Emotionally focused therapy and emotion-focused therapy (EFT) are types of humanistic therapy used to help individuals, couples, and families solve emotional and relationship problems. These therapies use methods from experiential therapy, such as person-centered and Gestalt therapies, along with ideas from systemic therapy and attachment theory. A key idea is that emotions affect how people think, what they do, and what they need. The goals of EFT include changing unhealthy behaviors, like avoiding emotions, and helping people learn to notice, accept, express, and manage their emotions, as well as understand relationships. EFT is typically a short-term treatment lasting eight to 20 sessions.

Emotion-focused therapy for individuals was first called process-experiential therapy and is still referred to by that name in some situations. EFT should not be confused with emotion-focused coping, which is a different concept about strategies to manage emotions. EFT has been used to help clients improve their ability to cope with emotions.

History

Emotionally Focused Therapy (EFT) started in the mid-1980s to help couples improve their relationships. Sue Johnson and Les Greenberg created and tested EFT in 1985. The first book explaining EFT for couples was published in 1988.

To develop EFT, Johnson and Greenberg studied videos of therapy sessions. They looked for patterns that helped couples make positive changes. Their work was influenced by Carl Rogers and Fritz Perls, who believed that paying attention to emotions in the present moment helps people understand themselves and their actions. Johnson and Greenberg combined this idea with a view that emotions and actions are connected to the whole situation in which they happen. In this method, problems in a relationship are not seen as the fault of one person but as repeated patterns of how partners interact. Emotions are not only personal but also part of the relationship as a whole.

In 1986, Greenberg decided to focus more on helping individuals with their own emotions. He and others worked on a method that uses emotional experiences to help people understand themselves. They built on ideas from Rogers, Perls, and others like Eugene Gendlin. They also used their own research on how emotions help people adapt. In 1993, Greenberg, Rice, and Elliott created a guide with clear steps for a method they called process-experiential therapy. Later, Elliott and others added more details to this method, including tools for helping people in therapy.

Johnson continued to improve EFT for couples. She used ideas from attachment theory, which explains how people form close relationships, and combined them with other methods. Her approach kept the original three stages, nine steps, and two sets of techniques that help rebuild the emotional connection between partners. One set of techniques helps couples change how they interact, and the other helps them process emotions. Johnson’s goal is to create positive patterns where partners can support each other emotionally.

Greenberg and Goldman created a version of EFT for couples that includes some ideas from Johnson and Greenberg’s original work but adds new steps and stages. They identified three key factors that affect how people manage emotions in close relationships: (1) attachment, (2) identity or power, and (3) attraction or liking.

Similar terminology, different meanings

The terms "emotion-focused therapy" and "emotionally focused therapy" can mean different things to different therapists.

Les Greenberg uses the term "emotion-focused" to describe psychotherapy methods that focus on emotions. He believed that certain approaches, such as the process experiential method, share enough similarities to be grouped together under the general name "emotion-focused approaches." Greenberg and his colleague Rhonda Goldman chose the term "emotion-focused" instead of "emotionally focused" because it is more commonly used in the United States. Greenberg explains that "emotion-focused therapy" refers to the idea of combining an emotional focus into any type of psychotherapy. He believes that focusing on emotions is a shared element in many therapy systems, including psychodynamic, cognitive-behavioral, systemic, and humanistic approaches. Greenberg co-wrote a chapter about the importance of research in therapy and the integration of different therapy methods.

Sue Johnson uses the term "emotionally focused therapy" to describe a specific model of relationship therapy. This model combines systems and experiential approaches and is based on attachment theory, which explains how emotions are regulated in relationships. Johnson believes that attachment needs are essential for survival in mammals. Her approach to emotionally focused therapy (EFT) focuses on how attachment, caregiving, and sexual relationships are connected. She views attachment theory as a framework that includes the need for personal independence, trust in others, and a sense of personal and relational value. Johnson’s EFT aims to help people develop healthier relationship patterns and better emotional regulation to improve physical, emotional, and relational well-being.

Features

All EFT approaches focus on the importance of understanding and connecting with clients' feelings. They emphasize helping clients explore their emotions as they happen during therapy sessions. This means that paying attention to emotions in the moment is a key part of all EFT methods. All EFT theorists believe that people interact with others based on their emotions, and they build their sense of self through repeated emotional experiences with others.

EFT approaches combine ideas from two main areas: the theory of how people process emotions (as explained by researchers like Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic focus on expressing emotions in the present (based on earlier work by Carl Rogers, Fritz Perls, and Eugene Gendlin). These ideas have been central to EFT since its beginning. EFT views emotions as both the goal and the tool for change, showing how emotions, thoughts, and actions are connected. EFT suggests that emotions are often the first, unconscious reaction to experiences. All EFT methods also use the idea of primary emotions (direct responses to events) and secondary emotions (reactions to primary emotions).

Greenberg and other EFT theorists have grouped emotion responses into four types to help therapists guide clients: primary adaptive (helpful emotions), primary maladaptive (harmful emotions), secondary reactive (emotions caused by other emotions), and instrumental (emotions used to achieve goals). Greenberg also outlined six steps for processing emotions: (1) noticing or naming feelings, (2) expressing emotions, (3) managing emotions, (4) reflecting on experiences, (5) changing emotions through other emotions, and (6) learning new ways to handle emotions through real-life experiences in therapy and life. Primary adaptive emotions are seen as reliable guides for behavior, while primary maladaptive emotions are not reliable (along with other challenges like poor emotional awareness, difficulty managing emotions, or trouble making meaning of experiences).

Johnson does not often separate adaptive and maladaptive primary emotions, nor does he label emotions as helpful or unhelpful. Instead, he sees primary emotions as normal reactions to stress, such as the distress caused by separation from someone important (as described by John Bowlby). In EFT for couples, like other therapies focused on relationships, the problem is often the patterns of how people interact. These patterns can change when therapists help clients understand the hidden primary emotions driving unproductive, negative cycles of interaction. Acknowledging reactive emotions and rethinking the original emotions behind these patterns is part of the process of change.

Individual therapy

Goldman & Greenberg 2015 created a 14-step process to help understand how emotional problems develop. They believe these problems can come from four main causes: not noticing or avoiding emotions, having trouble managing emotions, reacting to emotions in unhelpful ways, or struggling to understand experiences. This theory includes four types of emotional responses, divides needs into "attachment" and "identity" categories, explains four kinds of emotional processing challenges, describes different types of empathy, lists at least 12 tasks for therapy, uses two types of emotional and story-based processes to learn about clients, and assumes a model of growth that combines change over time with emotional patterns.

Therapists may use techniques like the Gestalt therapy "empty chair" method to help clients resolve unfinished issues or the "two-chair" method to address self-critical thoughts.

Emotion-focused experts say people organize their emotions into unique patterns that change over time. For practical purposes, emotions can be grouped into four types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.

• Primary adaptive emotion responses are the first emotions a person feels in response to a situation, and they help the person deal with the situation. For example, sadness after a loss, anger when something is unfair, or fear when something dangerous happens. These emotions can also include feelings of being in control or unsure, or a general sense of emotional pain. These responses are explored in therapy to understand how they help solve problems.

• Primary maladaptive emotion responses are also initial emotions, but they come from patterns that no longer help the person. These might include sadness when others are happy, anger when others care, or fear in safe situations. These responses often develop from past trauma. For example, someone might feel angry when others show care because they learned to associate care with harm as a child. These emotions are explored in therapy to change unhelpful patterns.

• Secondary reactive emotion responses happen when a person reacts to their own primary emotions and then feels a new emotion. For example, someone might feel hopeless after sadness or fear after anger. These can also include emotions like feeling angry to avoid sadness or scared to avoid anger. These responses are explored in therapy to understand their causes and find more helpful emotions.

• Instrumental emotion responses occur when a person uses emotions to influence others, such as making others pay attention or approve of them. Examples include pretending to cry to get help or showing anger to control a situation. These responses are explored in therapy to understand their purpose and how they affect the person’s life.

Each type of emotional response requires a different approach in therapy. Primary adaptive responses are explored to use their helpful information. Primary maladaptive responses are examined to find unmet needs and change them. Secondary reactive responses are explored to understand their causes. Instrumental responses are studied to understand their role in relationships.

Primary emotions are not called "primary" because they are more real than others; all emotions feel real. Therapists use these categories to help clients understand how emotions work and how to address them.

A therapeutic task is a specific problem a client must solve during therapy. In the 1970s and 1980s, researchers like Laura North Rice studied therapy sessions to better understand how clients change. This research led to a standard list of therapeutic tasks in emotion-focused therapy. A table from 2012 summarizes these tasks, which are grouped into categories.

Couples therapy

A systemic perspective is important in all methods of Emotionally Focused Therapy (EFT) for couples. Tracking patterns of conflict, often called a "dance" in Johnson's work, has been a key part of Johnson and Greenberg's approach since 1985. In Goldman and Greenberg's newer method, therapists also help couples work on changing themselves and addressing pain from unmet childhood needs, in addition to improving how they interact. They explain that not all relationship problems can be fixed only by changing interaction patterns.

In Greenberg and Goldman's approach, attachment is one of three important parts of how couples function, along with identity/power and attraction/liking. In Johnson's approach, attachment theory is the main idea behind adult love, and it guides therapists in helping couples process emotions.

Greenberg and Goldman's method focuses on addressing identity issues and helping both partners learn to comfort themselves and each other, in addition to changing how they interact. Johnson's approach aims to rebuild attachment bonds and create "effective dependency," which includes secure attachment.

EFT for couples uses a nine-step process to rebuild the attachment bond between partners. The goal is to reshape the bond, improve how partners regulate emotions together, and increase their ability to manage stress. In successful cases, couples learn to meet each other's unmet needs and heal from childhood injuries. A secure attachment bond can help protect couples from past and present trauma.

Greenberg and Goldman's method adds to Johnson and Greenberg's original three-stage, nine-step EFT framework. Their approach has five stages and 14 steps. It starts by helping partners explore their hidden feelings before changing negative interactions. This is considered important because partners need to understand their own emotions first to better connect with their partner and change how they interact.

Johnson (2008) describes the nine steps in EFT for couples as a process that repeats in a cycle, with each step leading to the next. In couples with mild problems, both partners usually move through the steps at a similar pace. In more troubled couples, the more withdrawn partner may move slightly faster.

Step 1: Identify the main conflicts between partners.
Step 2: Identify the negative interaction cycle where these conflicts happen.
Step 3: Explore the emotions related to each partner's position in the cycle.
Step 4: Reframe the problem using the cycle, unacknowledged emotions, and attachment needs.

During this stage, the therapist creates a safe space for the couple to discuss any concerns about therapy, including trust in the therapist. The therapist also learns about the couple's positive and negative interactions and helps them recognize negative patterns. Partners begin to see themselves as working together to solve problems, not as victims of their cycle.

Step 5: Explore unspoken needs, emotions, and self-views.
Step 6: Help each partner accept the other's experiences.
Step 7: Encourage partners to express their needs and reshape interactions based on new understanding.

This stage helps couples expand their emotional experiences by recognizing their attachment needs and changing how they interact. At first, new ways of interacting may feel strange, but as partners become more aware, they can stop old patterns from returning.

Step 8: Help couples create new stories and solutions to old problems.
Step 9: Strengthen new patterns of behavior.

This stage focuses on reflecting on new emotional experiences and self-views. It helps couples integrate new ways of handling problems within themselves and in the relationship.

Johnson & Sims (2000) described four attachment styles that influence therapy:

• Secure attachment: People who feel safe and trusting see themselves as lovable and can express their needs clearly. They are flexible and open in relationships.
• Avoidant attachment: People who struggle to express feelings or needs often keep their distance and solve problems without showing emotion. This can hurt their partner.
• Anxious attachment: People who feel anxious often demand reassurance and may use blame or pressure to get attention.
• Fearful–Avoidant attachment: People who have experienced trauma may alternate between needing closeness and pushing others away. This is sometimes called disorganized attachment.

Family therapy

Emotionally Focused Family Therapy (EFFT), created by Johnson and her team, helps families with emotional problems build stronger, more secure relationships. This therapy follows a three-step process: (1) reducing harmful patterns of communication that cause conflict and fear between parents and children; (2) changing how parents and children interact to create safe and supportive connections; and (3) strengthening these new, positive relationships. The main goal is to help parents respond more clearly to their children’s needs, ensuring children feel safe and supported. EFFT focuses on three key actions: helping parents be more emotionally available to their children, identifying and understanding children’s emotional needs, and improving how parents and children interact in caring ways. Some therapists have combined EFFT with play therapy to help children express their feelings.

A group of therapists, influenced by Greenberg’s methods, created a treatment plan for families dealing with eating disorders. This approach combines ideas from four therapies: emotion-focused therapy, behavioral family therapy, motivational enhancement therapy, and the New Maudsley family skills-based method. The goal is to help parents support their child in managing emotions, improve parent-child relationships, and reduce the need for eating disorder behaviors to cope with difficult feelings. The treatment includes three main areas of focus, four guiding principles, and five steps based on Greenberg’s emotion-focused approach and influenced by John Gottman. These steps are: (1) paying attention to the child’s emotions, (2) identifying the emotions, (3) acknowledging the emotions as valid, (4) meeting the child’s emotional needs, and (5) helping the child work through their emotions, solving problems if needed.

Efficacy

Johnson, Greenberg, and their colleagues have spent many years as researchers, sharing the results of studies that examine different types of emotion-focused therapy (EFT).

The American Psychological Association states that EFT for individuals is a treatment supported by research for depression. Studies show that EFT may help with depression, problems in relationships, trauma, and avoidant personality disorder.

People who use EFT say that research shows patients often improve significantly after therapy. Most of these studies were done by EFT researchers. They claim that EFT for couples helps improve troubled relationships, creating stronger and more lasting connections. In 1999, Johnson and others reviewed four of the most thorough studies before the year 2000. They found that the original nine-step, three-stage EFT method for couples had a greater effect than other couple therapy methods at that time. However, psychologist James C. Coyne later strongly criticized this review, calling it a low-quality analysis of studies that should not have been used as proof of EFT’s success. A 2005 study with brain imaging technology, conducted with neuroscientist Jim Coan, suggested that EFT for couples may reduce how the brain reacts to threats when a romantic partner is present. This study was also criticized by Coyne.

A 2019 review of EFT for couples therapy found that the approach improves relationship satisfaction, and these improvements lasted for up to two years after therapy ended.

Strengths

The strengths of EFT approaches include the following:

• EFT works with clients in a teamwork way, using methods that focus on the client’s experiences and also using approaches that look at the whole system (like family or relationships).
• Strategies and methods for change are clearly defined based on careful study of how therapy works.
• EFT has been proven effective through 30 years of scientific research. There is also research about how changes happen and what helps therapy succeed.
• EFT has been used for many different problems and groups of people, but more research is needed on different groups and how it works in various cultures.
• EFT for couples uses ideas about marriage problems and adult love that are supported by research on how adults form relationships.

Criticism

In 2014, psychotherapist Campbell Purton wrote a book titled The Trouble with Psychotherapy, in which he criticized several types of therapy, including behavior therapy, person-centered therapy, psychodynamic therapy, cognitive behavioral therapy, emotion-focused therapy, and existential therapy. He claimed these therapies have carried too many or incorrect ideas that differ too much from how people normally understand personal problems. About emotion-focused therapy, Purton said the success of therapy tasks can be understood without complex theories, and that what clients say is better explained by their situation, their reaction to it, and the language they use to describe their feelings.

Also in 2014, psychologist James C. Coyne pointed out that some research on emotion-focused therapy lacked strong scientific methods, such as not having enough data or being at high risk of bias. However, he noted these issues are common in psychotherapy research overall.

In 2015, Richard D. Lane and colleagues wrote an article in Behavioral and Brain Sciences about "memory reconsolidation, emotional arousal, and the process of change in psychotherapy." They summarized a common idea in emotion-focused therapy research: that emotional arousal is an important part of making changes in therapy and is essential for successful treatment. In a response to this article, Bruce Ecker and colleagues, who created coherence therapy, disagreed. They argued that the key to change in therapy involving memory reconsolidation is not emotional arousal but a person’s feeling that what they expected to happen does not match what actually happens.

Other responses to Lane et al. (2015) suggested that their emotion-focused approach would improve if it included predictions about other factors that might affect how well therapy works, ways to help people who do not benefit from treatment, and a discussion of how their model explains differences in how people develop mental health problems. They also said the model needs more development to explain the variety of mental health issues and the processes that keep or worsen them.