Introduction

The iconoclasts who created couple, marriage, and family therapy (CMFT) denounced the prevailing medical assumptions of their time in favor of a systemic approach. They came to believe that family systems—not biological or intrapsychic dysfunction—accounted for the problems that bring clients to therapy (Watzlawick et al. 1967). Consequently, early systemic approaches to therapy focused primarily on relational intervention. The medical field has evolved since the days of CMFT’s establishment to recognize biological, psychological, social, and spiritual factors as interconnected components of a person’s overall health (Engel 1977; Wright et al. 1996). There is a wealth of research highlighting the complementary effects of these factors upon one’s mental and emotional health and even upon relational outcomes (Aamar et al. 2015; Trump et al. 2015; Wood et al. 2011). The field of CMFT has also evolved to more fully recognize the interconnectedness of biology, psychology, social experiences, and spirituality in shaping mental, physical, and relational health (McDaniel et al. 2012). Models have emerged that prize intrapsychic, psychological intervention (e.g., internal family systems therapy (IFS), Schwartz 1995; cognitive behavioral therapy (CBT) for couples and families, Epstein and Baucom 2002). Constructivism has uncovered the vital place of social constructs in shaping and determining individual and family meaning-making (White 2007). Thanks largely to contributions from EFT, CMFTs have addressed the importance of relational attachments and emotion in therapy (Johnson 2004). Even spirituality has been incorporated into CMFT treatment by some (e.g., The Satir Model; Satir et al. 1991). Yet, considering these developments, it seems that CMFTs tend to focus primarily on aspects or portions of the BPS-S framework that are emphasized in their models, rarely intervening in a way that holistically utilizes BPS-S resources to produce change (MacDonald and Mikes-Liu 2009). There appears to be room for systemic models of therapy to evolve so they can incorporate biological, psychological, social, and spiritual resources that have been empirically shown to improve health.

Demonstrating how the BPS-S model can be incorporated into specific therapy models seems to be a needed next step in the progression of systemic clinical practice. By using the BPS-S model to guide their clinical practice and research, medical family therapists have notably brought the BPS-S model more fully to the forefront of CMFT (Tyndall et al. 2014), but our experiences indicate that many CMFTs believe the BPS-S is only relevant when working in medical settings. To help more fully incorporate BPS-S factors into CMFT generally, we believe it is important to demonstrate how BPS-S resources can be incorporated with specific therapy models. It is likely that many CMFTs are incorporating BPS-S resources into their chosen therapy models, but little is written about how this is accomplished.

Our focus in this article is to provide clinicians with practical guidance regarding how to integrate specific BPS-S resources into EFT (Johnson 2004). We have selected EFT as the focus of this article for two primary reasons. First, the popularity of EFT makes our applications particularly far-reaching (Wiebe and Johnson 2016). Second, the emphasis of emotionally focused therapists upon in-session change targeted to create a more secure couple attachment (Johnson 2004) makes incorporating BPS-S resources into treatment especially challenging. By choosing to incorporate the BPS-S model with EFT, we highlight our belief that BPS-S resources can be utilized in all systemic therapy models.

Emotionally Focused Couple Therapy

EFT is an experiential couple therapy model aimed at improving couples’ attachment bonds (Johnson and Greenberg 1985; Greenberg and Johnson 1988). EFT consists of nine steps of change within 3 main stages: de-escalation, re-engagement, and consolidation (Johnson 2004). In Stage I (de-escalation), therapists build a strong alliance, characterized by empathetic attunement to the clients’ feelings, and conduct assessment which they integrate into the couple’s interactions. The therapist then helps the clients experientially understand the emotions that fuel their positions in their negative patterns of interacting and view these negative patterns as the barrier to connection. In Stage II (re-engagement), couples begin restructuring their interactions to increase the security of their attachment bond. This stage facilitates two important change events: withdrawer re-engagement, where the withdrawing partner moves from avoidance to emotional connection, and blamer softening, where the attacking partner vulnerably expresses emotional needs instead of criticism (Bradley and Furrow 2004; Johnson 2004). As clients are able to de-escalate and re-structure their negative interactions into more secure patterns of emotional connection, therapy transitions to Stage III (consolidation), in which the therapist helps the couples integrate therapeutic gains by applying their new patterns of interaction to other relational issues (Johnson 2004).

While EFT’s primary objective is to improve couples’ attachment bonds, a growing body of research is examining EFT’s applicability on other family issues as well (Wiebe and Johnson 2016). For example, recent studies have analyzed EFT therapy’s impact on various presenting problems (Wiebe and Johnson 2016), mental disorders (Wittenborn et al. 2012), family structures (Allan 2016; Lee et al. 2017), and health issues (Chawla and Kafescioglu 2012; Mclean et al. 2013; Wiebe and Johnson 2016). Researchers have also called for studying EFT across different cultural groups (Wiebe and Johnson 2016). The recent research advancements and calls for further research demonstrate clinical interest in integrating EFT with a wider array of models such as EMDR and mindfulness (Johnson and Zuccarini 2010; Maier 2015; Seponski 2016) as well as interventions such as psychotropic treatment protocols (Beckerman and Sarracco 2011; Denton and Golden 2012; Negash et al. 2018).

The Biopsychosocial-Spiritual Model

Engel (1977) proposed that health is composed of three interlocking domains—biology, psychology, and social experience—that interact systemically. His model, the biopsychosocial (BPS) model, challenged the prevailing model of health of his time, the biomedical model, which identified biological dysfunction as the cause of illness and disease (Engel 1977). He identified this reductionist perspective of health as inadequate and incomplete (Engel 1977). His model of health holistically accounted for psychology and social experiences as vital components of health and wellness (Engel 1977). Various scholars have since argued for the addition of spirituality to Engel’s biopsychosocial model (Phelps et al. 2009; Wright et al. 1996). Burgeoning research indicates how biology, psychology, social experience, and spirituality each intertwine to shape one’s health. The BPS and BPS-S models have become accepted frameworks of health in various health-related fields, including medicine, addiction studies, CMFT, psychology, and social work (Frankel et al. 2003).

Biology, psychology, social experience, and spirituality are broad domains. A multitude of clinical factors or concerns fit within each one. It can be difficult at times to conceptualize where specific clinical factors might fit within the specific domains of the BPS-S. Robinson and Taylor (2016) illustrated how they organize pertinent clinical factors using a BPS-S framework. Within the domain of biology they listed the current health, past health history, and health behaviors (including diet, exercise, sleep, and substance use) of clients. Personality, mood, mental health conditions, degree of hope, and stressors were identified as psychological factors. Within the social domain they identified relationships with family members, friends, and colleagues, as well as broader social experiences like community connections, sociopolitical environment, and culture. Spiritual practices, meaning making, feeling connected to society, experiencing a sense of awe and wonder, and centering or mindfulness practices were grouped within the spiritual domain. It is important to note that no factors fit strictly in just one domain, and that the placement of some of these factors could be up for debate. Since the BPS-S model is a systemic framework, identified factors could easily be included in multiple domains. Still, we believe it is valuable to conceptually group different factors under specific domains and find Robinson’s and Taylor’s identifications useful.

Incorporating BPS-S Resources in EFT

Systemic thinkers might be especially adept at incorporating BPS-S factors into treatment, because the BPS-S model is, itself, a systemic model of health (Engel 1977). Thus, systemic clinicians might naturally see how clients’ biological, psychological, social, and spiritual experiences are systemically affecting and shaping clients’ overall wellness and their relational experiences. It can be challenging, though, for systemic therapists to understand where the BPS-S model fits within their clinical approach. This is primarily because the BPS-S is not a therapy model (MacDonald and Mikes-Liu 2009). A clinician finds little guidance regarding healthy family dynamics within the BPS-S, nor does the BPS-S offer specific interventions to utilize in-session with clients. Considering these facts, some have taken the stance that the BPS-S is simply a framework to organize clinical assessment (Williams et al. 2011). Those who take this stance fail to acknowledge the profound implications of the BPS-S on treatment. Using BPS-S resources, clinicians help clients make changes in various domains of their lives, realizing that such changes accelerate change and work together synergistically to improve wellness. Medical family therapists tend to see the BPS-S as a framework that overlays systemic therapy models, shaping how cases are conceptualized and guiding treatment (Tyndall et al. 2014). We concur with this conceptualization of the BPS-S model as it relates to CMFT therapy models. We believe it is vital, though, to specifically articulate how specific BPS-S resources should be incorporated into chosen CMFT therapy models. Such articulations are presently scant.

In terms of EFT, we view the BPS-S as a framework that overlays and enhances the quality of EFT assessment and treatment. We reiterate that the BPS-S model is not a therapeutic modality, and we do not integrate the BPS-S and EFT as two complementary therapeutic modalities. Instead we demonstrate how emotionally focused therapists can draw from the larger BPS-S framework, using it to shape assessment and intervention in a way that accelerates the effectiveness of EFT.

There are a multitude of biological, psychological, social, or spiritual factors that might be incorporated into EFT to influence couple connection and attachment. Discussing the role that each of them might play in accelerating the goals of EFT is beyond the scope of this paper. Furthermore, for an emotionally focused therapist to feel like they need to incorporate a vast number of resources into treatment is daunting and impractical. Therefore, we first provide general guidelines regarding how to incorporate the BPS-S model in EFT. We then discuss how each area of the BPS-S model may integrate with EFT process and provide examples of how therapists could incorporate interventions from each area in their therapeutic work. The resources we identified—exercise (biological domain), mindfulness (psychological domain), volunteerism (social domain), and prayer (spiritual domain)—were chosen after collectively drawing upon our clinical experiences and carefully reviewing empirical literature concerning BPS-S resources that impact couples and health. The resources were primarily selected based on two criteria: (a) potential benefits to EFT process and goals, such as strengthening couple attachment, and (b) empirical validation and prevalence in relevant literature. The rationale for selecting each factor is provided further under each BPS-S section. By discussing the incorporation of these sample resources in depth, we aim to illustrate the plausibility and potential effectiveness of incorporating BPS-S resources into EFT (see Fig. 1).

Fig. 1
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The Incorporation of BPS-S Factors into EFT

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General Guidelines

First, we offer four general guidelines to aid emotionally focused therapists as they incorporate BPS-S resources into their treatment plans. These guidelines apply to each domain of the BPS-S framework, and illustrations of how to apply these general guidelines are provided by the in-depth examples later in the paper.

Assess for BPS-S Factors

As EFT therapists are assessing conflict issues and identifying the negative interaction cycle, they may naturally hear clients describe biopsychosocial-spiritual factors that either contribute to or help with their conflict. Adding a BPS-S lens in conceptualization can help EFT therapists better understand the couples’ interaction cycle. For example, understanding an individual’s biological or psychological systems can help the therapist better explain attachment needs and interpret reactivity to partner behavior. Additionally, assessing what BPS-S resources clients already utilize or want to utilize more can help therapists know what supplemental resources to suggest for managing emotional reactivity or improving couple interactions. Such assessment can guide clinicians in both conceptualization and treatment and help them determine which BPS-S resources to focus on. Assessment formally occurs during the first conjoint or individual sessions, but is also an ongoing process. EFT therapists are “always learning about [their] clients and assessing their needs,” so applicable BPS-S factors and others can be assessed throughout treatment (Johnson 2004, p. 113). When therapists learn what resources their clients have tried or may want to incorporate, the therapists can then discuss these more in-depth.

Take a Collaborative Stance

Taking a collaborative stance with clients is strongly encouraged for emotionally focused couple therapists. In EFT, “the therapist is a collaborator who must sometimes follow and sometimes lead, rather than an expert” (Johnson 2004, p. 8). Therapists can “lead” by suggesting certain resources they believe will strengthen attachment bonds and enhance treatment, and by providing education about the potential benefits of those resources, including how they may help clients reach their goals. Therapists can “follow” by asking about the clients’ desires for change, being sensitive to their client’s abilities and values, respecting the wishes of their clients, and never pressuring or shaming their clients into making lifestyle changes. When the clients determine that they want to incorporate certain resources, the therapists should then discuss with their clients how those needs will best be met.

Collaborate with Other Professionals (When Appropriate)

Emotionally focused therapists are not experts in all aspects of the BPS-S, nor are they expected to be. The goals and aims of EFT are specific and focused. Thus, when clients desire help with problems that fall outside of an emotionally focused therapist’s scope of practice (e.g., a client is seeking a prescription to treat attention-deficit/hyperactivity disorder), the client can be referred to the appropriate professional(s) who can treat their specific problem. Furthermore, where applicable, the therapist can strive to collaborate with that professional in helpful ways. Provided that proper ethical and legal standards are adhered to, collaborating with other mental health professionals, medical providers, financial counselors, or clergy to ensure that BPS-S resources are incorporated effectively and within the professional scope of the emotionally focused therapist can be very beneficial for clients (McDaniel et al. 2012).

Set Goals and Use Homework

If the therapists and clients decide that certain resources would be helpful to discuss and incorporate as part of their EFT treatment, they can begin by setting reasonable personal or couple goals relating to their chosen BPS-S resources. We recommend focusing on one resource at a time, following up consistently, and integrating and consolidating clients’ newly developed habits before moving onto a new goal. Certain goals may require clients to do things outside of session. Our recommendation that emotionally focused therapists utilize homework might seem at odds with EFT to some. Johnson (2004) explained that emotionally focused therapists are primarily concerned with the present and in-session change rather than family-of-origin issues. There is “less use of future-oriented interventions such as… homework” in EFT than there is in behavioral approaches (Johnson 2004, p. 9), but homework was never disallowed from EFT. The approach we are recommending maintains EFT’s emphasis on in-session change. We maintain that change occurs as couples experience each other in new ways in-session, and that incorporating useful BPS-S resources into clients’ lives outside of session can help to accelerate the EFT processes that occur in session.

Biological Resources

Several biological factors such as exercise, disease, sleep quality, substance use, and medication use are all biological factors that can contribute to couple conflict cycles (Hasler and Troxel 2010; Oaten and Cheng 2006; Rodriguez et al. 2013; Woods and Denton 2014). For example, one client was frequently unable to sleep because of anxious, racing thoughts. On nights when she did not sleep, she was more irritable, grouchy, and often got in fights with her partner. Her partner often withdrew from her during these fights, which made her more anxious. As illustrated by this example, biological factors can play an important role in shaping couples’ negative interaction cycles. Emotionally focused therapists should be able to formulate how factors of biological health contribute to a couple’s relational dance within Stage I of EFT. By addressing these resources and helping clients to make associated changes, the processes of de-escalation (Stage I) and re-engagement (Stage II) can potentially be accelerated.

Exercise

While each of the mentioned biological resources can significantly impact how partners interact with one another, we discuss the incorporation of exercise as our primary example. We chose exercise for several reasons: (a) exercise can improve both short-term and long-term emotional regulation (Oaten and Cheng 2006), which can directly aid the clients de-escalating and re-engaging more effectively in and out of session; (b) many clients may have more control over their exercise habits than certain other biological factors; (c) therapists can easily suggest incremental improvements in exercise habits (e.g. adding one 5-minute walk); and (d) research highlighting the positive effects of exercise upon mental and emotional health and couple conflict is voluminous. Exercise has been shown to reduce anxiety, depression, and negative mood, and improve self-esteem and cognitive functioning (Callaghan 2004). Exercise has also been shown to improve relational outcomes. For example, women’s exercise was shown to be significantly associated with an increased report of positive relationship events for both men and women in clinical couples (Johnson et al. 2017). Positive relational outcomes of exercise may largely be attributable to better emotional regulation (Johnson, et al. 2017), and a plethora of studies have found that exercise helps to increase the ability of individuals to regulate their emotions (Grandey 2002; Oaten and Cheng 2006). Emotional regulation is a primary mechanism of change for EFT because couples who stay within moderate levels of physiological arousal are better able to respond with acceptance and compassion rather than reflexively (Porges 2012). Specifically, maintaining moderate levels of physiological arousal can benefit both the partner who under-regulates through pursuing and the partner who over-regulates through withdrawing. Thus, improved emotional regulation enables partners to effectively de-escalate (Stage I), and soften and re-engage (Stage II). Additionally, because of exercise’s long-term effects on emotional regulation, forming sustainable exercise habits could promote consolidation (Stage III) and protect against regression into previous negative interaction cycles. In light of these findings, it may be beneficial to incorporate exercise into treatment for couples who are receiving EFT.

Incorporating Exercise in Treatment

Given that exercise is naturally an out-of-session intervention, we are not suggesting a strict integration of exercise routines into EFT process, such as doing push-ups during an enactment. We are, however, suggesting that initiating conversations about habits that promote emotional regulation can happen naturally during the course of emotionally focused therapy. For instance, during formal assessment, therapists can ask about the clients’ coping mechanisms, habits, and practices, such as exercise, that influence the clients’ ability to escape their negative interaction cycle. While this can occur during initial assessment, a conversation about emotion regulating practices can also occur when the therapist believes the clients could benefit from extra support. For example, when therapists observe that rapid or prolonged emotional heightening repeatedly inhibits productive partner responses, the therapists may consider offering additional resources for emotional regulation, such as exercise, so the clients come more physiologically prepared to compassionately consider their partner’s needs in session.

Understandably, clinicians often feel uncomfortable bringing up exercise in-session and report not knowing how to talk about exercise with their clients. The following is a script of how we might bring up exercise in-session:

It’s important to me, as I’m getting to know you both, to ask a couple of questions about exercise. There’s a lot of research indicating that exercise can improve mental and emotional health. Sometimes, exercising also seems to help couples I’ve worked with to fight less and to feel a greater sense of connection. So, I think exercise might be a resource that could help you to accomplish your goals in therapy. At the same time, I know that it is awfully hard to exercise regularly. I will be the first to admit that I struggle to exercise as much as I would like to. So please know that this is a judgment-free zone! Would you mind telling me a bit about your current exercise habits?

After introducing the topic of exercise in this manner and listening to the clients’ responses, a clinician might go on to ask about what types of exercise clients enjoy, assess the obstacles that hinder them from exercising, and help them to set exercise-related goals for the upcoming week.

When helping clients to establish exercise related goals, it is helpful to know established exercise guidelines. The United States Department of Health and Human Services (2018) encouraged adults to get at least two and a half hours of moderate- intensity cardiovascular exercise a week, or 75 min of vigorous cardiovascular exercise a week. Additionally, adults are encouraged to engage in muscle-strengthening activities on two or more days a week. While we believe these guidelines are important standards, we also stress the importance of meeting clients where they are at and helping them to set goals they can achieve (Avenell et al. 2006). Simply setting the goal to go on a brisk walk for a half hour once during an upcoming week might be a valuable initial goal for clients to make.

We offer several cautions to consider when incorporating exercise into EFT. First, we reemphasize the importance of taking a collaborative stance with clients when discussing incorporation of exercise into their lives. Clinicians must be careful with clients who do not exercise regularly to ensure that they do not feel judged. Appropriate self-disclosure can help put clients at ease. We, for example, often mention briefly that we sometimes struggle to make time to exercise when talking with our clients. They report appreciating our acknowledgment that it can be hard. Second, we recognize that there are many obstacles to exercise. Lack of time or lack of access to a gym appear to be two of the most common challenges that prevent exercise. However, exercising from home for short periods of time can have positive effects on one’s health and is better than not exercising at all (Callaghan 2004). Lastly, emotionally focused therapists especially need to be sensitive to if one partner does not exercise regularly but the other partner does. It is possible that feelings of inadequacy and/or insecurity accompany this dynamic. Thus, emotionally focused therapists should be leery of adding pressure to exercise upon the partner who is not regularly exercising. Clinicians should consider accessing the primary emotions of the partners in such situations. It is possible for conversations about exercise to result in the identification and expression of attachment needs.

Psychological Resources

Incorporating psychological factors into conceptualization and practice could help EFT expand into other areas and accentuate its overall effectiveness, as improving individual mental and emotional health may make it easier for couples to bond. For example, addressing trauma in EFT can both decrease post-traumatic stress symptoms and increase relationship satisfaction (Johnson and Williams-Keeler 1998). In addition, using EMDR with EFT has been suggested to help heal from the trauma of infidelity (Negash et al. 2018). As therapists address psychological factors, they may help clients become unstuck and participate more fully in the EFT process. For example, creative expression could help clients access underlying attachment emotions, which might otherwise be uncomfortable or foreign for many people and cultures.

Mindfulness

Therapists may assess for and intervene using many psychological factors; however, we chose to discuss mindfulness in depth as our primary example for several reasons: (a) mindfulness has received substantial attention in psychological literature, and several studies have found positive impacts on relationships (Barnes et al. 2007; Wachs and Cordova 2007), (b) despite promising benefits for couple therapy, little research describes how to specifically incorporate mindfulness into couple therapy models, and (c) whereas some psychological factors and interventions adopt an individual focus, mindfulness may be easily directed at a partner, maintaining its systemic focus.

Mindfulness has been defined as directed attention toward present experience in a curious, open, and accepting manner (Bishop et al. 2004). Practicing mindfulness has been shown to improve emotional health and relationship satisfaction (Adair et al. 2018; Montes-Maroto et al. 2017). In Adair et al.’s study (2018) on mindfulness, spouses with higher mindfulness traits like “non-judgment” and “observing” were rated higher in responsiveness by their partners, which predicted relationship satisfaction (Adair et al. 2018). As responsiveness is a secure attachment behavior (Sandberg et al. 2012), mindfulness might help strengthen attachment by increasing responsiveness, thereby supporting the EFT objectives. The notion that mindfulness may complement EFT in session has been suggested by other researchers (Beckerman and Sarracco 2011) and may fit neatly into the EFT process. For example, mindfulness has been shown to help partners emotionally regulate and connect (Quaglia et al. 2015), which could help them avoid their negative interactional cycle and engage during session. In addition, mindfulness may help partners develop compassion and empathy for each other (Lord 2017), further strengthening their emotional engagement.

Incorporating Mindfulness in Treatment

The practice of mindfulness outside of session may be used in several ways that support therapy. Firstly, practicing mindfulness individually at home or at work has been shown to positively influence relational interactions when re-united (Montes-Maroto et al. 2017). The therapist may consider inviting the couple to practice brief mindfulness techniques during a morning routine, at work, or during stressful moments in the day. Secondly, therapists may invite couples to practice mindfulness as a couple outside of session. This could help them practice calming their physiology together to decrease emotional reactivity and increase security. To begin discussing mindfulness, therapists can explain the concept of mindfulness from a psychological perspective and then evaluate the clients’ interest and motivation (Zou et al. 2016). While mindfulness can encompass a wide array of specific techniques, therapists can explain the basic principles and suggest well-researched common practices, such as mindfulness meditation. To implement mindfulness meditation, couples find a quiet space and a comfortable posture, direct their attention toward present experience such as breathing, and practice opening their mind to thoughts while withholding judgement (Robins et al. 2014). This practice can be done in only a few minutes or longer, as desired by the clients.

Therapists can also incorporate a short mindfulness meditation practices at the beginning of session. This may bring clarity to help couples identify their negative cycles (step 2) and access primary emotions (step 3). In addition, a short mindfulness practice before enactments may help couples identify with disowned needs and aspects of self (step 5) and accept their partner’s experiences (step 6; Lord 2017). When couples become emotionally flooded during session, a mindfulness practice may interrupt the interactional cycle and help couples emotionally regulate, restructuring the interaction (step 7). After interrupting the cycle, the therapists can check in with their clients’ emotional self-awareness and then propose a brief mindfulness technique to calm their physiology. Thus, mindfulness, may be an effective addition in structuring an enactment. For more ideas for incorporating mindfulness in session, see (Beckerman and Sarracco 2011).

Social Resources

Clients’ social environments contain influences from many interconnecting systems, such as friends, family, communities, and cultural contexts. Truly systemic therapists should consider the influence of and support from larger systems in their formulation and treatment. This assessment can add robustness to EFT conceptualizations and help therapists understand the clients’ situations more holistically. Disregarding the influence of larger systems can be detrimental, especially for clients of more collectivistic cultures. Helping clients connect to their communities can also be particularly helpful for ostracized groups, such as sexual minorities, refugees, racial/ethnic/cultural minorities, and families in rural areas. As first-line sources of mental health support, we should be familiar with specialized resources that could benefit the couple. This could also help where EFT is limited, such as in cases of domestic violence, suicidality, and substance use. A helpful resource is 2-1-1, which is a phone number individuals and families can dial to connect to community-based organizations and access basic need resources, mental health resources, family support, and much more. Many services could supplement couple therapy, such as parenting courses, psychiatric care, community organizations, financial planning, etc. The therapist can discuss what resources have been accessed in initial assessment and provide relevant referrals when appropriate.

Volunteerism

In addition to assessment of social contexts and connection to social resources, we wish to illustrate a specific example of how therapists might incorporate a social-related intervention into treatment. We chose volunteerism for several reasons: (a) volunteering may augment EFT process by helping partners experientially consider others’ needs, (b) at the same time, volunteering could promote out-of-session bonding experiences by aligning the partners in focusing on an externalized issue (consider Step 4 of EFT), (c) volunteering is adaptable to most clients’ interests and schedules, (d) volunteering may be a way to become integrated into communities, and (e) volunteering has been shown to offer several benefits to mental health and relational well-being. For example, connecting with others through volunteer organizations has been shown to increase life satisfaction (Renzaho et al. 2012). A longitudinal study found that volunteering predicted psychological well-being, and this was moderated by level of social integration, with the less integrated benefitting the most (Piliavin and Siegl 2007). The study found the association to be the strongest among subjects who volunteered consistently and at a variety of organizations. While most couples may find it difficult to allocate time towards frequent volunteering, many time-sensitive opportunities exist that can provide couples with bonding experiences outside of session. Therapists can discuss with clients what type of volunteering would be the most meaningful to them and potentially provide the most fulfillment. For couples struggling with relational and emotional challenges, serving others can be a way to use their pain to connect with others, which can help them emotionally regulate and avoid their negative interaction cycle.

Encouraging Volunteerism in Treatment

If during initial assessment, clients reveal a lack of connection to their community, therapists can ask if they are open to new ways for connecting and provide suggestions for doing so, such as through volunteering. It is important for therapists to explain the potential benefits of their suggestions; yet, therapists should also take a collaborative approach and not pressure clients into adopting unwanted practices. As an example, a military couple with no children reported repeated examples of poor experiences and lack of support in their rural town, and that these constant feelings of frustration and loneliness affected their marriage. They felt alone in their community and had little social connections from their work, church, and neighborhood. The therapist asked if they were interested in volunteering as a way to connect with other people who felt alone in their community. The therapist explained that this connection could potentially relieve stress entering their relationship and provide a uniting experience for them. The couple agreed to try volunteering at a local food bank. After several volunteering experiences, the couple reported feeling like they were “on the same side” and began more quickly reframing their issues in terms of their cycle, rather than each other. They also reported a decrease in loneliness and frustration that reduced their frequency of entering negative interaction cycles.

Spiritual Resources

Several clinicians and academics have called for better integration of spirituality into therapy because of its potential influence on marital interactions (Carlson et al. 2011; Mahoney and Cano 2014; Kusner et al. 2014; Rauer and Volling 2015). The subfield of relational spirituality focuses on how couples can draw on their spiritual beliefs and practices to transform their relationships (Mahoney 2010). Despite potentially strong effects of spirituality on couple interactions, many therapists do not know how to incorporate spirituality into their practice or may have valid concerns, such as precautions about imposing their religious values or going beyond their scope of practice (Sullivan and Karney 2008). Several suggestions have been provided in the relational spirituality literature to enhance treatment while avoiding these pitfalls, and we will briefly discuss their relevance to EFT.

In terms of assessment, both religion and spirituality can be major sources of conflict, and since they are often of core importance to people, spiritual differences or conflicts may be more likely to cause attachment wounds than many other areas of conflict. EFT therapists can assess for these experiences as important “landmarks” in their relationship history (Johnson 2004). In addition, positive spiritual coping has been shown to buffer the negative effects of attachment avoidance and marital adjustment (Pollard et al. 2014), so an early assessment of spiritual practices could inform the therapist and remind the couple about potential strengths and behaviors to help them emotionally regulate and escape their negative interaction cycles. Whereas spiritual factors such as meaning making may be natural for therapists to bring up, other topics such as the influences of religious beliefs or spiritual practices on a couple’s relationship require more caution. Researchers strongly recommend using a client-led approach in discussing these matters. For example, therapists can inquire about the clients’ belief systems and what practices are most helpful to them, and while using the clients’ own language system, discuss how these practices might benefit their relationship (Beach et al. 2008). Clients may bring up a variety of spiritual practices that could potentially enhance couple interactions, such as meditation, yoga, singing, fasting, and studying spiritual texts. In order to demonstrate navigating ethical and tactical considerations when incorporating spiritual resources, we wish to provide guidance on a specific spiritual practice.

Petitionary Prayer

We chose prayer for several reasons: (a) some form of prayer is a common practice within most spiritual orientations, (b) petitionary prayer encourages consideration for partner, which could aid in the EFT process, and (c) prayer is one of the only spiritual practices for couples which has significant research backing and suggestions for incorporation (Beach et al. 2008; Fincham and Beach 2014). For example, partner-focused petitionary prayer (PFPP) is a type of prayer that “invokes the deity’s help in response to specific needs” and is “focuses on the partner’s well-being” (Fincham and Beach 2014, p. 587). This type of prayer has been linked with increases in commitment (Fincham and Beach 2014), which may increase security in the relationship. Praying for one’s partner and praying with one’s partner has also been linked with increased trust, mediated by couple unity (Lambert et al. 2012). Petitionary prayer’s benefits of increased commitment, security, trust, and unity could support EFT’s objectives of secure attachment.

Incorporating Petitionary Prayer in Treatment

To incorporate prayer in therapy, several recommendations and cautions have been outlined in previous studies. Firstly, researchers warn against pushing prayer or other interventions on the couple, and they recommend against the couple bringing up conflictual spiritual topics (Sullivan and Karney 2008). Secondly, if the couple shows interest in incorporating prayer into their relationship, the therapist should be aware that only certain types of prayers have been found to show positive relational benefits (Fincham and Beach 2014); thus, providing specific suggestions (within the client’s realm of spiritual practice) can help couples successfully apply this practice to their relationship and avoid unhelpful prayers (Beach et al. 2008). For example, self-focused prayer (SFP) is a common type of prayer that asks for help to cope with one’s own life challenges and negative emotions, but this form of prayer has not been shown to increase commitment to the relationship (Fincham and Beach 2014). On the other hand, PFPP may facilitate the consideration of their partner’s needs and contribute to healthy attachment bonding. Thus, therapists should provide very specific direction for the prayers’ content and may consider following up with the clients in subsequent weeks to understand what types of prayer the clients are introducing.

We reiterate that therapists should follow the client’s lead on spiritual discussion and intervention and not introduce a practice such as petitionary prayer if it does not fit with client practices. Therapists also must not intervene outside their scope of practice. If clients request help specifically with spirituality, therapists should consider making referrals. Therapists should remember that they are not trying to intervene in their clients’ spirituality; however, they can draw upon spiritual practices, resources and strengths to supplement couple therapy process.

Conclusion

The BPS-S framework can be a valuable, encompassing framework to accentuate EFT’s effectiveness and help it expand and adapt to other presenting problems, comorbidities, populations, and cultures. However, several cautions are advised in its incorporation. The BPS-S framework is purposefully broad, and therapists should avoid trying to do too much by addressing all systems at once. Certainly, EFT therapists should maintain a clear focus of treatment and intervene within their area of expertise, using the BPS-S framework to enhance the model’s effectiveness, not distract from it. They can do this through addressing contributing factors when they are relevant and within their scope of practice. The BPS-S conceptualization also helps therapists view what factors should be addressed outside of their scope of practice, thus encouraging them to become better collaborators.

The interventions discussed in this paper are only examples that incorporation is possible and are by no means fully developed. A small fraction of possible assessments and interventions could be addressed, and these could only be elaborated on briefly. In choosing how to incorporate BPS-S interventions in clinical practice, EFT therapists should incorporate what fits theoretically and what fits the specific needs of the client, always maintaining a strong therapeutic alliance. These limitations invite future research, such as ascertaining how the incorporation of BPS-S principles affects client outcomes. Future research could also inform BPS-S incorporation with other models of couple therapy, as well as therapy for individuals and families. Lastly, future research can address how BPS-S and family therapy models might be applied more specifically to diverse populations. Despite these limitations, the incorporation of the BPS-S framework into couple therapy models adds increased scientific backing and credibility. Combined with relational therapeutic models’ specific interventions, the incorporation of the BPS-S framework helps the field of couple therapy maintain its systemic roots and use current research to improve formulation and intervention for couples.