The Model and Evidence Base
A community based model rooted in a deep and unwavering belief in the healing power of families and systems, the essence of EFFT is to afford caregivers and significant others a role in supporting their loved one’s mental health and well-being. The therapist’s role would then be to support and empower caregivers in mastering the skills, tasks, and feelings involved in four main domains:
A. Offering targeted behavioral support, that is, assisting their loved one – regardless of age – in the interruption of symptoms and maladaptive behaviors (anxiety, depression, OCD, addictions, an eating disorder, etc.), in the transition from stressful life events, and the increased engagement in health-focused behaviors
B. Offering targeted emotional support, that is supporting their loved one to approach, process and manage stress and distress, making symptoms less necessary to cope
C. Facilitating therapeutic apologies in order to help loved ones to let go of the weight of old pain/self-blame/self-stigma, and;
D. Working through and resolving the fears and obstacles that will undoubtedly surface in the caregiver during this sometimes-challenging journey.
This last step is necessary when a caregiver's fears limit or get in the way of their ability to support their loved one. For example, some caregivers are afraid of engaging with their loved one (child/partner) with the tasks of behavioral and emotional support in case it leads to their loved one feeling far too overwhelmed, or it causes too much disruption for other family members. These powerful fears can lead couples and families to become stuck in unhelpful patterns (walking on eggshells, feeling resentful, etc).
The “usual suspects” include the fears that if they tend to their their loved one's painful emotions or problematic behavior patterns, they might: 1) run away; 2) become depressed or suicidal and 3) move in with the other custodial parent (in the case of split-families). There are many other "emotion blocks" that can surface throughout a family’s journey to supporting their loved one to wellness. For example, caregivers may sometimes feel resentful that their loved one continues to struggle, and this resentment can influence their helping behaviors. Other caregivers may feel helpless and without skills and thus find themselves relying on less-than optimal techniques to try to motivate behavior change in the other. Support and specific skills training are sometimes necessary to release parents and caregivers from the shackles that keep them from feeling hopeful and secure in their helping roles.
EFFT is meant to be implemented with deep respect for all those involved, and guided by the following principles:
• Community-based support and caregiver empowerment
• Family-Focused (of origin or found)
• Focus on emotions, emotion processing, nervous system arousal
• Skills Training
• 1 Degree Effect / Difference from Baseline
• Transparency and Collaboration
• No-blame framework
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Who is this approach suited for?
Parents and caregivers can learn these skills and take on these roles regardless of their loved ones’s level of motivation or involvement in formal treatment. EFFT is a lifespan approach that can be delivered with individuals only, parents and caregivers only, and with families. Click here for print and audio-resources related to EFFT.
Where can I find more information on the approach?
The Emotion-Focused Family Therapy Clinician's manual is finally available on Amazon, as is the new parenting book. For more information on the EFFT model and related topics, visit our sister site Mental Health Foundations. If you are interested in working with an EFFT clinician or therapist in your area or via video, visit the International Institute for EFFT and consult their directory of certified practitioners.
Evidence Base:
A strong research base for EFFT has been recognized as a result of numerous scientific papers examining the processes and outcomes of EFFT, including follow-up studies:
Sabey, A. K., Lafrance, A., Furrow, J., Diamond, G., & Hughes, D. (2024). A family reunion of “clinical cousins”: Attachment and emotion in four family‐oriented therapy models. Family Process.
Attachment theory and the science of emotion provide a strong foundation for intervention at the family system level. Four therapeutic models in particular, Attachment-Based Family Therapy, Emotion-Focused Family Therapy, Dyadic Developmental Psychotherapy, and Emotionally Focused Family Therapy, demonstrate how a broad and accurate view of attachment relationships and emotion can be utilized to effectively intervene for a variety of presenting problems in a relational and empathic way for all involved. This paper continues a conversation that began at the Summit for Attachment and Emotion in Family Therapy in 2021 and aims to foster openness, collaboration, and affirmation between four different models of family therapy with shared theoretical roots. The presenters at the Summit and the authors of this paper view similarities across these models as validating and differences as opportunities to serve more families in unique ways, learning from one another's creativity to promote healing within families in the most effective and efficient ways possible. The paper frames the value of attachment theory and emotion science for family therapy, discusses the importance of learning from a variety of models with shared theoretical roots, presents brief summaries of the four models presented at the Summit, compares the models for similarities and complementarities, and shares highlights from each of the presenters from the Summit.
Goveas, A., Duku, E., Sabey, A., Uppal Dhariwal, T., & Duncan, L. (2024). Outpatient treatment of children and adolescents using emotion-focused family therapy (EFFT) caregiver workshops: A pre-to postintervention evaluation. Couple and Family Psychology: Research and Practice.
Caregiver participation in their child’s treatment for mental health difficulties can lead to improvements in the child’s emotion processing and mental health symptoms. Emotion-focused family therapy (EFFT) is a transdiagnostic treatment model designed to help caregivers actively support their child’s treatment. Three of EFFT’s aims are to (1) increase caregiver’s confidence in their ability to enact strategies supporting recovery, (2) improve caregiver’s awareness about their own reactions to their child’s needs, and (3) provide caregivers with behavioral and emotion-focused skills to support their child at home. We examined the short-term impact of group-based manualized 2-day EFFT caregiver workshops delivered in person from 2017 to 2020 to 463 caregivers of children and adolescents seeking community outpatient services. Before and after the workshop, caregivers completed questionnaires assessing caregiver self-efficacy, emotion blocks, reflective functioning, perceptions of their child’s emotion regulation and mental health challenges. Quantitative and qualitative workshop satisfaction data were collected. Accounting for caregiver clustering, effects from paired t tests for differences in mean scores before and immediately after the intervention revealed the following: (a) increases in caregiver self-efficacy (d = 1.23) although internal consistency of scale scores was low in our sample; (b) small improvements in caregiver perceptions of the child’s mental health difficulties (d = .26), particularly externalizing (d = .32) and conduct (d = .36) problems; and (c) small improvements in caregiver perceptions of their child’s negative affect and changeable/extreme moods (d = .23). These results, combined with high levels of caregiver satisfaction, suggest EFFT caregiver workshops may be an efficient, cost and resource effective intervention option for caregivers of children experiencing mental health difficulties.
Foroughe, M., Browne, D. T., Thambipillai, P., Cordeiro, K., & Muller, R. T. (2023). Brief emotion‐focused family therapy: A 12‐month follow‐up study. Journal of Marital and Family Therapy, 49(2), 394-410.
This study provides a 12-month follow-up evaluation of caregivers after participating in a 2-day Emotion-focused family therapy (EFFT) intensive, a brief intervention for caregivers of youth struggling with mental health difficulties. Caregivers (N = 498) of children (N = 337) completed measures of caregiver self-efficacy and child mental health difficulties 1 week before the intervention, immediately after the intervention, and at 4, 8, and 12-month follow-ups. Piecewise latent trajectory models revealed that parental self-efficacy showed a large immediate increase following the intervention, β = 1.61 (1.32, 2.14), and although this effect was attenuated by 4 months, β = −0.77 (−1.31, −0.52), it did not change further by 12 months. Reductions in child mental health difficulties were observed by 4 months, β = −0.54 (−0.77, −0.37), and remained stable through the 12-month follow-up. Caregivers reporting more increases in self-efficacy also reported greater reductions in their children's symptoms at 4 and 12 months.
Smith, J. A., Bandealy, A., & Browne, D. T. (2023). A case study of virtually delivered emotion‐focused family therapy. Journal of Marital and Family Therapy, 49(3), 692-713.
Clinical psychologists and therapists are increasingly taking advantage of internet and mobile-based technologies to deliver mental health services for individuals and groups since the COVID-19 pandemic. However, there is a dearth of research evaluating the appropriateness of virtual platforms for family interventions. Further, no research has examined the effectiveness of weekly emotion-focused family therapy (EFFT). This case study presents a virtually delivered 8-week EFFT intervention, which supported caregivers to manage child symptoms of depression, anxiety, and anger, facilitate emotion processing, and strengthen relationships. Two parents from one family during a marital separation participated and completed brief measures of therapeutic alliance, family functioning, parental self-efficacy, and parental and child psychological distress at 12 time points as well as a posttreatment semistructured interview. A strong therapeutic alliance was formed, and general family functioning, parental self-efficacy, parent psychopathology, and child depression, anger, and anxiety symptoms improved over the course of therapy.
Sabey, A. K., Stillar, A., & Lafrance, A. (2022). Processes and outcomes of an emotion‐focused family therapy two‐chair intervention for transforming problematic parenting patterns. Journal of Marital and Family Therapy, 48(3), 738-757.
Emotion-focused family therapy (EFFT) is a therapy model which includes a two-chair intervention aimed at facilitating awareness and an interruption of problematic patterns of parenting as well as a reconnection to healthy caregiving instincts. The present study employed a task analysis to examine the process of this intervention with parents in a therapeutic setting and report on preliminary outcomes. Four trained EFFT therapists conducted chair work interventions with four parents (total of 16) and parents completed questionnaires directly following the intervention. Results indicated that most parents experienced significant emotional resolution of their love-based fears and an increase in confidence in supporting their children struggling with mental health issues. Use of the intervention in clinical settings is an effective and efficient way to support parents in responding to their children's mental health challenges.
Stillar, A., Merali, N., Gusella, J., Scarborough, J., Nash, P., Orr, E., ... & Lafrance, A. (2022). Caring for a child with an eating disorder: Understanding differences among mothers and fathers of adolescent and adult children. European Eating Disorders Review.
This study involved a secondary analysis of pre-treatment data from a subsample of 143 parents (95 mothers; 48 fathers) from a Canada-wide multi-site study. Parents completed the Caregiver Traps Scale, Parents Versus Anorexia Scale, and the Accommodation and Enabling Scale for Eating Disorders. Data were analysed using factorial Multivariate Analysis of Variance and mediation via multiple regression. Mothers reported higher levels of treatment-engagement fears than fathers. Among mothers, higher fear predicted lower self-efficacy and more accommodating and enabling behaviours. Among fathers, neither fear nor self-efficacy predicted accommodating and enabling. No differences in treatment-engagement fear or self-efficacy between parents of adolescent child and adult children were found at pre-treatment. Mothers' and fathers' experience different levels of fear related to their involvement in their ill-child's treatment at pre-treatment, and that fear is uniquely related to variables that impact treatment outcomes. There is a need to support parents even when their child is an adult. This study can inform family-based treatments vis-a-vis tailoring interventions for mothers and fathers and providing support to parents of children with eating disorders across the lifespan.
Cordeiro, K., Wyers, C., Oliver, M., Foroughe, M., & Muller, R. T. (2022). Caregiver maltreatment history and treatment response following an intensive Emotion Focused Family Therapy workshop. Clinical Psychology & Psychotherapy.
This single-arm, repeated measures study investigated the impact caregiver trauma history may have on treatment response following an intensive, 2-day Emotion Focused Family Therapy (EFFT) caregiver workshop. Caregivers (n = 243) completed questionnaires regarding their child's emotion regulation and clinical symptoms, as well as their own childhood trauma history (i.e., exposure to various forms of child maltreatment), caregiver self-efficacy and caregiver blocks (e.g., fears) to support their child's treatment and recovery. Questionnaires were administered prior to and immediately following the workshop and again 4, 8 and 12 months later. At baseline, caregivers who reported experiences of childhood maltreatment demonstrated more blocks compared with caregivers who did not (B = 6.35, SE = 2.62, p < 0.05). Results indicated that caregivers with and without maltreatment histories reported similar, significant gains in their child's total difficulties (B = 0.64, SE = 0.41, p = 0.12) and emotional negativity and lability (B = 0.51, SE = 0.48, p = 0.29) at 12-month post-workshop. Caregivers with maltreatment histories reported greater improvements in caregiver blocks (B = 5.15, SE = 1.34, p < 0.001) and child emotion regulation (B = 0.90, SE = 0.18, p < 0.001) than caregivers without maltreatment histories. They also report less, but still significant, improvement in parental self-efficacy (B = −0.68, SE = 0.26, p < 0.01) when compared with caregivers without maltreatment histories. Findings suggest that EFFT workshops may be an acceptable and effective trans-diagnostic intervention for families presenting with complex histories, including caregiver exposure to childhood maltreatment.
Lafrance, A., Strahan, E. J., & Stillar, A. (2021). Treatment-engagement fears in family-oriented interventions: validation of the caregiver traps scale for eating disorders. Eating Disorders, 1-16.
As more caregivers of children (of any age) struggling with an eating disorder are recruited as partners in care, it is important to identify potential barriers to such involvement. The Caregiver Traps Scale for Eating Disorders (CTS-ED) was developed as a measure of caregiver fears with respect to treatment-engagement. The purpose of this study was to evaluate its psychometric properties. One hundred and twenty four parents of children with ED participated in the validation of this instrument. Data were analyzed through exploratory factor analysis. The exploratory factor analysis revealed one factor, accounting for 39% of the variance, with a mean of 3.99 (scale from 1 to 7), indicating that caregivers endorsed clinically significant fears relating to their involvement in their child’s treatment. The scale yielded high internal consistency (α = .89). As expected, the CTS-ED was significantly positively correlated with a measure of accommodating and enabling of ED symptoms, and negatively correlated with a measure of parental self-efficacy. This scale shows promise as a measure for clinicians and researchers to identify parental fears that could potentially fuel accommodating, enabling or treatment-interfering behaviors. Suggestions for its utility as a clinical and supervision tool are also provided.
Nash, P., Renelli, M., Stillar, A., Streich, B., & Lafrance, A. (2020). Long-Term Outcomes of a Brief Emotion-Focused Family Therapy Intervention for Eating Disorders Across the Lifespan: A Mixed-Methods Study. Canadian Journal of Counselling & Psychotherapy/Revue Canadienne de Counseling et de Psychothérapie, 54(2).
Abstract: Emotion-focused family therapy (EFFT) empowers caregivers to support their loved one's eating disorder (ED) recovery. Data were collected over time from 74 caregivers who participated in a 2-day EFFT workshop. Results revealed positive outcomes related to self-efficacy, treatment engagement fears, and the accommodation and enabling of behaviours. A thematic analysis of interviews conducted with eight caregivers identified the following themes: (a) increasing self-efficacy with emotion, (b) working through emotion blocks, (c) strengthening interpersonal relationships, (d) experiencing togetherness among participants, and (e) benefiting from experiential practice via role-play. Results suggest this brief intervention is associated with positive caregiver outcomes that can be maintained over time.
Wilhelmsen-Langeland, A., Aardal, H., Hjelmseth, V., Fyhn, K. H., & Stige, S. H. (2019). An Emotion Focused Family Therapy workshop for parents with children 6-12 years increased parental self-efficacy. Emotional and Behavioural Difficulties, 1-13.
Abstract: In this pilot study, we examined whether a 2-day Emotion-Focused Family Therapy workshop strengthened parental self-efficacy, satisfaction and beliefs regarding their ability to help their children regulate emotions and reduce the children’s symptoms of behavioural- or psychological difficulties. Twenty-three caretakers with 17 children (9 boys) aged 6 to 12 years old completed the workshop. Pre, post and 3-month follow-up data on the Parents` Beliefs About Children`s Emotions – Guidance scale and Parenting Sense of Competence scale, as well as pre and 3-month follow-up data on the Child Behaviour Checklist parent form, were used to assess the effects of the intervention. Parental self-efficacy significantly increased, the caretakers` satisfaction in the parenting role significantly increased but faded after 3 months and the caretakers` beliefs that children can guide their emotions on their own were significantly reduced. Finally, oppositional defiant problems in the children significantly declined.
Foroughe, M., Stillar, A., Goldstein, L., Dolhanty, J., Goodcase, E. T., & Lafrance, A. (2018). Brief Emotion Focused Family Therapy: An Intervention for Parents of Children and Adolescents with Mental Health Issues. Journal of Marital and Family Therapy.
Abstract: This study evaluated the 2-day intensive modality of Emotion Focused Family Therapy (EFFT). The intervention attempts to prepare parents to take a primary role in their child's recovery from a range of mental health issues. One hundred and twenty-four parents completed the intervention and provided data a week prior to intervention, post-intervention and at 4-month follow-up. Results include significantly reduced parent blocks and increased parental self-efficacy in relation to involvement in their child's recovery, as well as significant improvement in child symptomatology. The findings confirm positive results from an earlier pilot study involving eating disorders and demonstrate the potential for EFFT as an intervention for a range of clinical problems in children and youth.
Bøyum, H., & Stige, S. H. (2017). «Jeg forstår henne bedre nå» – En kvalitativ studie av foreldres opplevelse av relasjonen til egne barn etter emosjonsfokusert foreldreveiledning [“I understand her better now” – A qualitative study of parents’ experiences of their relationship to their children after Emotion-Focused Family Therapy (EFFT)]. Scandinavian Psychologist, 4, e11.
Abstract: In this article, we report from a qualitative study investigating whether and how parents experience Emotion-Focused Family Therapy’s (EFFT’s) impact on the relationship to their children. Six parents who had attended a two-day course of EFFT were interviewed, with qualitative in-depth interviews taking place two to four months after completion of the course. We used a hermeneutic-phenomenological approach in analyzing these interviews. Analysis resulted in four main themes: Increased understanding of the child; Stronger confidence in their role as parents; Increased focus on emotions improving relationships; and Improved communication with the child. The study shows how the parents experienced becoming more secure in their role as parents and obtaining increased confidence in their own abilities. In addition, they experienced improved contact with, and better understanding of, their children. The parents underscored how these processes were ongoing and demanding and how they entailed considerable effort. Further research will contribute to expanding and nuancing our knowledge on how parents experience receiving EFFT and how such therapy affects parents’ experiences of their relationships with their children.
Strahan, E. J., Stillar, A., Files, N., Nash, P., Scarborough, J., Connors, L., ... & Orr, E. Lafrance, A. (2017). Increasing parental self-efficacy with Emotion-Focused Family Therapy for eating disorders: a process model. Person-Centered & Experiential Psychotherapies, 16(3), 256-269.
Abstract: A process model was tested whereby parental fear and self-blame were targeted in order to enhance parental self-efficacy and supportive efforts in the context of emotion-focused family therapy (EFFT) for eating disorders (ED). A 2-day EFFT group intervention was delivered to parents of adolescent and adult children with ED. Data were collected from eight treatment sites (N = 124). Data were analyzed using t-tests, regression analyses and structural equation modeling. The findings supported the proposed process model. Through the processing of parents’ maladaptive fear and self-blame, parents felt more empowered to support their child’s recovery. This increase in self-efficacy led to an increase in parents’ intentions to engage in recovery-focused behaviors. This study is the first to test a method for clinicians to increase supportive efforts by targeting and enhancing caregiver self-efficacy via the processing of emotion.
Stillar, A., Strahan, E., Nash, P., Files, N., Scarborough, J., Mayman, S., . . . Lafrance Robinson, A. (2016). The influence of carer fear and self-blame when supporting a loved one with an eating disorder. Eating Disorders, 24(2), 173-185.
Abstract: Carers often feel disempowered and engage in behaviours that inadvertently enable their loved one’s ED symptoms and yet little is known regarding these processes. This study examined the relationships among fear, self-blame, self-efficacy, and accommodating and enabling behaviours in 137 carers of adolescents and adults with ED. The results revealed that fear and self-blame predicted low carer self-efficacy in supporting their loved one’s recovery as well as the extent to which carers reported engaging in recovery-interfering behaviours. The relevance of these findings are discussed in the context of family-oriented ED therapies and highlight the importance for clinicians to attend to and help to process strong emotions in carers, in order to improve their supportive efforts and, ultimately, ED outcomes.
Lafrance Robinson, A., & Kosmerly, S. (2015). The influence of clinician emotion on decisions in child and adolescent eating disorder treatment: a survey of self and others. Eating disorders, 23(2), 163-176.
Abstract: Eating disorder clinicians from various disciplines participated in one of two surveys: the “self” group (n = 143) completed a survey assessing the negative influence of emotions on their own clinical decisions, while the “other” group (n = 145) completed a parallel version of the survey that assessed their perceptions of the negative influence of emotion in their colleagues. Both groups endorsed this phenomenon to some degree, although differences in reporting were noted between groups. The perceived negative influence of emotion with regards to specific treatment decisions fell within three categories: decisions regarding food and weight, decisions regarding the involvement of the family in treatment, and decisions related to autonomy and control. Decisions regarding the involvement of the family were perceived to be the most emotionally charged, in particular the involvement of a critical or dismissive parent.
Lafrance Robinson, A. L., Dolhanty, J., & Greenberg, L. (2015). Emotion‐focused family therapy for eating disorders in children and adolescents. Clinical psychology & psychotherapy, 22(1), 75-82.
Abstract: Family‐based therapy (FBT) is regarded as best practice for the treatment of eating disorders in children and adolescents. In FBT, parents play a vital role in bringing their child or adolescent to health; however, a significant minority of families do not respond to this treatment. This paper introduces a new model whereby FBT is enhanced by integrating emotion‐focused therapy (EFT) principles and techniques with the aims of helping parents to support their child's refeeding and interruption of symptoms. Parents are also supported to become their child's ‘emotion coach’; and to process any emotional ‘blocks’ that may interfere with their ability to take charge of recovery. A parent testimonial is presented to illustrate the integration of the theory and techniques of EFT in the FBT model. EFFT (Emotion‐Focused Family Therapy) is a promising model of therapy for those families who require a more intense treatment to bring about recovery of an eating disorder.
Lafrance Robinson, A., & Kosmerly, S. (2015). The influence of clinician emotion on decisions in child and adolescent eating disorder treatment: a survey of self and others. Eating disorders, 23(2), 163-176.
Abstract: Eating disorder clinicians from various disciplines participated in one of two surveys: the “self” group (n = 143) completed a survey assessing the negative influence of emotions on their own clinical decisions, while the “other” group (n = 145) completed a parallel version of the survey that assessed their perceptions of the negative influence of emotion in their colleagues. Both groups endorsed this phenomenon to some degree, although differences in reporting were noted between groups. The perceived negative influence of emotion with regards to specific treatment decisions fell within three categories: decisions regarding food and weight, decisions regarding the involvement of the family in treatment, and decisions related to autonomy and control. Decisions regarding the involvement of the family were perceived to be the most emotionally charged, in particular the involvement of a critical or dismissive parent.
Lafrance Robinson, A., Dolhanty, J., Stillar, A., Henderson, K., & Mayman, S. (2014). Emotion-Focused Family Therapy for Eating Disorders Across the Lifespan: A Pilot Study of a 2-Day Transdiagnostic Intervention for Parents. Clinical Psychology & Psychotherapy, 23(1), 14-23.
Abstract: Emotion‐focused family therapy is a transdiagnostic approach that affords parents and caregivers a significant role in their loved one's recovery from an eating disorder. A 2‐day intervention was developed on the basis of emotion‐focused family therapy principles and delivered to 33 parents of adolescent and adult children. Data were collected pre‐ and post‐intervention. Through education and skills practice, parents were taught strategies with respect to meal support and symptom interruption as well as emotion coaching. Parents were also supported to identify and work through their own emotional blocks that could interfere with their supportive efforts. Analyses revealed a significant increase in parental self‐efficacy, a positive shift in parents' attitudes regarding their role as emotion coach and a reduction in the fears associated with their involvement in treatment, including a decrease in self‐blame. Overall, this broad‐based, low‐cost intervention shows promise, and future research is warranted.