Critical Incidents that Help and Hinder Learning Emotionally Focused Therapy for Couples

Danielle Duplassie Chuck Macknee Meris Williams

ABSTRACT. The study's purpose was to identify and categorize the factors that helped or hindered therapists' ability to learn and implement Emotionally Focused Therapy (EFT) for Couples. Fourteen therapists were interviewed using the Critical Incident Technique and asked to describe experiences that had helped or hindered their learning process. A total of 532 critical incidents were documented, which were sorted into 10 "helpful" and 8 "hindering" categories. Among the helpful factors were exposure to and discussion of EFT concepts, the use of an online listserv, and personal "fit" with model. Hindering factors included thera-

Danielle Duplassie, MA, is affiliated with the Department of Educational and Counseling Psychology and Special Education, University of British Columbia, Vancouver, British Columbia. Chuck Macknee, PhD, is affiliated with the Department of Psychology, Trinity Western University, Lan|ley, British Columbia. Meris Williams, MA, is affiliated with the Department of Educational and Counseling Psychology and Special Education, University of British Columbia, Vancouver, British Columbia. Address correspondence to: Danielle Duplassie at Department of Educational and Counseling Psychology and Special Education, 2125 Main Mall, Scarfe Building, University of British Columbia, Vancouver, BC, Canada, V6T 1Z4 (E-mail: dduplass@interchange.ubc.ca). This paper is revised from the first author's thesis, submitted for partial fulfillment for the degree of Master of Arts in the Graduate Program in Counseling Psychology at Trinity Western University, Langley, BC. Joumal of Couple & Relationship Therapy, Vol. 7(1) 2008 Available online at http://jcrt.haworthpress.com 2008 by The Haworth Press. All rights reserved. doi: 10.1080/15332690802129689

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THERAPY

pist anxiety about implementing EFT effectively, countertransference reactions, and the therapist's personal distractions and limitations. Implications of the results for training EFT therapists are discussed, doi:
doi: 10.1080/15332690802129689 [Article copies available for a fee from The Haworth Document Delivery Service: l-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> 2008 by The Haworth Press. All rights reserved.]

KEYWORDS. Therapist training. Emotionally Focused Therapy (EFT) for Couples, critical incident Two major goals of marital therapy are to help couples alleviate relational distress and develop closer relationships. Currently, there is an increased demand for efficacious psychotherapy (The University of York, 1999), which has been informed by the argument that "unless research-based evidence and guidance is incorporated into practice, efforts to improve the quality of care [for clients] will be wasted" (p. 1). A number of empirically supported therapeutic interventions have been designed to achieve the goals of marital therapy. However, a therapeutic intervention is only as effective as the therapist who delivers it. One model of marital therapy. Emotionally Focused Couples Therapy (EFT; Johnson & Greenberg, 1985), has demonstrated strong empirical support (e.g., Dandeneau & Johnson, 1994; Johnson, Maddeaux, & Blouin, 1998; Johnson & Greenberg, 1988; Walker, Johnson, Manion, & Cloutier, 1996). EFTT views relationships from an attachment perspective, which has been described as "the most promising theory of adult love" (Johnson, Hunsley, Greenberg, & Schindler, 1999, p. 68). The goals of EFT are to increase awareness of oneself and one's partner, heighten emotional intimacy, and create new, positive interaction cycles that help couples cope effectively with conflict. EFT for Couples has been shown to be efficacious with a variety of populations. An early study demonstrated that EFT reduced relational distress among 14 couples (Johnson & Greenberg, 1985). Walker and colleagues (1996) found that, for couples with chronically ill children, the EFT approach was helpful in increasing marital accord (which was maintained for at least 5 months after therapy). Using a randomized design, Dandeneau and Johnson (1994) compared EFT with Cognitive Martial Therapy (CMT) and found that EFT produced significantly higher means on intimacy and dyadic adjustment scales than CMT at a 10-week follow up assessment. Denton and Burleson (2000) found that

Duplassie, Macknee, and Williams

EFT was effective in advancing marital satisfaction even when administered by novice therapists in a training clinic. Several articles have outlined other possible uses of EFT. It has been suggested that EFT be used to address couples' sexual issues (MacPhee, Johnson, & Van Der Veer, 1995), the effects of trauma in relationships (e.g., Johnson, 2003a, 2003b; Johnson & Makinen, 2003; Johnson & Williams-Keeler, 1998), and the stress of chronic illness (e.g., Cloutier, Manion, Walker, & Johnson, 2002; Walker, Johnson, Manion, & Cloutier, 1996). EFT has also been recommended for family issues (e.g., Dankoski, 2001; Johnson & Best, 2003; Johnson, Maddeaux, & Blouin, 1998; Johnson, 1998), depression (Dessaulles, Johnson, & Denton, 2003), and can be integrated with other therapeutic theories or modalities (e.g., Vatcher & Bogo, 2001). Although EFT is being used increasingly with couples, only one conceptual article to date has addressed the process of becoming an EFT therapist (Palmer & Johnson, 2002). Palmer and Johnson outlined the complexities of EFT and highlighted some of the struggles experienced by therapists who were learning and implementing the model. The authors stated that effective practice of EFT entails both a strong therapeutic alliance and the therapist's personal belief in the theoretical assumptions of EFT. Potential pitfalls included countertransference issues (e.g., feeling uncomfortable and not knowing how to respond to intense emotion); an inability to stay with and expand emotional responses due to lack of experience with the model; and difficulty implementing simultaneous interventions. The authors emphasized the importance of supervision while learning EFT. Specifically, they recommended that supervision incorporate discussions of EFT theory and practice, and provide a safe place for trainees to explore and reflect upon their own reactions during the therapy process. Although Palmer and Johnson (2002) provided a useful first step in describing the potential challenges experienced by EFT trainees, scant attention has been paid to the factors that influence a trainee's ability to learn the model. The purpose of the current study was to explore the experiences and events that helped or hindered therapists' ability to learn and implement EFT for Couples. An understanding of these factors could assist in improving the training and support provided to therapists who are attempting to learn and integrate the EFT model into their practice, as well as provide a relevant categorical map for EFT trainers.

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METHOD The Critical Incident Technique (CIT; Flanagan, 1954) is a qualitative approach that focuses on an individual's personal experience of a particular phenomenon. It was originally developed to study U.S. Air Force pilots during World War 11. The CIT has been used to investigate a range of phenomena in psychology including the investigation of performance in psychology internships (Ross & Altmaier, 1990) and the development of a list of significant psychotherapist behaviors (Plutnick, Conte, & Karasu, 1994). Over the past 50 years, the CIT has seen increasing use and it is currently acknowledged as an effective tool for empirical investigation and exploration (Butterfield, Borgen, Amundson, & Maglio, 2005; Chell, 1998; Woolsey, 1986). In the current study, the CIT was employed to investigate the experiences of EFT therapists regarding what helped or hindered their ability to learn and implement EFT. The approach entailed interviewing therapists who were learning EFT and documenting the specific events and/or experiences (i.e., critical incidents [CIs]) that they perceived had helped or hindered this process. Participants Fourteen participants (2 male and 12 female) were recruited via word-of-mouth and an EFT electronic mailing list. All participants had completed EFT training within the past three years. They ranged in age from 26 to 67 years (M = 4\ .6). Their overall clinical experience ranged from 2 to 46 years (M = 15.9), and their experience with EFT ranged from 6 months to 3 years (M = 1.6 years). Participants were recruited from a variety of geographical areas in North America including the provinces of Alberta (1 participant), British Columbia (8 participants), Ontario (2 participants), and Quebec (1 participant) in Canada, and the state of Texas in the United States (2 participants). Procedure Each participant was interviewed once, in person, using a semi-structured format. The average length of the interviews was approximately 45 minutes. Participants were asked to recall specific events and experiences that they believed had helped or hindered their ability to learn and implement EFT skills. This process continued until participants were unable to recall any other events. All interviews were audiotaped and

Duplassie, Macknee, and Williams

transcribed by the first author. Subsequently, CIs were extracted from the transcribed accounts. Following Woolsey's (1986) analysis, the CIs were extracted if they demonstrated clear context, specificity, and outcome. They were then recorded onto separate pieces of paper and categorized according to the type of event/experience, the source and context of the event/experience, and the outcome (i.e., helped or hindered the learning and implementation of EFT). In keeping with Flanagan's (1954) method of categorization, 15% of the CIs were set aside for a validity check. In a CIT study, validity refers to whether the categories correctly capture the real meaning of the stories and incidents shared by the participants (i.e. the categories' "trueness"). The validity of categories can also be gauged by assessing the results in relation to the findings of previous research (Woolsey, 1986), which will be addressed in the Discussion. A reliability check (i.e., inter-rater agreement) was also conducted in which an independent sorter categorized a random sample of 80 items into the established categories. Andersson and Nilsson (1964) recommend a minimum of 75% inter-rater agreement. RESULTS A total of 532 CIs were extracted from the transcribed audiotapes. Thefirstauthor sorted the CIs by similarity into a set of categories as per Flanagan (1954) and Woolsey (1986). These categories underwent several modifications until all CIs were sorted. A final scheme of 18 categories accommodated all 532 CIs. Of the 18 categories, 10 represented factors that were helpful to the therapist's ability to learn and implement EFT for Couples and 8 categories represented factors that were unhelpful in this regard. Category Descriptions and Characteristics Helpful Factors. Table 1 summarizes the 10 categories (comprised of 238 incidents) that represented factors that were helpful for therapists learning and implementing EFT for Couples. Appearing in the table are category descriptions, the number of CIs in the category and the incidence rate, the number of participants who provided CIs and the incidence rate, and examples of the CIs. Hindering Factors. Table 2 summarizes the 8 categories (comprised of 294 incidents) concerning what hindered therapists in learning and

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TABLE 1. Category Descriptions and Characteristics-Heipful Factors in Learning EFT

CategotY Name 1 Discussing/ Consulting wiih EFT Practitioners Personal Agreement witli Theory Reading lor Direction and to Understand Audio/Visual Exposure Category Description Discussion of the theory/ practice of EFT with other practitioners and receiving feedback The model "clicked* with the therapist's personality, values, theoreticai orientation The therapist mad various materials (e,g,, articles, books. E R training manual) The therapist watched video tapes and iive EFT therapy sessions, or listened to audiotapes. Cl freq,; IR 52; 22% 36; 15% Participant freq,; IR 13; 93% Sample Cis 1 wili be getting together with people, doing a lot of talking, brainstoniting,,. Collaborating, networking [works], ; i i i 1

12; 88%

I really believe in [the theory], 1 reaiiy think thiat it's got ; great potential,, ,it's what's needed specifically for our j way of interacting and our attachment issues and al) of i that, 1 think it can be very poweriui, ; 1 think looking at [the book] and going to eacli one of the steps and seeing, for instance, in the [training] binder-it had different types of ways to ask questions; different things that we could expect to happen and that was helpful, 1 vtfatched my last two tapes with a ciient, and then I watched Sue's first and third teaching tapes. And I'm going to do that again and again because i see what 1 did and 1 see what she does and I can get clearer and clearer about,.,<io wonder 1 got lost. And usually i got lost because 1 was following the content so much. So, watching both mine and the teaching tapes is a real heip, 1 think just a lot of practice,, ,would make a wortd of difference. You need to have the opportunity to use the model,,,it's going to work the hugs out; it's going to see what works and what doesn't work; what kinds of people and personalities are quicker; what injuries are more difficuit to work with. j i i j i : i i | j j i i i

34; 14%

14; 100%

34; 14%

12; 88%

Practicing EFT Interventions

The therapist practiced EFT interventions with different clients and situations The therapist realized that the model "fit" with clients' experiences and change processes

a%

19;

8; 57%

Confirmation of Model in Work will! Clients

ia; 6%

9; 64%

Using Personal Resources

Confirmation ol Model in Therapists' Own Relationship EFT Framework/ Steps

The therapist used personal resources (e,g,, being genuine in therapy, selfreassurance) to decrease anxiety Tl^o therapist realized how the model applied in his/her own relationships

15; 6%

8; 57%

[Clients] vaiidate the model for me,,.in how they are ; end in what they say-it pretty much resonates the truth of il. That reaiiy is what's going on; there reaiiy is a negative and directional cycle; there really is emotion attacfied and these people reaiiy do want to be close; they really do need to be soothed or comforted. Somehow they validate the model for m and in some ways they teach me,, ,the trutii of it and they also teach me how to work with it. 1 think my strength is more the intuitive sense of my own tieart and how I need to work with people.

13; 5%

8; 57%

The steps and structure of EFT provided the therapist with direction in terms of defining therapeutic goats and conducting therapy sessions The therapist had adequate access to office space and clients with whom EFT work could be done.

12; 5%

8; 57%

1 guess my own relationship [heips] in a sense. It's protty solid and it wasn't aiways Ihat way and, again, the model speaks to it. When i think of how we became close over the years nnd worked through difficulties and we didn't actuaity get therapy for it, which 1 woukJ have liked, but along the way I think we did the work of EFT It's the framework of EFT that aiso fits with me. You Know, when I'm in the middle of a session and 1 have e couple sitting in fnsnt of me, there's something to fail back on,,, iike a madmap so to speak,.,a framework with these 9 steps.

10

Access to Facilities and Ciients

5:2%

2; 14%

i think this is reaiiy important-to have ciients with whom 1 can use tile model ciearty and couid use it, 1 thinit that was helpful.

Nole. IR = Iticidcnce Rate, Cl = Critical Incident,

Duplassie, Macknee, and Williams TABLE 2. Category Descriptions and Characteristics-Hindering Factors in Learning EFT
Category Name Lack of Experionco with Model Category Description BIO therapist's lack of experience with EFT results In a lack of confidence, 'stucknoss," and/or inability to grasp concepts/skills A tack of opportunities for the therapist to discuss EFT theory and practice with others The Iherepist's feelings of anxiety about employing the EFT model correctly, and in response to clients' expectations of the therapist The therapist's response to intense emolion and/or the triggering of his/her own Issues in the therapy process The therapist's personal limitations, induding intra personal, interpersonai, and logistical constraints The therapist's lack of personal beliel tn the EFT theory/model Cl freq.; iR 78; 27% Participant freq.; iR 14; 100%

#
1

Sample CIS [A] hindrance would be my lack of experience. I'm fairiy new to all of this and i haven't had a lot of experience with therapy, in generai, iet alone couples therapy.

Lack of Discussion/ Consultation Feelings of Anxiety and/or Pressure about Employing EFT Properly Personal Reactions to Clionts and/or Countertransference Personal Distractions and/or Limitations Lack of Belief in the Model/Theor V Insuffldent Audio and/or Visual Modoting

69; 23%

14; 100%

36; 12%

13; 93%

What 1 need is to have supervision...that gives me feedback on, 'This is where you should be moving; this is what you should be saying; ttiis is where you should nnove; you're getting bogged down in content here; you're movinq too quickly here," [A] huge hindrance is my ovm anxiety. You know, i'm in the middie of a session and my couple starts freaking out at each other and I'm so caught up in the details that I don't know where 1 am with the model, or where I'm going, or what the goat is. i think 1 become a bit afraid [of the anger). The anger, 1 think tfiat has to do wllh my own personal discomfofi wittv-J guess it's pjirtiy being triggered in some things in myseif-my own story. [A) hindrance has been finances. You know, it costs money for supervision and., .training. That makes It difficult when I'm on a limited income.

36; 12%

12: B6%

34; 12%

11;7fl%

14; 5%

5; 36%

1 know that 1 resist pure model-l have a hard time "following recipes when I'm cooking'-l like to throw this In and try this. Although the videos are helpfui, the videos that Sue Johnson has put out, they're atso a bit of a hindrance because you have a 7&-minute session condensed into 15 minutes. So 1 guess 1 don't know how a whole session is supposed to kx)k.

The therapist's 14:5% insufficient exposure to nKxJeling (iive, audioorvidoo}by other EFT prat::titioner8 and/or trainers, and desire to see a visual diagram to explain the EFT process Emotionai The therapist's 8 13; 4% Concepts difficulty in Difficult to implementing the Implement model with certain wfth Some clients, pariiailarly Culturos those who do not and/or connect with Clients emotional tanquaqe. Note. IR = Incidence Rate. Cl ^ Criticul Incident. 7

8:57%

5:36%

Some ciients like having concrete suggestions or they have a different way of looking at things. They don't prefer talidng about their emotional experiences. So Mflth those clients 1 have found it very challenging to uso the model.

implementing EFT for Couples. Again, category descriptions are presented, along with the number of CIs in each category and the incidence rate, the number of participants who provided CIs and the incidence rate, and examples of the CIs.

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Reliability and Validity Analyses In a reliability check, a random sample of 80 CIs (approximately 15%) was drawn from the pool of 532. A counseling psychology student was provided with the title and a brief description of each category and was asked to place the 80 CIs into the 18 categories. The level of agreement was found to be 89%, which exceeds the recommended level of 75% (Andersson & Nilsson, 1964). A validity check consisted of placing another 80 CIs (which were set aside prior to sorting and categorizing) into the 18 categories. This task was completed with no difficulty, which suggested a comprehensive category system. DISCUSSION This study identified 10 categories of events and experiences that helped therapists learn and implement EFT and 8 categories that hindered this process. The categories, as they relate to extant research, are described below within the context of four main themes that emerged across the categories: (1) Exposure to and Discussion of EFT Concepts, (2) Personal Experiences, (3) Agreement with the EFT Model/Theory, and (4) Framework and Structure of EFT. Theme 1: Exposure to and Discussion of EFT Concepts Exposure to the EFT model was a major theme across several categories. The categories included in this theme were: Discussing/Consulting with EFT Practitioners (1+), Reading for Direction and Understanding (3-I-), Audio/Visual Exposure (4+), Practicing EFT Interventions (5+), Access to Facilities and Clients (10+), Lack of Experience with Model (1-), Lack of Discussion/Consultation (2-), and Insufficient Audio and/ or Visual Modeling (7). The bracketed information refers to the category number and whether the category was helpful (+) or hindering ( - ) . Specific helpful components included the therapist's reading of resources related to EFT and/or attachment theory; watching live therapy sessions and/or videos of therapy sessions; discussing cases with colleagues and supervisors; and practicing the model through role-plays and/or experimentation with clients. When therapists were unable to gain sufficient exposure via these methods, they reported a lack of confidence in using EFT interventions. These findings are consistent with research suggesting that exposure aids in skill acquisition. Benshoff (1993) reported that peer supervision (i.e., the peer-to-peer discussion of personal experiences and clinical

Duplassie, Macknee, and Williams

cases) helped counselors develop their counseling skills and deepen their theoretical understanding. Ray and Altekruse (2000) found that supervision in any form could be helpful to practitioners who were learning therapeutic skills. O'Donovan and Dawe (2002) stated that clinical practice, training manuals, and exercises designed to develop conceptualization skills contributed to skill acquisition. Other researchers have recommended the use of films to promote the development of counseling skills and conceptual understanding (Higgins & Dermer, 2001; Toman & Rak, 2000; Tyler & Guth, 1999). Greenberg and Goldman (1988) stressed that "training is most effective when it includes conceptual instruction, experiential learning, [and] skill training that involves modeling and practice" (p. 698). The findings of the current study corroborate Palmer and Johnson's (2002) opinion that the more experience a therapist acquires, the more he/she will trust the process of, and feel confident in using, EFT. The literature described above underscores the importance of using multiple strategies to help therapists grasp and implement EFT concepts. Insufficient use of a variety of methods (e.g., clinical practice, training manuals, supervision) could contribute to therapists' lack of learning and growth in developing EFT clinical skills. Kolb's (1984) experiential learning theory (in particular, the grasping and transformational dimensions) may also be useful in situating the above findings. Kolb stated that knowledge is created through the transformation of experience. He posited that learners grasp concepts and information through concrete experience, abstract conceptualization (grasping components), reflective observations, and active experimentation (transforming components). Applied to the current study, Kolb's model suggests that direct, concrete contact with EFT through reading and watching therapy sessions helped therapists grasp the model through tangible means, which then impacted their internal reflection and experimentation, thereby transforming their practice of EFT. The process of reflection may have enabled the therapists to conceptualize their experience abstractly. For example, many participants indicated that watching, reading, and/or discussing EFT helped them apply, in a practical manner, conceptual learning to their own clinical cases. They subsequently experimented with this learning in therapy sessions (active experimentation). Some participants explicitly stated that the more they watched, read, and/or discussed cases and experiences, the easier it was for them to grasp the EFT model. Discussion and consultation with other EFT practitioners was the most frequently cited CL Dunn and Dunn's (1993) learning style model

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postulates that some learners grasp information more easily through social stimuli. Such stimuli include working in pairs or groups, and/or under the supervision of an authority figure. All participants in the current study identified the need to consult with others through peer consultation and/or supervision with an EFT trainer. Participants who had opportunities to receive peer supervision with colleagues or EFT trainers indicated that such contact facilitated their understanding of the EFT model and helped them implement it with greater ease in therapy sessions. Participants who reported insufficient opportunities to receive supervision associated this insufficiency with a lack of confidence and skill in using EFT. This finding provides support for Palmer and Johnson's (2002) view that supervision is of crucial importance for EFT practitioners-in-training. It may also be important that therapists receive supervision and support after their initial EFT training, which could further enhance their ability to learn and implement the model. Several therapists referred to the helpfulness of an electronic mailing list. CIs referring to the list were placed into the Discussing/Consulting with EFT Practitioners category. The Internet has been identified as a useful tool for consultation among counselors and therapists. For example, in their investigation of e-mail supervision, Graf and Stebnicki (2002) found that e-mail supervision, combined with group and individual supervision, helped therapists-in-training develop their skills. Each of the findings described above was experiential in nature. That is, the forms of exposure to EFT described by participants were "handson" interactions (e.g., direct contact with clients, reading, receiving supervision, watching live therapy sessions). Therefore, EFT trainers may want to ensure that a variety of "hands on" learning activities are incorporated into training activities. It may also be important to consider that the experiential nature of EFT may draw specific types of learners (e.g., those who enjoy social stimuli and learn through experience). Theme 2: Personal Experiences All participants in the study referred to personal experiences, which suggested the importance of the self in learning and implementing EFT skills and interventions. The categories included in this theme were: Using Personal Resources (7-I-), Personal Reactions to Clients and/or Countertransference (4), and Personal Distractions and/or Limitations (5 - ) . Therapists who cited the use of personal resources indicated that it felt liberating to be genuine about their feelings, thoughts, and values during therapy sessions. They reported giving themselves per-

Duplassie, Macknee, and Williams

11

mission to bring parts of their personal experiences into the therapy process, which helped them learn and implement the model with ease. Participants noted that implementing the EFT model without the anxiety of delivering it the "proper way" enabled them to be more fully present, which, in turn, permitted them to model genuineness to their clients. They reported that when their performance anxiety abated, they learned the model more easily. Similarly, Strupp and colleagues (1988) argued that skill acquisition involves personal involvement with clients and that the more a therapist is able to bring him/herself into the process, the more competent he/she becomes. They argued that efficacy is not strictly dependent on the use of techniques and/or specific interventions, and that therapists will learn more effectively when performance anxiety is not present. In terms of hindering factors, participants indicated that personal and/or countertransference reactions were not helpful in the process of learning and implementing EFT. For example, participants felt hindered when they did not know how to cope with a client's emotional responses or when they felt uncomfortable about those responses due to their own difficult emotional experiences. In their study of hindering phenomena in group supervision, Enyedy and colleagues (2003) found that supervisees were hindered in their ability to learn group therapy skills when they experienced personal reactions to group members, co-therapists, and supervisors. In a study investigating trainees' perspectives on learning empathic communication, Nerdrum and Ronnestad (2002) noted that empathic interventions led to more involvement on the part of the therapist, which could prove challenging for the therapist when the client expressed a highly negative emotion. The participants in that study reported that such clients contributed to strains and challenges for the therapist while the therapist learned empathic interventions. However, participants indicated that such challenges were necessary for their overall learning. Palmer and Johnson (2002) also stated that therapists who experienced countertransference and/or personal reactions during therapy had difficulty implementing EFT interventions. The current study, using therapists' own perspectives, supports and expands upon this idea. In the research literature, there has been scant attention given to the therapist's own personal distractions or limitations. In the current study, the CIs included in the Personal Distractions and/or Limitations category referred to life circumstances that were unique to the participant. Participants reported that distractions (e.g., the sensation of physical discomfort during therapy sessions) and limitations (e.g., language bar-

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riers, lack of time and/or financial resources, an insufficient number clients with whom to utilize the model, personal life stress, lack of office space, and difficulty integrating the model into their existing theoretical orientation) made it challenging for them to focus on their learning process, and contributed to their inability to fully grasp and/or implement EFT interventions. The above findings suggest that the incorporation of training activities that address the personal experiences of EFT trainees (e.g., how a therapist might bring parts of his/her experience into the therapy process; how to cope with countertransference issues, distractions, and perceived limitations) could assist trainees in learning and implementing the EFT model. Theme 3: Agreement with the EFT Model/Theory The categories included in this theme were: Personal Agreement with Theory (2+), Confirmation of Model in Work with Clients (6+), Confirmation of Model in Therapists' Own Relationships (8->-), Lack of Belief in the Model/Theory (6), and Emotional Concepts Difficult to Implement with Some Cultures and/or Clients (8). Participants reported that, as they began to perceive the model and theory of EFT operating in "real life," they were increasingly able to agree with, believe, and invest in the principles of the model. That is, therapists came to believe in the EFT model/theory, in part, due to witnessing its applicability and "fit" with their own, and their clients', lives and relationships. These findings support Palmer and Johnson's (2002) assertion that, "becoming an EFT therapist will be less of a challenge if the therapist's general perspective on relationship problems and therapeutic change is consonant with, or at least not contrary to, the assumptions of EFT" (p. 3). Moreover, they suggested that EFT would be difficult to learn if the principles of the model did not fit with the personal style of the therapist. Nerdrum and Ronnestad (2002) found that observing clients' experiences helped the therapist learn therapeutic interventions. For example, the therapist participants in their study reported that their observation of the effects of empathic communication on clients helped the therapists acquire a more complete understanding of therapeutic mechanisms. The authors also found that therapists' own experiences of being a client in therapy facilitated the learning process. When participants were able to feel the positive effects of empathic communication in their own process, they became more convinced that it could work with their clients.

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13

Skovholt and McCarthy (1988) found that clients were able to contribute to the therapist's skill development through their reactions to, and successes and failures with, clinical interventions. The authors reported that undergoing personal therapy aided therapists in their skill development because it increased their understanding of what was helpful in their own therapeutic process. The findings of the current study suggest that EFT trainees could benefit from ongoing opportunities to assess whether EFT "fits" with their own beliefs about relationships as well as the ability of EFT to explain, and assist with, their clients' relationship challenges. Theme 4: Framework and Structure of EFT The categories included in this theme were: EFT Framework/Steps (9+) and Feelings of Anxiety and/or Pressure about Employing EFT Properly (3-). Several participants reported that the framework and steps of EFT Jiad facilitated their learning because they enjoyed structure. Moreover, participants reported being able to refer to the framework for direction, which enabled them to "locate" their work with clients in the EFT process. However, the framework was anxiety provoking for other participants. For example, it was reported to inhibit learning when the steps were followed inflexibly. One potential reason for this anxiety may be EFT's status as an evidence-based treatment (i.e., participants may have felt obligated to adhere strictly to the empirically supported format). One participant commented, "I know it's been carefully documented and very carefully written about and researched. But it seems to me that it would be the most effective and efficient in the form in which it's designed." Reifer (2001) discussed the anxiety felt by beginning therapists in supervision. However, such anxiety could manifest in any counselor or therapist learning a new therapeutic modality. Because most therapists desire to facilitate positive change in their clients' lives, professional success or failure can be viewed as a reflection of the therapist's own character development and functioning (Reifer, 2001). Arkowitz (2001) highlighted perfectionism in trainees, which could also contribute to feelings of anxiety. The author posited that perfectionism could function as a hindrance to trainees' learning if it contributed to a fear of making mistakes. When the fear of making mistakes arises, "the ability to make an intervention is blocked, as the supervisee-therapist rejects possibilities as not good enough" (p. 39-40). In summary, although some participants in the current study found the EFT framework help-

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ful. Others who felt the need to perform EFT "by the book" found it to be hindering. Palmer and Johnson (2002) commented: A novice therapist learning the [EFT] model can get caught by the lure of the stages of change and can, as one young male student did, become absorbed by what stage his couple was at and how could he move them through the steps. His concern with being able to perform the model successfully and, therefore, have his couple complete the nine steps of therapy obscured his vision of what was happening in the moment in the session, (p. 8) Our study's findings suggest that it may be beneficial for EFT training to address the issue of flexibility within the structure and framework of the model, with perhaps particular attention paid to trainees' potential anxieties about delivering EFT "by the book." CONCLUSIONS AND RECOMMENDATIONS The objective of this study was to investigate EFT therapists' opinions about what helped or hindered their ability to learn and implement the EFT for Couples model. The perspectives of the participants in this study may be helpful in informing the direction of current and future training for EFT for Couples. The study's results suggest the following recommendations. Trainers are encouraged to review their training activities to ensure that adequate "hands-on" experiences have been incorporated (e.g., experimentation with interventions through role plays or with client actors and then receiving feedback from trainers). In addition, a comprehensive discussion of trainees' personal experiences when using EFT, including any countertransference issues, may be useful. For example, role plays or worksheets presenting a variety of difficult scenarios likely to evoke a reaction in the therapist could be developed. Group discussions could also be employed to debrief the complexities of coping with intense emotion and to identify various methods of grounding oneself when personal reactions interfere with the delivery of EFT. We also recommend the development of several, centrally-located EFT training centers where therapists can observe EFT-trained therapists on video or through a one-way mirror in real time. In addition, our findings suggest that supervision and support facilitated trainees' ability to learn and implement EFT. Therefore, increased opportunities for

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individual and/or group supervision with EFT supervisors (and peer supervision with colleagues) are also likely to be critical. In this supportive context, trainees could assess how EFT "fits" with their personal style and own beliefs about relationships, as well as with their clients' relationship problems. Moreover, to decrease therapist anxiety, it would be helpful to develop realistic, full-length training videos that could help therapists learn EFT interventions and provide them with the opportunity to observe how EFT can be implemented during both the intense and less intense moments of therapy. In particular, observing the less intense moments of therapy might encourage therapists to exert less pressure on themselves to "go by the book" because they could see that EFT does not always unfold in predictable ways. Finally, the use of a training manual that incorporates a variety of exercises (e.g., role play ideas, identifying attachment issues, countertransference issues, transcripts) could enhance training by facilitating the discussion and practice of EFT concepts. Such exercises could help trainees acquire a deeper understanding of how to manage difficult situations in therapy and aid in expanding their theoretical understanding of the EFT model. The limitations of the current study included the small number of participants, which may have decreased the comprehensiveness of the results; the possibility that the lists of helpful and hindering components were not exhaustive; the use of retrospective self-report (i.e., participants' memories may not have been completely accurate); and the varying amounts of EFT training possessed by participants (e.g., only some participants had received further training and consistent supervision after completing the basic 40-hour EFT externship). Future research using a different research method or sample of participants could help refine and validate the categories that were developed in this study. Investigating whether the "helpful" CIs elicited in this study contribute to positive clinical outcomes might also prove informative. Finally, therapists could be surveyed regarding the helpfulness of EFT training workshops and materials and asked to make recommendations for improvement. REFERENCES
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RECEIVED: 07/07/06 ACCEPTED: 11/02/06