The effect of therapists’ enactment interventions in promoting vulnerability sharing in emotion focused couple therapy

Abstract

Objective

The primary purported change process in emotion-focused therapy for couples (EFT-C) involves partners accessing and revealing their underlying vulnerable emotions and responding empathically when their partners disclose their vulnerable emotions. One main intervention to facilitate vulnerability sharing is enactment – guiding partners to interact directly with each other. The objective of the current study was to identify interventions therapists can use to help partners share vulnerability in the context of enactment. The primary hypothesis of this study was that promoting these interventions would lead to more vulnerability expressions during enactments.

Method

One hundred and five vulnerability enactment events were identified from videod therapy sessions of 33 couples dealing with a significant emotional injury who received 12 sessions of EFT-C. Four therapists’ interventions were coded: setting a meaningful systemic context, promoting the revealing partner’s emotional engagement, preparing the revealing partner for enactment, and promoting the listening partner’s emotional engagement in the enactment. In addition, vulnerability expression was coded.

Results

Multilevel regression models showed that two interventions were significantly associated with greater levels of expressed vulnerability: setting a meaningful systemic context, and preparing the revealing partner for enactment.

Conclusion

These findings suggest that therapists can facilitated vulnerability sharing using specific preparatory interventions.

KEYWORDS:

• emotion focused therapy for couples
• couples therapy
• enactment
• vulnerability
• therapists' interventions

Clinical or methodological significance of this article: Vulnerability enactment – guiding partners to share vulnerable emotions with each other – is a primary change process in emotion-focused therapy for couples (EFT-C). The current work identified interventions therapists can use to effectively promote vulnerability sharing (e.g., setting a meaningful systemic context, preparing the revealing partner for enactment).

Emotion-Focused Therapy for Couples (EFT-C; Greenberg & Goldman, 2008; Greenberg & Johnson, 1988) is an evidence-based couples therapy integrating systemic, humanistic, and experiential elements grounded in emotion science (Woldarsky Meneses, 2017). According to EFT-C, a couple's dynamic is determined by each partner's emotional experience and how these interact. Conflicts and distress are conceptualized as resulting from rigid and repeated maladaptive interactional cycles that arise when the partners’ basic emotional needs for closeness and validation are not met (Woldarsky Meneses, 2017). When these needs are thwarted, partners experience emotional pain (fear, loneliness, and shame), which drives them to engage in maladaptive behaviors in an attempt to elicit a response from their partner and protect themselves from their emotional pain. However, such attempted solutions (Fisch et al., 1982; Greenberg & Goldman, 2008; Watzlawick et al., 1974; Weakland et al., 1974) often lead to conflict escalation.

For example, when Sarah asks for Dan's help getting the children ready for school in the morning, and Dan is not attentive, Sarah may feel unsupported, alone, and even abandoned. She often tries to regulate her emotional pain by critically demanding that Dan attend to and support her. However, her attempted solutions are experienced as threatening to Dan, who then reacts by withdrawing and distancing himself even more. Her demands and criticism can trigger Dan's feelings of shame, worthlessness, and failure. These painful emotions lead him to feel frustrated and to withdraw. His withdrawal further reinforces Sarah's loneliness, and the cycle is escalated and perpetuated. Such demand-withdraw interactions have been extensively researched and found to be central to marital conflict (Baucom et al., 2015; Eldridge & Baucom, 2012; Fogarty, 1976; Johnson, 2009; Vanhee et al., 2018).

In EFT-C, Sarah's feelings of loneliness and abandonment are considered primary vulnerable emotions, whereas her demanding anger is considered a secondary emotion. Dan's shame is considered a primary vulnerable emotion, and his frustration is a secondary one. Secondary emotions and their associated action tendencies (e.g., blaming) often obscure the more primary vulnerable painful emotions. Therefore, EFT-C is based on the idea that to restructure partners’ maladaptive cycle, partners should be helped to access and reveal their underlying vulnerable emotions and respond empathically to such disclosures (Greenberg & Johnson, 1988).

To foster this restructuring process, EFT-C therapists help partners access their underlying vulnerable emotions and related attachment and identity needs (e.g., closeness and validation). Therapists then encourage the partners to take the emotional risk of revealing and exposing their vulnerability to each other. Thus, Dan needs to openly reveal his shame and its associated need for unconditional acceptance and appreciation, whereas Sarah needs to openly reveal her vulnerable fear of abandonment and its associated need for closeness. Unlike secondary emotions, which tend to elicit defensive reactions from partners, vulnerability is more likely to evoke a compassionate response. Such responsiveness (i.e., understanding, validation, and care) helps restore the partners’ capacity to regulate their emotions dyadically; i.e., to feel safe, connected, and self-worth in each other's presence (Greenberg & Goldman, 2008; Johnson & Greenman, 2006).

Empirical support for a vulnerability-responsiveness event as a restructuring process can be found, for example, in the York Emotional Injury Research Project (Greenberg et al., 2010). In this project, couples struggling with a lingering emotional injury (e.g., betrayal) took part in 12 EFT-C sessions. McKinnon and Greenberg (2013) found that the partners rated sessions in which vulnerable emotions were expressed as more productive. Relatedly, couples who expressed vulnerable emotions at least once during their treatment reported more significant improvement in trust and general levels of relationship satisfaction (see also McKinnon & Greenberg, 2017).

Other EFT-C process studies have focused on specific in-session events related to expressing vulnerable primary emotions. For example, in what is termed a “blamer softening event”, the demanding blaming partner (often referred to as the pursuer) accesses primary emotions and is guided by the therapist to share them with the withdrawing partner. The therapist then works with the withdrawing partner to facilitate empathic and compassionate responses. Several studies have shown that successful blamer-softening events predicted a variety of favorable outcomes, including increased levels of trust, connection, and general levels of relationship satisfaction (Bradley & Furrow, 2004; Burgess Moser et al., 2018; Furrow et al., 2012; Greenman & Johnson, 2013; Makinen & Johnson, 2006; Myung et al., 2022).

One primary intervention EFT-C therapists utilize to facilitate vulnerability sharing is enactment. Enactment is traditionally defined as “an interaction stimulated in structural family therapy in order to observe and then change transactions which make up family structure” (Nichols, 1984, p. 584). Thus, during enactments, therapists ask family members to talk directly to each other and not to the therapist. In structural family therapy, therapists use enactments to assess the family's structure (e.g., alliances, boundaries, hierarchies) as reflected in its members’ interactional patterns (Minuchin & Fishman, 1981). Later in therapy, enactment is used by structural family therapists to instill new interactional patterns to modify the family structure. In other words, enactment allows therapists to intervene and change the interaction by coaching, increasing intensity, and indicating alternative interactional possibilities (Allen-Eckert et al., 2001; Davis & Butler, 2004).

Although it originated in systemic family therapy (Minuchin & Fishman, 1981), more recent work has conceptualized enactment as a “common factor” in a range of marital and family therapy models (Gardner & Butler, 2009). However, Butler and Gardner (2003) noted that despite the potential utility of enactments across theoretical models, therapists often do not have a clear conceptual or operational understanding of enactment. This lack of understanding is likely to impede therapists’ efforts to use this intervention successfully (Butler et al., 2008).

As noted above, one of the primary paths to change in EFT-C is hypothesized to involve vulnerability enactment. However, in many instances, therapists find it challenging to use enactments to help partners reveal their vulnerability (Bradley & Furrow, 2004; Tilley & Palmer, 2013; Zuccarini et al., 2013). Expressing vulnerability entails considerable emotional risk. Based on past experiences, partners often expect their vulnerability to be dismissed, ignored, invalidated, or judged. These potential responses are likely to exacerbate feelings of loneliness and shame and therefore partners often chose to avoid exposing their vulnerability to each other.

The current study aimed to identify the different interventions therapists can use to prepare partners to share their vulnerability in the context of enactment. Grounded in humanistic and experiential traditions, EFT-C therapists often focus on helping clients get in touch with their experiences, especially with those that are often avoided or at the margin of their awareness (Greenberg & Goldman, 2008). By integrating systemic elements EFT-C therapists attempt to provide a relational reframe to couples’ experience and distress; i.e., they use the cycle framework to clarify partners’ interactional patterns. To transform these maladaptive cycles, therapists often take on the “choreographer role” where they direct couples to try out different interactional moves.

To help partners share their vulnerability, several preparatory interventions focusing on meaning-making, experience deepening, and interactional guidance are thus likely to result in more successful vulnerability enactments. Specifically, therapists should provide meaningful systemic meaning to the vulnerable content by associating it to the context of attachment or identity needs and the couple’s cycle (e.g., “so Dan when Sarah blames you for not helping, you feel not good enough, inadequate, as if you're letting her down, so you just have to get away”). In addition, therapists work to deepen the revealing partner’s emotional engagement through empathy-based experiential interventions such as validation, conjectures, evocation, and heightening. The therapist intensifies vulnerability, for example, by repeating and lingering on the primary emotion and experience (e.g., “Can you tell me how bad it feels inside? What is it like for you right now? this feeling of shrinking”?).

Finally, the therapist should focus on providing the conditions needed to promote interactional change, by centering on both the listening and the revealing partner. Specifically, the therapist works with the listening partner and invites his or her receptivity. The therapist verifies that the listening partner is attentive, open, and curious (“Sarah, what would it be like for you to hear him tell you how small he feels in those moments?”). Similarly, the therapist helps the revealing partner to focus on his or her most poignant experience, which involves explaining the purpose of the enactment in bringing the partners closer to each other, and validates the emotional risk of exposing vulnerability (e.g., “Being able to share this with her is so meaningful. It would enable you to connect from a new place. Can you tell her the how bad and inadequate you feel in those moments?”).

Thus overall, we predicted that promoting these processes during the preparatory enactment work would lead to greater expressions of vulnerability on the part of the revealing partner during the enactment. We specifically focused on four preparatory interventions: (a) setting a meaningful systemic context; (b) promoting the revealing partner’s emotional engagement; (c) promoting the listening partner’s emotional engagement; and (d) preparing the revealing partner for enactment. To test this prediction, we used data from the York Emotional Injury Research Project (Greenberg et al., 2010) to identify segments of vulnerability enactments and to examine the role of therapists’ preparatory interventions in predicting partners’ vulnerability sharing.

Method

Participants

We used data from the York Emotional Injury Project (Greenberg et al., 2010; Woldarsky Meneses & Greenberg, 2014). This project involved 33 heterosexual couples dealing with a significant emotional injury that had been unresolved for at least two years. Each couple received 10–12 sessions of EFT-C. The relational injuries included affairs, deceptions related to finances or drug use, insisting on an abortion, and failing to provide support at a critical time. The participants were over 18, had lived together for at least two years, and intended to stay together and overcome their unresolved anger and hurt. In most cases (87.9%), the male partner was identified as the offender. Participants were excluded if they were already in another form of couple therapy or if there was any sign of violence, relational abuse, substance abuse, severe psychological disturbances, or severe personality disorders. The clients ranged in age from 27 to 73 (M = 45.26, SD = 9.86) and had been in a romantic relationship for 5 to 41 years (M = 16.31; SD = 9.39). On average, they had two children (M = 1.82; SD = 0.94).

Therapists

Eighteen therapists participated in the original study. Each therapist treated one to four couples. The therapists were registered psychologists, marriage and family therapists, or advanced doctoral students in clinical psychology. Fifteen therapists were women. The therapists received 30 h of specialized training in EFT-C related to resolving emotional injuries. To ensure adherence to the EFT-C, weekly supervision with video reviews was conducted by Leslie Greenberg, one of the developers of the model.

Procedure

A team of four undergraduate research assistants identified and marked occurrences of enactment events in all sessions for the 33 couples. An enactment event was defined as when the therapist explicitly asked one of the partners to share vulnerable content they had just processed with the therapist. For 27 couples (out of the 33 that participated in the project) the coders identified at least one enactment event during their therapy sessions. The number of enactment events per couple ranged from 1 to 13 (M = 3.88; SD = 3.22). Once all the enactment events had been marked, a second team of three coders rated the therapists’ interventions during the preparatory phase. In this study, the preparatory phase was operationalized as the five minutes preceding the enactment marker. Finally, a third team of four coders coded the level of shared vulnerability (McKinnon, 2014). The therapists’ preparatory interventions and vulnerability were coded globally; i.e., one score per enactment event was assigned to each of the four therapists’ preparatory interventions and the sharing partners’ vulnerability. The training for each team involved a weekly meeting during the coding period in which they were first taught about the theory of EFT-C and the specific component they were coding. Next, they watched examples of enactment events and therapists’ interventions from videotaped examples of sessions not included in the study. They then practiced coding and received feedback in their weekly meeting.

Measures

Therapist preparatory interventions

Therapist preparatory interventions were coded by a coding scheme developed by our team for this study. Though we are unaware of any published work detailing these interventions, they are routinely taught in EFT-C training. Based on this training material, the first and last authors of this study, who are certified EFT-C supervisors, developed the coding system. Specifically, by intensively reviewing several enactment segments, the codes were articulated and refined. The final version was reviewed by Dr. Greenberg. In essence, this process followed the “discovery phase” of task analysis (Greenberg, 2007).

This coding scheme was used to code therapists’ preparatory interventions during the five-minute preparatory phase of the enactment. The codes included in the scale were as follows: (I) Setting a meaningful systemic context (focusing on systemic meaning): The therapist emphasizes vulnerability and links it to the partners’ cycle or to the revealing partner's attachment or identity needs. (II) Promoting the revealing partner’s emotional engagement (focusing on experience): The therapist deepens the revealing partner's experience (e.g., using empathy, validation, conjectures, and heightening), to intensify and crystalize vulnerability. (III) Promoting the listening partner’s emotional engagement in the enactment (focusing on interaction): The therapist verifies that the listening partner is attentive, open, curious, and receptive. (IV) Preparing the revealing partner for enactment (focusing on interaction): The therapist explicitly highlights the opportunity and helps the revealing partner focus on the most poignant content. The therapist explains the purpose of the enactment and validates the emotional risk of sharing the pain. Note that the first two interventions often occur earlier, when the therapist sets the stage for the enactment (i.e., by highlighting the new meaning and experience), whereas the last two often occur just before the enactment when the therapist guides the partners to interact directly with each other (i.e., focusing on transforming interactional patterns).

The three coders used a 3-point scale (0 =  “not present”, 1 =  “slightly present”, 2 =  “clearly present”) to indicate the presence of each of the interventions in the segment. The raters were allowed to watch the five-minute segments as many times as they needed to code all four interventions. The entire team coded 25% of the 105 events to assess inter-rater reliability. We used Gwet's AC2 coefficient, which is suitable for multiple raters providing ordinal ratings with a low base rate (Gwet, 2008). In other words, compared to other measures of reliability (e.g., Cohen’s Kappa, Krippendorff’s alpha) Gwet’s AC2 is considered to be more robust and less affected by the coded event prevalence (Quarfoot & Levine, 2016). The reliability (0.65) was in the “good” range (Wongpakaran et al., 2013).

Expressed vulnerability

The partners’ expressed vulnerability was assessed on the Couples Vulnerability Scale-Revised (McKinnon, 2014; McKinnon & Greenberg, 2017). A team of four coders rated the extent to which the revealing partner shared vulnerability. The criteria were as follows: (a) The partner expresses a primary attachment or identity related emotion relevant to the couple’s relationship; (b) There is evidence of emotional arousal in the partner’s voice and/or body language (c) The expression has a revealing/disclosing quality; (d) The expression is “soft” (i.e., non-demanding, non-escalatory, and with little or no criticism or complaint); (e) The expression contains little or no attacking anger, hostility, contempt, or disgust directed at the other partner; (f) The expression is about the self’s experience and the individual takes responsibility for what he or she is experiencing (i.e., by using “I” language). Guidelines for making judgments regarding each criterion are provided in the scale.

Based on these criteria, the coders used a three-point scale to indicate the presence of each of the six vulnerability expression codes (0 =  “not vulnerable”, 1 = “mildly vulnerable”, 2 = “vulnerable”), and a total score was calculated as the mean of the six items. To assess inter-rater reliability, the entire team coded 25% of the 105 events. Gwet's AC2 coefficient was in the “very good” range (0.82).

Results

Descriptive Clinical Illustration of the Therapists’ Preparatory Interventions

Before reporting the quantitative associations between these interventions and expressed levels of vulnerability, we illustrate how these preparatory interventions were reflected in the couples’ therapy sessions. Note that the verbatims were modified to ensure anonymity and disguise personal information. As noted above, four therapists’ preparatory interventions (TPIs) were examined in the current study as predictors of vulnerability expression: setting meaningful systemic context (TPI-1); promoting revealing partner’s emotional engagement (TPI-2); promoting listening partner’s emotional engagement (TPI-3); and preparing the revealing partner for enactment (TPI-4). In the vignette below we relate each therapist’s speech turn to a specific intervention, but the therapists’ preparatory interventions were codded globally (i.e., interventions were rated once for each enactment event).

Example #1: In this segment, the therapist discusses the distance the male partner puts between himself and his partner. While exploring the emotional pain triggering this protective wall in the male partner, he reveals feelings of inadequacy and fear of being exposed. These feelings are related to childhood trauma. Then, using empathic conjectures (Goldman & Greenberg, 2013), the therapist explores how these early painful emotions are triggered in the current relationship and connects them to the couple’s cycle. The therapist then encourages the male partner to share these vulnerable feelings directly.

T:

so as we speak of this, what's happening inside of you just right now? (TPI -2; the therapist guides the partner to focus on his internal experience)

M:

I'm just trying to clear this out of me.

T:

yeh … if you could just let this out, from what you've told me, there was a lot of … stuff, you had a really tough time growing up. A lot of trauma and … (TPI -1; the therapist connects the vulnerability felt in the relationship to early life sensitivity)

M:

it's just that I don't want to be weak around her; I don't want her to see me like that.

T:

you are saying, sometimes I feel really bad and maybe even inadequate, and when that happens, I get … I guess I put up this wall (TPI -1; the therapist links the vulnerability to the protective withdrawing behavior)

M:

yeah

T:

I feel bad about myself and get scared of your anger (TPI -2; the therapist reaches into the undisclosed emotion and speaks for the partner, using “I language”)

M:

right, I feel bad about myself and pull away.

T:

yes. So can you tell her? Can you look at her right now and share that? (an enactment marker)

Example #2: The couple, in their late fifties, is dealing with despair over the long-lasting emotional distance in their relationship. Here, the female partner talks about the pain she had carried for many years, which is related to insistence on the part of her partner to cut ties with her family of origin when they were first married. Once the female partner reaches into her pain, the therapist prepares her to share it.

T:

Tell me about the tears you are now holding back (TPI -2; the therapist deepens the emotion through the bodily reaction in the present moment)

F:

I wish we could have shared these years before, not so late like now. I was all by myself. I didn't have anybody. I had no one to speak to about this, just me. I couldn't say it to my sisters or Mom. No one. And I didn't think I could talk about this with him.

T:

So it is so painful not to have had anybody for you there at that time. I was feeling so alone (TPI -1& TPI -2; the therapist evocatively validates and “speaks for” the partner's vulnerable experience while linking the content to attachment needs)

F:

Totally alone. it was just me. (sighing) it was just me for me. And I didn't feel comfortable talking about it to my friends or anybody. I did not want people to think badly of him.

T:

So, can you tell him that? It was so painful, and I needed you. Can you look at him and tell him I was so alone and had no one? It's important that he hears your pain. (TPI -4; the therapist prepares the partner to share by focusing on the poignant pain and emphasizing the importance of sharing this experience)

F:

ahh … 

T to M:

Are you ready to hear her tell you about her loneliness? Can you listen to her pain now? (TPI -3; the therapist turns to the listening partner and uses anticipatory questions to facilitate receptivity)

M:

Eh, yeah

T:

So, can you tell him some of it? I was so alone and felt I had no one (An enactment Marker)

Example #3: In this segment, the therapist explores with the couple the emotional injury initially caused by the male partner by leaving his wife after she became pregnant. Here the therapist goes deeper into the male partner’s fear of abandonment and the emotional danger he feels from exposing this fear to his partner. The therapist deepens the experience using empathy-based interventions, links them to the cycle, and then prepares the male for sharing his vulnerability.

T:

Can you describe where you feel it in your body? Is it here? (TPI -2; the therapist focuses on the felt bodily experience)

M:

Like a tightness, like a weird chill in me.

T:

So let the words come from that place in your body; it's like a signal (TPI -2; focusing on internal feeling)

M:

I don't want to be scared in my own home. I don't want to … 

T:

Right … right … what is the fear? if you try to give it a voice, I'm afraid of (TPI -1; the therapist helps the male to make sense of his feeling)

M:

I'm afraid that my words will make her angry. That I'll make her mad

T:

Yes. So scary. Stay with what's happening inside even though it's hard (TPI -2; the therapist validates and tries to focus and heighten the experience)

M:

(crying)

T:

A lot is going on inside and doesn't get a chance to have a voice. If you could imagine it in your body. What's happening now? (TPI -2; the therapist heightens the primary emotion through the felt sense in the present moment.)

M:

It feels like a vibration.

T:

So if you let the words come from that vibrating place in your body, what would that vibration say? What does it want you to know? What is it about? (TPI -1; the therapist explores to make sense of the emotion)

M:

I don’t know, scared. I feel scared and can’t let her know.

T:

So, what would it be like to actually look her in the eye and tell her that. To turn to her now and share this with her. To say to her underneath my distance, I feel so scared that I … say it in your words (TPI -4; the therapist prepares the revealing partner for the enactment, organizes and highlights the connection between the vulnerable internal feeling exposed and the protective tendency to withdraw)

M:

eh (hesitates)

T:

I know this is scary for you but can also be so meaningful for both of you, to be able to share this with her (TPI -4; the therapist validates the partner's fear of the emotional challenge and points out the opportunity direct revealing presents for the couple)

Main Results

Table I presents the frequency of the four preparatory interventions. The most common intervention was preparing the revealing partner for enactment. In 43.8% of enactment segments, all four interventions were co-present (their scores were higher than 0). The means and standard deviations of the variables as well as the bivariate correlations are presented in Table II. To account for the interdependence in the data (i.e., multiple enactments were coded per couple), we used the r package correlation (Makowski et al., 2022) which allowed us to account for differences between clusters (i.e., couples) by partialization of the group variability. As shown, vulnerability expression was positively associated with the following therapist’s preparatory interventions: (a) setting meaningful systemic context (TPI -1), (b) promoting the revealing partner’s emotional engagement (TPI -2), and (c) preparing the revealing partner for enactment (TPI -4). By contrast, expressed vulnerability was not associated with promoting the listening partner’s emotional engagement intervention (TPI -3).

Table I. Frequencies of therapist preparatory intervention ratings.

Intervention	0 Not present	1 Slightly present	2 Clearly present
TPI #1: Setting a meaningful systemic context	28.5%	29.5%	41.9%
TPI #2: Promoting the revealing partner’s emotional engagement	29.5%	25.7%	44.7%
TPI #3: Promoting the listening partner’s emotional engagement	26.6%	28.5%	44.7%
TPI #4: Preparing the revealing partner for enactment	3.8%	26.6%	69.5%

Table II. Means and correlations of therapists’ preparatory interventions and expressed vulnerability.

	Expressed vulnerability	TPI #1	TPI #2	TPI #3	TPI #4
Expressed vulnerability	1.00 (.52)	r = .33**	r = .26*	r = −.03	r = .30*
TPI #1: Setting a meaningful systemic context		1.13 (0.83)	r = .67***	r = .01	r = .16
TPI #2: Promoting the revealing partner’s emotional engagement			1.15 (0.83)	r = .07	r = .19
TPI #3: Promoting the listening partner’s emotional engagement				1.18(0.83)	r = .09
TPI #4: Preparing the revealing partner for enactment					1.66 (0.5)

*p ≤ 0.05. **p ≤ 0.01. ***p ≤ 0.001.

To examine the unique contribution of each preparatory intervention in predicting expressed vulnerability, we regressed expressed vulnerability on the four therapists’ preparatory interventions. Because our data had a multilevel structure (e.g., enactment segments nested within couples), we used multilevel regression models. We followed Bolger and Laurenceau's (2013) recommendations to treat repeated measure data from distinguishable dyads as involving two levels, while taking into account their non-independence by estimating separate random intercepts (and level-1 residuals) for men and women and allowing them to co-vary. In addition, we compared a model that included the level of the therapist (3-level model) to the one that did not (2-level model). The deviance test indicated that the more complex model (i.e., the 3-level model) did not fit the data better than the more parsimonious one (i.e., the 2-level model; χ2[3] = 4.01, p = .261). Therefore, the estimated model can be regarded as dyadic 2-level multilevel model. These models have two levels (a within-couple level and a between-couple level) and can take the non-independence of segments in a couple and partners in a dyad into account. Note that multilevel regression models can accommodate non-balanced data (e.g., here, each couple had a different number of enactment segments). In the estimated model, expressed vulnerability was the outcome, and the therapists’ preparatory interventions were the predictors. Separate random intercept terms for males and females were modeled as well as their level-2 covariation. Estimating the predictors as random effects at level 2 did not improve the model fit (χ2[18] = 13.31, p = .773).

The results of the multilevel model are presented in Table III. Two therapists’ preparatory interventions were significantly associated with levels of expressed vulnerability when all the predictors were included in the model. Specifically, setting meaningful systemic context as well as preparing the revealing partner for enactment were positively associated with greater levels of expressed vulnerability.

Table III. Results of the multilevel model analysis.

	Estimates (SE)	95% CI	Stand. Est.^a	p
Intercept	0.439 (0.17)	0.098−0.780		.012
TPI #1: Setting a meaningful systemic context	0.222 (0.085)	0.052−0.391	.357	.011
TPI #2: Promoting the revealing partner’s emotional engagement	−0.063 (0.091)	−0.244−0.118	−.104	.490
TPI #3: Promoting the listening partner’s emotional engagement	−0.028 (0.057)	−0.141−0.086	−.044	.630
TPI #4: Preparing the revealing partner for enactment	0.260 (0.091)	0.078−0.442	.277	.006

Note: ^a Standardized effects were obtained by standardizing the outcome and the continuous predictors and rerunning the model (see Baldwin et al., 2014).

Discussion

This study examined the effect of therapists’ preparatory interventions in facilitating vulnerability enactments. These interventions are intended in EFT-C to help partners disclose primary vulnerable emotions directly, which often elicit empathic responses in the other partner. These enactments are, thus considered the main path to restructuring couple's relationships in EFT-C (Tilley & Palmer, 2013). However, despite their central role in facilitating relational change (Greenberg & Goldman, 2008), therapists often report avoiding the use of enactment interventions (Bradley, 2018; Bradley & Furrow, 2004; Greenman & Johnson, 2013; Sandberg et al., 2015; Woolley et al., 2012; Zuccarini et al., 2013). This may partly be due to the lack of knowledge concerning effective interventions to prepare partners to express vulnerability openly (vs. more secondary reactive emotions; e.g., blaming anger).

The current study sought to test the effect of four such preparatory interventions: (a) Setting meaningful systemic context; (b) Promoting the revealing partner's emotional engagement; (c) Promoting the listening partner's emotional engagement; and (d) Preparing the revealing partner for enactment. The findings showed that the two interventions that were most predictive of vulnerability expression were “Setting meaningful systemic context”; and “Preparing the revealing partner for enactment.”

In the “setting meaningful systemic context” intervention the therapist helps the revealing partner to relate the emotional pain to the couple’s old and familiar maladaptive interactional cycle. In other words, the therapist provides a systemic lens through which partners can organize and give new meanings to their pain. Rather than perceiving their partner as the source of their distress, this intervention helps the revealing partner to acknowledge the vicious cycle, and opportunities to change it by taking the risk of sharing the vulnerable emotional content with their partner. In particular, reframing the dyads’ distress in terms of the cycle is considered a therapeutic task that should be realized before partners are encouraged to share their vulnerability (Greenberg & Johnson, 1988; Johnson & Greenberg, 1988). However, our results suggest that it may be helpful to re-emphasize this systemic framing when partners are on the verge of trying new interactional possibilities.

The other intervention shown here to be predictive of vulnerability expression was “preparing the revealing partner for sharing”. In this intervention, therapists motivate the revealing partners to share their pain by providing the rationale for doing so. They often further assume the “choreographer” role, in which they direct the partners to face each other to create eye contact. Therapists also refocus the revealing partner on the poignant, vulnerable experience and help them to find words that fit their current emotional capacity. Sharing vulnerability is often experienced as risky, especially for distressed couples (Khalifian & Barry, 2021). Our results indicate that providing such a therapeutic scaffold in these sensitive moments may be critical to allow partners to dare to share their vulnerability.

Unexpectedly, promoting the revealing partners’ emotional engagement with the vulnerability experience did not predict vulnerability sharing. It should be noted, however, that even though the effect was non-significant in the multilevel model, there was a significant simple-order association (r = 0.23) between this intervention and vulnerability sharing. Therefore, one possible explanation for the null finding may be related to the overlap between this intervention (which focuses on experience) and the one focusing on meaning (i.e., setting meaningful systemic context). This may reflect the dialectical interplay between meaning-making and emotional experiencing, as highlighted by Emotion Focused Therapy (Greenberg & Pascual-Leone, 2001). When people attend to their experiences, new meaning often emerges; when provided with new ways to understand experience (e.g., systemic perspective), the way people interact and access their experiences is often transformed. In fact, the correlation between the two interventions was high (r = 0.67), suggesting that during vulnerability enactments, it is difficult to differentiate between an intervention focusing on meaning creation and an intervention designed to evoke experiencing.

Yet another possible explanation for this pattern of findings may be that in couple therapy it is less critical to work intra-psychically with partners to deepen and amplify their experience than to work more interpersonally to direct them to share their emotions. For example, inviting the revealing partners to look at the listening partners’ eyes as they try to share their vulnerability may in itself deepen and intensify the emotional experience. As noted above, the intervention focusing on directing and preparing the revealing partner to share their vulnerability was predictive of vulnerability expression. Clinically, this may imply that unlike in individual work, interventions directly designed to heighten experiencing (e.g., focusing on bodily sensations) may be less crucial than attempting to change the interaction between partners.

Promoting listening partner’s emotional engagement was also not predictive of vulnerability sharing. This intervention involves the therapist actively ensuring and guiding the listening partners to be attentive and engaged. We reasoned that such prompted receptivity would encourage the revealing partners to share their vulnerability. In particular, we only coded explicit verbal preparation behaviors (e.g., the therapist asks the listening partners if they can listen openly to the vulnerability that is about to be shared). However, when therapists perceive the listening partner to be sufficiently engaged, they may not find it necessary to interrupt the interaction by explicitly facilitating engagement but rather decide move more smoothly to direct the revealing partners to share their vulnerability. Therefore, future studies should try to identify when this intervention may be more critical (e.g., when the listening partner is explicitly inattentive and withdrawn).

In addition, this intervention may play a more significant role in facilitating the listening partner’s responsiveness following vulnerability sharing. One of the limitations of the current study is that we focused solely on the vulnerability of the revealing partners and not on the listening partners’ response quality. Therapists may refrain from using enactments to avoid putting partners at a relational risk, such as receiving an unresponsive or even judgmental response when sharing vulnerability. Further research should focus on interventions that facilitate the second component of the vulnerability enactment; i.e., interventions that promote listening partners’ responsiveness. Specifically, although there are instances where the expression of vulnerability elicits a spontaneous empathic and compassionate response from the listening partner, partners often need the therapist’s guidance to process their new experience in response to the revealed vulnerability (e.g., “What happened to you when you heard her share her pain just now?”), organize its meaning (e.g., “So hearing her words made you feel you want to be close to her, connect with her?”), and encourage the expression of empathy toward the revealing partner (e.g., “Could you turn to her and tell her this, how moved you feel, how you see her pain now?”). In our clinical experience, compassionate responses are often blocked for a variety of reasons (fear of compassion, equating compassion with weakness, etc.) and therapeutic work is needed to help the listening partner to overcome such blocks. We assumed that along with the level of expressed vulnerability, these therapists’ interventions would also be critical to expressing supportiveness. Therefore, to provide a comprehensive systemic understanding of enactment interventions, future studies should further examine the interventions therapists use to facilitate both vulnerability and responsiveness.

Several other limitations of this study should be noted. First, we assessed therapists’ interventions and partners’ vulnerability using global codes. However, as we exemplified above, enactments unfold gradually. Future studies should code therapists’ interventions and clients’ responses moment-by-moment to better clarify the specific impact of different interventions as they evolve over time (Tsvieli et al., 2020; Tsvieli et al., 2022). In addition, although enactment is a common intervention in systemic therapy (Gardner & Butler, 2009) this study only focused on one type of enactment (vulnerability enactment) within one specific therapy model (EFT-C). Notably, vulnerability expression has been more recently conceptualized as a process shared by several evidence-based couple therapy models (Lebow & Snyder, 2022). However, future studies should examine whether the interventions we found effective in promoting vulnerability sharing are as effective in the context of other therapy models. Finally, our sample was homogeneous (e.g., heterosexual couples dealing with past emotional injury) and not culturally diverse (e.g., the majority of the sample identified themselves as being of White-European descent). Therefore, to improve generalizability, future studies should use larger and more diverse samples.

Summary

The transformational process proposed by EFT-C involves one partner revealing vulnerable emotions and the other responding compassionately (Greenberg & Goldman, 2008; Greenberg & Johnson, 1988). This process is often fostered by therapists using enactment. The results help clarify which highlight preparatory interventions that couple therapists can use to effectively assist partners in sharing their vulnerability. Specifically, they point out specific ways therapists can prepare the revealing partner to share their emotions more openly. We hope that these findings will help therapists feel more capable of guiding couples in challenging moments, yet potentially leading to relational growth.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10503307.2023.2245961.

Appendix A.

Therapist Preparatory Intervention (TPIs) Coding Scheme

Table

TPIs	Therapist Interventions	Description	Examples
TPI- 1	Setting a meaningful systemic context	Therapist explores and links the vulnerable content to the revealing partner’s attachment or identity needs Or/ and to his or her cycle Therapist emphasizes what is first exposed in the vulnerable content.	“it is scary to need her so much and to feel alone without her”
			“it’s hard to feel bad inside, as if you’re not good enough, and you just have to distance yourself from her” “I feel small and voiceless in that place. I can’t stand it so I shout things at her. Is that how it is?”
TPI-2	Promoting revealing partner’s emotional engagement	Therapist deepens the emotional experience using empathy-based interventions, validation, conjectures, heightening, repetition, focusing on body experience, “I language”. Therapist differentiates and intensifies the vulnerable core experience, and it becomes present and crystalized in the room, implicitly or explicitly.	“Can you tell me about how scared you are”?
			“What is it like in your body? This heavy weight on your chest”? “This is painful. So so painful … ”
			“This younger child inside you feeling so unseen and small”.
			“Can you tell me about how scared you are”? “Can we slow this down”? “Can we stay here for a minute”?
			“This heaviness in my body … weight on my chest. This pain of feeling like nothing”
TPI-3	Promoting listening partner’s emotional engagement	Therapist checks that the listening partner is attentive, open, and curious Therapist invites receptivity in the listening partner and leans in with anticipatory questions.	“What would it be like for you to hear her tell you how much she needs you”
			“Can you listen with an open heart to what he will share with you now? This vulnerable new place he revealed?”

Table

TPI-4	Preparing the revealing partner for enactment	Therapist asks the partner to share focusing and organizing the vulnerable content that was exposed Therapist explains the purpose of the enactment and explicitly highlights the opportunity of taking a new move of sharing vulnerability. Therapist validates the risk in sharing vulnerability. If the fear is overwhelming, therapist slices it thinner, or encourages revealing the fear Therapist specifies the vulnerable aspect that was exposed and will now be shared	“Can you look into her eyes and tell her this” …
			“What would it be like for you to share with your wife how scared you are to be” …
			“Being able to share this new vulnerable place with each other is so meaningful. It enables you to connect with each other from a new place”
			“Can you tell him you want to share it with him but you don’t know how”.
			“Can you tell her how you want to be close to her and also how much it scares you.”