckley, P., Conte, H. R., Plutchik, R., Karashu, T. B., & Wild, K. V. (1982). Learning dynamic psychotherapy:

A longitudinal study. American Journal of Psychiatry, 139, 1607.

Burlingame, G. M., Fuhriman, A., Paul, S., & Ogles, B. M. (1989). Implementing a time-limited therapy pro-

gram: Di!erential e!ects of training and experience. Psychotherapy: Theory, Research, Practice, Training, 26,

303–313.

Crits-Christoph, P., Connoly Gibbons, M. B., Crits-Christoph, K., Narducci, J., Schamberger, M., & Gallop, R.

(2006). Can therapists be trained to improve their alliances? A preliminary study of alliance-fostering psy-

chotherapy. Psychotherapy Research, 16, 268–281.

Denton, W., Johnson, S., & Burleson, B. (2009). Emotion-focused therapy—therapist fidelity scale (EFT-

TFS): Conceptual development and content validity. Journal of Couple & Relationship Therapy, 8, 226–

246.

Duplassie, D., MacKnee, C., & William, M. (2008). Critical incidents that help and hinder learning emotionally

focused therapy for couples. Journal of Couple and Relationship Therapy, 7, 1–18.

Fauth, J., Gates, S., Vinca, M. A., Boles, S., & Hayes, J. A. (2007). Big ideas for psychotherapy training. Psycho-

therapy: Theory, Research, Practice, Training, 44, 384–391.

Fraley, R. C. (2005, July 23). Information on the experiences in close relationships-revised (ECR-R) adult attach-

ment questionnaire. Retrieved February 27, 2010, from http://www.psych.uiuc.edu/~rcfraley/measures/

ecrr.htm

Fraley, R. C., & Shaver, P. R. (2000). Adult romantic attachment: Theoretical developments, emerging controver-

sies, and unanswered questions. Review of General Psychology, 4, 132–154.

Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item response theory analysis of self-report measures

of adult attachment. Journal of Personality and Psychology, 78, 350–365.

Furrow, J. L., Johnson, S. M., Bradley, B., & Amodeo, J. (2011). Spirituality and emotionally focused couple

therapy: Exploring common ground. In J. L. Furrow, S. M. Johnson & B. Bradley. (Eds.), The emotionally

focused casebook: New directions in treating couples (pp. 343–372). New York: Routledge.

Germer, C. K. (2009). The mindful path of self-compassion: Freeing yourself from destructive thoughts and emo-

tions. New York: The Guilford Press.

Gilbert, P., & Proctor, S. (2006). Compassionate mind training for people with high shame and self-criticism:

Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13, 353–379.

Guttman, H. A., Feldman, R. B., Engelsmann, F., Spector, L., & Buonvino, M. (1999). The relationship between

psychiatrists’ couple and family therapy training experience and their subsequent practice profile. Journal of

Marital and Family Therapy, 25, 31–41.

Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L. (1993). E!ects of training in time-

limited dynamic psychotherapy: Mediators of therapists’ responses to training. Journal of Consulting and

Clinical Psychology, 61, 441–447.

Hill, C. E., & Lent, R. W. (2006). A narrative and meta-analytic review of helping skills training: Time to revive

a dormant area of inquiry. Psychotherapy: Theory, Research, Practice, Training, 43, 154–172.

Hilsenroth, M. J., Defife, J. A., Blagys, M. D., & Ackerman, S. J. (2006). E!ects of training in short-term

psychodynamic psychotherapy: Changes in graduate clinician technique. Psychotherapy Research, 16, 293–

305.

Iacoboni, M. (2005). Understanding others: Imitation, language, empathy. In S. Hurley & N. Chater (Eds.), Per-

spectives on imitation: From neuroscience to social science (pp. 77–100). Cambridge, MA: MIT Press.

390 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

International Centre for Excellence in Emotionally Focused Therapy. (2009). Retrieved June 8, 2009, from http://

www.iceeft.com/

Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in

psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.

Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master

therapists. Journal of Counseling Psychology, 46, 3–11.

Johnson, S. M. (2004). The practice of emotionally focused therapy: Creating connection (2nd ed.). New York:

Brunner-Routledge.

Johnson, S. M., Hunsley, J., Greenberg, L., & Schlinder, D. (1999). Emotionally focused couples therapy: Status

and challenges. Clinical Psychology Science and Practice, 6, 67–79.

Klohnen, E. C., & Bera, S. (1998). Behavioral and experiential patterns of avoidantly and securely attached

women across adulthood: A 31-year longitudinal perspective. Journal of Personality and Social Psychology,

74, 211–223.

Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy

outcome. Psychotherapy: Theory, Research, Practice, Training, 38, 357–361.

Levenson, H., & Svatovic, M. (2009). The EFT knowledge and competency scale: Construction and psychometric

properties. Unpublished Manuscript.

Levenson, H., Svatovic, M., & Montagno, M. (2009, October). The e!ects of training in EFT couple therapy. In

J. Sandberg (Chair), The process of learning EFT. Symposium conducted at the annual convention of the

American Association for Marriage and Family Therapy, Sacramento, CA.

Miller, W., & Mount, K. (2001). A small study of training in motivational interviewing: Does one workshop

change clinician and client behavior? Behavioural and Cognitive Psychotherapy, 29, 457–471.

Milne, D. L., Baker, C., Blackburn, I., James, I., & Reichet, K. (1999). E!ectiveness of cognitive therapy train-

ing. Journal of Behavior Therapy and Experimental Psychiatry, 30, 81–92.

Montagno, M. (2009). The long term e!ects of emotionally focused couple therapy training on knowledge, com-

petency, self-compassion, and attachment security. Dissertation Abstract International, 70(8). (UMI No.

AAT 3373817) Retrieved February 15, 2010, from Dissertations and Theses Databases.

Moore, P. (2008). Introducing mindfulness to clinical psychologists in training: An experiential course of brief

exercises. Journal of Clinical Psychology in Medical Settings, 15, 331–337.

Multon, K. D., Kivlighan, D. M. Jr, & Gold, P. B. (1996). Changes in counselor adherence over the course of

training. Journal of Counseling Psychology, 43, 356–363.

Naaman, S., Pappas, J. D., Makinen, J., Zuccarini, D., & Johnson-Douglas, S. (2005). Treating attachment

injured couples with emotionally focused therapy: A case study approach. Psychiatry: Interpersonal and Bio-

logical Processes, 68, 55–77.

Ne!, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and Identity, 2,

223–250.

Ne!, K. D., Hsieh, Y., & Dejitthirat, K. (2005). Self-compassion, achievement goals, and coping with academic

failure. Self and Identity, 4, 263–287.

Ne!, K. D., Rude, S. S., & Kirkpatrick, K. L. (2007). An examination of self-compassion in relation to positive

psychological functioning and personality traits. Journal of Research in Personality, 41, 908–916.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to

patients. New York: Oxford University Press.

O’Donovan, A., Bain, J. D., & Dyck, M. J. (2005). Does clinical psychology education enhance the clinical com-

petence of practitioners? Professional Psychology: Research and Practice, 36, 104–111.

O’Donovan, A., & Dawe, S. (2002). Evaluating training e!ectiveness in psychotherapy: Lessons for the AOD

field. Drug and Alcohol Review, 21(3), 239–245.

O’Donovan, A., & Dyck, M. J. (2005). Does a clinical psychology education moderate relationships between per-

sonality or emotional adjustment and performance as a clinical psychologist? Psychotherapy: Theory,

Research, Practice, Training, 42(3), 285–285.

Orne, M. T. (1962). On the social psychology of the psychological experiment: With particular reference to

demand characteristics and their implications. American Psychologist, 17, 776–783.

Palmer, G., & Johnson, S. M. (2002). Becoming an emotionally focused therapist. Journal of Couple and Relation-

ship Therapy, 1, 1–20.

Palmer-Olsen, L. (2007). A phenomenological exploration of the EFT therapist’s experience of EFT supervision

and training. Dissertation Abstract International, 68 (7). (UMI No. AAT 3273263) Retrieved February 22,

2010, from Dissertations and Theses Database.

Reid, R., & Harper, J. (2008). The Emotional Processing Inventory. Unpublished Manuscript.

Sandberg, J., & Knestel, A. (2009, October). The experience of learning emotionally focused couple therapy. In

J. Sandberg (Chair), The process of learning EFT. Symposium conducted at the annual convention of the

American Association for Marriage and Family Therapy, Sacramento, CA.

October 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 391

Schon, D. A. (1983). The reflective practitioner. New York: Jossey-Bass.

Schore, A. N. (2003). Affect regulation and the origin of the self: The neurobiology of emotional development.

Hillsdale, NJ: Erlbaum.

Shapiro, S., Brown, K., & Biegel, G. (2007). Teaching self-care to caregivers: E!ects of mindfulness-based stress

reduction on the mental health of therapists in training. Training and Education in Professional Psychology,

1, 105–115.

Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005).

We don’t train in vain: A dissemination trial of three strategies of training clinicians in cognitive-behavioral

therapy. Journal of Consulting and Clinical Psychology, 73, 106–115.

Sibley, C. G., Fischer, R., & Liu, J. H. (2005). Reliability and validity of the revised experiences in close relation-

ships (ECR-R) self-report measure of adult romantic attachment. Journal of Personality and Social Psychology,

31, 1524–1536.

Sibley, C. G., & Liu, J. H. (2004). Short-term temporal stability and factor structure of the Revised Experiences

in Close Relationships (ECR-R) measure of adult attachment. Personality and Individual Differences, 36,

969–975.

Svartberg, M., & Stiles, T. C. (1994). Therapeutic alliance, therapist competence, and client change in short-term

anxiety-producing psychotherapy. Psychotherapy Research, 4(1), 20–33.

Tori, C. D. (1989). Quality assurance standards in the education of psychologists: Reliability and validity of

objective comprehensive examinations developed at a freestanding professional school. Professional Psychol-

ogy: Research and Practice, 20(4), 203–208.

Wittenborn, A. K. (2009, October). EFT therapists’ contributions to treatment: The role of attachment and a!ect

regulation. In S. Woolley (Chair), New research findings in EFT for couples. Symposium conducted at the

annual convention of the American Association for Marriage and Family Therapy, Sacramento, CA.

NOTES

1For a copy of the EFT-KACS, please contact Hanna Levenson.2EFT, an experiential therapy model, implicitly includes principles of mindfulness, such as

present moment awareness, a nonjudgmental attitude, acceptance, and compassion toward selfand others (Furrow et al., 2011), but could do so more explicitly.

392 JOURNAL OF MARITAL AND FAMILY THERAPY October 2011

Copyright of Journal of Marital & Family Therapy is the property of Wiley-Blackwell and its content may notbe copied or emailed to multiple sites or posted to a listserv without the copyright holder's express writtenpermission. However, users may print, download, or email articles for individual use.