Emotionally Focused Therapy With Interabled Couples – Comprehensive Study Notes
Article Metadata
DOI: 10.1111/jmft.12594
Published in Journal of Marital and Family Therapy, 2022, Vol. 48, pp. 1206–1225.
Article Type: Original empirical study.
Title: Emotionally Focused Therapists' Experiences Serving Interabled Couples in Couple Therapy: An Interpretative Phenomenological Analysis.
Authors & Affiliations:
Jose L. Tapia-Fuselier Jr., PhD – Univ. of Colorado–Colorado Springs.
Dee C. Ray, PhD – Univ. of North Texas.
Robert Allan, PhD – Univ. of Colorado–Denver.
Ana Guadalupe Reyes, PhD – California State Univ.–Fullerton.
Key Definitions & Conceptual Grounding
Disability and Prevalence
CDC (2019) estimate: 61\text{ million} adults (≈26\% of U.S. population) identify as disabled.
Disability (U.S. DoJ, 2009): physical, sensory, mental, or intellectual impairment limiting full social participation.
Language: Identity-first ("disabled person") adopted to align with the social model.
Models of Disability
Medical Model – Disability as defect to be cured/fixed.
Social Model – Disability arises from societal barriers/ableism; emphasizes identity & rights.
Ableism – Systemic prejudice privileging nondisabled norms; manifests through deficit language, lower expectations, dehumanisation.
Interabled Couples
Definition: Partnerships where one partner is disabled, the other nondisabled.
Post-acquisition challenges:
Psychological: anxiety, depression, grief.
Relational: power imbalances, role renegotiation (e.g., caregiver dynamics).
Social: shifting support networks, financial strain, accessibility barriers.
Potential resilience factors: adaptive coping, external supports, shared meaning.
Emotionally Focused Therapy (EFT)
Attachment-based, empirically supported couple-therapy model (>35 years of research).
Three Stages & Nine Steps (Johnson, 2019):
De-escalation / stabilization of negative cycle.
Restructuring interactions & fostering bonding events.
Consolidation & integration of new patterns.
Efficacy: Meta-analysis shows 70\text{–}73\% improvement in distress; 46.4\% maintain gains at 24-month follow-up.
Prior EFT diversity studies: infertility, breast cancer, end-stage cancer, etc.
Purpose & Guiding Question
Gap: Minimal qualitative insight into how EFT clinicians work with interabled couples; limited disability-focused training in COAMFTE & CACREP curricula.
Research Question: How do EFT therapists make sense of their lived experience working with interabled couples in couple therapy?
Methodology
Interpretative Phenomenological Analysis (IPA)
Philosophical pillars: Phenomenology (lived experience), Hermeneutics (interpretation), Idiography (case-level depth).
Dual analytic commitment (Larkin et al., 2006): giving voice + making sense.
Participants
Sampling: Purposeful, homogeneous.
n = 10 ICEEFT-Certified EFT therapists.
Gender: 2 men, 8 women.
Race: 9 White; 1 undisclosed.
Age: M_{age} = 46.3, SD = 11 (range 28\text{–}63).
Licensure: LMFT (4), LCSW (3), LPC (1), Psychologist (1), Dual LMFT/LCSW (1).
EFT experience: M = 6.1 years, SD = 2.6 (range 2\text{–}>10).
Couples served: M = 2.9 interabled couples, SD = 2.6.
Data Collection
Semi-structured interviews (35–70 min).
Eight guiding questions + demographic form.
Interviews transcribed verbatim; member-checked by participants.
Data Analysis Steps (Smith et al., 2009)
Immersive reading & margin noting.
Three comment layers: descriptive, linguistic, conceptual.
Emergent theme generation via hermeneutic circle.
Case-specific theme maps cross-case patterning → superordinate themes.
Auditor review at 10\%, 50\%, 100\% coding; peer debriefs; reflexive journaling (personal & epistemological).
Saturation achieved; study met "good" IPA quality criteria (Smith, 2011).
Trustworthiness Strategies
Audit trail, member checking, quality checklist, positionality disclosure, peer debriefing.
Researcher Positionality
Lead: Gay Latinx cis man; 10 yrs disability-sector experience; not personally disabled nor in interabled relationship → engaged in bracketing.
Auditor: PhD counselor with multiple marginalized identities & qualitative expertise.
Results – Four Superordinate Themes
1. Ableism
Deficit Language: “permanently damaged,” “affliction,” “darkness,” “physically challenged.” Seven of ten clinicians defaulted to medical/deficit phrasing.
Discomfort With Term ‘Disability’: One therapist felt "belittling"; preferred “relatively able.”
Occasional Resistance: Some therapists explicitly named social-construction of disability, sought respectful curiosity.
2. Self-of-the-Therapist
a. Therapist Insecurities
Fear of “getting it wrong,” building alliance across disability difference, accommodating authentically.
b. Impact on Therapist Behaviour
Tentativeness in raising disability; risk of over- or under-focusing.
Example: Avoiding requests for repetition with client who had speech impairment → clinician missed content.
c. Emotional Impact
Feelings of frustration, sadness, helplessness.
Struggle with recognition of life’s inequities (“it’s really not fair … nothing can fix this”).
d. Heightened Self-Awareness
Expanded appreciation of pain spectrum; vigilant for micro-ruptures; active solicitation of client feedback.
3. Reported Relationship Dynamics of Interabled Couples
a. Disabled Partner Experience
Negative view-of-self; heightened abandonment fears; doubt of being loved “just as they are.”
b. Nondisabled Partner Experience
Caregiver/translator roles, attendance at spouse-support groups; balance between helper identity & intimate partner.
c. Couple-Level Dynamics
Intensified grief, loss, financial & physical burdens.
Power imbalance; unprocessed shared trauma; cycle where disability becomes external stressor fueling negative pattern.
d. Therapist Conceptualisation
Necessity to weave disability context into EFT cycle mapping; risk of missing view-of-self elements if disability ignored.
4. “Fit” of EFT With Interabled Couples
a. Strengths
Universality of attachment framework; externalisation of cycle (enemy) resonates across presenting problems.
EFT fosters non-judgmental acceptance.
b. Limitations
Standard pacing & experiential intensity may exceed disabled client’s cognitive/physical capacities.
Clinicians felt constrained, less confident without model tweaks.
c. Disability-Responsive Adaptations
Pre-session accessibility audits (measure doorways, rearrange seating).
Slower tempo; shorter or more frequent breaks.
Explicit integration of disability into Stage 1 cycle work; externalise disability to reduce shame/blame.
Strength-based intake questions, website accessibility statements.
d. Future Recommendations
Call for dedicated EFT masterclass & clinical videos on interabled couples.
Ongoing supervision on disability-responsive practice.
Discussion & Broader Implications
Ableist Language in therapists’ narratives evidences pervasive societal messaging; risks therapeutic harm if unexamined.
Medical Model Dominance contributes to viewing disability as defect → affects assessment, goal-setting, intervention.
Training Gaps: COAMFTE & CACREP lack robust disability content; therapists request formal EFT modules.
Supervision: Even certified supervisors often lack interabled expertise; need for self-of-supervisor exploration of ableism.
Clinical Recommendations:
Structured reflection on ableist assumptions (journals, consultation).
Integrate disability studies & social-model content across curricula.
Develop adaptive EFT protocols (e.g., sensory aids, flexible timing).
Elevate lived expertise of disabled persons within training material.
Study Limitations
Small, homogeneous sample (White, U.S-based, ICEEFT-certified); n=10 limits transferability.
Focus on acquired physical disabilities; congenital & invisible disabilities not represented.
Only therapists interviewed; absent couple/partner voices.
Qualitative design precludes outcome efficacy claims.
Conclusion
EFT therapists experience ableism, personal insecurities, and the necessity for model adaptations when serving interabled couples.
Addressing these factors through targeted training, supervision, and curriculum reform could enhance disability-responsive couple therapy and mitigate service barriers for the estimated 26\% of U.S. adults living with disability.
Selected Key References
Chawla & Kafescioglu (2012) – EFT for chronic illness.
Johnson (2019) – Attachment Theory in Practice.
Nario-Redmond (2019) – Ableism.
Rivas & Hill (2017) – Counselors-in-training & disability.
Smith, Flowers, & Larkin (2009) – IPA: Theory, Method and Research.
Article Metadata
This original empirical study, published in the Journal of Marital and Family Therapy in 2022 (Vol. 48, pp. 1206–1225), holds the DOI 10.1111/jmft.12594. Titled Emotionally Focused Therapists' Experiences Serving Interabled Couples in Couple Therapy: An Interpretative Phenomenological Analysis, it was authored by Jose L. Tapia-Fuselier Jr. (Univ. of Colorado–Colorado Springs), Dee C. Ray (Univ. of North Texas), Robert Allan (Univ. of Colorado–Denver), and Ana Guadalupe Reyes (California State Univ.–Fullerton).
Key Definitions & Conceptual Grounding
Disability and Prevalence
The Centers for Disease Control (CDC) estimated in 2019 that approximately 61\text{ million} adults, or about 26\% of the U.S. population, identify as disabled. The U.S. Department of Justice (2009) defines disability as a "physical, sensory, mental, or intellectual impairment limiting full social participation." For consistent alignment with the social model of disability, the identity-first language, such as "disabled person," is adopted throughout this article.
Models of Disability
Disability is conceptualized primarily through two models: the Medical Model and the Social Model. The medical model views disability as an individual defect that needs to be cured or fixed. In contrast, the social model, which is preferred in this study, posits that disability results from societal barriers and ableism, emphasizing identity and human rights. Ableism is further defined as systemic prejudice that privileges nondisabled norms, often manifesting through deficit language, lower expectations, and dehumanization towards disabled individuals.
Interabled Couples
Interabled couples are defined as partnerships in which one partner is disabled and the other is nondisabled. These couples often face unique challenges post-disability acquisition, including psychological distress such as anxiety, depression, and grief. Relational difficulties can arise from new power imbalances and the renegotiation of roles, particularly the emergence of caregiver dynamics. Socially, they may experience shifting support networks, financial strain, and accessibility barriers. Despite these challenges, potential resilience factors such as adaptive coping mechanisms, reliance on external supports, and the development of shared meaning can strengthen these relationships.
Emotionally Focused Therapy (EFT)
Emotionally Focused Therapy (EFT) is an empirically supported couple-therapy model, grounded in attachment theory, with over 35 years of research backing its efficacy. It operates through Three Stages and Nine Steps, as outlined by Johnson (2019). The first stage, De-escalation, focuses on stabilizing and de-escalating negative interactional cycles. The second stage involves restructuring these interactions and fostering new, positive bonding events. Finally, the third stage focuses on the consolidation and integration of these newly established patterns. Meta-analyses have consistently shown EFT to lead to significant improvement in relationship distress in 70\text{–}73\% of cases, with 46.4\% of couples maintaining these gains at a 24-month follow-up. Prior EFT diversity studies have explored its application in contexts such as infertility, breast cancer, and end-stage cancer.
Purpose & Guiding Question
This study addresses a notable gap in professional literature, specifically the minimal qualitative insight into how Emotionally Focused Therapy clinicians work with interabled couples. This gap is exacerbated by limited disability-focused training within COAMFTE (Commission on Accreditation for Marriage and Family Therapy Education) and CACREP (Council for Accreditation of Counseling and Related Educational Programs) curricula. Thus, the central research question guiding this study was: How do EFT therapists make sense of their lived experience working with interabled couples in couple therapy?
Methodology
Interpretative Phenomenological Analysis (IPA)
The study employs Interpretative Phenomenological Analysis (IPA), a qualitative research approach rooted in three philosophical pillars: Phenomenology, which explores lived experience; Hermeneutics, focusing on the theory of interpretation; and Idiography, which emphasizes in-depth, case-level understanding. IPA involves a dual analytic commitment, as articulated by Larkin et al. (2006), centered on giving voice to participants' experiences while simultaneously making sense of those experiences through researcher interpretation.
Participants
The research included a purposeful, homogeneous sample of 10 ICEEFT-Certified EFT therapists. The participant group consisted of 2 men and 8 women, with 9 identifying as White and 1 declining to disclose their race. Their ages ranged from 28 to 63, with a mean age (M_{\text{age}}) of 46.3 years and a standard deviation (SD) of 11. Regarding licensure, the sample included four Licensed Marriage and Family Therapists (LMFTs), three Licensed Clinical Social Workers (LCSWs), one Licensed Professional Counselor (LPC), one Psychologist, and one clinician holding dual LMFT/LCSW licenses. The therapists had an average of 6.1 years of EFT experience (SD = 2.6, range 2\text{–}>10 years) and reported having served an average of 2.9 interabled couples (SD = 2.6).
Data Collection
Data were collected through semi-structured interviews, lasting between 35 and 70 minutes. Each interview was guided by eight key questions, supplemented by a demographic form. All interviews were transcribed verbatim and subsequently member-checked by the participants to ensure accuracy.
Data Analysis Steps (Smith et al., 2009)
The analysis followed a systematic process based on Smith et al. (2009). Initially, the researchers engaged in immersive reading of the transcripts, making margin notes. This was followed by three layers of commenting: descriptive, capturing what participants said; linguistic, examining their language use; and conceptual, interpreting underlying meanings. Emergent themes were then generated employing a hermeneutic circle, iteratively moving between the part and the whole of the data. Case-specific theme maps were developed and subsequently used for cross-case patterning to identify superordinate themes. To ensure rigor, an auditor reviewed the coding at 10\%, 50\%, and 100\% intervals, supplemented by peer debriefings and extensive reflexive journaling, covering both personal and epistemological reflections. The researchers confirmed that saturation was achieved, and the study met the criteria for "good" IPA quality criteria (Smith, 2011).
Trustworthiness Strategies
To ensure the trustworthiness of the study's findings, several strategies were employed, including maintaining an audit trail of decisions, member checking with participants, using a quality checklist, providing a clear positionality disclosure, and conducting peer debriefing sessions.
Researcher Positionality
The lead researcher identified as a Gay Latinx cis man with 10 years of experience in the disability sector, though not personally disabled nor in an interabled relationship, and engaged in bracketing to mitigate bias. The auditor was a PhD counselor possessing multiple marginalized identities and extensive qualitative expertise.
Results – Four Superordinate Themes
The qualitative analysis yielded four superordinate themes detailing EFT therapists' experiences with interabled couples.
Ableism
Therapists' narratives frequently contained evidence of ableism. This was particularly noticeable in the prevalence of deficit language, with terms such as “permanently damaged,” “affliction,” “darkness,” and “physically challenged” being used, often unconsciously. Seven out of ten clinicians defaulted to this medical/deficit phrasing. Some therapists also expressed discomfort with the term 'disability,' with one preferring "relatively able" due to a feeling that 'disability' was "belittling." Despite these occurrences, there was occasional resistance, with some therapists explicitly acknowledging the social-construction of disability and practicing respectful curiosity.
Self-of-the-Therapist
a. Therapist Insecurities
Therapists reported various insecurities, including a fear of "getting it wrong" when working with interabled couples, concerns about building alliance across disability differences, and anxieties about authentically accommodating clients' needs.
b. Impact on Therapist Behaviour
These insecurities often led to tentativeness in raising the topic of disability in sessions, and a risk of either over-focusing or under-focusing on it. An example cited was avoiding requests for repetition from a client with a speech impairment, which ultimately caused the clinician to miss important content.
c. Emotional Impact
Therapists experienced a range of emotional impacts, including feelings of frustration, sadness, and helplessness. They grappled with the recognition of life’s inherent inequities, acknowledging that "it’s really not fair… nothing can fix this."
d. Heightened Self-Awareness
Despite the challenges, therapists reported heightened self-awareness, which expanded their appreciation of the spectrum of pain, made them more vigilant for micro-ruptures in the therapeutic relationship, and prompted active solicitation of client feedback.
Reported Relationship Dynamics of Interabled Couples
a. Disabled Partner Experience
Disabled partners often presented with a negative view-of-self, heightened fears of abandonment, and doubts about being loved "just as they are."
b. Nondisabled Partner Experience
Nondisabled partners frequently reported taking on caregiver and translator roles and seeking support through spouse-support groups. They struggled to balance their identity as a helper with their identity as an intimate partner.
c. Couple-Level Dynamics
At the couple level, there was often intensified grief, loss, and significant financial and physical burdens. Power imbalances and unprocessed shared trauma were common, with the disability frequently becoming an external stressor that fueled negative interactional patterns.
d. Therapist Conceptualisation
Therapists recognized the necessity of weaving the disability context into the EFT cycle mapping. They noted the risk of missing critical elements of the view-of-self if the disability was not adequately addressed.
“Fit” of EFT With Interabled Couples
a. Strengths
The universality of the attachment framework within EFT was identified as a key strength, as was the externalization of the cycle (the negative interactional pattern) as an enemy, which resonates across various presenting problems. EFT's capacity to foster non-judgmental acceptance was also highlighted.
b. Limitations
However, limitations were noted, particularly that the standard pacing and experiential intensity of EFT might exceed the cognitive and physical capacities of some disabled clients. Clinicians often felt constrained and less confident without making specific adaptations to the model.
c. Disability-Responsive Adaptations
Therapists suggested several disability-responsive adaptations, including pre-session accessibility audits (e.g., measuring doorways, rearranging seating), adopting a slower tempo, and implementing shorter or more frequent breaks. Explicit integration of disability into Stage 1 cycle work and externalizing disability to reduce shame/blame were also recommended. Furthermore, strength-based intake questions and website accessibility statements were seen as beneficial.
d. Future Recommendations
Future recommendations included a call for a dedicated EFT masterclass and clinical videos specifically on working with interabled couples, along with the need for ongoing supervision focused on disability-responsive practice.
Discussion & Broader Implications
Discussion and broader implications highlight several critical areas. The pervasive ableist language observed in therapists’ narratives underscores deeply ingrained societal messaging, which, if unexamined, poses a risk of therapeutic harm. The continued dominance of the medical model contributes to perceiving disability as a defect, thereby influencing assessment, goal-setting, and intervention strategies. Significant training gaps exist, as COAMFTE and CACREP curricula lack robust disability content, leading therapists to request formal EFT modules on the subject. Additionally, supervision is often inadequate, with even certified supervisors frequently lacking expertise in interabled dynamics, underscoring the need for self-of-supervisor exploration regarding ableism. Clinical recommendations derived from the study suggest structured reflection on ableist assumptions through journaling and consultation, integrating disability studies and social-model content across curricula, developing adaptive EFT protocols (e.g., sensory aids, flexible timing), and elevating the lived expertise of disabled persons within training materials.
Study Limitations
The study acknowledges several limitations including a small, homogeneous sample (n=10) composed primarily of White, U.S.-based, ICEEFT-certified therapists, which limits the transferability of findings. The focus was predominantly on acquired physical disabilities, meaning congenital and invisible disabilities were not represented. Furthermore, only therapists were interviewed, excluding the voices of the couples or partners themselves. Finally, as a qualitative design, the study cannot make claims regarding outcome efficacy.
Conclusion
In conclusion, Emotionally Focused Therapy therapists experience ableism, personal insecurities, and the necessity for model adaptations when serving interabled couples. Addressing these factors through targeted training, supervision, and curriculum reform is crucial to enhance disability-responsive couple therapy and mitigate service barriers for the estimated 26\% of U.S. adults living with disability.
Selected Key References
Key references supporting this study include Chawla & Kafescioglu (2012) on EFT for chronic illness, Johnson (2019) with Attachment Theory in Practice, Nario-Redmond (2019) on Ableism, Rivas & Hill (2017) on counselors-in-training and disability, and Smith, Flowers, & Larkin (2009) on IPA: Theory, Method and Research.
Article Metadata
This original empirical study, published in the Journal of Marital and Family Therapy in 2022 (Vol. 48, pp. 1206–1225), holds the DOI 10.1111/jmft.12594. Titled Emotionally Focused Therapists' Experiences Serving Interabled Couples in Couple Therapy: An Interpretative Phenomenological Analysis, it was authored by Jose L. Tapia-Fuselier Jr. (Univ. of Colorado–Colorado Springs), Dee C. Ray (Univ. of North Texas), Robert Allan (Univ. of Colorado–Denver), and Ana Guadalupe Reyes (California State Univ.–Fullerton).
Key Definitions & Conceptual Grounding
Disability and Prevalence
The Centers for Disease Control (CDC) estimated in 2019 that approximately 61\text{ million} adults, or about 26\% of the U.S. population, identify as disabled. The U.S. Department of Justice (2009) defines disability as a "physical, sensory, mental, or intellectual impairment limiting full social participation." For consistent alignment with the social model of disability, the identity-first language, such as "disabled person," is adopted throughout this article.
Models of Disability
Disability is conceptualized primarily through two models: the Medical Model and the Social Model. The medical model views disability as an individual defect that needs to be cured or fixed. In contrast, the social model, which is preferred in this study, posits that disability results from societal barriers and ableism, emphasizing identity and human rights. Ableism is further defined as systemic prejudice that privileges nondisabled norms, often manifesting through deficit language, lower expectations, and dehumanization towards disabled individuals.
Interabled Couples
Interabled couples are defined as partnerships in which one partner is disabled and the other is nondisabled. These couples often face unique challenges post-disability acquisition, including psychological distress such as anxiety, depression, and grief. Relational difficulties can arise from new power imbalances and the renegotiation of roles, particularly the emergence of caregiver dynamics. Socially, they may experience shifting support networks, financial strain, and accessibility barriers. Despite these challenges, potential resilience factors such as adaptive coping mechanisms, reliance on external supports, and the development of shared meaning can strengthen these relationships.
Emotionally Focused Therapy (EFT)
Emotionally Focused Therapy (EFT) is an empirically supported couple-therapy model, grounded in attachment theory, with over 35 years of research backing its efficacy. It operates through Three Stages and Nine Steps, as outlined by Johnson (2019). The first stage, De-escalation, focuses on stabilizing and de-escalating negative interactional cycles. The second stage involves restructuring these interactions and fostering new, positive bonding events. Finally, the third stage focuses on the consolidation and integration of these newly established patterns. Meta-analyses have consistently shown EFT to lead to significant improvement in relationship distress in 70\text{–}73\% of cases, with 46.4\% of couples maintaining these gains at a 24-month follow-up. Prior EFT diversity studies have explored its application in contexts such as infertility, breast cancer, and end-stage cancer.
Purpose & Guiding Question
This study addresses a notable gap in professional literature, specifically the minimal qualitative insight into how Emotionally Focused Therapy clinicians work with interabled couples. This gap is exacerbated by limited disability-focused training within COAMFTE (Commission on Accreditation for Marriage and Family Therapy Education) and CACREP (Council for Accreditation of Counseling and Related Educational Programs) curricula. Thus, the central research question guiding this study was: How do EFT therapists make sense of their lived experience working with interabled couples in couple therapy?
Methodology
Interpretative Phenomenological Analysis (IPA)
The study employs Interpretative Phenomenological Analysis (IPA), a qualitative research approach rooted in three philosophical pillars: Phenomenology, which explores lived experience; Hermeneutics, focusing on the theory of interpretation; and Idiography, which emphasizes in-depth, case-level understanding. IPA involves a dual analytic commitment, as articulated by Larkin et al. (2006), centered on giving voice to participants' experiences while simultaneously making sense of those experiences through researcher interpretation.
Participants
The research included a purposeful, homogeneous sample of 10 ICEEFT-Certified EFT therapists. The participant group consisted of 2 men and 8 women, with 9 identifying as White and 1 declining to disclose their race. Their ages ranged from 28 to 63, with a mean age (M_{\text{age}}) of 46.3 years and a standard deviation (SD) of 11. Regarding licensure, the sample included four Licensed Marriage and Family Therapists (LMFTs), three Licensed Clinical Social Workers (LCSWs), one Licensed Professional Counselor (LPC), one Psychologist, and one clinician holding dual LMFT/LCSW licenses. The therapists had an average of 6.1 years of EFT experience (SD = 2.6, range 2\text{–}>10 years) and reported having served an average of 2.9 interabled couples (SD = 2.6).
Data Collection
Data were collected through semi-structured interviews, lasting between 35 and 70 minutes. Each interview was guided by eight key questions, supplemented by a demographic form. All interviews were transcribed verbatim and subsequently member-checked by the participants to ensure accuracy.
Data Analysis Steps (Smith et al., 2009)
The analysis followed a systematic process based on Smith et al. (2009). Initially, the researchers engaged in immersive reading of the transcripts, making margin notes. This was followed by three layers of commenting: descriptive, capturing what participants said; linguistic, examining their language use; and conceptual, interpreting underlying meanings. Emergent themes were then generated employing a hermeneutic circle, iteratively moving between the part and the whole of the data. Case-specific theme maps were developed and subsequently used for cross-case patterning to identify superordinate themes. To ensure rigor, an auditor reviewed the coding at 10\%, 50\%, and 100\% intervals, supplemented by peer debriefings and extensive reflexive journaling, covering both personal and epistemological reflections. The researchers confirmed that saturation was achieved, and the study met the criteria for "good" IPA quality criteria (Smith, 2011).
Trustworthiness Strategies
To ensure the trustworthiness of the study's findings, several strategies were employed, including maintaining an audit trail of decisions, member checking with participants, using a quality checklist, providing a clear positionality disclosure, and conducting peer debriefing sessions.
Researcher Positionality
The lead researcher identified as a Gay Latinx cis man with 10 years of experience in the disability sector, though not personally disabled nor in an interabled relationship, and engaged in bracketing to mitigate bias. The auditor was a PhD counselor possessing multiple marginalized identities and extensive qualitative expertise.
Results – Four Superordinate Themes
The qualitative analysis yielded four superordinate themes detailing EFT therapists' experiences with interabled couples.
Ableism
Therapists' narratives frequently contained evidence of ableism. This was particularly noticeable in the prevalence of deficit language, with terms such as “permanently damaged,” “affliction,” “darkness,” and “physically challenged” being used, often unconsciously. Seven out of ten clinicians defaulted to this medical/deficit phrasing. Some therapists also expressed discomfort with the term 'disability,' with one preferring "relatively able" due to a feeling that 'disability' was "belittling." Despite these occurrences, there was occasional resistance, with some therapists explicitly acknowledging the social-construction of disability and practicing respectful curiosity.
Self-of-the-Therapist
a. Therapist Insecurities
Therapists reported various insecurities, including a fear of "getting it wrong" when working with interabled couples, concerns about building alliance across disability differences, and anxieties about authentically accommodating clients' needs.
b. Impact on Therapist Behaviour
These insecurities often led to tentativeness in raising the topic of disability in sessions, and a risk of either over-focusing or under-focusing on it. An example cited was avoiding requests for repetition from a client with a speech impairment, which ultimately caused the clinician to miss important content.
c. Emotional Impact
Therapists experienced a range of emotional impacts, including feelings of frustration, sadness, and helplessness. They grappled with the recognition of life’s inherent inequities, acknowledging that "it’s really not fair… nothing can fix this."
d. Heightened Self-Awareness
Despite the challenges, therapists reported heightened self-awareness, which expanded their appreciation of the spectrum of pain, made them more vigilant for micro-ruptures in the therapeutic relationship, and prompted active solicitation of client feedback.
Reported Relationship Dynamics of Interabled Couples
a. Disabled Partner Experience
Disabled partners often presented with a negative view-of-self, heightened fears of abandonment, and doubts about being loved "just as they are."
b. Nondisabled Partner Experience
Nondisabled partners frequently reported taking on caregiver and translator roles and seeking support through spouse-support groups. They struggled to balance their identity as a helper with their identity as an intimate partner.
c. Couple-Level Dynamics
At the couple level, there was often intensified grief, loss, and significant financial and physical burdens. Power imbalances and unprocessed shared trauma were common, with the disability frequently becoming an external stressor that fueled negative interactional patterns.
d. Therapist Conceptualisation
Therapists recognized the necessity of weaving the disability context into the EFT cycle mapping. They noted the risk of missing critical elements of the view-of-self if the disability was not adequately addressed.
“Fit” of EFT With Interabled Couples
a. Strengths
The universality of the attachment framework within EFT was identified as a key strength, as was the externalization of the cycle (the negative interactional pattern) as an enemy, which resonates across various presenting problems. EFT's capacity to foster non-judgmental acceptance was also highlighted.
b. Limitations
However, limitations were noted, particularly that the standard pacing and experiential intensity of EFT might exceed the cognitive and physical capacities of some disabled clients. Clinicians often felt constrained and less confident without making specific adaptations to the model.
c. Disability-Responsive Adaptations
Therapists suggested several disability-responsive adaptations, including pre-session accessibility audits (e.g., measuring doorways, rearranging seating), adopting a slower tempo, and implementing shorter or more frequent breaks. Explicit integration of disability into Stage 1 cycle work and externalizing disability to reduce shame/blame were also recommended. Furthermore, strength-based intake questions and website accessibility statements were seen as beneficial.
d. Future Recommendations
Future recommendations included a call for a dedicated EFT masterclass and clinical videos specifically on working with interabled couples, along with the need for ongoing supervision focused on disability-responsive practice.
Discussion & Broader Implications
Discussion and broader implications highlight several critical areas. The pervasive ableist language observed in therapists’ narratives underscores deeply ingrained societal messaging, which, if unexamined, poses a risk of therapeutic harm. The continued dominance of the medical model contributes to perceiving disability as a defect, thereby influencing assessment, goal-setting, and intervention strategies. Significant training gaps exist, as COAMFTE and CACREP curricula lack robust disability content, leading therapists to request formal EFT modules on the subject. Additionally, supervision is often inadequate, with even certified supervisors frequently lacking expertise in interabled dynamics, underscoring the need for self-of-supervisor exploration regarding ableism. Clinical recommendations derived from the study suggest structured reflection on ableist assumptions through journaling and consultation, integrating disability studies and social-model content across curricula, developing adaptive EFT protocols (e.g., sensory aids, flexible timing), and elevating the lived expertise of disabled persons within training materials.
Study Limitations
The study acknowledges several limitations including a small, homogeneous sample (n=10) composed primarily of White, U.S.-based, ICEEFT-certified therapists, which limits the transferability of findings. The focus was predominantly on acquired physical disabilities, meaning congenital and invisible disabilities were not represented. Furthermore, only therapists were interviewed, excluding the voices of the couples or partners themselves. Finally, as a qualitative design, the study cannot make claims regarding outcome efficacy.
Conclusion
In conclusion, Emotionally Focused Therapy therapists experience ableism, personal insecurities, and the necessity for model adaptations when serving interabled couples. Addressing these factors through targeted training, supervision, and curriculum reform is crucial to enhance disability-responsive couple therapy and mitigate service barriers for the estimated 26\% of U.S. adults living with disability.
Selected Key References
Key references supporting this study include Chawla & Kafescioglu (2012) on EFT for chronic illness, Johnson (2019) with Attachment Theory in Practice, Nario-Redmond (2019) on Ableism, Rivas & Hill (2017) on counselors-in-training and disability, and Smith, Flowers, & Larkin (2009) on IPA: Theory, Method and Research.
Article Metadata
This original empirical study, published in the Journal of Marital and Family Therapy in 2022 (Vol. 48, pp. 1206–1225), holds the DOI 10.1111/jmft.12594. Titled Emotionally Focused Therapists' Experiences Serving Interabled Couples in Couple Therapy: An Interpretative Phenomenological Analysis, it was authored by Jose L. Tapia-Fuselier Jr. (Univ. of Colorado–Colorado Springs), Dee C. Ray (Univ. of North Texas), Robert Allan (Univ. of Colorado–Denver), and Ana Guadalupe Reyes (California State Univ.–Fullerton).
Key Definitions & Conceptual Grounding
Disability and Prevalence
The Centers for Disease Control (CDC) estimated in 2019 that approximately 61\text{ million} adults, or about 26\% of the U.S. population, identify as disabled. The U.S. Department of Justice (2009) defines disability as a "physical, sensory, mental, or intellectual impairment limiting full social participation." For consistent alignment with the social model of disability, the identity-first language, such as "disabled person," is adopted throughout this article.
Models of Disability
Disability is conceptualized primarily through two models: the Medical Model and the Social Model. The medical model views disability as an individual defect that needs to be cured or fixed. In contrast, the social model, which is preferred in this study, posits that disability results from societal barriers and ableism, emphasizing identity and human rights. Ableism is further defined as systemic prejudice that privileges nondisabled norms, often manifesting through deficit language, lower expectations, and dehumanization towards disabled individuals.
Interabled Couples
Interabled couples are defined as partnerships in which one partner is disabled and the other is nondisabled. These couples often face unique challenges post-disability acquisition, including psychological distress such as anxiety, depression, and grief. Relational difficulties can arise from new power imbalances and the renegotiation of roles, particularly the emergence of caregiver dynamics. Socially, they may experience shifting support networks, financial strain, and accessibility barriers. Despite these challenges, potential resilience factors such as adaptive coping mechanisms, reliance on external supports, and the development of shared meaning can strengthen these relationships.
Emotionally Focused Therapy (EFT)
Emotionally Focused Therapy (EFT) is an empirically supported couple-therapy model, grounded in attachment theory, with over 35 years of research backing its efficacy. It operates through Three Stages and Nine Steps, as outlined by Johnson (2019). The first stage, De-escalation, focuses on stabilizing and de-escalating negative interactional cycles. The second stage involves restructuring these interactions and fostering new, positive bonding events. Finally, the third stage focuses on the consolidation and integration of these newly established patterns. Meta-analyses have consistently shown EFT to lead to significant improvement in relationship distress in 70\text{–}73\% of cases, with 46.4\% of couples maintaining these gains at a 24-month follow-up. Prior EFT diversity studies have explored its application in contexts such as infertility, breast cancer, and end-stage cancer.
Purpose & Guiding Question
This study addresses a notable gap in professional literature, specifically the minimal qualitative insight into how Emotionally Focused Therapy clinicians work with interabled couples. This gap is exacerbated by limited disability-focused training within COAMFTE (Commission on Accreditation for Marriage and Family Therapy Education) and CACREP (Council for Accreditation of Counseling and Related Educational Programs) curricula. Thus, the central research question guiding this study was: How do EFT therapists make sense of their lived experience working with interabled couples in couple therapy?
Methodology
Interpretative Phenomenological Analysis (IPA)
The study employs Interpretative Phenomenological Analysis (IPA), a qualitative research approach rooted in three philosophical pillars: Phenomenology, which explores lived experience; Hermeneutics, focusing on the theory of interpretation; and Idiography, which emphasizes in-depth, case-level understanding. IPA involves a dual analytic commitment, as articulated by Larkin et al. (2006), centered on giving voice to participants' experiences while simultaneously making sense of those experiences through researcher interpretation.
Participants
The research included a purposeful, homogeneous sample of 10 ICEEFT-Certified EFT therapists. The participant group consisted of 2 men and 8 women, with 9 identifying as White and 1 declining to disclose their race. Their ages ranged from 28 to 63, with a mean age (M_{\text{age}}) of 46.3 years and a standard deviation (SD) of 11. Regarding licensure, the sample included four Licensed Marriage and Family Therapists (LMFTs), three Licensed Clinical Social Workers (LCSWs), one Licensed Professional Counselor (LPC), one Psychologist, and one clinician holding dual LMFT/LCSW licenses. The therapists had an average of 6.1 years of EFT experience (SD = 2.6, range 2\text{–}>10 years) and reported having served an average of 2.9 interabled couples (SD = 2.6).
Data Collection
Data were collected through semi-structured interviews, lasting between 35 and 70 minutes. Each interview was guided by eight key questions, supplemented by a demographic form. All interviews were transcribed verbatim and subsequently member-checked by the participants to ensure accuracy.
Data Analysis Steps (Smith et al., 2009)
The analysis followed a systematic process based on Smith et al. (2009). Initially, the researchers engaged in immersive reading of the transcripts, making margin notes. This was followed by three layers of commenting: descriptive, capturing what participants said; linguistic, examining their language use; and conceptual, interpreting underlying meanings. Emergent themes were then generated employing a hermeneutic circle, iteratively moving between the part and the whole of the data. Case-specific theme maps were developed and subsequently used for cross-case patterning to identify superordinate themes. To ensure rigor, an auditor reviewed the coding at 10\%, 50\%, and 100\% intervals, supplemented by peer debriefings and extensive reflexive journaling, covering both personal and epistemological reflections. The researchers confirmed that saturation was achieved, and the study met the criteria for "good" IPA quality criteria (Smith, 2011).
Trustworthiness Strategies
To ensure the trustworthiness of the study's findings, several strategies were employed, including maintaining an audit trail of decisions, member checking with participants, using a quality checklist, providing a clear positionality disclosure, and conducting peer debriefing sessions.
Researcher Positionality
The lead researcher identified as a Gay Latinx cis man with 10 years of experience in the disability sector, though not personally disabled nor in an interabled relationship, and engaged in bracketing to mitigate bias. The auditor was a PhD counselor possessing multiple marginalized identities and extensive qualitative expertise.
Results – Four Superordinate Themes
The qualitative analysis yielded four superordinate themes detailing EFT therapists' experiences with interabled couples.
Ableism
Therapists' narratives frequently contained evidence of ableism. This was particularly noticeable in the prevalence of deficit language, with terms such as “permanently damaged,” “affliction,” “darkness,” and “physically challenged” being used, often unconsciously. Seven out of ten clinicians defaulted to this medical/deficit phrasing. Some therapists also expressed discomfort with the term 'disability,' with one preferring "relatively able" due to a feeling that 'disability' was "belittling." Despite these occurrences, there was occasional resistance, with some therapists explicitly acknowledging the social-construction of disability and practicing respectful curiosity.
Self-of-the-Therapist
a. Therapist Insecurities
Therapists reported various insecurities, including a fear of "getting it wrong" when working with interabled couples, concerns about building alliance across disability differences, and anxieties about authentically accommodating clients' needs.
b. Impact on Therapist Behaviour
These insecurities often led to tentativeness in raising the topic of disability in sessions, and a risk of either over-focusing or under-focusing on it. An example cited was avoiding requests for repetition from a client with a speech impairment, which ultimately caused the clinician to miss important content.
c. Emotional Impact
Therapists experienced a range of emotional impacts, including feelings of frustration, sadness, and helplessness. They grappled with the recognition of life’s inherent inequities, acknowledging that "it’s really not fair… nothing can fix this."
d. Heightened Self-Awareness
Despite the challenges, therapists reported heightened self-awareness, which expanded their appreciation of the spectrum of pain, made them more vigilant for micro-ruptures in the therapeutic relationship, and prompted active solicitation of client feedback.
Reported Relationship Dynamics of Interabled Couples
a. Disabled Partner Experience
Disabled partners often presented with a negative view-of-self, heightened fears of abandonment, and doubts about being loved "just as they are."
b. Nondisabled Partner Experience
Nondisabled partners frequently reported taking on caregiver and translator roles and seeking support through spouse-support groups. They struggled to balance their identity as a helper with their identity as an intimate partner.
c. Couple-Level Dynamics
At the couple level, there was often intensified grief, loss, and significant financial and physical burdens. Power imbalances and unprocessed shared trauma were common, with the disability frequently becoming an external stressor that fueled negative interactional patterns.
d. Therapist Conceptualisation
Therapists recognized the necessity of weaving the disability context into the EFT cycle mapping. They noted the risk of missing critical elements of the view-of-self if the disability was not adequately addressed.
“Fit” of EFT With Interabled Couples
a. Strengths
The universality of the attachment framework within EFT was identified as a key strength, as was the externalization of the cycle (the negative interactional pattern) as an enemy, which resonates across various presenting problems. EFT's capacity to foster non-judgmental acceptance was also highlighted.
b. Limitations
However, limitations were noted, particularly that the standard pacing and experiential intensity of EFT might exceed the cognitive and physical capacities of some disabled clients. Clinicians often felt constrained and less confident without making specific adaptations to the model.
c. Disability-Responsive Adaptations
Therapists suggested several disability-responsive adaptations, including pre-session accessibility audits (e.g., measuring doorways, rearranging seating), adopting a slower tempo, and implementing shorter or more frequent breaks. Explicit integration of disability into Stage 1 cycle work and externalizing disability to reduce shame/blame were also recommended. Furthermore, strength-based intake questions and website accessibility statements were seen as beneficial.
d. Future Recommendations
Future recommendations included a call for a dedicated EFT masterclass and clinical videos specifically on working with interabled couples, along with the need for ongoing supervision focused on disability-responsive practice.
Discussion & Broader Implications
Discussion and broader implications highlight several critical areas. The pervasive ableist language observed in therapists’ narratives underscores deeply ingrained societal messaging, which, if unexamined, poses a risk of therapeutic harm. The continued dominance of the medical model contributes to perceiving disability as a defect, thereby influencing assessment, goal-setting, and intervention strategies. Significant training gaps exist, as COAMFTE and CACREP curricula lack robust disability content, leading therapists to request formal EFT modules on the subject. Additionally, supervision is often inadequate, with even certified supervisors frequently lacking expertise in interabled dynamics, underscoring the need for self-of-supervisor exploration regarding ableism. Clinical recommendations derived from the study suggest structured reflection on ableist assumptions through journaling and consultation, integrating disability studies and social-model content across curricula, developing adaptive EFT protocols (e.g., sensory aids, flexible timing), and elevating the lived expertise of disabled persons within training materials.
Study Limitations
The study acknowledges several limitations including a small, homogeneous sample (n=10) composed primarily of White, U.S.-based, ICEEFT-certified therapists, which limits the transferability of findings. The focus was predominantly on acquired physical disabilities, meaning congenital and invisible disabilities were not represented. Furthermore, only therapists were interviewed, excluding the voices of the couples or partners themselves. Finally, as a qualitative design, the study cannot make claims regarding outcome efficacy.
Conclusion
In conclusion, Emotionally Focused Therapy therapists experience ableism, personal insecurities, and the necessity for model adaptations when serving interabled couples. Addressing these factors through targeted training, supervision, and curriculum reform is crucial to enhance disability-responsive couple therapy and mitigate service barriers for the estimated 26\% of U.S. adults living with disability.
Selected Key References
Key references supporting this study include Chawla & Kafescioglu (2012) on EFT for chronic illness, Johnson (2019) with Attachment Theory in Practice, Nario-Redmond (2019) on Ableism, Rivas & Hill (2017) on counselors-in-training and disability, and Smith, Flowers, & Larkin (2009) on IPA: Theory, Method and Research.