The Emotionally-Focused Clinical and Research Training Program (EFCRTP)

The Emotionally-Focused Clinical and Research Training Program (EFCRTP) developed by Dr. Margaret Keiley, involves training practitioner in the principles and practices of Emotionally-Focused Therapy (EFT) for individuals, couples, and families and the Multiple Family Group Intervention (MFGI) for use with symptomatic adolescents or adults and their families. These two treatments have been shown to be clinically effective in reducing conflict and the resulting rigid interactional cycles, problematic behaviors: externalizing (e.g., aggression, violence, sex-offending, addiction) and internalizing (e.g., depression, eating disorders, cutting) behaviors. In the EFRCP practitioner also are trained in the principles and practices of clinical research -- learning how to conduct quantitative and qualitative assessments as well as data analyses, how to write academic articles for publication, and how to prepare presentations for state and national conferences.

Need for EFT and MFGI: Many educational programs and clinical treatments have been developed that have shown significant pre- to post-treatment decreases in adolescents’ drinking, smoking, and risky sexual behaviors or individual, couple, and family conflict. Unfortunately, many studies that have followed participants over longer periods (6 months to several years) have found that the small to moderate effect sizes tend to dissipate. Perhaps we are missing a piece of the puzzle. Why do these effects often disappear in the long run? I would suggest that what might be missing is something physiological that interferes with the retrieval of information learned in these programs. Recent research shows that at high levels of emotional arousal, cognitive functioning is disrupted, often inaccessible, resulting in a panic-ridden reversion to over-learned, habitual, and sometimes maladaptive behaviors. In addition, previous attachment research has helped us to understand how these over-learned, habitual, and sometimes maladaptive behaviors develop. I suggest here that we attend to coupling these two lines of research – attachment and physiological arousal – in order to improve the efficacy of our educational and clinical interventions.

Attachment to caregivers in infancy greatly influences the development of individuals’ habitual ways of responding to difficult and arousing situations. At any age, the attachment behavioral system is activated by stress with the goal of reducing arousal, reinstating a sense of security, and allowing a return to active engagement with the environment. And, early experiences with caregivers have enduring effects on the development of these behavioral patterns and their continuation from infancy through adolescence to adulthood. Secure individuals in difficult situations are able to regulate high arousal using strategies that involve seeking comfort or self-soothing. The reduction of arousal allows them, in turn, to re-engage with the environment and use their cognitive skills to deal with the difficulty. Secure individuals display prosocial behaviors when interacting with others, even during stressful situations, and are able to continue toward their goals. On the other hand, insecure (avoidant, anxious) individuals in similar situations have difficulty regulating arousal, managing stressful situations, and maintaining exploration and self-confidence in new situations. In stressful and high arousal situations, individuals who are avoidant tend to restrict the communication of anger and distress then withdraw or flee from the interpersonal interactions in which this arousal arose. Anxious individuals become hypervigilant to their own symptoms of arousal and also to the situations in which they experience this high arousal. They heighten their distress and show increased fear, anger, or aggression, thus alienating the very people they hope will comfort them. These response patterns, related to attachment quality (secure-flexibility, avoidant-flight, anxious-fight) from infancy, often become habitual over time and are difficult to alter. The result is that in some situations, particularly highly arousing situations, whether in childhood, adolescence, or later in life, those with insecure attachment revert to their habitual defensive position – fight, flight.

Many educational programs and clinical treatments have been developed to help individuals learn to alter these habitual responses (aggression, anxiety, fear, withdrawal) and behaviors (drinking, smoking, sexual behaviors, drug use) that individuals may begin in adolescence to manage high levels of arousal. But, as mentioned above, long-term or permanent changes in these behaviors are rare or difficult to achieve. One reason may be the lack of attention in these programs to the ways that the autonomic nervous system works when individuals are in difficult or highly stressful situations. What follows is a very brief and somewhat simplistic explanation of how this system responds in highly stressful situations.

The first response to environmental stress is from the parasympathetic nervous system. Physiological arousal alerts individuals to environmental stressors. If individuals (usually secure individuals) are able to keep their arousal at a manageable level, they can then re-engage with the environment, and use their cognitive abilities to manage the situation. If the parasympathetic system is overwhelmed by the arousal, the sympathetic system kicks in and individuals enact, unthinkingly, their habitual patterns—fight, flight–-which have developed as a result of their attachment (anxious, avoidant) in infancy. The key point here is that individuals in these very stressful situations no longer have access to their cognitive abilities; therefore, they do not remember what they learned in an educational program or from clinical treatment. But, we also know that for interventions to be effective in permanently changing behaviors, participants must experience high enough levels of arousal within the intervention that their habitual response is triggered. Once triggered in the intervention, individuals can learn how to inhibit these habitual responses (fight or flight), allowing them to access their cognitive processes in times of stress and engage in less habitual, reactive, and destructive behaviors. Being able to experience and tolerate high arousal in an intervention once is rarely sufficient, however, to ensure permanent change in these habitual patterns. Intervention that focuses on helping individuals change their habitual ways of tolerating and responding to physiological arousal usually depends on repeated practice.

Mechanism of Change: The mechanism by which change occurs in these two treatments – MFGI and EFFT – is the alteration of the family members’ cognitive internal working models (IWMs) that influence their responses to conflict (Zimmerman, 1999). By changing these IWMs, the family members are able to de-escalate the coercive cycles and negative emotion that occur in these families allowing the adolescents and family members to create closer bonds (Moore et al., 1998). The development of this attachment security also curbs a relapse to delinquent behavior, substance abuse, and sexual offending by the adolescents (Cook, 2000).

Development and Implementation of MFGI: To meet these needs, I have been conducting research and publishing in areas of family therapy, emotion regulation, delinquency, and other high-risk behaviors. In my intervention-focused research, I first investigated emotion regulation and attachment in adjudicated and non-adjudicated youth and their families (e.g., Keiley & Seery, 2001). From this pilot work, I developed and piloted the Multiple Family Group Intervention (MFGI) for use with incarcerated adolescents and families to foster re-attachment and more functional emotion regulation. The theoretical basis of MFGI is the research on affect regulation and attachment as described above; the clinical basis is Emotionally-Focused Therapy (EFT). In randomized clinical trials, EFT had proven to be effective in treating disruptive attachment and affect regulation patterns of individuals, couples, and families. In addition, research had shown that sex-offending, delinquent, and addicted adolescents and their families had attachment and affect regulation problems similar to those experienced by distressed couples and families. The MFGI is a 8-week manualized program in which parents and adolescents attend a weekly 90-minute psycho-education group that focuses on helping them manage their arousal, experience their fears, then risk expressing their vulnerabilities.

At Purdue University, my clinical team and I successfully conducted the MFGI at three Indiana correctional facilities over several years (Keiley, 2002a, 2002b). We also adapted the MFGI for use with incarcerated adults and their families who were struggling with addiction, and with pre-marital couples. Our qualitative data analysis indicated that adolescents and parents who had been through the MFGI program had improved relationships with each other, even if the adolescent had re-offended. The respondents also noted that they were very grateful to have had this opportunity to work together on family issues while the adolescent was still incarcerated. Many stated that they felt the MFGI provided a “missing piece” in the treatment options at the correctional facilities. Our quantitative data analyses (over 70 adolescents and families) indicated that, MFGI was effective in the short-term in reducing delinquent behavior and improving parent-adolescent relationships (6-month follow-up), and at 12 months, only 20% of the adolescents had been re-incarcerated, a considerably lower percent than usual at state and national levels. At Auburn University, my team and I have been implementing the MFGI with incarcerated adolescents who sexually offend and their families for the past 10 years. Once again, this has proven to be a very effective treatment for this population and only 4% of the adolescents released from the facilities reoffend sexually. (Link to MFGI Manual and Outcome Study)

Development of EFT: Because many of the attachment and affect regulation difficulties these families experience are pervasive, intractable, and enduring, they require individual, couple, or family therapy rather than a multiple-family group psycho-educational intervention (Keiley, 2001). Hence, I developed an adaptation of EFT to treat these populations. A key assumption of EFT is that emotion is primary in organizing attachment behaviors in relationships and internal working models (IWMs). Key factors in relational distress are excessive levels of negative emotion and destructive and conflictual interactional patterns that arise from, reflect, and create negative emotion. In EFT, new emotional experiences and interactions with others are seen as necessary for change to occur in internal working models and hence in relationships. The EFT process of change occurs in 3 stages, often completed in 9 to 12 sessions. Beginning sessions involve assessment and de-escalation of problematic interactional styles that maintain attachment insecurity and emotional distress. Middle sessions focus on the creation of specific change events, in which interactional positions shift. In these events, clients access the more vulnerable fears and hidden feelings that are masked by their distress or anger or stone-walling. In this process, therapists must learn to be very risk-taking in order to increase the level of arousal in the therapy room that will invite the clients to move into their habitual ways of responding. Then the therapist will stop that escalation and proceed to direct a new cycle that allows the expression of the clients’ more vulnerable feelings. In-session directives are essential for therapy of any kind to effect long lasting change. Final sessions address consolidation of change and integration of these changes into everyday life. Studies of EFT have shown that it is effective in interrupting cycles of coercive behavior and in leading to positive shifts in interactional patterns. (Link to EFT Manual)

Mechanism of Change: The mechanisms by which change occurs in these two treatments – MFGI and EFT – are 1) the alteration of the individual, couple, and family members’ cognitive internal working models (IWMs) that influence their responses to conflict. By changing these IWMs, the family members are able to de-escalate the coercive cycles and negative emotion that occur (1st order change); 2) in-session directives escalate arousal levels of clients during which they are helped by the therapist to access their fears and risk expressing those to create new, non-coercive interactional cycles (2nd order change). Describing the system of interaction de-escalates the cycle and ‘blowing the system up’ changes the structure in which clients are stuck.

Current Research Project: This project includes training practitioner in understanding, designing, and conducting clinical research. The field of individual, couple, and family therapy recently has advocated the use of evidence-based therapy. Solid research on the process and outcome of some therapy is available, but many treatments have not undergone treatment development or clinical trials. The current project involves conducting MFGI at Mt. Meigs Department of Youth Services Facility with incarcerated sex-offending adolescents and their families. If you are interested in learning more about how you can become involved in these projects, please email Margaret Keiley at keilemk@auburn.edu.