Psychological health and satisfaction in romantic relationships appear to have a complex link. There is a clear association between elevated mental health issues such as depression and anxiety and relational discord in romantic relationships (Leach et al., 2013; Whisman et al., 2021). Satisfaction in a romantic relationship may have an impact on an individual’s difficulties, and similarly individual difficulties can further impact romantic relationship satisfaction (Whisman et al., 2023). While an individual’s mental health issues can be a potential stressor for their partner and the relationship, an unsatisfactory romantic relationship may also compound the individual’s difficulties. On the other hand, the romantic partner’s availability and responsiveness may serve as a buffer against mental health difficulties such as depression and anxiety (Baucom et al., 2020). Indeed, dyadic coping is a well-researched area demonstrating that one partner’s stress impacts on the other partner’s well-being, but also that a joint coping is a potential asset available to the partners (Bodenmann et al., 2019).

There exists a relative boom for couple therapies targeting co-morbid mental health issues and relational difficulties. The latest edition of the major edited volume that serves as a reference point for the field of couple therapy, Clinical Handbook of Couple Therapy (Lebow & Snyder, 2023), offers chapters presenting couple therapy for posttraumatic stress (PTSD) (Monson & Fredman, 2023), alcohol problems (McCrady et al., 2023), and depression and anxiety (Whisman et al., 2023). Indeed, one of the most studied co-morbid presentations, depression, accrued at least 14 randomized controlled outcome studies as attested in a recent meta-analysis (Barbato & D’Avanzo, 2020). The studies in the named meta-analysis also showed that couple therapy for co-morbid depression and relational discord improves both the relationship and the depressive symptoms. In terms of the models used, cognitive-behavioural couple therapy (Baucom et al., 2020) appears to be the most studied model (e.g., Baucom et al., 2018; Monson et al., 2012). Other therapies, such as emotion-focused/emotionally focused therapy for couples also have some evidence for their efficacy with relational difficulties and co-morbid presentations, such as depression and PTSD (e.g., Denton et al., 2012; Weissman et al., 2018).

Emotion-Focused/Emotionally Focused Therapy for Couples

Emotion-focused/emotionally focused therapy for couples (EFT; Greenberg & Johnson, 1988) is an approach to couple therapy that builds on humanistic and systemic traditions in psychotherapy. It is one of the most studied couple therapy approaches in regard to its efficacy (Spengler et al., 2022). Building on the initial work of Greenberg and Johnson (1988), it has developed into two distinct traditions. The original Greenberg and Johnson (1988) formulation emphasized the delineation of the problematic interactional cycle in which the couple gets caught, which is fuelled by each partner’s more vulnerable emotion leading to the behaviour (e.g., blaming, withdrawal) that elicits the other partner’s vulnerable emotions. The therapeutic work is focused on understanding the cycles, but with an aim to eventually help the partners to reveal their vulnerable emotions and associated needs to each other, thus eliciting more responsive reactions from each other.

Over the years, Johnson (2020) and her colleagues have stressed the relevance of attachment theory for understanding why seeking and offering a soothing response matters so much in the life of a couple (Johnson, 2019). Greenberg (see Greenberg & Goldman, 2008), on the other hand, expanded the original work by emphasising that apart from attachment -related problematic cycles (e.g., are you there for me, when I am distressed?), a couple can also be caught in identity-related conflicts (e.g., do you accept me as I am?). In the area of therapeutic work, Greenberg (together with a co-author Goldman) also stressed the individual’s work within the couple, where an individual tends to their own vulnerability as well.

In terms of the delineation of the approach for working with couples with co-morbid mental health issues, there is no prior literature that would provide a systematic framework outlining EFT with co-morbid relational and metal health issues, hence the goal of this paper. The exception is a formulation of Johnson (2002) for working with trauma that primarily discusses how traumatic experiences and PTSD may bring extra challenges to typical couple work. Johnson (2002; p. 97) frames the underlying emotional experience fuelling the problematic interactional cycles in the context of the echoes of trauma. Johnson stresses that underlying emotional experiences may be avoided in the partner with the past trauma. She also stresses that while working with couples where one of the partners suffers from PTSD, the therapist may encounter challenges to alliance formation (e.g., issues with trust). Severity of distressing experiences in the partner with the history of trauma and difficulties with affect regulation may also pose challenges for therapy. While pointing out specific challenges, it appears that the overall therapeutic approach remains true to the original EFT formulation (Johnson, 2020).

Transdiagnostic Emotion-Focused Therapy for Couples: A Framework

When we want to provide an outline of working with co-morbid romantic relational dissatisfaction and mental health issues, we need to qualify which mental health issues we mean, as it is clearly a very broad area. We focus here on depression, anxiety and related disorders (such as obsessive-compulsive disorder [OCD] or post-traumatic stress disorder [PTSD]) as these are the most prevalent mental health issues that share many characteristics and are also targeted with common transdiagnostic therapeutic strategies (e.g., Barlow et al., 2018). Twelve months prevalence for any anxiety disorder, inclusive of OCD and PTSD, is about 18%, and for depression almost 7% with dysthymia being at 1.5% – (Kessler et al., 2005; depression and anxiety problems are also often co-morbid). While not the focus of this paper, depression, anxiety and related disorders are also often compounded by personality difficulties, formally classified as personality disorders (Lenzenweger et al., 2007). Depression, anxiety, and related disorders also have many shared elements (Lahey et al., 2021). These elements not only include a very high co-morbidity (which means a co-occurrence of at least two ‘disorders’ at one point in time or sequentially over a long period of time), but also etiology (e.g., genetic vulnerability, adverse events).

The existing psychological treatments for depression, anxiety and related disorders also share many common therapeutic strategies which have led to the development of so-called transdiagnostic treatments (Kennedy & Barlow, 2018). A transdiagnostic variant of emotion-focused therapy for depression, anxiety and related difficulties, building on the original work of Greenberg and colleagues in individual EFT (Greenberg et al., 1993), was also recently conceptualized and presented in a manualized format (Timulak & Keogh, 2022). Timulak and Keogh’s formulation differentiated between the symptom level distress and underlying emotional vulnerability that gave rise to that distress. They thus conceptualized two levels of therapeutic work, one symptom-level and the other transformation of underlying vulnerability level.

The symptom-level work targeted common transdiagnostic symptoms in depression and anxiety such as worrying, rumination, and avoidance of (protection from) painful emotional experiences. The common therapeutic processes in the symptom-level work included increasing awareness of the client own agency (self-worrying) in the symptoms as well as the cost of such processes (e.g., anxiety and tiredness generated by the worrying). The clients are then facilitated to let go of the symptom inducing processes (letting go of worrying) or set a boundary to them (e.g., boundary to the worrying). The transformational work in the transdiagnostic formulation focused on the underlying vulnerability in a typical EFT way (Greenberg et al., 1993). The underlying vulnerability (e.g., core shame in social anxiety or depression) was accessed and helped to be tolerated. The unmet needs within it (e.g., for acceptance) were articulated, and the new adaptive responses such as compassion and boundary-setting anger were generated.

Timulak and Keogh’s (2022) transdiagnostic formulation has led us into extending this formulation from an individual format to work with couples where at least one of the partners meets formal clinical criteria for depression, anxiety or a related disorder. The following descriptions conceptualize the place of these mental health difficulties in the problematic interactional cycles and propose therapeutic strategies that can be used to address co-morbid mental health issues and relational dissatisfaction, building on the framework presented by Greenberg and Goldman (2008). We thus hope to provide a coherent framework conceptualizing transdiagnostic emotion-focused couple therapy for co-morbid relational dissatisfaction and depression, anxiety and related disorders.

Depression, Anxiety, and Related Difficulties’ Interplay with Relational Dissatisfaction

EFT for couples identifies the primary source of relational dissatisfaction in the partners’ interactional cycle that generates painful emotions in both partners. This cycle arises from underlying emotions and their secondary expression (e.g., I feel invalidated but I will attack my partner rather than reveal my hurt). In classical EFT for couples (Greenberg & Goldman, 2008) the focus is usually on one dominant problematic cycle although the focus may shift to other cycles in a longer therapy. A problematic interactional cycle may present itself as follows:

A behaviour of partner A (e.g., emotional unavailability) elicits a painful experience (e.g., feeling alone) in partner B that leads to (often protective but ineffective) behaviour in partner B (e.g., blaming partner A), which in turn elicits a painful feeling in partner A (e.g., a sense of failing their partner) that leads to behaviour in partner A (e.g., withdrawal) that further compounds the painful feeling in partner B (a sense of loneliness and abandonment) and contributes to further (escalation of) problematic behaviour (blaming). The circle is thus established and the vicious cycle solidified and living a life of its own. The underlying vulnerability (e.g., lonely abandonment, fear, shame) is difficult to stay with and show to the partner, but secondary emotions (e.g., anger) or a behaviour stemming from them (e.g., stonewalling and withdrawal) are shown (as they are less vulnerable) which further compounds the experienced vulnerable emotions.

From the perspective of an individual transdiagnostic EFT, mental health difficulties that constitute symptoms that define depression, anxiety, and related difficulties are seen as symptom-level emotional difficulties that are secondary to the more underlying emotional vulnerability (Timulak & Keogh, 2022). The symptom-level distress can present as hopelessness, helplessness, irritability, anxiety, general feelings of overwhelm, or interruption/avoidance of feelings that characterise depression and anxiety. The underlying emotional vulnerability in depression and anxiety appears to consist of chronic and overwhelming painful experiences of loneliness (or loss), shame, and fear (e.g. Dillon et al., 2018; Keogh & Timulak, 2023; McNally et al., 2014; O’Brien et al., 2019). This vulnerability likely develops as a result of an interplay of biological predispositions that shape our emotionality and adverse events, particularly in developmentally sensitive periods of time, that generate painful overwhelming emotional experiences. These overwhelming emotional experiences are often chronic or particularly powerful. The emotional needs embedded in the emotions generated in these adverse events, e.g., the need for connection in loneliness, the need for acceptance in shame, the need for protection in fear, are typically not met.

People thus develop unique emotional sensitivities to particular types of events, triggers. Classical EFT discusses the development of problematic emotion schemes (Greenberg, 2017) which can be triggered in our interaction with a particular social environment. The triggering of this emotional vulnerability (particularly if it is chronic or very pivotal) may amount to the level of distress and suffering that meets a clinical threshold or diagnostic criteria for the disorders, such as depression and anxiety and related difficulties. As a side note, longitudinal studies show that virtually none of us are immune to experiencing distress which meets criteria for a mental health disorder over the course of our lifetime (Caspi et al., 2020).

In a couple, a partner’s emotional vulnerability (sensitivity to certain triggers and experiences they bring) often predates the relationship (Greenberg & Goldman, 2008). Often (or even typically), adverse events in developmentally sensitive times are pivotal here, but at times traumatic or otherwise adverse experiences may happen later in life, during the course of the relationship or in the context of the relationship (the concept of emotional injuries in the romantic relationship speaks to that – see Meneses & Greenberg, 2019). In particular contexts, and for some people more so than for others, this sensitivity may give rise to clinical levels of distress. The trigger may come from outside the couple relationship or it may come from the other partner. Given that the primary romantic relationship is typically the most significant relationship, it particularly hurts if the partner’s behaviour or emotional expression triggers the underlying vulnerability. Even if the current trigger comes from outside the relationship (e.g., work, family of origin, in-laws, illness) the perceived response of the romantic partner to the emotional consequence may be experienced as compounding rather than soothing the hurt. If the triggered vulnerability gives rise to clinical levels of distress, it may become harder for the other partner to be able to respond in a soothing or validating manner. It can then particularly burden the interaction and may lead to the development of a problematic cycle of interaction compounded by the clinical levels of experienced distress. The cyclical interaction may be even more complex if both partners’ distress reaches clinical levels.

Chronic emotional vulnerability that has the potential to rise to clinical levels of distress may complicate a romantic relationship in several manners. For instance, in some cases:

1. it may make one partner particularly sensitive to the misattunements of their partner (or to certain aspects of their partner’s behaviour), while their partner may be genuinely puzzled by the hurt they are bringing.
2. In other cases, the levels of experienced distress (e.g., the depth of depression) in one partner may make it difficult to respond to the other partner.
3. In some other cases, the underlying painful emotions (e.g., loneliness, shame, fear) are so difficult to stay with that the person may have difficulty accessing them and being able to tolerate them let alone showing them and sharing them with their partner.
4. Furthermore, in other cases, the pain of the underlying vulnerable feelings may lead the person to try not to feel them and may require them to control (or avoid) their environment for any potential threats that could trigger those feelings (e.g., wanting to decline invites to social events), which may include trying to involve the partner in such a behaviour, to which the partner may not be able (or not want) to comply to, which in turn can be experienced as hurtful.
5. Yet in other cases, expressing instrumental emotions (e.g., expressing irritability with the hope that the partner will understand the inner suffering) may prevent the other partner to respond authentically to the underlying pain.

In all of these examples, the level of underlying vulnerability and the level of distress that it brings about makes the interaction susceptible to leading to difficulties. Thus, the triggered vulnerability not only brings suffering to the person impacted, but also increases the stakes for the other partner’s responsiveness. The interaction then may not go well and the partner’s response may fail to serve as a buffer against the vulnerability’s rise to a fully-fledged clinical disorder. On the other hand, the centrality of the partner’s response to the underlying emotional vulnerability indicates a possibility that the romantic relationship has the potential to serve as a mitigator of pain or buffer against a further rise in distress. Indeed, the potential function of the relationship as being a resource in the context of difficult experiences (Bodenmann et al., 2019) is at the core of the couple treatments developed for co-morbid relational and mental health difficulties (Whisman et al., 2023).

Therapeutic Strategies for Co-Morbid Depression/Anxiety and Relational Difficulties

The EFT for couples framework as outlined by Greenberg and Goldman (2008) provides an optimal scaffolding for a transdiagnostic EFT approach to couple therapy that targets relational as well as depression- and anxiety-related presentations. The original EFT framework assumes that couple therapy focuses on the delineation of the problematic interactional cycle and also on identifying individual partners’ sensitivities and emotional vulnerabilities at the core of the interactional positions in that cycle. This framework is compatible with the view presented here that such vulnerabilities not only play a role in relational but also individual distress such as depression and anxiety. The focus on the historical origins of the relational sensitivities and vulnerabilities differentiates Greenberg and Goldman’s formulation from Johnson’s (2020) formulation, with Johnson looking for the historical context of underlying vulnerable feelings more from the perspective of historical attachment-seeking behaviour when experiencing distress (e.g., seeking soothing from other, having experiences of soothing other). Greenberg and Goldman’s view is much broader as it looks at what experiences led to the formation of such sensitivities and vulnerabilities. We should also stress that while emotional vulnerabilities that are linked to the relational or depression/anxiety difficulties are often formed in developmentally sensitive periods of time, they can be developed at any point in time including in the context of the relationship itself.

Greenberg and Goldman’s (2008) formulation (similar to the original formulation by Greenberg & Johnson, 1988 and Johnson, 2020) further assumes that the revealing of vulnerable emotions in session is at the core of transformative exchanges when the partners are facilitated by the therapist to respond to vulnerable feelings with acceptance and care. The blocks to such a process are identified (their protective function brought to awareness) but they are also facilitated to be overcome. Greenberg and Goldman introduce a new element to the therapeutic work here (one that was not present in the original 1988 Greenberg and Johnson’s formulation and is not present in Johnson’s own formulation), i.e., an internal work of each of the partners on their own vulnerability, albeit in the presence of the partner (e.g., working on self-acceptance alongside getting validating responses from the partner). This is a process that will be particularly relevant for the transdiagnostic formulation for working with relational dissatisfaction and co-morbid depression and anxiety difficulties, as the underlying vulnerability is seen as being at the core of the dynamic that may give a rise to clinical levels of distress and will need to be attended to both relationally but also individually, with the partner being a witness to the work.

The additional focus of transdiagnostic EFT for couples builds on Greenberg and Goldman’s formulation in the following ways:

1. Firstly, it explicitly acknowledges that the sensitivities and emotional vulnerabilities may make the partner particularly sensitive to the partner’s misattunements or hurtful behaviour (regardless of whether the ‘flaring’ of the vulnerability is triggered by the partner or whether it is triggered outside the relationship but the partner’s response is experienced as not soothing or further hurting). Given that we are all vulnerable to a clinical level of distress (see above reference to Caspi et al., 2020), we do not really look at the ‘designated’ patient, but assume that both partners are liable to reach the clinical level of distress at some point (although only one of the partners may be reaching that level of distress at the point of therapy). The work here is explicitly focused on the underlying vulnerability in each partner and its context, but also the dynamics of this vulnerability, particularly if it starts to descend to psychopathological/clinical levels (e.g., if I feel chronically alone and the other is not there, I feel so hopeless and helpless that I collapse into hopelessness and helplessness levels of depression). In that sense, the therapeutic work is focused on exploring and tracking one’s vulnerability, but also explicitly normalising, naming it, and acknowledging the challenge of being with the emotional vulnerability. The acknowledgment of this challenge can broaden its understanding and de-blame each of the partners (that vulnerability may require a concerted effort to look after or heal and is not that easy to bear or respond to).
   Greenberg and Goldman (2008) stress in their framework that exploration of the historical origins of the partners’ underlying vulnerability helps to broaden self and other understanding, which in turn helps to de-escalate problematic interactional cycles. In addition, in transdiagnostic EFT for couples, we explore and track the process of how the vulnerability leaves the partner sensitive to particular triggers, and how, when activated, the chronic painful feelings may become overwhelming, unbearable, difficult to be with and pointing to chronically unmet needs (e.g., for connection, recognition, safety). This may give rise to symptom levels of distress (e.g., hopelessness, helplessness, overwhelm, tension, anxiety, irritability) and accompanying intra-psychological processes (e.g., self-criticism, self-worrying) and behaviour (e.g., withdrawing, avoidant, and/or controlling behaviour that tries to neutralize, mitigate or avoid triggers of chronic vulnerable painful feelings).
2. Secondly, transdiagnostic EFT for couples explicitly tracks the impact of clinical distress on relational interaction and acknowledges that clinical levels of emotional distress are difficult to respond to for the partner (e.g., profound hopelessness, extreme avoidance or control of potential threats). The suffering partner may have unrealistic expectations on the responding partner in terms of how simple vs. difficult it is to address the suffering. The responding partner is not trained to respond, may be unsure of how to respond, or may get flooded by their own reactions to their partner’s distress, and may not be able to respond in a way that alleviates the distress in the already distressed partner. Indeed, the response or lack thereof may even further contribute to this distress. The vicious cycle of interaction may then start. For instance, an overly worrying partner who is anxious about being judged (by people outside the relationship but perhaps also by the partner) may engage in worrying that makes them exhausted, constantly anxious, and very difficult to get through to in a soothing and affirming manner by their partner. The therapeutic work on initially tracking intra-psychological escalation of one’s own vulnerability is then looked at through the prism of how this clinical level of distress impacts on relational expectations from the partner, or how it colours the responses from the partner and makes it challenging for the partner to be responsive. Again, it is central to acknowledge that both partners are vulnerable to such an intra-psychological escalation that makes optimal responding to the underlying vulnerability difficult for the responding partner.
3. Thirdly, in in transdiagnostic EFT for couples we are trying to explicitly differentiate between the internal work of each of the partners on their vulnerabilities and the relational work or responsiveness (or willingness to respond) they may get from their partner. Thus, we can work on the interactional enactments, when an aroused vulnerable feeling is accessed and expressed (e.g., I feel so alone in my life and I always felt that from early on in my life) to facilitate the partner’s response (e.g., I am here and I want to be with you), but we can also work on the intra-psychological enactments in the presence of the partner (e.g., if you look at that little boy who had no friends in school and who wanted his parents not to know about it so they would not be disappointed in him for not being able to make friends – what do you feel towards him and what would you want to say to him?). The transformational work on one’s own underlying vulnerability (in both partners) is then seen as both an intra-psychological and a relational task.
4. Furthermore, we can also explicitly work on the symptom level distress (Timulak & Keogh, 2022) internally for each of the partners, but also relationally. For instance, a partner with a clinical level of distress who feels overwhelmed may learn active experiential tasks promoting regulation (e.g., Clearing a Space – Elliott et al., 2004 or symptom level soothing by an imagined soothing other – Timulak & Keogh, 2022), but may also avail of soothing time with their partner (a regular walk at the end of the day). Similarly, a partner with clinical levels of worry may learn, e.g., through an in-session dialogue between two parts of the self, Worrier and Experiencer, that they are an active agent in generating worries that are trying to prepare them for potential dangers, but these have a substantial cost (constant anxiety and tiredness) and thus they may be determined to let go of the worries or stand up to them internally. Relationally, the other partner may be of help to spot when the worry is taking hold and may help with setting a boundary to it, rather than offering a futile, short-lived reassurance. Virtually all symptom-level experiential tasks used in individual transdiagnostic (Timulak & Keogh, 2022) can be adapted to be used in transdiagnostic EFT for couples for intra-psychological and relational work. Their use is however sparse, as the couple therapy space is more focused on the dominant interactional cycles and the new way of relational responding, orchestrated in the session, to each other’s vulnerability.
5. While relevant for all couple therapies, transdiagnostic EFT also assumes very active work with tailored homework. When one or both of the partners is experiencing clinical levels of distress, it suggests that the relational and intra-psychological difficulties may be particularly difficult to address in everyday life, as the vulnerabilities may be easily re-triggered. The therapeutic work has to closely monitor the interplay between the in-session experiences and the individual’s wellbeing or interactional relating between the sessions. It is likely that an extra scaffolding (through jointly devised homework) is needed to support internal work of the partners as well as their interactional ways of being. This would address the underlying vulnerability and symptom-level work, but also practicing new transformational ways of being with each other and responding to each other. This is a particularly fruitful area for further exploration and research. There are recent suggestions for what type of homework can be used to support the in-session work outside of the sessions in a broader EFT community and they can be tweaked for their use in the context of couple therapy (Greenberg & Warwar, 2006; Kwatra et al., 2022; Warwar & Ellison, 2019).
6. Finally, we want to propose one further suggestion stemming from our early work on developing the transdiagnostic EFT for couples adaptation and that is that many couples have a propensity to have two cycles early on in therapy that may be of similar importance (e.g., Dailey et al., 2023). Apparently, this can be linked to the sensitivity that is triggered first in each of the partners, before something becomes cyclical. Traditionally, in EFT for couples, the focus is on one problematic cycle, or, if the focus is on more cycles then it is usually done sequentially by firstly focusing on the more problematic one. While there may be good reasons to focus on the most problematic cycle, it is important to monitor whether there is another potential cycle linked to another vulnerability that gets triggered first by the other partner (not the one that the most problematic cycle is focusing on). The therapists need to be cautious that they do not focus only on the cycle that the more dominant partner may thematize in therapy. Obviously, due to the cyclical nature of the interactions, the vulnerability of both partners gets triggered in a problematic cycle. Given that we have more vulnerabilities some may flare up more quickly in partner A, leading to a problematic interaction, and some may flare up in partner B. It has been our observation that cycles are often linked, but it may be of value to look at them separately in more detail.

For instance, partner A (with a history of scary experiences where parents were not available and things were overwhelming) may be sensitive to the insecurity that things are not predictable, and partner B does not share the importance of controlling for unpredictable overwhelming situations (in child care, in looking after the household). This may contribute to clinical levels of anxiety that is also linked to the uncontrollable situation in partner A’s work unrelated to what is happening at home. This may lead partner A to criticize their partner and define the expected and acceptable behaviour for partner B. Partner B feels criticized and invalidated and it triggers their chronic feelings of inadequacy (I am letting down my partner, anything I do is wrong). This leads to paralysis in partner B and not being ‘on the ball’ when it comes to childcare or household tasks or when it comes to alleviating partner A’s anxiety. This in turn escalates partner A’s anxiety. This then may clearly appear as the problematic cycle. There is an underlying vulnerability in partner A (fear) and an underlying vulnerability in partner B (shame/inadequacy).

But partner B can also feel chronically lonely, and the overwhelmed partner A may be too anxious and unhappy, leading them to, for instance, withhold intimacy. This may leave partner B irritated and critical of their partner, which may leave partner A feeling inadequate. Thus a second cycle may be created with partner A feeling lonely but showing irritability and partner B feeling inadequate but withdrawing and being irritable back. This second cycle may interact with the first cycle, and the anxiety of partner A and the unhappiness with partner B’s behaviour may also be expressed instrumentally (outside awareness) by pushing back partner B’s attempts at intimacy.

The example illustrates an existence of two cycles being linked to each other. We would therefore recommend to routinely check for two potential cycles, even if the work may primarily focus on one of them (the one that appears currently to be more entrenched and generating more distress). The focus on only one cycle may particularly be the case when couple therapy is time-limited. In the case of transdiagnostic EFT for couples, this may mean focusing on the cycle that most contributes to the generation of clinical levels of distress.

Case Example

To illustrate how transdiagnostic EFT for couples may look in practice, we will look at a composite example from our current project looking at an adaptation of EFT as a therapy for comorbid relational dissatisfaction and depression, anxiety and related difficulties in at least one of the partners. A heterosexual couple, in their late thirties, Mark and Sonja, are presenting as having a communication problem (Mark’s perspective) and/or a conflict about Mark not stepping up in looking after the household and childcare for their two children (Sonja’s perspective). In addition to the relational conflict and dissatisfaction, Mark presents with a primary diagnosis of depression (with repeated episodes previously, with one particularly severe episode that required him to attend an inpatient treatment facility) and Sonja meeting criteria for a primary generalized anxiety disorder (and co-morbid depression).

As the therapy unfolds, a dominant cycle of interaction is established for this couple with the therapist tracking it and communicating it back to the couple. In the cycle, Sonja is feeling overwhelmed (secondary distress) about looking after the household and with her parenting responsibilities. She is resentful that Mark does not contribute or she feels he is not reliable in his contribution. She feels anxious that things may go wrong and they will not be able to provide for their children, or that they are letting their children down by not offering optimal parenting (e.g., making sure that children have sufficient stimulation and can develop their talents for art and sport). Sonja feels alone in her efforts. She is often in a panic, but what she shows is a resentment of Mark and doubt that he can look after the household and children. She often criticizes Mark and takes over the chores or childcare that Mark originally undertook. Mark in turn feels criticized, doubted, invalidated, and also controlled. Inside he feels that he is incompetent, but what he shows is a resentment back or withdrawal (being unresponsive, pensive), which in turn panics Sonja more as she perceives him as unavailable. The more withdrawn and unavailable Mark is, the more Sonja takes over and criticizes Mark.

There is also a second cycle that the therapist, with the help of the partners, distils. To keep our illustration simple, we will not focus on this second cycle and the involved work here, but just to say that it is characterised by Mark feeling alone and seeking closeness and intimacy, with Sonja withdrawing, but inside feeling as if she is failing Mark. While Sonja feels as if she is failing Mark for not being interested in closeness with him, she shows anger at him: how come he is not available to help with the household chores and parenting, if he wants her to not be resentful and to be interested in him (here is the link to the dominant cycle). The more Mark pursues her for closeness, the more Sonja withdraws and gets angry in response.

The therapeutic work focuses on tracking the dominant cycle, and for simplicity our descriptions will only concern the dominant cycle here. We highlight how the underlying panic leads Sonja to increase her leading and giving instructions to Mark, which is very invalidating for Mark and leaves him to withdraw more. The underlying vulnerability (panic, fear, self-doubt, and being alone for Sonja and a sense of inadequacy for Mark) is explored in the context of an individual history. Pivotal memories are freshly and experientially accessed and revealed to the partners and the partners are asked to respond from inside to their partner’s vulnerable feelings.

It transpires that Sonja was chronically invalidated by her mother who was very anxious, but at the same time unavailable (often hospitalised with her mental health issues) that left Sonja fearful and overwhelmed with responsibility (that was also openly required from her by both of her parents given that she was the oldest sibling). Early on, Sonja took on a lot of responsibility and looked after her father and her younger siblings but felt very overwhelmed by it. She constantly worries about what can go wrong. She is particularly concerned that her children will have some of the experiences that evoked feelings of panic and shame in her when she was growing up. She is trying to shield them from it. Her worrying about the situation at home can be compounded by the worries at work, where she is in a leadership position and deals with threats to her position and pressures to be successful in her job. Her vulnerability (not feeling supported, feeling scared that things can go wrong, but also feeling alone and feeling like she is failing) escalates to clinical levels of worrying (generalized anxiety) and sleeplessness, but also overprotective and controlling behaviour. Her mood is also low and she is easily irritable.

In therapy, the dynamic in Sonja’s vulnerability and how it escalates to clinical levels of distress was clearly mapped out. Her vulnerability was freshly and experientially accessed (through episodic memories that predate the relationship but also through pivotal events in the relationship with Mark). As the vulnerability was accessed with an accompanying emotional arousal and unmet needs for support and care, it was also expressed and revealed to Mark in the therapist-facilitated enactments (asking Sonja to share directly with Mark). Mark was moved and responded in a very caring and moving way:

I am here, you are not alone, I do not want you to feel that it is all on you, I want to be in it with you.

Sonja was also facilitated to unpack her worrying processes, recognizing her own agency in the worrying [how do you worry yourself?] and seeing the impact of the worrying (anxiety and tiredness). She was facilitated in the session in an individually focused work (with Mark present) to see whether she could try to let go of the worry or set a boundary to it. She was also facilitated by the therapist to use a Clearing a Space task (where stressful feeling are put aside in one’s imagination) to regulate when she feels overwhelmed (outside the sessions). Mark was also determined to help recognize (in a non-blaming way) when she starts to worry and panic and agreed to remind her how she can lean on the processes she touched on in the session (letting go of worry or setting a boundary to it). They had some success with trying this approach as homework between sessions.

The context of Mark’s underlying vulnerability is that he grew up as a very good student but in adolescent times, problems with concentration prevented him from having good academic results. Given that both of his parents were very studious, he began to sense that he was letting them down. This was compounded by occasional criticism, particularly from his mother, who had the impression that he was not trying enough. He often felt like a failure, having a sense that his parents were right that he was not trying. Whenever he encountered these feelings of being a failure and a disappointment, he had difficulty in bouncing back and usually shut down and felt flat and withdrawn. This was the case throughout his later adolescent years, but got significantly worse a few years back when he lost his job at his company because it was not doing well financially. This was a time when his sense of failure, linked with self-criticism, manifested itself in a pronounced shutdown and inability to function (he could not get out of bed), which led to his inpatient treatment for depression.

In the current couple therapy, Mark’s feeling of being a failure when Sonja criticized him was freshly accessed in the sessions. The pivotal memories of feeling like a disappointment and being traumatised when let go at work, where freshly accessed. The unmet need for acceptance and validation was expressed (also in an enactment to Sonja). Sonja was genuinely moved and responded from a caring place in several poignant enactments in the sessions. Mark also had an imaginary dialogue, in Sonja’s presence, with his younger self that felt like a disappointment and was supportive and validating to his imagined adolescent self (that felt alone and lost). This also brought to him a sense of feeling cared for. The work also focused on the self-critical process. Mark was able to see parallels between his own self-criticism and his parents criticism. He could see the function of the criticism (to be better), but also the emotional impact (paralysing shame). He was resolved to try to let go of his self-criticism and set a boundary to it (I have value).

This was very moving for Sonja, who felt very caring towards Mark. She also started to understand that when he goes silent, he may be battling his own sense of failure and she expressed determination to try to be patient and there for Mark in such moments. Mark, through a thorough tracking by the therapist, realized how his withdrawal protects him from feeling judged but that it also leads to further shutdown from which it is harder and harder to bounce back. He recognized (and also expressed in some enactments directly to Sonja) the value of standing up for himself and giving a boundary to his own critic, but also to other people, primarily Sonja (and historically his parents). This assertive anger, while difficult to take at times for Sonja, was valued by her more than the withdrawal that they descended to previously.

Conclusion

Relational satisfaction is in some cases linked to clinical levels of mental health issues such as depression, anxiety and related difficulties. EFT, similarly to other forms of couple therapy, has potential to be used as a therapy for co-morbid relational dissatisfaction and depression, anxiety and related disorders. Here, we outlined the basic tenets of transdiagnostic EFT for couples. We suggested to treat psychopathological symptoms as secondary symptoms of an underlying chronic emotional vulnerability that can be triggered (at times also formed) in the couple relationship or triggered outside the relationship, with the responding partner being unable to provide healing or mitigating soothing or validation. We suggested to explicitly work with the concept of underlying vulnerability together with explicit work on tracking and highlighting how the triggering of this vulnerability gives rise to clinical levels of distress. We further looked at how the clinical distress and its symptoms are burdening and compounding the interactions in the couple, eventually leading to a problematic interactional cycle - the clinical distress bringing an extra weight to otherwise common problematic interactional cycles.

We suggested that the therapeutic work has to explicitly devote time to each partners’ intra-psychological work on their vulnerability (e.g., building self-compassion and self-validation), as well as processes that give rise to symptoms of depression and anxiety (e.g., worrying). We also highlighted the importance of using the relationship as a means of providing healing and transformational experiences (of love, protection and validation) to the underlying vulnerability, as well as a resource that helps soothe the clinical distress, and be an asset in fighting distress-generating intra-psychological processes (e.g., self-criticism, self-worrying, emotional overprotection). Finally, we stressed the importance of collaborative use of homework and ensuring that all relevant problematic cycles are attended to.