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Journal of Couple & Relationship Therapy, 9:3147, 2010 Copyright Taylor & Francis Group, LLC ISSN: 1533-2691

1 print / 1533-2683 online DOI: 10.1080/15332690903473069

Resolving Attachment Injuries in Couples Using Emotionally Focused Therapy: A Three-Year Follow-Up
University of Ottawa, Ottawa, Ontario, Canada

Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada, and University of Ottawa, Ottawa, Ontario, Canada

University of Ottawa, Ottawa, Ontario, Canada; Alliant University, San Diego, California, USA; and International Center for Excellence in Emotionally Focused Therapy, Ottawa, Ontario, Canada

Couples who seek therapy for marital distress often do so because they have suffered an attachment injury, characterized by an abandonment or betrayal during a time of critical need. This follow-up assessed the efcacy of the newly developed Attachment Injury Resolution Model based in Emotionally Focused Therapy (EFT). Twelve couples with attachment injuries who received EFT were assessed to determine if the signicant improvement in relationship distress observed in resolved couples at post-treatment would be maintained at 3-year follow-up. Results demonstrated that improvements in dyadic adjustment, trust, and forgiveness, as well as decreases in the severity of the attachment injury, were maintained over time. This follow-up study provides initial evidence of the long-term benets of the Attachment Injury Resolution Model. KEYWORDS couples, attachment, attachment injury, emotionally focused therapy

Address correspondence to Judy A. Makinen, Ottawa Couple and Family Institute, 1869 Carling Avenue, Suite 201, Ottawa, Ontario, K2A 1E6, Canada. E-mail: judy.makinen@rohcg. 31


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Couples seeking therapy have typically endured signicant relationship distress. In some cases, this distress is precipitated by an attachment-related incident in which one partner failed to support or betrayed the other in a critical time of need. Recently this concept has been conceptualized into what is known as an attachment injury (Johnson, Makinen, & Millikin, 2001). This event may then become the standard for the offending partners dependability, instead of the exception, and manifest as a clinically recurring theme that blocks relationship repair. Indeed, such distress is often propagated, maintained, and exacerbated because partners are entrapped in a vicious cycle of negative emotions and ways of interacting (i.e., blame-withdraw), which undermines their desire to heal their relationship and reach out to each other in more positive ways. The attachment injury concept has roots in attachment theory, and also arose from the theory and application of emotionally focused therapy (EFT). EFT is one of todays leading short-term interventions in couples therapy (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). EFT centers on changing attachment behaviors as a means to improve distressed relationships (Johnson, 2004). It views relationship distress as resulting from a breakdown in a couples ability to communicate their emotions and cope with feelings of insecurity, which leads to negative interactional cycles. Its goals are therefore to help the couple access underlying emotions and foster positive interactions that promote accessibility and trust between partners. EFT has been successfully applied to a broad range of populations, from those dealing with posttraumatic stress disorder (Johnson & Williams-Keeler, 1998), to couples dealing with chronic illness (Gordon-Walker, Johnson, Manion, & Cloutier, 1996) and depression (Dessaulles, Johnson, & Denton, 2003). Moreover, EFT has demonstrated relatively high treatment effects (Johnson, Hunsley, Greenberg, & Schindler, 1999), in addition to stable recovery rates (Gordon-Walker, Manion, & Cloutier, 1998). With respect to adult romantic relationships, adult attachment theory is based on the assumption that romantic partners will develop an affectional bond and serve as the main attachment gure for the other (Hazan & Shaver, 1987). The ensuing attachment patterns (i.e., secure, insecure) are based on the quality of their affectional bond and are reected in each partners psychological well-being. Securely attached couples exhibit more positive functioning, characterized by high levels of trust, commitment, and satisfaction (Kobak & Hazan, 1991). Insecure attachment, resulting from a partners lack of responsiveness or inaccessibility, can lead to relational distress. Further research has characterized distress as involving reciprocal negativity, ineffective communication, and holding negative relationship schema (Halford, Kelly, & Markman, 1997). Such interactions cause impasses in resolving issues, as they tend to cycle, and ultimately inhibit positive interaction. Rigid negative attributions then dominate how each partner tends to view the others behavior and the relationship in general (Johnson, Makinen, & Millikin, 2001).

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In couples suffering from an attachment injury, this violation or breach of trust by their attachment gure indicates to the injured partner that the other can no longer be counted on for caring and support when needed (Johnson, Makinen., & Millikin, 2001). What is more, such incidents are observed to have disproportionately damaging effects on close relationships, which often then seem irreparable (Simpson & Rholes, 1994). Injuries may be compounded if the injured partner approaches the offending partner about the event and is met with responses such as dismissal or denial. With time, a failure to remedy fractured bonds results in increased feelings of despair and alienation (Johnson, 2004). What constitutes an attachment injury is highly variable for every couple, and may not necessarily mark the beginning of distress; rather a relationship may be distressed long before an explicit event occurs (Makinen & Johnson, 2006). Particularly vulnerable periods include times of loss, physical illness, and life transitions. What is important is how the injured partner views the event, with respect to their expectations, perceptions, and beliefs (Jones & Burdette, 1994). Correspondingly, therapy is not concerned with the actual event itself, but instead focuses on the emotional effects that result from an attachment injury. Main and Hesse (1990) pointed out that relationships where the primary attachment gure serves as both the source and solution to pain are especially difcult to endure and result in disorganization of the attachment bond. The injured partner is caught in a cycle of hyper- and hypo-arousal whereby they vacillate between seeking and withdrawing from the other partner, who nds this type of interaction chaotic and aversive. To make matters worse, the injured partner cannot accept or trust any comfort offered by their partner (Schore, 1994). This makes it difcult to overcome the sense of alienation, as open conding and coping are impossible (Pennebaker, 1985). The psychological effects on couples experiencing such trauma include intensied negative affect and hypervigilance toward further acts of betrayal (Johnson & Williams-Keeler, 1998). Couples that are successful in recovering from betrayal refer to forgiveness as a mediating factor (Gordon, Baucom, & Snyder, 2000). The conceptualization of an attachment injury arose when clinicians noted that certain couples did not repair their distress following EFT and found that clear patterns emerged. Specically, some couples would refer back to specic incidents of betrayal or abandonment, during which they would use the language of trauma (i.e. life and death terms) to describe it. If the therapist could not succeed in helping the couple address and deal with the breach in trust, then couples were not able to achieve new positive ways of interacting and, hence, continued to suffer distress (Johnson & Greenberg, 1988). Thus, this concept is crucial in understanding impasses so that interventions may be tailored to confer long-lasting changes. Recently, the process of resolving attachment injuries has been outlined and tested. Milliken (2000) collected exploratory data on three couples


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that successfully resolved their attachment injuries through 15 EFT sessions. From this, the rational-empirical Attachment Injury Resolution Model was developed. This model assumes that an attachment injury is a workable concept that may be implemented at the beginning of EFT and continue through to resolution, through four conceptual phases: identifying the attachment injury marker, differentiating affect, re-engagement between partners, and forgiveness and reconciliation. The purpose of the rst phase is to help couples understand the origin of the attachment injury and the negative interactional cycle that has developed. Following this, the injured partner is encouraged to share the full impact of the injury on their attachment bond with the offending partner, who in turn is helped to hear and understand its signicance. Subsequently, partners begin to increase their emotional involvement. In particular, the injured partner further explores and processes the emotional pain of the loss of the attachment bond, and the offending partner observes this vulnerability, acknowledges their role in its disruption, and expresses their empathy, remorse, and regret. Finally, the injured partner takes a risk and reaches to the other for comfort and care, who in turn responds effectively, which ultimately repairs the trauma and restores the attachment bond (Milliken, 2000). In a subsequent study, Makinen and Johnson (2006) investigated the attachment injury resolution model using a sample of 24 couples. The purpose of this study was two-fold, to offer validation of the model using process measures to compare resolved and nonresolved groups, and to relate the process of change to distal outcomes. With respect to this second objective, it was found at post-treatment that resolved couples reported higher levels of dyadic adjustment and forgiveness than nonresolved couples. The two groups were not distinguished on their levels of avoidant and anxious attachment or pain, although changes in these measures were found at posttreatment. It was noted that there was a limited amount of therapy sessions that could be offered to participants; the average length of therapy was 13 sessions. Also, most of the nonresolved couples had reported compound attachment injuries, whereas the resolved couples reported only single injuries. At present, only one study has demonstrated the longer-term benets of EFT. This 2-year follow-up study by Cloutier, Manion, and Walker (2002) demonstrated that improvements in marital functioning in couples with chronically ill children showed not only maintenance, but also continued improvement. Therefore, there is a need for further evidence outlining the enduring effects of EFT. The current study was designed as a follow-up study to previous research examining the verication phase of the attachment injury resolution model. Specically, it serves to determine if the signicant improvement in marital distress of resolved couples at post-treatment would be observable 3 years after EFT. With respect to the attachment injury resolution model and its long-term outcome effects, it was predicted that at 3-year follow-up

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resolved couples would show stability in decreased marital distress, increased relationship trust, decreased avoidant and anxious attachment, increased forgiveness, decreased emotional pain, and decreased attachment injury severity, as exhibited at post-treatment.

METHOD Participants
Participants included a volunteer sample of couples with an attachment injury who had previously participated in an outcome study that assessed the validity and effectiveness of the attachment injury resolution model in alleviating relationship distress (Makinen & Johnson, 2006). To maintain a degree of homogeneity in the sample, couples had to meet the following inclusion criteria: (1) living together for at least 1 year; (2) one partner had to have identied an incident of betrayal or loss of trust in the relationship; and (3) scores on the Dyadic Adjustment Scale (DAS) had to be in the mild to moderate distress range for at least one partner (i.e., scores between 80 and 97); scores lower than 97 indicate marital distress, yet scores lower than 80 indicate severe distress and scores 70 or below correspond to those couples seeking divorce (Spanier, 1976). Exclusion criteria included (1) drug or alcohol problems; (2) psychiatric history; (3) a history of sexual abuse; and (4) physical violence in the relationship. Of the 24 couples who participated in the original study, 12 couples participated in the follow-up study (i.e., 8 resolved couples and 4 nonresolved couples from post-treatment). Of these couples, there were 9 injured wives and 3 injured husbands. The types of attachment injuries reported were an actual abandonment (n = 2), perceived abandonment following a miscarriage (n = 1), indelity (n = 5), irtation (n = 1), friendship with opposite sex (n = 2), and nancial deception/loss (n = 1). The mean age was 36.5 years (SD = 8.6). Couples had lived together for a mean of 10.1 years (SD = 7.1), and had a mean of 1.5 children (SD = 1.2). In terms of racial groups, all couples were Caucasian, excluding one nonresolved couple who were of East Indian descent. Finally, with respect to socioeconomic status, the range of gross family income ranged from $40,000 to $100,000 and $50,000 to $90,000 in resolved and nonresolved couples, respectively.

SELF-REPORT MEASURES The following self-report instruments were selected as they were used to assess outcome measures in the original study and thus were essential for comparison purposes. In addition, they have previously demonstrated theoretical relevance to EFT and an ability to predict outcome in distressed couples (Johnson & Talitman, 1997; Millikin, 2000).


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DYADIC ADJUSTMENT SCALE (DAS) The DAS (Spanier, 1976) is a 32-item self-report measure of marital satisfaction that uses a Likert-type response format. Reliability for this scale has been determined to be 0.96 (Spanier, 1976). The DAS is scored by summing the weights of each xed response. Scores can range from 0 to 151, with lower scores indicative of more distress and lower adjustment. Mean total scale scores of 114.8 are indicative of happily married couples and 70.7 for divorced couples (Spanier, 1976). A couples mean score is obtained by averaging the sum of each partners score. For the follow-up sample, Cronbachs alpha for the DAS was .97.

RELATIONSHIP TRUST SCALE (RTS) The RTS (Holmes, Boon, & Adams, 1990) is a 30-item self-report inventory designed to assess interpersonal trust using a Likert-type response format. Reliability for this scale has been determined to be .89 (Holmes et al., 1990). The theoretical range of scores is 30 to 210. High scores indicate a stronger presence of trust between partners. A couples mean score is obtained by averaging the sum of each partners score. For the follow-up sample, Cronbachs alpha for the RTS was .98.




The ECR (Brennan, Clark, & Shaver, 1998) is a 36-item measure consisting of two 18-item self-report scales that assess individual differences with respect to attachment-related anxiety and avoidance. Reliability coefcients for the avoidance and anxiety scales were .94 and .91, respectively (Brennan et al., 1998). Responses are recorded using a Likert-type response format. Each subscale is individually summed, and scores may range from 18 to 126. High scores indicate avoidance and anxiety. For the follow-up sample, Cronbachs alpha for avoidance and anxiety scales was .95 and .89, respectively.

INTERPERSONAL RELATIONSHIP RESOLUTION SCALE (IRRS) The IRRS (Hargrave & Sells, 1997) is a 44-item measure consisting of two scales designed to assess the extent to which a person continues to feel pain as a result of an offense and has forgiven that person for the offence. Reliability coefcients for the forgiveness and the emotional pain scale were .92 and .95, respectively (Hargrave & Sells, 1997). Injured partners were asked to respond with yes or no to each item. High scores on the forgiveness scale indicate that the individual has made little progress in the work toward forgiveness. Conversely, high scores on the pain scale indicate that the

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individual has made considerable progress in dealing with their pain. For the follow-up sample, Cronbachs alpha for the forgiveness and emotional pain scales was .78 and .80, respectively. ATTACHMENT INJURY MEASURE (AIM) The AIM (Millikin, 2000) is a modication of the single-item Target Complaints Discomfort Box Scale (Battle et al., 1966). The measure was expanded to four items designed to measure the current severity of the injury using a 5-point scale ranging from 1 (severe) to 5 (negligible). Items included: How do you rate the event that injured your relationship bond? How does it affect the level of trust between you and your partner? How does the injury interfere with your relationship now? When you talk to your partner about the injury how much of a problem does it create? The theoretical range of scores is 4 to 20. High scores indicate greater resolution of the attachment injury than low scores. A couples mean score is obtained by averaging the sum of each partners score. For the follow-up sample, Cronbachs alpha for the AIM was .77.

All couples who originally received EFT were contacted by telephone and invited to participate in the 3-year follow-up study. Couples who agreed to participate were sent a complete set of questionnaires corresponding to those used in the original study along with postage-paid return envelopes. The questionnaires were self-report outcome measures: the DAS, the RTS, the ECR, the IRRS, and the AIM. Along with the questionnaires, couples were sent an information and consent form. This study was conducted in compliance with the University of Ottawas Research Ethics Board.

To test the hypothesis that previously resolved couples would show stability in prior treatment gains, repeated-measures analyses with resolved and nonresolved groups as the between-subjects independent variable and time (i.e., post-treatment and follow-up) and partner type (i.e., injured vs. offending) as the within-subjects independent variables were conducted. Separate analyses were conducted on each dependent variable (i.e., dyadic adjustment, relationship trust, avoidant attachment and anxious attachment, and the attachment injury measure). As the IRRS forgiveness and emotional pain scores existed only for the injured parties, the only within-subjects independent variable used was time.


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TABLE 1 Means and Standard Deviations for Resolved and Nonresolved Groups on Dyadic Adjustment at Post-treatment and Follow-up for Injured and Offending Partners Post-treatment Groups Resolved Nonresolvedb

Follow-up Injured 100.25 (26.49) 67.25 (27.17) Offending 103.38 (17.49) 81.25 (11.27)

Injured 114.38 (14.81) 78.25 (11.50)

Offending 110.63 (12.92) 84.50 (8.81)

Note. Values in parentheses represent standard deviations. an = 8 couples. bn = 4 couples.

Given that 12 couples that had participated in the original study were not part of the follow-up study, this limited the type of analyses that could be performed and what corrections were feasible. Due to the exploratory nature of these data, Bonferroni corrections were not made, to reduce the possibility of making a Type II error. DYADIC ADJUSTMENT There was a signicant difference between groups on dyadic adjustment from post-treatment to follow-up, F(1,10) = 13.89, p < .005, p 2 = .58, suggesting that treatment effects remained stable over time. See Table 1 for means and standard deviations. RELATIONSHIP TRUST There was a two-way interaction for partner type by group on relationship trust, F(1,10) = 5.36, p < .05, p 2 = .35, and a main effect for partner type, F(1,10) = 21.15, p = .001, p 2 = .68. The injured partners level of relationship trust was signicantly lower than for the offending partners level of relationship trust at both times. There was also a signicant effect between groups, F(1,10) = 11.99, p < .01, p 2 = .55. See Table 2 for means and standard deviations.
TABLE 2 Means and Standard Deviations for Resolved and Nonresolved Groups on Relationship Trust at Post-treatment and Follow-up for Injured and Offending Partners Post-treatment Groups Resolveda Nonresolvedb Injured 158.38 (28.72) 92.00 (22.91) Offending 167.00 (23.59) 110.75 (17.78) Injured 146.75 (46.69) 88.50 (20.70) Follow-up Offending 155.38 (48.12) 122.00 (11.28)

Note. Values in parentheses represent standard deviations. an = 8 couples. bn = 4 couples.

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TABLE 3 Means and Standard Deviations for Resolved and Nonresolved Groups on Avoidance at Post-treatment and Follow-up for Injured and Offending Partners Post-treatment Groups Resolved Nonresolvedb

Follow-up Injured 50.88 (30.82) 68.50 (24.08) Offending 47.00 (21.90) 58.75 (6.08)

Injured 49.08 (15.32) 45.25 (17.93)

Offending 44.00 (11.30) 61.25 (12.84)

Note. Values in parentheses represent standard deviations. an = 8 couples. bn = 4 couples.

AVOIDANT ATTACHMENT DIMENSION There was a three-way interaction for partner type by time by group F(1,10) = 5.14, p < .05, p 2 = .34. Table 3 shows the means and standard deviations for the avoidance attachment dimension. The presence of a three-way interaction suggests that there are differences over time between both partner type and by group placement. Specically, nonresolved injured partners reported higher levels of avoidant attachment at follow-up. ANXIOUS ATTACHMENT DIMENSION There was no signicant difference between groups in terms of anxious attachment, F(1,10) = .85, p > .01, p 2 = .08. See Table 4 for means and standard deviations. EMOTIONAL PAIN FORGIVENESS


In terms of forgiveness, there was a signicant difference between groups, F(1,10) = 9.55, p <.05, p 2 = .49. Resolved partners reported more forgiveness than nonresolved partners at follow-up. With respect to emotional pain, there was a signicant difference between groups, F(1,10) = 10.54, p <.01, p 2 = .51. Higher scores reported by resolved partners indicate that they
TABLE 4 Means and Standard Deviations for Resolved and Nonresolved Groups on Anxiety at Post-treatment and Follow-up for Injured and Offending Partners Post-treatment Groups Resolveda Nonresolvedb Injured 60.13 (14.71) 60.75 (25.91) Offending 71.02 (20.23) 72.00 (14.54) Injured 49.12 (15.60) 70.00 (24.86) Follow-up Offending 57.00 (22.85) 59.00 (9.13)

Note. Values in parentheses represent standard deviations. an = 8 couples. bn = 4 couples.


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TABLE 5 Means and Standard Deviations for the Resolved and Nonresolved Groups on Emotional Pain and Forgiveness at Post-treatment and Follow-up for Injured Partners Post-treatment Groups Resolved Nonresolvedb

Follow-up Injured 42.00 (1.31) 37.75 (3.59) Offending 26.00 (4.41) 30.75 (4.65)

Injured 40.21 (1.32) 37.25 (4.99)

Offending 24.36 (1.90) 31.00 (2.16)

Note. Values in parentheses represent standard deviations. an = 8 partners. bn = 4 partners.

TABLE 6 Means and Standard Deviations for Resolved and Nonresolved Groups on Attachment Injury Resolution at Post-treatment and Follow-up for Injured and Offending Partners Post-treatment Groups Resolveda Nonresolvedb Injured 15.13 (2.17) 8.00 (4.24) Offending 14.50 (2.00) 9.50 (3.11) Injured 15.75 (3.06) 9.25 (2.06) Follow-up Offending 13.06 (2.48) 12.25 (3.95)

Note. Values in parentheses represent standard deviations. an = 8 couples. bn = 4 couples.

have made more progression than nonresolved partner in terms of dealing with their emotional pain. See Table 5 for the means and standard deviations for the resolved and nonresolved groups on emotional pain and forgiveness at post-treatment and follow-up. ATTACHMENT INJURY RESOLUTION There was a two-way interaction between partner type by group, F(1,10) = 5.16, p < .05, p 2 = .34. In addition, there was a signicant effect between groups, F(1,10) = 21.13, p = .001, p 2 = .68. The two-way interaction between group and partner is likely due to injured partners reporting higher levels of attachment injury resolution in the resolved group, and lower levels in the nonresolved. See Table 6 for means and standard deviations.

The purpose of this research was to investigate the long term effects of EFT at three year follow-up, and to explore whether resolved and nonresolved couples having undergone EFT for an attachment injury are discriminated by distal outcome measures. This follow-up study speaks to the lack of

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long-term follow-up assessments in the area of marital research in the general population (Jacobson & Addis, 1993). The hypothesis that couples previously identied as having resolved their attachment injury would show stability in their gains in dyadic adjustment from post-treatment to follow-up was supported. This is a substantial nding for EFT as the majority of research on long-term follow-up with Behavioral Marital Therapy indicates that for the majority of couples, marital satisfaction regresses to pre-treatment levels 4 to 5 years after treatment (Snyder, Wills, & Gradys-Fletcher, 1991). For the resolved couples, the mean couple DAS score showed no signicant changes from post-treatment to follow-up, despite a slight decrease. The nonresolved couples also showed nonsignicant changes in dyadic adjustment despite slight decreases from post-treatment to follow-up with mean DAS scores remaining signicantly lower than resolved injured couples. The nonresolved couples mean DAS scores indicate that they are still distressed. Moreover, injured nonresolved partners reported a mean DAS score of 67 at follow-up, which is below the average of 70.7 for divorced couples (Spanier, 1976). These results are not surprising as nonresolved couples, specically the injured partners, have been living in a distressed relationship for several years, and without resolution they are likely still entrapped in their cycles of being unable to reach for each other and provide support (Johnson, 2004). As for the decreases in scores for both groups, it should be noted that this may be due to increased variability due to the small sample size. Nevertheless, there were still significant differences between the two groups indicating the strength of effects conferred to resolved couples having undergone EFT. Stability in post-treatment results at follow-up was also found among resolved and nonresolved couples on the level of relationship trust. The mean scores for resolved couples decreased slightly from post-treatment to follow-up, but this was not signicant. The nonresolved couples also showed no signicant difference from post-treatment to follow-up, although offending partners showed a slight increase in trust over time. The observed stability in the levels of dyadic adjustment and trust over time, in both resolved and nonresolved couples, is consistent with the literature, which reports these two variables to be related (Holmes & Remple, 1989), and that positive scores on these variables are characteristic of securely attached couples (Kobak & Hazan, 1991). This suggests that over time couples who were able to resolve their attachment injury in therapy sessions, were more likely to maintain high levels of marital satisfaction and greater trust in their relationship than those couples who did not manage to resolve their attachment injury in therapy. The hypothesis that resolved couples would show signicant decreases in anxious and avoidant attachment at follow-up compared to nonresolved couples was not supported by the data. Despite the nonsignicant ndings between groups, there was a signicant three-way interaction effect between


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time, partner type, and group for the avoidance dimension. This suggests that over time, injured and offending partners responded differentially depending on whether they had been designated as resolved or nonresolved with respect to their attachment injury. Specically, nonresolved injured partners reported higher levels of avoidance in their relationship at follow-up than at post-treatment. Again, this is likely attributable to the fact that injured partners have spent 3 years in a relationship with an insecure attachment that has not been remedied, and hence, have increased their avoidance of their partner who serves as both the solution to and a source of distress to them (Main & Hesse, 1990). The anxiety dimension did not show any signicant changes over time, with respect to partner type or between groups. Consistent with previous results comparing pre- and post-treatment attachment, these ndings also show attachment anxiety and avoidance as measured by this scale to be poor predictors of attachment injury resolution (Makinen & Johnson, 2006). Moreover, as was suggested in the previous study (Makinen & Johnson, 2006), the ECR scale was adjusted so that questions were worded to measure attachment behaviors exclusive to the couple, in hopes of increasing sensitivity to any resulting changes. Previously this measure was administered with ambiguous wording that left room to interpret questions as being directed specically towards ones current partner, or as a general trend arising from ones previous romantic history. Unfortunately, changes to the scale did not approach signicance, as effect sizes remained small for the avoidance and anxiety dimensions for the two groups. The lack of signicant ndings between resolved and nonresolved groups on the attachment measures may be due to several reasons. To begin, it should be noted that couples attachment patterns could not be ascertained prior to the injurious event. Thus, it cannot be precisely determined whether the couples work on their attachment injury altered their long-standing attachment patterns. Another possibility as suggested in the original study is that this attachment measure is not sensitive enough to detect changes in avoidance or anxiety resulting from treatment (Makinen & Johnson, 2006). Despite changes made to the ECR in an attempt to increase this sensitivity, perhaps another scale would provide improved distinction over time, across partners, and between groups. However, given that resolved couples reported increased marital satisfaction and improved trust over time, it seems unlikely that there would not be a corresponding shift in attachment patterns. As noted in the original study, perhaps EFT helps couples to interact in more positive ways, rather than alter underlying attachment styles (Makinen & Johnson, 2006). Following from this, another possible explanation stems from previous research, which has noted the extreme difculty in altering attachment behaviors associated with specic patterns (Brennan et al., 1998; Keelan, Dion, & Dion, 1994). Furthermore, attachment patterns have demonstrated substantial continuity over time when there is continuity in the environment

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(Baldwin & Fehr, 1995; Davila, Karney, & Bradbury, 1999). Perhaps the nonresolved couples did not experience enough security in therapy to be able to change their environments, which could be due to the limited amount of therapy sessions and the fact that they had compounded attachment injuries. Research has shown that security allows an individual to be open to new experience (Bar-Haim, Sutton, Fox, & Marvin, 2000). A likely circumstance is that the traumatic injury triggered attachment-related behaviors consistent with the insecure attachment patterns. At present there exists a lack of research examining the stability of attachment patterns in adults who have experienced traumatic events (Scharfe, 2003). Lastly, the nonsignicant ndings may also be due to low power associated with small sample size. A risk with any study with small n is that it is inherently difcult to account for a lack of signicance. Especially given that EFT has been shown to be effective at reducing relationship distress (Johnson et al., 1999), it is possible that the actual changes in the attachment dimensions are small and cannot be detected with a small sample. With respect to forgiveness, the hypothesis that resolved injured partners would show stability with respect to increased forgiveness levels at post-treatment was supported, as there were no changes with respect to time. In terms of forgiveness, the lack of signicant group differences over time was as expected. Post-treatment data revealed that the resolved couples made signicant gains in terms of their level of forgiveness through therapy (Makinen & Johnson, 2006), whereas no change was noted for the nonresolved couples. Therefore, nding no signicance in differences over time suggests that these gains were maintained over the last 3 years. The hypothesis that there would be a decrease in pain levels over time was not supported. Original post-treatment data reported that there was no signicant difference between resolved and nonresolved partners following therapy (Makinen & Johnson, 2006). However, there were signicant group differences in terms of pain at follow-up. Specically, resolved injured partners reported slightly lower levels of pain than nonresolved injured partners. It is possible that differences across time for the two groups were not detected because of low levels of internal consistency for the forgiveness and pain subscales. Resolved partners may in fact have experienced higher levels of forgiveness and less pain, than nonresolved partners. Compared to the literature, reliability analyses revealed low internal consistency for the pain subscale at post-treatment (.73) and at follow-up (.80). The prediction that couples identied as having resolved the attachment injury at post-treatment would show stability in their gains of attachment injury resolution from post-treatment to follow-up was supported. The mean score for resolved couples was stable from post-treatment to follow-up. The nonresolved couples also showed no signicant difference from posttreatment to follow-up, despite a slight increase in scores. There were significant differences between resolved and nonresolved couples at follow-up.


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The two-way interaction between partner type and group is due to the fact that resolved injured partners report higher levels of attachment injury resolution than nonresolved injured partners. This makes sense as resolved injured partners experienced the injury as more severe than offending partners prior to therapy (Makinen & Johnson, 2006). Therefore, it makes intuitive sense that injured partners will report higher levels of resolution than offending partners. Conversely, injured partners who have not resolved their injury are likely still experiencing insecurity surrounding the injury and correspondingly still view the injury as more severe than offending partners. In general, then, hypotheses were supported except for insignicant group differences found for the anxious and avoidant attachment dimensions and reported pain levels. Signicant differences were detected between couples on measures of dyadic attachment, trust, forgiveness, and attachment injury severity. There are several important limitations inherent to the study that deserve consideration. The most striking of these is the small sample size. Unfortunately but not unsurprisingly, half of the sample was lost at follow-up, which resulted in there being little power available to determine signicant differences between groups. Consequently, although results were determined using ANOVAs, our small sample size indicates that these must be interpreted with caution and may only be considered preliminary support for the longterm impact of EFT. Indeed, additional follow-up studies will be needed to help further support ndings. Another limitation relates to the fact that there was no control group used in the original study or the follow-up. This certainly poses a threat to the internal validity of this research as only a single group was used and no random assignment was possible. Unfortunately, the addition of a control group would have been difcult, expensive, and inefcient. In terms of choosing a control group, this would have had to consist of another group of distressed couples that did not receive therapy. From an ethical standpoint, researchers would have had to provide the control group with therapy afterward, and this was simply beyond the means of the researchers to do so. Also, as the original study was process oriented, where the focus was to investigate the steps underlying the development of forgiveness and reconciliation and to examine how this differs between resolved and nonresolved couples, a control group was simply beyond the scope of the study. A further limitation stems from the fact that partners scores were summed to yield a mean couple score on all outcome variables of interest. This was in keeping with the original article that also focused on exploring resolved and nonresolved group differences. Unfortunately, this method restricted our ability to examine gender differences within the sample and across groups, but given our small sample size and limited power, the exploration of smaller subgroups would have been statistically unfeasible.

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Future research will endeavor to adopt a more classic experimental design in which distressed couples are randomly assigned to either an EFT treatment group or to a control group where couples would receive educational classes on forgiveness. Also, it is recognized that more follow-up studies are needed to conrm the lasting effects of EFT, and longitudinal studies are being actively designed and implemented to address this. At present, the most likely reason for the stability of results in this study appears, in the light of clinical practice in EFT and the understanding offered by attachment theory, to be that once a couple can resolve these kinds of injuries and have a mutually accessible and responsive dialogue, the bond between then becomes more secure. This security buffers them against future stress and relationship distress, allowing them to deal with stressors as a team and thus continually strengthens their relationship. In terms of clinical relevance, this study highlights the utility of EFT as a clinical treatment method whose effects may endure with time. The benets conferred to couples who resolved their attachment injuries through the attachment injury resolution model are stable over 3 years. In addition, the model continues to discriminate between resolved and nonresolved couples on measures of dyadic adjustment, trust, forgiveness, and injury severity.

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