Notes on Hold Me Tight by Dr Sue Johnson

I recently read Hold Me Tight by Dr Sue Johnson, a highly regarded relationship therapy book. The book outlines the process of Emotionally Focused Therapy (EFT), a short-term therapy that places great emphasis on love as an attachment bond.

The book provides a few useful frameworks and memes for navigating relationship difficulties. I thought I’d share them here for those who don’t want to read the whole book, or who are just interested. I had a few gripes with the book, particularly with regards to the evidence base for the efficacy of EFT, but still think it’s worth reading if just to get more of a sense of what couples therapy actually looks like.

Part 1: Attachment and Presence

The core part of any relationship, according to Johnson, is the strength and security of the attachment. Johnson has three core criteria that need to be met to maintain a secure attachment in the context of a romantic relationship, loosely acronymised as “ARE you there?”:

• A = Accessible. Each partner needs to be emotionally accessible; each partner can read the other’s emotional state and recognise important shifts in that state. I expect this means that, if asked, each partner is willing to share how they’re feeling (beyond “I’m fine” or similar).
• R = Responsive. Each partner can acknowledge and respond emotionally to their partner’s needs if they make requests. They aren’t dismissive or distracted, they are present when called upon.
• E = Engaged. Outside of requests, each partner remains emotionally engaged. They value their partner, check in regularly and remain close.

I find it somewhat hard to distinguish between these criteria (if one partner enquires about the other’s emotional state and the other responds well, is that accessible or responsive? Or both?).

These criteria can probably best be packaged together as “be emotionally present” — tell your partner how you feel! If they express a negative emotion — Listen! Sympathise! Empathise!

I think this is the key insight from the book, largely because it’s easy to think through these criteria and check whether you actually meet these criteria for your relationship. For example, I think I’m reasonably good at responding and engaging to my partner's emotional needs but I’m often emotionally inaccessible — I have a steady surface emotional state, even if I’m stressed, anxious or very happy. This means my partner often has to enquire actively about my mood and thoughts, leaving her somewhat insecure before she receives confirmation that I’m okay.

In a secure attachment, both partners can meet the others’ attachment needs. These probably vary depending on each person’s history — some need security, others need to feel heard and understood — but a secure attachment is necessary for these needs to be met, much like a child needs a secure attachment with their mother to develop cognitively.*

Johnson returns to the importance of attachment throughout the case studies in the book. In her sessions, she aims to identify attachment fears and reframe them as attachment needs that can be met via a more secure attachment:

• Attachment Fear = A fear that your attachment is not strong enough e.g. “I’m worried you will leave me because I am X” / “I am scared of commitment because past partners hurt me.”
• Attachment Need = What you need for your attachment to feel strong e.g. “I need you to still love me, even if I am X” / “I need you to promise not to hurt me like that again.”

*See e.g. Walsh et. al (2019). Though note that other research in this field has failed to replicate. It seems likely to me that this claim will turn out to be too strong, or the effect will be largely attributed to other causes.

The Seven Conversations

In the second part of the book, Johnson outlines the 7 conversations that make up EFT. I think that each of these serves as a template for ~1 therapy session in EFT but I’m not totally sure. As you can see, EFT seems to be aimed at couples who are quite severely distressed — I expect couples who just want to build a stronger relationship can focus on conversations 4 onwards.

1. Demon Dialogues — ‘Demon Dialogues’ are what Johnson calls cyclical, recurring arguments that couples regularly get into. The classic “are we going to go over this all again” kind of argument. The first part of EFT is to identify that these are going on — Johnson often recommends that couples learn what their demon dialogues are and actively name them when they start happening (“ah, we’re doing that circular argument thing again”).

2. Raw Spots — Johnson thinks that Demon Dialogues are often initiated by one partner rubbing another’s ‘Raw Spot’, an issue they feel particularly sensitive about. This can be anything from “you’re always late” (because you don’t care about me) to “I don’t like when you’re around other men/women” (because maybe you’ll prefer them to me). Johnson will work with couples to find out what each partner’s Raw Spots are.

3. Revisiting rocky moments — To examine a couple’s Demon Dialogue and identify the Raw Spots, Johnson encourages couples to re-play a recent argument and provide meta-commentary about what they think is going on. E.g. “when you mentioned that you might miss our date night, I became infuriated because that’s a real raw spot for me. That made me attack and tell you I can’t trust you, but I know that hurts to hear. I think that’s why I do it, to raise the stakes”.

4. Hold me tight — Once couples have a stronger sense of how their arguments tend to play out, Johnson encourages them to try and express their Raw Spots as attachment fears and needs (see above). This requires a great deal of vulnerability and introspection, and usually involves taking a surface complaint (e.g. not committing to plans), expressing the fear behind the complaint (e.g. “I’m worried you’re losing interest in me”) and reframing this as a need (e.g. “I need you to show me that you still prioritise me”).

Johnson encourages the more distanced person to go first, usually the male in heterosexual relationships. She also encourages clients to use and repeat handles to access the deepest emotions. Handles are words or phrases that really capture the emotion according to the client, often the word of phrase that first accurately describes the emotion (e.g. “helpless… yes that’s exactly it, I feel helpless”).

5. Forgiving injuries — A barrier to expressing attachment needs, according to Johnson, is a past relationship trauma. A relationship trauma is where one partner explicitly fails to fulfil an attachment need and realises an attachment fear. A vivid example from the book is where a woman receives bad medical news and her husband walks past her on the stairs without comforting her. This confirmed her worst fears; that her husband isn’t there to support her when she needs it most. In this example, the woman no longer trusts her partner to meet her attachment needs and refuses to make herself vulnerable to him again.

Johnson encourages the couple to revisit the trauma much like a rocky moment (conversation 3) and give the partner at fault the opportunity to understand and apologise. This conversation seems particularly tricky to get right and I expect navigating this kind of trauma requires a whole other set of therapeutic expertise which isn’t really disclosed in the book.

6. Sex and touch — As something of an aside, Johnson describes three modes of sex and touch that couples can fall into, depending on the state of the relationship:

• “Sealed off” sex — In this mode, the goal of sex and touch is simply to reduce sexual tension. People who feel emotionally unsafe in their relationship will gravitate to this mode and will focus on impersonal gratification and sensation.
• “Solice” sex — Couples tend to have solice sex when one partner is seeking reassurance or a relief from anxiety. Sex is used as a means of resolve and not pursued in and of itself.
• “Synchrony” sex — In this mode, partners are emotionally present during sex and touch, and combine physical sensation with exploration, eroticism and love. This is the mode of sex and touch couples should aim for, according to Johnson.

7. Keeping love alive — In the final conversation, Johnson encourages couples to set up processes to ‘keep their love alive’. She emphasises the importance of rituals — weekly meals, date nights, habits, leaving notes for one another, annual rituals — anything that regularly brings the couple together. If therapy has involved a lot of healing, the couple should also write and maintain a story about their growth, rather than move on from it completely (e.g. “early in our relationship, we struggled with X, then we learned how to communicate about X and now we’re much closer”).

In the penultimate chapter, Johnson explores how EFT has helped couples who have experienced significant traumas — they are some really moving case studies but it doesn’t build on the advice much beyond “encourage your partner to share their experience of trauma with you, and acknowledge pain on both sides”.

The final chapter is a rousing call to arms about how love can solve all the problems in the world. Johnson describes how a couple of charities were founded by people who were motivated by compassion for others (it’s not totally clear how this is relevant to the rest of the book, which quite explicitly focuses on love in romantic relationships).

Commentary

This book provided me with some clarity about the importance of emotional presence in the context of romantic relationships. I’ve found myself thinking about the “ARE you there?” criteria and noticing how an absence of emotional presence is a familiar sign of dysfunctional relationships (consider how so many relationship breakdowns seems to start with “they seemed distant” — emotional distance is the opposite of emotional presence).

One of the other most valuable things about the book was simply listening into therapy sessions. It’s fascinating to be able to listen to another couple argue and be able to point out what’s going wrong (e.g. “ooh, it’s clear he’s sensitive about that and she’s just rubbing his raw spot. Man, they’re in such a cycle”). It’s perhaps even more insightful to hear therapy go well — some of my favourite moments from the case studies are the parts where one partner really clearly expresses their needs or makes an extremely sincere and heartfelt apology.

For this reason, I also strongly recommend the podcast Where Should We Begin? with Esther Perel. The podcast is a collection of one-time relationship therapy sessions with an excellent therapist. If you want to learn how to spot relationship difficulties and what couples get right and wrong, this is a treasure trove.

However, there were some aspects of the book I found frustrating:

• For EFT to work well, it seems as if the fundamental problem at the heart of the relationship must be some sort of benign misunderstanding (“I close off because I’m actually just scared of losing you! I get angry because I need you so much!”). Each partner is supposed to voice their attachment needs and then, if they’re genuine, the other just… meets them? Maybe this is often how it goes but I didn’t hear of examples where the attachment needs couldn’t be met or if the fear is actually well-justified. It all felt a bit too clean.
• Johnson is very self-aggrandizing. She’s often the hero in the case studies and regularly describes how clients have life-changing moments of realisation in her sessions after she offers a breathtaking insight. These moments are clearly heavily embellished and they make me distrust her as a narrator.

Finally, is EFT as efficacious as Johnson makes it out to be? Not really. A lot of papers cited as demonstrating the efficacy of EFT involve a very small n and were written by the therapists who developed the therapy, often Johnson herself (see e.g. this table from Johnson’s 1999 meta-analysis). This guy thinks that at least one of Johnson’s papers is total bullshit and I’m inclined to agree. That said:

• Beasley & Ager (2019) ran a meta-analysis and did find that marital satisfaction was improved and sustained by EFT (I haven’t read the details).
• Another RCT not by the developers found that EFT caused “greater improvement in relationship satisfaction among men and women” (I didn’t dive in here either).

This all makes me think: “EFT is probably a decent style of couples therapy, but my priors are very low on this kind of thing being reliably effective so this isn’t saying much.”

I still recommend reading Hold Me Tight, especially as a first venture into what effective couples therapy might look like.