Journal of Systemic Therapies, Vol. 26, No. 4, 2007, pp.

17–24

EMOTIONALLY FOCUSED FAMILY THERAPY:

DEVELOPING THE MODEL
GAIL PALMER, M.S.W., R.M.F.T.
Ottawa Couple and Family Inc.
DON EFRON, M.S.W., R.S.W.
Madame Vanier Children’s Services

Emotionally Focused Therapy is a model which combines attachment theory

and systemic theory. This article is a transcript of a plenary given by Gail
Palmer and Don Efron at a conference called the “EFT Summit” which was
held in Ottawa in Spring, 2006. The authors discuss the development of
Emotionally Focused Family Therapy and describe two cases from two quite
diverse treatment settings.

GAIL PALMER:

In our offices, we meet families of all shapes and sizes. Scanning my own therapy
archives, I remember the single mom with her only child. She was struggling to
help her daughter who suffered from both juvenile diabetes and bulimia. On the
other end of the spectrum was the adult son who felt lost and alone even though
his family was not only large (they had 16 children) but was also powerful and
influential. Emotionally Focused Family Therapy (EFFT) is a therapeutic approach
that allows us to engage each and every family we meet, from the family seeking
help through a private practice clinic to the parents and siblings of an emotionally
disturbed child, Emotionally Focused Family Therapy can reconnect those bonds
vital to health and well-being. Joan Didion (2005) wrote in her memoir, The Year
of Magical Thinking, about her terrible loss of both her husband and her daugh-
ter. She said that her grief and connection to them gave her meaning and purpose.

Gail Palmer works at the Centre for Emotionally Focused Therapy, Ottawa, Canada. She is also the
co-founder of the Ottawa Couple and Family Institute.
Don Efron is the Supervisor of the Brief Therapy Program at Madame Vanier Children’s Ser-
vices, London, Ontario.
Address correspondence to Gail Palmer 201-1869 Carling Ave, Ottawa, ON K2A1E6 at
gailpalmer53@hotmail.com; or to Don Efron at Don@vanier.com.

17
18 Palmer and Efron

“This much I know is true. I was loved and I loved” (p. 186). Our families provide
us with a framework for our existence and when the bonds are secure, meaning
there is a responsiveness and accessibility, we carry this gift of love. EFFT helps
ignite, repair, and restore the attachment bonds so that each family member may
realize and actualize their connection to one another. Children need this connec-
tion to grow and develop as well as to leave the home. Parents need this connec-
tion to grow and develop. Family is our secure base. How do we build this base?
How do we repair the foundation when it is broken? How do we rebuild when
families are transformed through death or divorce? EFFT provides us with a
roadmap to follow to answer these questions and guideposts along the way to help
us facilitate this process with the families we meet. Following is an overview of
EFFT, what it looks like, and how it has evolved with one family I have worked
with in my office at the Ottawa Child and Family Institute.
With the families we meet, the EFFT therapist engages the family through an
attachment perspective. Our families are not in conflict because of communica-
tion problems, parenting dysfunctions, or individual psychopathology, although
all of these may be evident. They are in distress because they are struggling with
attachment dilemmas. From an EFFT framework, negative interactional patterns
and individual symptomology are reflective of unmet attachment needs. Our need
to seek and connect to our caretakers is primal and the ability of our caretakers to
be emotionally responsive and accessible, especially when the chips are down, is
critical to the quality of our family life and to our individual emotional health.
Allen and Land (1999) found that families with avoidant attachments tended to
have adolescents who exhibited problems such as delinquency, substance abuse,
and aggression and these were those children who had the least amount of au-
tonomy and relatedness.
Consequently, for the EFFT therapist the acting out adolescent is not seen as a
conduct disorder but as an adolescent struggling with an individual need for au-
tonomy and a continuing need for emotional connection to his or her parents.
The EFFT therapist begins with a family by framing the problem in attachment
terms and normalizes the family’s distress as arising out of an attachment crisis.
Attachments needs within a family vary in terms of quality and intensity depend-
ing on a number of variables. These include: times of transition and change, for
example the birth of a child or the loss of a parent, which signal an increase in the
need for comfort and support; the age and developmental stages of the children,
for example the infant versus the adolescent; the interaction between the genera-
tions for attachment priority as when children, parents, and grandparents com-
pete for their attachment needs to be met. This is especially true in stepfamilies
where attachment needs oftentimes compete and collide but also in intact fami-
lies where children and parents compete for time, attention, and support. Fami-
lies become distressed when there is an inability to adjust to the changing needs
of each family member. This lack of responsiveness or accessibility then creates
negative interactional patterns that become entrenched and reinforcing. The nega-
Developing the EFFT Model 19

tive cycle then works to further distance family members from each other and
creates increased negative affect which further limits the family’s ability to be
responsive and accessible. The EFFT therapist frames this negative interactional
cycle that has developed out of the attachment struggle as being the problem—
instead of the parents or the children—and helps the family to begin viewing their
problem as the cycle as opposed to blaming themselves or each other.
A family that I worked with recently at the Ottawa Child and Family Institute
presented with a mother and her three children, two girls ages 18 and 16 and the son
age 13. The family had recently experienced a marital breakdown and the two girls
had chosen to live with their father. The mother and son were living alone and there
was very little contact with the four family members as a group. An alliance be-
tween the two daughters existed as did an alliance between mother and son and there
was an emotional estrangement between the mother and her daughters and also within
the sibling group. In my first meeting with the family group the atmosphere in the
room was one of anger and tension between mother and daughters. The son gener-
ally avoided contact with his sisters and tended to placate and please Mother. The
daughters were in the positions of the withdrawers in the family as their typical stance
was to be silent and distant with their mother and stonewall her around her ques-
tions and inquiries. The mother was the pursuer, feeling hurt and betrayed by her
daughters’ abandonment of her. Her interactions with the girls were often critical
and blaming, and she would occasionally threaten to pull out of the relationship
entirely. In the beginning session, the negative interactional cycle was tracked and
identified as each member told their story of how they saw their family. The cycle
was identified and their struggle was framed as being a response to the marital break-
down and normalized as characteristic of this transition. Each family member was
struggling to find their place in this newly formed family and due to this sudden
change, there had been a rupture in the bonds between these family members that
needed to be healed. Providing this framework helped the family to feel hope around
their future and provided a focus for the working through sessions.
The work with this family then progressed through a series of sessions with
family subsystems. Dyadic sessions between mother and child were held with each
child and also sibling sessions without the mother. This format allows for attach-
ment needs of each relationship to be addressed directly and to focus on increased
emotional responsiveness in each relationship. The dyadic sessions with the mother
varied between the daughters and the son, as their presentation was different, al-
though the underlying issue of attachment accessibility was the same, and each
needed to be responded to uniquely and separately. The focus for these sessions
was encouraging direct expression of attachment emotions so that they were more
central to the family’s awareness and part of the family’s dialogue. By session
six, all of the children were talking about connection and closeness, especially
with each other, and it turned into light-hearted banter between them.
With the daughters, there was need first to reengage them with their mother
which began with them expressing their anger and disappointment around being
20 Palmer and Efron

abandoned by their mother emotionally in the past. The girls were encouraged to
express their feelings directly with their mother and their secondary emotions were
validated and normalized using an attachment frame. The mother needed a lot of
help in being able to sit and listen to her children without responding defensively
or striking back. (“You hurt me, so I will hurt you back.”) I consistently affirmed
her position as mother and reinforced how important and irreplaceable she was to
her girls. This helped to contain and hold the mother. She was able to arrive at a
stage where she was able to tell her middle daughter that she was there and she
was listening now. She recognized she did not listen well in the past but she was
stronger now and she could listen. This then allowed one of the daughters to take
a further step and express her more vulnerable feelings, her fear, and sadness, and
how lost and invisible she had felt, particularly at this time of crisis in the family.
In turn, this allowed the mother to come forward and give her comfort and pro-
vide her with support. “You know I give good hugs.” A further session with the
mother and daughter then progressed with the mother telling her more about the
circumstances of the separation, not the intimate details, but more of what was
happening to her emotionally, for which the daughter thanked her. “This is the
most honest you have been. I knew what was happening, but you were always
angry and it seemed you were angry at me.”
The EFFT therapist seeds secure attachment by working through, within each
dyad, the following steps:

• Accessing the underlying feelings and attachments needs

• Reframing the problem in terms of the unmet attachment needs
• Promoting the acceptance of the others’ emotional experiences
• Facilitating the expression of attachment needs and creating new interactional
responses

The EFFT therapist holds the map for the family to be defined as a secure base
by envisioning relationships that are supportive, comforting, nurturing, and safe
and identifies and promotes emotional responses and behaviors that create this
safe haven. By unlocking the negative cycle of criticize/defend and helping the
daughter and the mother talk more directly about their needs in this relationship,
the expression of positive affect and increased collaboration and problem solving
can occur between them.
Generally, the underlying emotions accessed in this early stage of treatment are
those related to feeling of failure for both parents and children and fears around
loss, disconnection, and abandonment. Children can experience feelings of un-
lovability unworthiness and inadequacy and these vulnerable feelings can be
directly soothed and comforted by a parent. Parents also may have insecure mod-
els of self that are triggered in their interactions with their children and soothing
and comforting those feelings are not the responsibility of the child. Parents can
however feel more competent, worthy, and lovable when they are able to estab-
Developing the EFFT Model 21

lish a secure and positive connection with their children. While the parent–child
relationship is not a mutual one it is reciprocal as each person affects and shapes
the emotional experience of the other. Developmentally, an adolescent is more
capable of a mutually supportive relationship than a child, as is a young adult more
able to establish more of a friendship-like relationship with a parent.
The final stage of therapy is consolidation, where the EFFT therapist works to
nurture and maintain secure bonding through intimate exchanges and family ritu-
als. The therapist heightens and validates the family’s strengths and reinforces
family rituals that promote and encourage family connection and emotional sup-
port. The entire family is often seen at this stage to consolidate the changes and
reinforce the rituals. In this family, the new family grouping began to establish
movie nights and rituals for connection for all family members. The girls reached
out to their brother by bringing over a movie he loved and then insisted on shar-
ing it with him. Mother’s participation was also requested and she was also able
to ask for help from the kids in preparing the meals.

DON EFRON:

EFFT is a tool which we utilize in the treatment of emotionally disturbed and

behaviorally challenging children in the intensive therapy programs at Vanier
Children’s Services, a Children’s Mental Health Centre in London, Ontario. We
provide services to the type of families which one would not automatically asso-
ciate with EFFT. The children are seen as the “terrors” of their schools. The fami-
lies present as poor and filled with histories of abuse, addiction, deprivation, mental
illness, and loss. Despite these realities we have found that EFFT can provide an
invaluable extra tool for therapists. We hope this discussion will encourage oth-
ers to experiment in using EFFT in intensive programs.
We use EFFT with caution. We know it would not be advisable to provide this
intensive emotionally involving therapy to all or even most of our clients. Nor do we
have the resources available to provide EFFT to many families. So, we have devel-
oped guidelines which help determine which families might best be offered EFFT.
The first guideline is that the family establishes a good working relationship
with one of our therapists and has found one of our programs to be helpful. This
suggests that the family is “workable” and that a certain amount of trust has been
established between them and Madame Vanier as an agency.
The second guideline is that at some point the therapy gets “stuck.” The family
appears to the therapist to be unable to make full use of the parenting and impulse
control skills which are offered. They spin their wheels. Very often this signals to
the therapist that there are deeply rooted attachment injuries and interactive cycles
produced by the injuries which prevent change and growth.
If these conditions are met, the therapist can make a referral to our EFFT core
group (myself and three colleagues trained by Sue Johnson and Gail Palmer). We
22 Palmer and Efron

review the case and if we believe that EFFT is indeed called for, we offer to pro-
vide co-therapy with the referring therapist or to provide consultation.
The therapy is usually for one or both parents and the child but might include
other children or be multigenerational. We ask the therapist to inform the parents
that the therapy will be emotionally powerful and could cause them or the chil-
dren some distress. If they are willing to take this risk we proceed.
Typically EFFT therapy is offered weekly or biweekly. The average number
of sessions would be about 10 to 15. This permits us to offer the therapy within
the time frames of our programs.
I will present a case that illustrates the potential of the model in our setting. I
have changed identifying information.
James, 10 years of age, lived with his biological father, one older sister and one
younger sister. James’s parents had separated when he was four years old. The
children had lived with the father since the separation.
James was placed in our residential treatment cottage due to aggression toward
peers, siblings and adults, school suspensions, violent outbursts resulting in re-
straints, nightmares, suicidal gestures, enuresis and encopresis, impulsivity, op-
positional behavior, poor self-esteem, and severe learning disabilities.
We never met James’s mother. She had a long history of severe depression
(known to the children) and alcoholism (not known to them). She had erratic con-
tact, promised things to them and did not follow through, and was in a new rela-
tionship with a man with children of his own.
Milieu therapy at the residential treatment facility at Madame Vanier Children’s
Services had been moderately successful in most areas but we received a referral
from the primary therapist because of frightening episodes of James having un-
controlled rages. James would go into these rages whenever there was contact with
his mother or when contact was attempted unsuccessfully. For example, after his
mother called him, promised him a bike for his birthday and then did not show up
or bring a bike, he exploded.
A typical cycle around these rages was as follows: James would show anxiety
and request to contact his mother. He would make calls which were unanswered.
He would begin to withdraw. Attempts by his father or staff to engage him only
produced, “I don’t know”s. He would begin to react emotionally to peers or in
class. Seemingly little things triggered massive explosions in which he appeared
to lose all control. During these explosions, James screamed, hit or kicked, and
made threats to kill himself. The explosions could go on for hours and resulted in
physical restraint by staff or the father. Afterwards, he would not remember what
happened and was unable to give any explanation for his upset even if staff or
father reminded him of his attempt to contact his mother. He would say he did not
want to talk to her. Eventually the cycle repeated itself.
The violence of the explosions scared siblings and peers and they withdrew from
him leaving him more alone. Paradoxically, this most likely led to him needing
comforting and hence missing his mother all the more.
Developing the EFFT Model 23

EFFT ASPECTS

From an attachment perspective, James could be seen as “insecure-fearful/

avoidant.” This suggested that he had suffered tremendous damage to his ability
to form and keep secure relationships.
We decided to recommend therapy for the entire family because individual
therapy with James and therapy with the father and James by themselves had not
proven effective. We hoped that inclusion of the siblings might make the therapy
feel safer for James.
The specific goal of therapy was to explore how the mother’s absence might be
affecting James and how this might be connected to his anger outbursts. Addi-
tionally, we looked at how the mother’s behavior might cause the family mem-
bers to lose closeness and connection with each other.
James would not participate at first if questions were directed toward him.
However, when the focus was on the father’s and siblings’ feelings of anger, sad-
ness, confusion, and pain and their reactions to the mother letting them down he
began to participate. As time went on he was more able to talk about his feelings
about his mother in a manner which his father and siblings had never heard him
be able to do before.
I would like to share a few vignettes of our work with James and his family.
In one session, James’s father recounted a time when James was four years old
and his mother called. James talked to her, then turned the phone over to the oth-
ers saying, “She doesn’t hate us anymore.” James’s father then went on to talk
with the children about how he feared they thought it was entirely their fault that
she had left. They responded that they did have these thoughts at times. One of
the girls remembered the first time James had been suspended at school and con-
nected it to James’s feeling he was to blame for their mother leaving.
Another example from the sessions was when James’s father brought up an
incident which occurred the night after the sixth therapy session. James woke him
up in the early morning to say he was very angry at a previous counselor who had
suggested he live with his mother. In the session, James was able to say how angry
he was at his mother for not seeing him anymore. In turn this led to the family
looking more deeply at how they coped with their anger toward their mother. The
eldest girl realized she became bossy, “like a little mother.” The younger girl re-
alized she became too talkative and impulsive. All the children agreed to deal
differently in the future with their anger by talking to their father or grandmother
when they felt upset about her.
Therapy was not an easy course for James. There were many ups and downs
and a time when he went through an increase in the number of violent episodes in
the residence (though never at home). But his ability to communicate his feelings
to his father or staff continued to increase and the ability of the siblings and father
to comfort each other improved and they were able as a family to make decisions
about how to deal with such issues as Mother’s Day.
24 Palmer and Efron

One final vignette illustrates the enormous change with James. Toward the end
of therapy, his mother did call one day. Always in the past this had led to the rages.
This time James talked to her for a few minutes and then handed the phone over
to others. He did not have temper explosions afterward nor any other signs of
increased anxiety.
Therapy continued in weekly, then bi-weekly, sessions for three months and
ended shortly before James was discharged home.
One year later phone calls to the father and to James’s teacher confirmed that
he had maintained the gains he made in the therapy.
It is always a challenge to stretch models of therapy to fit settings like Vanier.
It takes a strong, flexible model to be that adaptable. EFFT is strong enough and
flexible enough to make the transition to our intensive treatment setting.

CONCLUSION

Emotionally Focused Family Therapy is the little sibling in the Emotionally Fo-
cused Therapy world. The potential for its use has been largely untapped to date.
There are many reasons for this including the historic development of Emotion-
ally Focused Therapy with couples and the greater difficulty of scheduling and
controlling what happens in family therapy sessions. Nonetheless, we feel strongly
that EFFT has much to offer families and should be more practiced by therapists
trained in EFT. The two presentations here show that EFFT is applicable to di-
verse settings and situations. We sincerely hope that readers will use this article
as a springboard for their own work with children and families.

REFERENCES

Levy, T., & Orlans, M. (2000). Attachment disorder as an antecedent to violence and
antisocial pattern in children. In T. M. Levy (Ed.), Attachment interventions
(pp. 1–25). London: Academic Press.