Emotionally Focused Therapy was developed by Dr. Leslie Greenberg and the late Dr. Sue Johnson in the 1980s and is a structured, relationship intervention (Greenberg & Johnson, 1988). In later years Dr. Johnson refined and developed the model that has come to be known as Emotionally Focused Couple Therapy (EFCT) (Johnson, 2007). EFCT aims to help couples identify and transform negative patterns of interaction, reduce emotional distress, and foster secure emotional bonds (Johnson, 2012; Quill, 2024). EFCT has strong empirical support for enhancing relationship satisfaction, intimacy, and attachment security across various populations and cultural settings. Two recent meta-analytic reviews underscore the robust and enduring efficacy and effectiveness of EFCT. Beasley and Ager (2019), in a systematic review of nine randomized controlled trials (RCTs), reported medium-to-large improvements in relationship satisfaction that were sustained at follow-up. Similarly, Rathgeber et al. (2019) synthesized 33 studies comparing EFCT with Behavioral Couples Therapy (BCT) and found medium effects on relationship satisfaction at post-treatment. Rathgeber et al. (2019) also showed EFCT outcomes to be comparable to, and at times stronger than those of BCT.

Dr. Johnson also developed a manualized couple relationship education workshop on the same principles as EFCT entitled ‘Hold Me Tight’ (Johnson, 2008). According to Johnson, it is designed for non-distressed couples and can be offered by lay people to couples in a group setting. It consists of seven conversations to be held in dyadic sessions between the couples. Hold Me Tight has also gained evidence as an effective couple intervention that according to various studies, increases relationship satisfaction and attachment security in diverse populations. (Conradi et al., 2018; Wong et al., 2018). In this paper we consider Hold Me Tight as part of the EFCT approach and its interventions. However, we distinguish between EFCT and Hold Me Tight throughout the paper and primarily focus on EFCT.

There is a growing body of evidence that supports the cross-cultural applicability of EFCT. Principles of EFCT have been found to resonate with clinicians in at least nine Spanish speaking countries, including Mexico, Costa Rica, Guatemala, Spain, Colombia, Argentina, Chile, Ecuador, and El Salvador (Sandberg et al., 2020). Even though cross-cultural efficacy studies are few, one study conducted in Taiwan found EFCT effective in reducing depression symptoms in couples in Taiwan, although, in that study, changes in couple distress were non-significant (Tseng et al., 2024). Edwards and colleagues (2025) found the attachment focus of EFCT to resonate with LGBTQ+ individuals, but stressed that therapists must explicitly address minority stress, challenge heteronormative assumptions, and validate varied identities and relationship structures during therapy. Allan et al. (2023) highlight culturally sensitive guidelines for adapting EFCT to address minority stress and identity-based concerns. Together, these findings support the possibility that EFCT, with its structured approach and focus on attachment and emotional security, has utility in culturally diverse and global contexts. With the popularity of EFCT gaining momentum in various African countries, such as Uganda, where mental health professionals have received both the first level of EFCT training (commonly known as the ‘externship training’) as well as the second level (i.e., Core Skills) (Asiimwe et al., 2025), it becomes critical to consider how culturally sensitive EFCT practice can be effectively implemented in Uganda and other African contexts that share common cultural values and family dynamics. This paper, therefore, proposes a cultural adaptation of EFCT for trainers and professionals conducting EFCT trainings and/or providing services to Ugandan clients and couples.

The Rationale for Proposing Culturally Sensitive EFCT Adaptations for Uganda

According to cultural psychologists Shweder and Sullivan (1993), every culture has its own psychology. Each culture develops a narrative about how people are and why they do the things they do. Uganda presents a culturally rich and complex context that necessitates the adaptation of EFCT to meet the unique needs of local couples. First, Uganda is home to over 65 tribes, each with distinct languages and traditions, yet united by collectivist principles, respect for elders, and spiritual understandings of wellness. Ugandan couples navigate relational dynamics shaped by patriarchal norms, extended-family involvement, sociopolitical pressures, and generational differences influenced by Western ideologies (Asiimwe et al., 2023). Compounding these dynamics are factors such as the legacy of colonialism, poverty, and limited access to quality mental and relational health services, which contribute to relational strain and emotional distress. Therefore, the focus of EFCT on strengthening relational bonds could offer a promising alternative for Ugandan professionals to address couples’ attachment needs while supporting relational healing.

By integrating local worldviews and communication patterns, culturally adapted EFCT can provide a framework that resonates with Ugandan couples, enhancing acceptability, engagement, and potential clinical efficacy. Additionally, although EFCT was originally developed in a North American setting, its focus on reducing relationship distress by strengthening attachment bonds may have universal applicability when culturally informed adaptations are integrated. Moreover, EFCT has been successfully adapted in non-Western contexts and diverse populations, demonstrating its potential for cross-cultural relevance when implemented thoughtfully (Tseng et al., 2024). These considerations underscore the importance of tailoring EFCT to Ugandan cultural realities as training initiatives continue to gain momentum in Uganda and other African countries with shared cultural, familial, relational value systems.

Training EFCT therapists in Uganda is well underway, with the first-ever EFCT externship of 81 mental health professionals, including participants from neighboring Kenya, held in July 2023, and a second-level of EFCT training of 35 mental health professionals held in July 2024 (Asiimwe et al., 2025). Supervision continues with about 20 therapists currently engaged in active supervision relationships with International Centre for Excellence in Emotionally Focused Therapy (ICEEFT) certified supervisors in North America. ICEEFT is the global network of mental health professionals founded by Dr. Johnson that promotes EFCT training and certification. For readers interested in Ugandan professionals’ perceptions of EFCT work, refer to Asiimwe and colleagues (2025). Although EFCT has been culturally adapted and empirically tested in various contexts around the world, it has not yet been adapted for Ugandan clients, despite recent EFCT trainings in this setting. This represents a notable gap in the science, particularly given the distinct cultural, relational, and socio-economic realities that shape couple dynamics in Ugandan society. Now that many Ugandan professionals are undergoing EFCT training, a logical next step is to begin cultural adaptation of the training to increase cultural fit. Once both cultural adaptation and fidelity are achieved, the efficacy of EFCT in Uganda can be tested. Currently it would be premature, as no Ugandan therapists have yet been certified by ICEEFT and cultural adaptations should precede clinical trials. The authors emphasize that achieving meaningful outcomes first requires a culturally informed adaptation of EFCT to ensure alignment with Ugandan values, relational dynamics, communication styles, and lived experiences. Only after these adaptations are carefully integrated should randomized clinical trials be conductd to evaluate the efficacy and effectiveness in this context. Culturally adapting EFCT will likely enhance the intervention’s relevance, acceptability, and engagement for Ugandan clients (Perera et al., 2020).

The main purpose of this paper is to propose a culturally informed process for identifying areas where EFCT could be adapted to fit the Ugandan context. As a diverse team of couple therapists from Uganda and other cultural backgrounds, our proposals are guided by a combination of our personal, clinical, and scholarly experiences with the EFCT and other models of therapy and from our experience in leading initiatives to introduce EFCT in Uganda and other African settings. This approach aims to inform EFCT training for Ugandan professionals while supporting culturally relevant practice with couples and families. Specifically, we ground our proposed adaptations in the eight dimensions of the Ecological Validity Model (EVM; Bernal et al., 1995), a widely accepted framework for adapting mental and relational health interventions to culturally diverse settings. In proposing this culturally sensitive adaptation, we hope to contribute to increased equity in access to quality mental and relational health interventions.

Positionality Statement

The author team consists of five therapists, from diverse backgrounds and perspectives that strengthen this qualitative paper. The first, third, fourth and fifth authors are graduate students from a Midwestern university, and the second author is a professor of Couple and Family Therapy at another Midwestern institution. The first author is from Uganda and actively involved in the EFT Uganda Project, with training in Emotionally Focused Therapy (EFT) and a strong commitment to adapting attachment-based models within diverse cultural contexts. The second author founded the EFT Uganda Project, is a licensed Marriage and Family Therapist in a Midwestern State and has extensive experience in qualitative research focused on integrating therapeutic modalities across cultures. The third author is a licensed Marriage and Family Therapist and Professional Counselor in two U.S. states, an ICEEFT-certified EFT therapist with extensive training in the model, and has experience facilitating EFT training for marginalized and minority groups in the Middle East. The fourth author is a clinical psychology doctoral student with training in psychodynamic psychotherapy who conducts attachment-based research. The fifth author is also from Uganda and trained in EFT and critically reflects on the cultural fit of the model within his own context. Together, this combination of diverse professional roles, cultural backgrounds, and clinical expertise enriches the paper by integrating multiple perspectives and thereby strengthening its contribution to the literature.

Historical and Contemporary Gender Norms and Relational Dynamics in Ugandan Marriages

Although present day Ugandan families are increasingly adopting western values, traditionally and historically Uganda has been a patriarchal society in which individuals largely take on traditional gender roles, with men conducting commercial activity or working outside the home to provide for the family’s needs and women being responsible for taking care of their partner, the home, children, and guests. Ugandan women were expected to be hospitable, and, alongside beauty, this was a key trait that was valued in marriage. Historically, men paid a bride price to the women’s family as compensation for his wife’s upbringing. Men that were able to pay more were preferred to those who were poor. Even though this tradition is fading away in some cultures, the belief that men should be the providers very much remains (Moore & Schneidermann, 2025).

Based upon the clinical experience of first, second and fifth authors, practitioners with professional work experience in Uganda, many men in Uganda describe feeling the weight and burden of being responsible for the financial well-being of the family. These responsibilities often do not stop at the nuclear family but extend to parents, in-laws, and sometimes adult siblings. Moreover, since most of the Ugandan population do not have health insurance and social security, the few people that are gainfully employed end up acting as the health insurance and social security for their entire extended family.

It is not only male partners who have it tough in Uganda, female partners also face hardship. In many homes the woman is expected to be subservient to the man and has less access to resources and power in the relationship. For example, in a recent qualitative study by Theeuwen and colleagues (2021), gender inequality was found to still be significant within the rice and cassava agricultural sectors in Uganda. Specifically, women provide the bulk of the cultivation labor, while men control the sales processes and the money.

In many ethnic groups in Uganda, for instance the Basoga tribe, it is assumed that the woman will geographically relocate and shift her primary allegiance to her husband’s family (Cultural Research Centre, 2013). Often this leads to a loss of social support. In some cultures, the issues of child brides as young as the age of 13 were common and, in such marriages, a paternal aunt would often accompany the girl to her husband’s family until she became used to the new setting. In modern days this practice is less common. Nonetheless, recent work with a sample that was representative of 10 subregions of Uganda suggests that around 1/3 of girls marry before age 18 (Wodon et al., 2016). Women and girls still experience the stress of adapting to new families and the loss of proximity to their own families. Almost always, the woman takes on her husband’s family name.

In many cases, the male partner tends to be emotionally distant from the children during their early years. Traditionally, fathers would become more involved, particularly with their sons, once the child reached puberty. Like in most cultures, Ugandan men are generally discouraged from showing vulnerable emotions. In Uganda, a man that displays these emotions is considered weak. Women, on the other hand, are allowed to cry and be sad, but they are often regarded poorly for being too assertive or forthright. It is strongly discouraged for Ugandan women to be assertive and angry, especially if the anger is directed towards more powerful members of their families.

The gender norms described above are reinforced by religious values and practices. The Ugandan population is highly religious with 80% identifying as Christian and 13.5% identifying as Muslim (UBOS, 2024). Within Christian teachings, women are often instructed to be submissive to their husbands (New International Version, 1978/2011, Ephesians 5:22) —a directive that, in some contexts, is interpreted as requiring subservience, potentially reinforcing gender hierarchies within marital relationships. Even within Ugandan traditional religious and cultural frameworks, the male is often regarded as the dominant authority within the household, with expectations of leadership, control, and decision-making power.

According to Isiko and Isabirye (2023), historically, Ugandan couples had just a limited number of avenues for establishing marital unions: (1) parents often went looking for a worthy bride for their son, (2) a man would identify a woman of interest and then ask his parents to help him in acquiring her hand in marriage, (3) without parental permission, two young people would sometimes decide to elope. Today, however, there is an increasing trend of couples who meet, fall in love, and inform their parents of their decision to marry, as is typical in Western countries. However, while parental input has reduced, they still can wield a lot of power. Parental disapproval can halt marriages or cause strained relationships, particularly if they decide to go ahead without parental blessing. It is not unusual for couples to decide to live together without formalizing the relationship while waiting for parental blessings.

Given this background, couples in Uganda demonstrate diverse relational dynamics and a strong trend towards westernization. Couples who enter relationships through mutual choice may exhibit more egalitarian patterns of communication, with both partners more likely to express their needs. In contrast, couples in more traditionally arranged unions may have dynamics that are largely shaped by traditional cultural norms, which will influence the communication of personal needs. Trends show that the younger and urban populations hold relationship ideas that integrate both African traditions and Western ideals (Isiko & Isabirye, 2023).

The transitions we see in the Ugandan marriage landscape have their parallel in the transitions in the American marriage landscape and the three hierarchies of marriage as described by Finkel and colleagues (2014). These include the institutional marriage, where spouses are dependent on each other for safety and physiological needs; the breadwinner-homemaker marriage, where couples try to get their intimacy and passion needs met; and the self-actualization marriage, where couples look to their marriage to help them meet their needs for esteem and growth. From the first, second and fifth authors’ clinical experiences, it seems that many Ugandan couples are oriented between the institutional and breadwinner-homemaker marriages with only a few in self-actualization marriages. Whereas more Western couples might mostly fall in self-actualization marriages, a great number of Ugandan couples still heavily exhibit breadwinner-homemaker marriages. Although Finkel and colleagues (2014) were writing about American marriages, the entire world is influenced by Western cultural norms. Isiko and Isabirye (2023) highlight the influence of colonialism and globalization on Uganda marriages, with traditional Ugandan marriages becoming more unusual. One final consideration is the notion that many African communities are collectivist in orientation. In other words, there is an emphasis on following group norms rather than on individual choices (Kim-Prieto & Eid, 2004). This aspect undoubtedly manifests in couples’ relationships and is likely to be an important consideration in therapeutic intervention settings. In a typical Ugandan context, the couple has more accountability to the community in preserving their relationship.

Justification for Adapting EFCT to Ugandan Contexts

Uganda is largely a coupling society, characterized by a high fertility rate and one of the youngest populations in the world—half of the population is under the age of 19 (UBOS, 2024). Many tribes in Uganda raise their children with the expectation of marriage. However, relationship indicators such as intimate partner violence, substance use by married individuals, and HIV-related sexual risk behavior suggest that many couples are experiencing significant distress (Gubi et al., 2020; Miller et al., 2022; Wandera et al., 2021). Couples in distressed relationships are more likely to suffer from anxiety, mood, and substance use disorders (Whisman, 2007).

Although couples in Uganda are provided relationship education through both traditional and religious institutions (Senyonyi et al., 2012), much of the relationship education revolves around communication and gender roles in marriage (Galukande, 2022). To our knowledge, none of the premarital interventions target the important dimension of attachment security, which according to the literature is a mammalian survival instinct. As Bowlby (1969/1982) asserts, “the propensity to make strong emotional bonds to particular individuals is a basic component of human nature, already present in babies and continues to old age. It is found in many species of mammals and birds and has obvious survival value” (pp. 52-53). The value of strengthening attachment bonds between humans in any culture should not be a subject of debate.

According to research, fostering communication skills does not always lead to improvements in attachment security (Lavner et al., 2016; Kennedy et al., 2019). In Uganda, based on existing emerging clinical insights, we contend that strengthening attachment bonds and fostering emotional security between couples will be helpful in promoting family stability and resilience in the face of significant socioeconomic, cultural, and political adversity. High rates of trauma stemming from political instability, poverty, and the lingering effects of armed conflict, combined with the ongoing challenges of widespread diseases such as HIV/AIDS and malaria, have placed immense strain on couple relationships (Kinyanda et al., 2016). Evidence-based relational interventions are urgently needed. Additionally, the prevalence of family violence further erodes trust, safety, and emotional connection within partnerships. These cumulative stressors often rupture relational bonds, leaving couples vulnerable to cycles of conflict, disengagement, and emotional isolation. By intentionally strengthening attachment security, couples in Uganda will be better equipped to provide mutual emotional support, navigate external hardships together, and create a stable relational environment that fosters healthy family functioning. In this way, enhancing couple attachment is not only a pathway to individual and relational healing but also a foundational step toward breaking intergenerational patterns of relational distress in Ugandan families. As Bowlby (1951) says, “children who suffer deprivation grow up to become parents deficient in the capacity to care for their children and adults deficient in this capacity are commonly those who suffered deprivation in childhood” (pp. 68-69). Intervening in couple relationships eventually impacts the quality of the whole society, as the couple will parent better and hopefully have more secure adults who will grow up to have secure children and so on and so forth.

In this context, EFCT remains one of the most robustly validated approaches when it comes to direct improvements in attachment security, both in distressed and non-distressed couples (Spengler et al., 2024). Moreover, in Uganda, like in the rest of the world, there is a mismatch in the field of counseling and psychology where individual approaches dominate mental health services despite the population’s collectivist orientation (Asiimwe et al., 2023).

Given the significant need for both evidence-based interventions and professional development of local therapists, EFCT holds promise for Uganda because it offers an evidence-based intervention that targets attachment processes (Johnson, 2019). Furthermore, ICEEFT, the governing body for EFCT, offers a clear path of training professional therapists to work systemically with couples and families. The EFCT community is already collaborating with Uganda Counseling Association, the institution that governs counseling in Uganda. Additionally, the EFCT community offers reduced membership fees for minority populations which makes resources including literature, training videos, and podcasts more accessible and ensures that practitioners’ knowledge and skills keep up to date.

The Ugandan mental health system is already significantly underfunded and understaffed, with only 1% of the national health budget allocated to mental health and only 310 mental health personnel available per 100,000 people (Kigozi et al., 2010). Scientists posit that it is more cost effective to adapt evidence-based interventions than to create new interventions and that achieving effectiveness in a new cultural context requires systematic adaptation (Moore et al., 2021; Wendt et al., 2015). Given Uganda’s emphasis on marriage and family and its young population, addressing relational health is important because we expect it to alleviate some pressure from Uganda’s mental health system.

Cultural Values that May Challenge the Standard use of the EFCT Model

The Ugandan population has experienced widespread psychological trauma due to colonization, years of political and economic instability, poverty, and the HIV/AIDS epidemic (Betancourt et al., 2009; Kinyanda et al., 2016). Within this context, the cultural devaluing of emotions is particularly prevalent among men (Mburu et al., 2014). However, it is essential to approach this work with care, curiosity, and cultural humility to avoid causing harm. Men’s emotion suppression, while potentially seen as a barrier, has in fact been found to be an adaptive strategy in some contexts (Bonanno et al., 2004). This skill most likely enables men to function while shouldering significant burdens within their context. The EFCT practitioner must skillfully introduce emotional flexibility—supporting the expression of a fuller range of emotions, including vulnerability—while understanding the usefulness of suppression within the culture and validating it.

Another issue to be aware of in the Ugandan context, is the rampant occurrence of infidelity and the cultural acceptance of multiple partners as an inevitable part of coupling and marriage. Although previous research has put the multiple partner figures of Uganda on a par with the USA, between 3% and 15.2% (UBOS as quoted by Bishai & Grossbard, 2007), a study by Kajubi et al. (2011) suggests that the prevalence of multiple partnerships could be as high as 50% in a sample of poor urban dwellers in Uganda. Although their findings were not generalizable to the whole country, the figures resonate more closely with the first, and second authors’ experience as clinicians and insiders to the culture. There are four contraindications to EFCT: Abuse, Affairs, Addictions and alternative Agendas (e.g., plan to divorce) (Johnson, 2019). However, in recent times these contraindications have been reduced to serious cautions (Brubacher, 2024). In addition, the Attachment Injury Resolution Model has been used in EFCT with couples that have experienced various levels of infidelity and can result in improvements in dyadic adjustment andtrust and forgiveness that are sustained after three years (Halchuk et al., 2010). It is on the basis of this cultural information, our clinical observations, and previous research that we propose a meaningful adaptation of EFCT for Uganda.

The Ecological Validity Model as a Framework for Culturally Adapting EFCT to Uganda with Clinical and Training Implications

To guide adaptation of EFCT to Uganda, we adopt the Ecological Validity Model (EVM), which considers interventions along eight dimensions: language,persons,metaphors,content,concepts,goals,methods,and context (Bernal et al., 1995). Alongside each dimension, we propose clinical and training implications.

The hypothesis that underpins this framework and guides our work is that culturally compatible interventions, those aligned with a population’s cultural patterns, are more effective than those that are not (Bernal et al., 1995). Conducting necessary cultural adaptations to the EFCT model for the Ugandan context will improve the acceptability of the model acceptability for Ugandan couples. This work will also contribute to the global evidence base for culturally responsive couple therapy. Building on this need, the EVM offers a comprehensive framework for guiding the careful cultural adaptation of EFCT, with its eight dimensions providing a structured lens through which the model can be tailored to align with the unique cultural, relational, and socio-economic realities of Ugandan couples.

Language

The constitutionally recognized national languages in Uganda are English and Swahili (Namyalo & Nakayiza, 2015). However, Swahili is not as widely spoken as English and Luganda. Yet English is the main language of education and professional training in Uganda. We therefore propose that the first adaptation of EFCT for Uganda be presented in Ugandan English where possible. This is a type of English with phrases and structure that are syntonic with Ugandan daily life and incorporate appropriate words and phrases of local regional languages (e.g., Luganda, Acholi, Runyankole, Lusamya). There are phrases in EFCT training that do not resonate with the wider Ugandan population. EFCT terms of art, such as “the tango” and even the word “attachment” itself, will have to be translated and/or altered to fit the Ugandan context. Additionally, in our cultural experience the words for emotions are varied and sometimes explained by idioms and metaphors. There is a need to develop specific lexicons of emotion to match local linguistic practices.

Persons

Establishing resonance with those delivering the intervention and the local population is essential to cultural adaptation (Bernal et al., 1995). Traditional and religious leaders have historically been regarded as authorities in relationship education in Ugandan communities (Senyonyi et al., 2012). Whenever possible, these leaders should be trained in EFCT and be the ones to offer it to couples in the community, particularly if administered in the group format. For this matter we think Hold Me Tight, the couple EFCT-inspired psychoeducational workshop that was developed by Dr. Johnson and designed to be administered by community leaders seems to be a good fit for the Ugandan context. A pilot project of Hold Me Tight has already been tested in Uganda with 23 religious leaders and their spouses (Galukande et al., manuscript in preparation). Hold Me Tight has also been introduced to South Africa on two occasions with good acceptability (Lesch et al., 2018; Blow et al., 2025). With a growing number of mental health professionals and community leaders, there is increasing potential for EFCT to be delivered by Ugandan practitioners who speak the local language of the people.

ECFT training is experiential and involves reviewing video of therapy sessions led by expert clinicians. However, many of the videos currently in use do not reflect Black African couples. It is therefore important that as Ugandan therapists become competent in the model and record sessions with clients, allowing for the development of a video archive that captures EFCT in the Ugandan context. Such recordings would increase the relatability of training and offer valuable insight into how the therapy unfolds with local couples.

Adapting EFCT along the Persons dimension requires an intentional and inclusive approach to training of those who will deliver the model in diverse cultural and relational contexts. In a country where many couples first seek support from community leaders, faith-based counselors, or community elders rather than formally trained therapists (Kyazike, 2016; Senyonyi et al., 2012), expanding EFCT training beyond mental health professionals to include these trusted community figures is essential. This includes targeted outreach to Muslim communities, where polygamous marital structures are recognized and practiced, an area where many Christian-leaning EFCT therapists in Uganda may lack cultural competence and sensitivity. Additionally, training must also prepare practitioners to engage emerging and often marginalized groups such as couples where one or both partners have HIV, a controversial but critical area where shaping professional, ethical, and compassionate narratives can counter stigma and promote relational well-being. Additionally, given that Uganda has several ethnic groups, the cultural competence of therapists can be enhanced through multicultural training and reflexive exercises to show how therapists’ own biases and cultural lens might influence how they view clients from different ethnic groups.

Furthermore, EFCT adaptation should prioritize equipping practitioners who work in nonprofit organizations, community mental health programs, and trauma-saturated contexts, such as refugee settlements, where relational wounds are compounded by displacement, loss, and chronic stress. By broadening the scope of “persons” who are skilled in delivering EFCT, spanning from highly trained clinicians to grassroots relationship helpers, we can create a network of culturally responsive support that addresses Uganda’s diverse couple realities while pioneering a more inclusive and contextually grounded model of couple therapy. The proposal to train local grassroots leaders in EFCT is a promising approach for expanding the intervention’s reach in Uganda. However, a notable limitation arises from current EFCT certification requirements, which typically mandate a master’s-level education, creating potential barriers for local practitioners seeking certification. In Uganda, there are a variety of educational pathways for registered mental health professionals. To enhance feasibility, training and certification criteria should be reconsidered for contexts outside the U.S. Specifically, ICEEFT could adapt requirements to align with Uganda’s professional standards while maintaining fidelity to EFCT principles. Such adaptations would make EFT training more accessible and support sustainable implementation within the Ugandan mental health workforce.

Metaphors

Most of the EFCT training language is reported as accessible to Ugandan practitioners (Asiimwe et al., 2025), some metaphors used in EFCT training like “the tango,” “circling shark,” “parking garage,” and “tying a bow” are not commonly used in the Ugandan context. The tango, named after a Latin American dance style, was used by Dr. Johnson, as a metaphor for the interactional dance between partners. In EFCT training, the tango refers to the central task in which emotional healing is developed through five structured steps (Furrow et al., 2022). Some EFCT trainers use both circling shark and parking garage as metaphors to explain that the EFCT practitioner lingers around a specific emotion exploration with a client in stage two of the work. Tying a bow is another metaphor sometimes used to describe the fifth step in the tango where the EFCT therapist concludes a successful enactment between partners, highlighting the couple’s achievement. These metaphors can be replaced by local alternatives. For example, the tango dance, hardly known in Uganda, can be replaced by a widely known regional dances, such as, “Bakisimba” in Buganda, the “Kinyankore” in Ankore, “Ekitagururo” in Bukiga, or “Ding Ding” in Acholi (Asaasira, 2015). These local words will convey more meaning to a Ugandan audience. There are intricacies to be aware of—for example, the dyadic synchrony typical of tango dancing characterizes only a small proportion of Ugandan dances, which are mostly group affairs (Nannyonga-Tamusuza, 2005). This difference can cause a loss of meaning and potentially reduce the power of the metaphor. Trainers and professionals must therefore pay careful attention to ensure that metaphors capture the intended meaning and remain culturally grounded (Bernal & Sáez-Santiago, 2006). Additionally, the “infinity cycle,” a heuristic used in EFTC, is also not a common symbol in Uganda. The phrase “vicious cycle” may be more familiar in Ugandan English. Ugandans, especially Baganda, rely on proverbs and idioms to convey messages succinctly (Kyazike, 2016). These features of language should be used in training and in therapy where appropriate. Local expressions are more effective in health communication and community dialogue.

Content, Concepts and Goals

EFCT therapists focus largely on emotional processes and not content (Greenman & Johnson, 2013). However, it will be important for therapists working in a Ugandan context to know that couples will often expect therapy to directly address the multiple issues that often loom large in couple relationships in Uganda: finances, infidelity, sex, and in-laws. For instance, a study by Matama and Mkwizu (2020) indicated that finances and resources are the main antecedents to family conflict in Uganda. There is a need to prepare professionals to not only be aware of the prevailing factors in the Ugandan context but also to directly address these matters while linking them to the EFCT model.

In the Ugandan context, relationship norms and expectations vary across cultural and religious groups. For instance, in many communities, polygamy is still socially and culturally sanctioned (Asiimwe-Mwesige, 2002). However, generally, marital infidelity is considered unacceptable and, according to the law, is sufficient grounds for a man to seek divorce from his wife while a wife would have to have an additional reason to seek divorce from her husband (Asiimwe-Mwesige, 2002). Nevertheless, extramarital relationships, particularly among men, remain relatively common despite the associated stigma. These patterns highlight the importance of cultural sensitivity when addressing issues of infidelity and commitment in couple therapy. A therapist working in the Ugandan context should anticipate this complexity and difference. Due to the historical acceptance of polygamy and family structures that allow for in-law involvement, therapists must familiarize themselves with the EFCT framework of competing attachments to be well prepared for addressing these issues in the Ugandan context. EFT Stage 1 work, in which a dyad examines the patterns of their negative cycle and processes their interaction dynamics, would be useful. In contrast to the Western view of polygamous relationships, we believe there is can be a sense of emotional security and stability in some polygamous relationships in Uganda. Polygamy arises for various reasons including infertility, individuals falling in love, single sex children from a partnership, pressure from families; some polygamous co-wives are accepting of each other (Naseer et al., 2021). Although negative psychological impacts are higher for women and children in polygamous marriages as compared to monogamous marriages, a key factor that reduces this impact is good family functioning, economic support, and fair treatment of co-wives (Din et al., 2024; Shaiful Bahari et al., 2021). We deem EFT Stage 1 work as viable in instances where the parties accept their polygamous arrangement. A similar sentiment is proposed by Edwards et al. (2023), who assert that EFCT is a viable intervention for polyamorous couples and those with multiple attachments.

Given that EFCT typically postpones direct engagement with content issues until the final phase of therapy (Stage 3: Consolidation), therapists working in Uganda may need to offer a more practical framing of therapeutic goals where needed (Johnson, 2008). For example, during Stage 1 of therapy (De-escalation), the therapist can frame economic and physical aspects of the relationship (i.e., finances, sex) in terms of attachment needs, thereby linking culturally salient content with the underlying process of emotion and attachment.

Another issue that might need to be considered when formulating goals is the expectation that there will be some sort of judgment of who is right and who is wrong in the couple. Historically, this has been a part of both traditional and religious interventions, especially in strong patriarchal societies where elders often enforce a balance of power, sometimes requiring the male partner to pay more goats or chickens for a wrong, or the female’s family to repay the bride price (Cultural Research Centre, 2013). EFCT therapists adopt a non-blaming stance, which can be difficult to learn and hold, as it values the two differing opinions of the couple without judgment. Research highlights that this attitude differs significantly from traditional judgmental approaches, requiring therapists to actively explore power dynamics and cultural differences with sensitivity rather than imposing blame, especially when adapting therapy across diverse cultural contexts (Sandberg et al., 2020).

Methods

EFCT practitioners primarily utilize triadic sessions between a couple and a professional therapist. Historically and even currently in Uganda, when couples encounter difficulties that they have failed to resolve on their own, they often seek guidance from older, respected married couples within their religious or familial communities. As EFCT work takes shape in Uganda, male and female co-therapy pairs could be explored to mimic this traditional custom.

When this level of help seeking fails, couples appear before elders (Kyazike, 2016). These could be parents of either party, the wider extended family, religious leaders, or other elders in the community. Couple therapy with an outsider is relatively new and would have been conducted by a religious minister who might be known to the couple. Couple therapy with a professionally trained mental health professional is only a few decades old, in Uganda and mostly used by middle to high income earners.

In the current landscape, hundreds if not thousands of couples undergo premarital education and marital enrichment seminars organized by Christian churches nationwide. Most of this work is done in both heterogenous and homogeneous gender groups. The most widely known groups are the Mothers and Fathers Unions hosted by The Church of Uganda, which meet on a weekly basis and promote family values. In line with existent structures, EFCT’s group-based program, Hold Me Tight, may offer a more culturally resonant and accessible approach for couples in this setting. A group approach to relational education especially in homogenous gender groups would parallel the traditional ways of preparing couples for intimate relationships. Homogeneous gender groups were also suggested by the community in South Africa that underwent HMT Training (Blow et al., 2025). The call for group adaptation does not rule out the couple therapy but would be a complement to the usual triadic format oftherapy.

Context

Uganda is still largely a patriarchal society in which men often hold decision-making power and control over resources (Kyazike, 2016). In this setting men, especially in marriage, have great authority and play a role of protector and provider. This identity is associated with a display of strength and stability and does not lend itself well to extreme emotional vulnerability. In contrast, women are allowed to be dependent and vulnerable, making EFCT a better fit for them. We propose that the EFCT practitioner uses the leverage provided by this model to address the issues of power and identity, by exploring the view of self and other using an attachment lens. For example, one can ask, “Where does that leave you, when you have to be the strong one every day?” The EFCT therapist also needs to be able to gauge if EFCT is a good fit for couples with a significant power imbalance and should willingly change approach or refer a couple out for more appropriate care.

Another issue from our experience is that Ugandan men are less likely to remain in therapy for long, especially a therapy that focuses on emotions. This combined with the fact that they wield a lot of power means the EFCT practitioner in a Ugandan context needs to be aware of the need to secure male buy-in in the therapeutic process. Without this, male partners are likely to drop out of therapy early and leave the female partners to face therapy alone.

A foundational step in adapting EFCT for Uganda could involve broad-based sensitization around the state of intimate relationships and the importance of attachment security and the value of expression of more vulnerable emotions within close family relationships. This public education effort should be carefully tailored to different audiences. Therapists in this context may need support in accessing their own vulnerable emotions as they develop EFCT skills. When addressing educated men, scientific language and evidence-based arguments may be effective. For men with less formal education, the same logical and scientific rationale should be conveyed using accessible metaphors particularly from current affairs, politics and sports, which tend to resonate well with Ugandan men. Wherever possible, respected male role models including political, religious, or community leaders could share personal testimonies about the transformative impact of emotional awareness and connection in their relationships. Messaging could also be disseminated through culturally relevant platforms such as songs, TV segments, and radio advertisements. This groundwork should precede or be implemented alongside the formal implementation of EFCT.

Within therapy sessions, EFCT practitioners should begin with targeted psychoeducation. Since it is common for EFCT practitioners to provide individual sessions to the couple, they may consider using the initial individual sessions for men to provide a private and respectful space to explore emotional awareness, minimizing the risk of embarrassment in front of their partner. Therapists should also assess financial strain, as it is a major source of relationship tension in Uganda (Matama & Mkwizu, 2020). Once male engagement is achieved, it is essential to maintain a balanced therapeutic approach that attends to the emotional needs of both partners. Male partners may need guidance in identifying and expressing their emotions and attachment needs in a way that is aligned with masculinity norms, which may require slowing down the work and expressing more curiosity so that the clients have time to search for and find what feels right for them. In this work the EFCT practitioner should use the skill of bracketing, which helps individuals identify their own opinions and mentally make an effort to put them aside temporarily, while helping the couple to become aware of negative cycles and articulating their attachment needs (Kocet & Herlihy, 2014).

Another important contextual consideration is the deeply religious orientation of many Ugandans. EFCT therapists practicing in this context should be prepared to engage with matters of faith when working with clients for whom spirituality is central. According to the last Ugandan Census, 93.5% of Uganda’s population belongs to one of the two largest religions Christianity and Islam (UBOS, 2024). Both religions have a central figure – God. Attachment theorists believe God can be viewed as an attachment figure who maintains proximity, provides a secure base and a safe haven in times of need. (Granqvist, 2020). Research indicates that integrating clients’ spiritual frameworks into therapeutic conversations is meaningful to couples whose values are similarly aligned (Ripley et al., 2022).

Lastly, in our experience, couples in Uganda do not last long in therapy. This could be partly due to the unique help seeking behaviors in the culture, the financial demands of people in a lower middle-income country where most people do not have health insurance and potentially a myriad of other barriers. There is a need for models of therapy to be brief and effective. Can the three stages of EFCT be completed in fewer sessions? Are there faster ways of getting to the main change events like softening of the pursuer, engagement of the withdrawer, consciousness of the cycle and expressed vulnerability?

One possible consideration is to initially use Hold Me Tight to a precursor to therapy so that by the time they engage in therapy, they are already past Stage 1 and can being with Stages 2 and 3 in dyadic therapy. Ugandans are committed to education and already have relational psychoeducation in groups around the nation (Galukande, 2022; Senyonyi et al., 2012). This approach seems to be more aligned with the culture. The HMT couple education model alongside EFCT might increase the cultural fit of the model to the Ugandan context.

Having outlined the necessary adaptations of EFCT in Uganda along the eight dimensions of the EVM, the next step is to illustrate how these adaptations might unfold in practice. To do so, we present a hypothetical case vignette of a Ugandan couple. This case example will highlight some of the EVM dimensions discussed earlier and offer a concrete illustration of how culturally informed adaptations can be integrated into EFCT with couples in the Ugandan context.

Case Example: Zainab & Kato–Applying an Adapted EFCT Model

Case Overview

Zainab and Kato, a Ugandan Muslim couple in their late 30s, have been married for 12 years and have four children. Kato works full-time as an engineer, while Zainab is a full-time homemaker. They present to therapy after years of unresolved tension, with conflict intensifying in recent months. The couple describes significant emotional disconnection, chronic financial stress, and increasing mistrust.

Kato reports feeling overwhelmed by the financial responsibilities of the household and frustrated by what he describes as Zainab’s “reckless” spending—particularly on gifts and frequent mobile money transfers to her family. He expresses a loss of trust in his wife’s handling of their finances and feels spiritually unsupported. Zainab, on the other hand, feels emotionally abandoned and spiritually invalidated. She says Kato is often critical and uses religious language to justify his emotional absence, contributing to a deepening sense of isolation. She views her financial behavior as a way to maintain social ties and cope with the emotional neglect she experiences in the home.

Their relationship took a deeper hit when Zainab discovered ongoing text conversations between Kato and a female colleague. While Kato insists the relationship was not physical, Zainab experiences it as a betrayal, especially upon learning that Kato had been spending money on dinners and small gifts for the woman. This, she says, makes his financial complaints feel hypocritical. Additionally, longstanding tension with Kato’s mother has compounded their distress. Zainab feels disrespected and sidelined by her in-laws and unsupported by Kato when conflicts arise. Kato, in turn, says he has struggled to mediate these dynamics and often feels caught in the middle, further retreating emotionally.

Cultural Considerations

In this case, the therapist takes time to understand the couple’s cultural and religious values around marriage, gender roles, and honor. Kato sees himself as fulfilling the traditional male role of provider or mu’asir (in Islamic faith) and feels disrespected when he perceives his efforts are taken for granted. Zainab, raised in a tightly knit Ugandan Muslim household, equates generosity and providing for others with her identity as a good wife and mother. She also feels immense shame about the possibility of marital breakdown, which is heavily stigmatized in her community.

The therapist validates both partners’ cultural narratives while reframing their interactional cycle: Kato criticizes and withdraws due to feelings of financial pressure and helplessness when faced with the rift between his wife and mother; Zainab protests and defends herself, driven by feelings of emotional abandonment and betrayal. Their conflict becomes not just about money or texting but about unmet attachment needs for safety and security, support, and companionship in the relationship.

Adapted EFCT in Practice

Before the EFCT work begins, the therapist meets with each individual separately to ensure that there is sufficient emotional and physical safety in the relationship to conduct EFCT. In Kato’s interview she explores his relationship with his female colleague, and Kato reports that he had already broken off the relationship and would communicate this with his wife. Convinced that the couple will be fit for EFCT, therapy begins.

During the de-escalation phase, the therapist helps the couple recognize their negative cycle—Kato’s criticism of Zainab’s spending evokes Zainab’s defensiveness, which further fuels his distancing. By carefully pacing the sessions and using culturally sensitive language (e.g., “feeling seen and respected,” “fulfilling your Islamic role as partners”), the therapist creates space for Kato to express vulnerability about feeling emotionally disconnected and financially burdened. Zainab begins to access the pain she carries—not just from the betrayal, but from feeling unseen and undervalued as a partner and mother.

In the bond restructuring phase, the therapist guides the couple through emotionally focused enactments. For example, Kato shares his fear that “no matter how much I provide, it’s never enough,” while Zainab responds with tears, saying, “I feel so alone in the marriage. I spend to cover up my loneliness.” The therapist supports them in experiencing and responding to each other’s vulnerable emotions, helping to rebuild safety and emotional responsiveness. The therapist also supports the resolution of the relationship rupture due to Kato’s inappropriate texting with his female colleague using the Attachment Injury Resolution Model (Halchuk et al., 2010).

In the final stage, consolidation, the therapist helps the couple create new ways to discuss financial decisions and emotional needs—grounded not in blame but in mutual understanding. Together, they agree to schedule regular check-ins to discuss budgeting and emotional connection. Ugandan traditional values of generosity and providing for family as well as Islamic values of rahma (compassion) and shura (consultation) are gently referenced to support this shift.

This vignette illustrates how EFCT, when culturally adapted, can help couples like Zainab & Kato move beyond surface-level conflicts to address the deeper emotional needs fueling their distress. By integrating sensitivity to cultural values and relational injuries, EFCT becomes a powerful tool for rebuilding trust and emotional intimacy in diverse couple relationships.

Conclusion

Implications for Practice

In this paper we have identified a need for an adaptation of EFCT for Ugandan couples and proposed a number of culturally informed modifications, utilizing the eight dimensions of the EVM. While our paper has focused on Uganda, this same framework is useful for cross-cultural adaptation of EFCT in any other culture. Some of the specific challenges we have identified here may apply to other collectivist cultures in the region and beyond.

Summary

We have highlighted several key areas where EFCT should be adapted for use with Ugandan couples. Uganda has a rich cultural tradition that often coincides with traditional values on gender roles and marriage. On the other hand, Uganda has an extremely young population, and some of the younger Ugandans are moving away from traditional cultural values. As such, any adaptation of EFCT needs to be responsive to both types of couples. As demonstrated in the case example, EFCT therapists serving Ugandan couples should have a particular emphasis on understanding the cultural dynamics at play in the relationship. Therapists should be mindful not to apply their own understanding of relationship health to their clients. Rather, clients’ difficulties, as well as the path forward, should be understood in light of their own values and their own views of a satisfactory relationship. Additionally, practical and/or financial considerations are often central to Ugandan couples. Initially, framing potential benefits of EFCT in terms of practical gains may help to increase buy in among couples. However, as shown in the case study, treatment must eventually move to understanding these practical issues in terms of underlying attachment needs.

Alongside these adaptations, the main focus of EFCT therapists remains on helping members of a couple to recognize and be responsive to each other’s attachment needs. Previous adaptations of EFCT to non-Western countries, as well as cross-cultural attachment research, suggests that attachment needs are universal (Allan et al., 2023; Edwards et al., 2025; Tseng et al., 2024). In other words, the core mechanism of change for EFCT remains at the heart of the treatment. The proposed adaptations are designed to help Ugandan couples understand their own attachment needs in a manner that aligns with their cultural values.

Would this focus on accessing emotion impose foreign values on Ugandan culture? We do not believe so. While the expression of attachment needs may vary across cultures, we are convinced that the needs themselves are universal. In African contexts, including Uganda, emotional suppression may be more culturally normative, and the EFCT practitioner must remain attuned to the unique ways attachment behaviors are expressed in this setting. Furthermore, Uganda’s cultural landscape is already evolving under the influence of global media. These cultural shifts bring both opportunities and challenges. The adaptations we propose aim not to replace cultural traditions, but to offer couples greater relational flexibility— similar to the way cognitive and emotional flexibility is cultivated in therapy for individuals experiencing depression. Our goal is not to discourage the practice of cultural norms, but to support individuals in articulating their attachment needs within those cultural frameworks. Importantly, the EFCT therapist does not impose predetermined needs onto couples but instead draws out these needs through careful attention to the clients’ own dilemmas.

It seems imperative that professional members of the local community in which EFCT is being delivered should be involved in discussions about how to apply the proposed adaptations to the specific population. As we have mentioned, the cultural diversity in Uganda is substantial and it is possible cultural adaptations that are more specific than those we have proposed would be required for each cultural group.

Although we believe our paper provides some guidance to an outsider delivering EFCT to Ugandan couples, it may be optimal for those intending to focus on a Ugandan population to experience Ugandan culture by visiting various regions in Uganda and to observe the culture for some time before starting to engage in EFCT. Reading about a culture can only provide a sense of the cultural dynamics at play—to truly experience another culture and learn about their practices, values, and norms, we suggest that the therapist has first-hand experience of the culture. In sum, EFCT is a treatment modality that has promising potential to help Ugandan couples, provided that several adaptations that address the unique cultural values and practices of Ugandan people are made.