Emotionally Focused Couple Therapy (EFT; Johnson, 2004) is an empirically validated approach to couple therapy that uses attachment theory to understand the needs and emotions of romantic partners. In EFT, relationship distress is conceptualized as resulting from negative affect, emotional disconnection, and unmet attachment needs. Although EFT is recognized as one of the most researched and effective approaches to couple therapy, little research has examined theoretically related characteristics of couples to changes in marital satisfaction throughout EFT. The present doctoral thesis examined this area of literature. Thirty-two couples were provided approximately 21 sessions of EFT. The goal of the first study was to identify intake characteristics related to change in marital satisfaction over the course of EFT. Couples completed self-report measures of marital satisfaction, attachment security, relationship trust, and emotional control at pre- and post-therapy and after each therapy session. Individuals higher on self-report attachment anxiety and higher levels of emotional control had greater change in marital satisfaction over the course of EFT. The goal of the second study was to examine intake levels of attachment security and its relationship to the occurrence of the blamer-softening event, a key change event in EFT, and changes in marital satisfaction. Results indicated that the occurrence of a blamer-softening event significantly predicted positive changes in marital satisfaction. Results also suggested that the occurrence of a softening event significantly moderated the relationship between attachment avoidance at intake and change in marital satisfaction from pre- to post-therapy. For couples who completed a blamer-softening event, partners with lower levels of attachment avoidance were more likely to have positive changes in marital satisfaction. However, this relationship was not evident for attachment anxiety. Overall, results from this thesis suggest that attachment security is a key characteristic of couple partners for therapists to consider when implementing EFT. Therapists may benefit from assessing attachment security at the start of therapy to help inform them of the emotion regulating strategies used by couple partners. This information may help therapists to tailor specific interventions such that couples may begin to develop more secure attachment bonds.

Couple therapy has been proven to be successful in treating marital distress and mental health problems; however, not everyone benefits from couple therapy. Although research suggests that some couple therapists are more effective than others, little research has explored the in-session behaviors of effective couple therapists. The purpose of this study was to code the therapist behaviors of therapist warmth, empathy, validation, presence, collaboration, systemically-based techniques, and session structure in the first session of 17 Emotionally Focused Therapy cases of couple therapy to examine their ability to predict pre-therapy to post-therapy change in male and female marital satisfaction. The seven hypotheses were tested utilizing Bayesian structure equation modeling (BSEM). Results indicate that 13 of the 14 hypothesized relationships between therapist behaviors and change in marital satisfaction were not significant. Only therapist empathy was a significant predictor, but it unexpectedly predicted a decrease in female marital satisfaction over the course of therapy. Possible explanations for the findings and clinical implications were discussed.

Unfulfilled attachment related needs and wants are viewed by many therapists as the heart of couple distress (Johnson & Whiffen, 2003; Johnson, 2004). As a result, efforts to discover and utilize therapeutic processes that encourage couples to identify and appropriately respond to their partner's core attachment needs and wants continue to increase. This study served as a pilot study for a planned, larger-scale investigation examining enactments as a potential best-practice change mechanism to strengthen secure attachment in marital therapy. Twelve couples were randomly assigned to one of two possible experimental groups. Group 1 experienced three therapist-centered therapy sessions, followed by three enactment-centered sessions. Group 2 experienced three enactment-centered sessions followed by three therapist-centered sessions. Before each experimental session, both spouses independently completed a measure assessing their attachment security to their spouse over the past week. After each experimental session, both spouses independently completed a measure assessing how their attachment security to their spouse changed during the session. Each participant's scores were averaged and analyzed descriptively to explore possible trends and trajectories regarding the relationship between an enactment-focused clinical process and secure attachment and how it compared to a therapist-centered clinical process. The results of this pilot study provide preliminary support of enactments as an effective treatment protocol for therapists to help couples strengthen their secure attachment. Findings revealed trends suggesting that enactment-focused therapy sessions tended to increase overall couple secure attachment, perhaps superior to that of a solely therapist-centered approach.

This study examined the mediating impact of couples' attachment behaviors on the relationship between poor quality family-of-origin experiences and marital communication quality. The couple data for this study was collected from the Relationship Evaluation (RELATE) database (see www.relate-institute.org). An Actor Partner Interdependence Model using structural equation modeling was used to evaluate 261 marriage relationships. Results indicated that the relationships between family-of-origin experiences and communication quality are significantly related, with more family-of-origin problems associated with poorer positive communication skills. When attachment behaviors (accessibility, responsiveness, and engagement) were added to the model, it significantly mediated the relationship. Implications for clinicians treating couples who present with communication problems are discussed, as are directions for future research.

While there is substantial evidence that marriage impacts health, no studies have explicitly analyzed the association between attachment behaviors and health practices. This study examines the relationship between couples' attachment behaviors and health practices, as measured by physical activity levels and dietary habits. Couple data was analyzed from the RELATE database (n= 4,957 couples). An Actor Partner Interdependence Model, using a multinomial logistic regression, was used to examine the relationships between attachment behaviors and health practices, as measured by activity level and dietary habits. Results for actor paths indicate that wives' own attachment behaviors significantly influence their own health practices. Husbands' attachment behaviors are not significantly related to their own health practices. Results also show no significant partner paths for either spouse. Clinical implications for treating women who present with health problems are discussed, as are directions for future research.

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In recent decades there has been an increase in literature regarding sexual addiction as well as a growing number of clients presenting in therapy with problems related to their sexual behaviors (including internet sexual addiction). More recently, the impact of sexual addiction on couples has been noted, but little is known regarding how couples can be assisted in the recovery process. In this qualitative study, I explored in depth the critical change processes in couple therapy for sexual addiction from the therapist's perspective, including the therapist's role in that process. The findings suggest that couple recovery from sexual addiction includes (a) individual responsibility in recovery (which includes themes of trauma, family-of-origin, emotional reactivity, depersonalizing, and utilizing other resources), (b) couple recovery (which includes the themes of family-of-origin, communication, empathy, intimacy, trust, and sexual intimacy), (c) balancing individual recovery with couple recovery in the process of healing (which includes the themes of education, accountability, and couple perspective) and (d) distinguishing affairs from sexual addiction. I discuss the implications of study findings, offering a sequential outline of the process of therapy with couples who are struggling to recover from sexual addiction, including therapist interventions that may assist in that process. Limitations to the study and implications for future research in sexual addiction generally and MFT specifically are presented. / Ph. D.

This research explored how transgender people and their partners experience the process of disclosing their gender identity, experiences of mental health, and how couple and family therapists can be helpful to relationships involving transgender people. The purpose of this study was to better understand transgender relationships to prepare couple and family therapists to work with this population. Participants were seven self-identified transgender people and three of their partners. In-depth interviews were used to explore experiences of transgender people's relationships. Nine themes were identified: decision to disclose, the road to acceptance, perceptions of sexual orientation, change, delineating between purposes for seeking mental health services, belief that therapists are not well-informed about transgender issues, value of well-informed therapists, couple and family therapists should be well-informed, and loved ones understanding of gender identity. This study provides insight into transgender people's relational issues relevant to couple and family therapy. Phenomenological, narrative and feminist lenses provide frameworks to view these findings. Implications for future research and clinical practice are discussed. / Ph. D.

Couple therapy research identifies partner empathy as a core process for positive outcomes. The Exeter Model of couple therapy (EMCT) for depression builds on both behavioural and empathic approaches in couple therapy to reduce unhelpful couple interactions and promote mutual understanding between partners where one partner is experiencing depression. Based on EMCT, this process research study aimed to investigate mutual understanding (MU), a transtheoretical concept that refers to the moment-by-moment therapy triad talk that constructs partner empathy. Thirty-four therapy sessions from seven couples in EMCT were screened for MU events, based on pre-defined theoretically derived criteria. A discourse analysis (DA) discursive psychology approach was utilised to examine identified MU events. Specifically, participant positioning and the constructive function of discourses were examined in the therapy extracts, as these DA concepts were closely linked to MU criteria. Findings provided insights into the couple and therapist interaction sequences that contribute to MU, suggesting that both systemic-behavioural and systemic-empathic EMCT techniques can facilitate the process. Specifically, circularities, active listening tasks, and eliciting vulnerability were identified as effective techniques for MU. Findings also pointed to clients' contributions and the impact of discordant discourses. Implications for EMCT practice, and directions for future couple therapy research are discussed.