I If you’re a therapist, you’ve undoubtably heard of Emotionally Focused Therapy, or EFT. This modality, which 35 years ago was the new kid on the treatment block, is now taught in more than 40 countries and widely considered one of the most influential and effective couples treatments available.
So what comes to mind when you first hear somebody mention EFT? High-conflict couples? Attachment? Emotions? The EFT Tango? Whatever associations you have, one word that may not readily come to mind is trauma.
But why not? Maybe it should.
Recently, trauma has become a frequent topic for news outlets and social media posts, shedding light on its ubiquity in individuals and in our collective culture. Similarly, the mental health field is more focused on trauma than ever before: if the phrase trauma-informed doesn’t appear in some aspect of your bio, you risk seeming obsolete to clients and potential employers. In this environment, many people are wondering whether popular, time-tested treatments, regardless of the target population, align with the latest trauma research.
Here, Sue Johnson, developer of EFT for couples and Emotionally Focused Individual Therapy (EFIT), offers her perspective on what it means to be trauma-informed and the many ways in which her emotionally focused approaches have been focused on trauma all along.
Ryan Howes: Does EFT work with trauma?
Sue Johnson: From the literature, we know secure attachment is one of the chief resources human beings have for healing from trauma. We’ve always created that resource for couples in EFT, and we’re currently focusing on it for individuals in EFIT. In fact, we’ve just done the first big EFIT study, and the results for its effectiveness with depression, anxiety, and trauma are promising.
EFIT and EFT are particularly well suited to trauma work because trauma is all about emotion: emotion regulation and dysregulation. You might say trauma is an emotional disorder. We’re socially bonding beings, so trauma is always about relationships, and relationships are a key to its cure. Secure, emotionally balanced people who can rely on close, supportive relationships are less likely to deal with trauma in a negative way. They have an internalized model of other people as resources, even if they don’t have a lot of friends in their lives.
RH: What does it mean to have a model of other people as resources?
Johnson: I always talk about my father as an illustration of this because he was my main attachment figure. At negative, scary moments in my life and at positive, amazing moments, I hear his voice in my head. He always saw me, a little English working-class girl—an uppity English working-class girl, as far as my other relatives were concerned—as competent and worthy and precious to him. According to John Bowlby, this is at the core of how an attachment figure fosters a healthy sense of self in a child.
If I hadn’t had that experience of absorbing my own worthiness through him, I probably would’ve been an alcoholic hairdresser in a small English town. That was what was expected of me. Lord knows where my father got this capacity for love and approval from. He was an incredible man. He always told me things like, “You can be who you want to be,” and “You can deal with things; you’re strong enough.” What he was really telling me was, “Vulnerability is manageable; you just have to find a way.” That’s a key protective factor with trauma.
In fact, how you regulate emotions and how you do this in relationships are critical to trauma treatment. They’re the essence of EFT and EFIT, which give us a map to working with clients in therapy based on attachment science. How does this unfold with trauma? I recently had a client with PTSD who had all kinds of symptoms and a really chaotic way of ordering his thoughts and his life. I don’t believe you can do good therapy without attuning to a client’s experience of self, of the world, and of others. So when I sit down with any client—even severely traumatized ones—I ask questions like, “Who are you? How do you do you? How do you create your experience moment to moment? How do you connect with others, or are you all alone?” If you are all alone, the attachment map says you’re bound to be more sensitive to threat. Someone who feels alone is more easily overwhelmed. I’m not making this up! It’s science.
The attachment map also tells me what health looks like and how to get there. Even with trauma, if you’re going to do efficient short-term therapy—and let’s face it, most psychotherapies try to be short-term these days—you have to know where you’re going. My focus is on emotion, which is the heart of the matter with trauma. The idea isn’t just to contain emotion, but to help people plug into it, tolerate it, learn from it, and use it as a compass. We do this within a relational frame, especially because many traumas happen in early relationships.
RH: Was that the case with the PTSD client you were mentioning?
Johnson: Yes. And, of course, it affected all his other relationships, including with himself. In the first five minutes of therapy, he called himself more derogatory names than I’ve heard in my whole career: disgusting, despicable, weak, pathetic. But it really struck me when he said, “I’m a traitor.”
RH: A traitor to what?
Johnson: Mostly, a traitor to his family. When he said this, it brought up a huge amount of shame, which pushed him into a state of apathy and emptiness. A lot of people who talk about their trauma don’t just talk about fear. They talk about loss, sadness, and a sense of shame and deficiency.
If you were a classic PTSD specialist doing CBT, you might focus on this client’s cognitions. But I was focused on his lack of ability to touch and tolerate his feelings. He wanted to stay on an intellectual, vague level, while I wanted him to dip into his experience and how he constructs it. I wanted to be there with him and help him change.
As we got deeper into his story, he told me about being wounded in a military training exercise, a major trauma in his life. But rather than expressing fear, which we associate with trauma, he said with contempt in his voice, “At the great warriors’ ceremony, at the end of the training, I limped down the mountain.”
RH: He was ashamed of himself.
Johnson: He didn’t match up to the image of the hero that the males in his family expected him to be. You could say he had depression, or anxiety, or war-related trauma, or shades of complex PTSD. Whatever diagnosis you labeled him with, he had what David Barlow considers the key essential factors in all emotional disorders: a sense of being completely out of control, and alone.
RH: How did you help him?
Johnson: My goal was to help him develop a secure connection with himself and others. To do this in EFIT, we take clients into what we call identity dramas—places where they were defined as unworthy and incompetent, moments where they couldn’t make sense of their emotions, where even touching an emotion was dangerous. Then we create specific “change events.”
What allows people to move on from trauma and create a different life?—not just to tolerate trauma better, but to create a fulfilling life? There has to be an emotional epiphany. People have to be able to go into that emotional place within themselves without feeling totally out of control and overwhelmed. They have to be able to be themselves in that emotional place.
Austrian biologist Ludwig von Bertalanffy wrote that in living systems, you can create two levels of change. At the first level, you can change some of the factors in the system. For example, you can help somebody who says they’re depressed change behavioral patterns, so they go out and get a job. Or you can help someone who’s stuck in paralysis start to exercise. But according to Bertalanffy, if you want real change, you have to create level-two change. This means you change the elements organizing the whole system. In therapy, you have to change the way people structure their emotions and engage in emotional regulation. That’s the heart of the matter. That reorganizes the system and changes everything.
RH: How do you help trauma clients manage and regulate emotions in a session?
Johnson: As attachment theorists, we create a safe, special alliance—a safe haven. Through this alliance, we help clients hold their emotions, name them, and stay with them, so they can go beyond the surface level of their emotional experience and see what happens in their body. For example, recently, when a distressed female client said, “I’m angry and irritated all the time; I can’t live with that feeling,” I stayed there with her and helped her slow down and let the emotion develop instead of cutting it off, or moving away from it, or freaking out because of it. As she stayed there with me longer, she found that she was overwhelmingly sad.
RH: There was sadness behind the irritation?
Johnson: Yes, and she couldn’t tolerate it. She was abused by a loved one in childhood, which is the worst trauma because it totally interferes with the development of self. When we began her emotional journey together, she was finally able to say, “I’m heartbroken.”
I said, “Well, if you’re heartbroken, your body knows what to do. You have to grieve. Your emotions have an action tendency. Emotions organize our actions, our body, and our thoughts.” Then, as she grieved, she was able to tolerate her grief. Her sense of herself and her inner world changed. She started to understand that she could tolerate the emotion. Gradually, with me, she could go into it and through it. She didn’t collapse. She began to picture the small, terrified part of her that was still hiding under a bed, trying to get away from the person who was sexually abusing her.
Her adult self was able to hold her young self, soothe her into emotional balance, and then reflect on that experience in a coherent way that left her with a different and more potent sense of who she is. Once she could do that, she could then take the risk of confiding in her safe, loving husband, who she’d never been able to allow in.
This trauma work is about being able to access the resource of relationships—internal and external. All experiential therapies tend to use the enactment of inner dramas in session, but EFIT implements this in a particular way that’s supported by a number of outcome studies based on the process of change in the EFT model. We help people put their emotions together and move through them, so they’re not only contacting them and tolerating them, but using them to grow.
RH: Is there a situation in which EFIT might not work for trauma treatment?
Johnson: If you’re having psychotic breaks, or you’re antisocial and aggressive, the work can be difficult. It’s hard to create an alliance. But Carl Rogers said a therapist’s job is to believe in people and their ability to grow. So if you go into the aggression with me as your therapist, and we can have a look at it, then I can probably work with you. In other words, it depends on your alliance and how open your client is.
Dr. Sue Johnson is an author, clinical psychologist, researcher, professor, popular presenter and speaker and a leading innovator in the field of couple therapy and adult attachment. Sue is the primary developer of Emotionally Focused Couples and Family Therapy (EFT), which has demonstrated its effectiveness in over 30 years of peer-reviewed clinical research. Sue Johnson is founding Director of the International Centre for Excellence in Emotionally Focused Therapy (ICEEFT) and Distinguished Research Professor at Alliant University in San Diego, California, and Professor, Clinical Psychiatry at the University of British Columbia, Canada, as well as Professor Emeritus, Clinical Psychology, at the University of Ottawa, Canada. Dr. Johnson is the author of numerous books and articles including Attachment Theory in Practice: EFT with Individuals, Couples and Families (2019) The Practice of Emotionally Focused Couple Therapy: Creating Connection (3rd edition, 2019) and Emotionally Focused Couple Therapy with Trauma Survivors (2002).