The Generalizability of An Attachment Based Group Intervention To Chinese Canadian Couples
The Generalizability of An Attachment Based Group Intervention To Chinese Canadian Couples
The Generalizability of An Attachment Based Group Intervention To Chinese Canadian Couples
To cite this article: Tat-Ying Wong, Paul S. Greenman & Valérie Beaudoin (2017): “Hold Me
Tight”: The Generalizability of an Attachment-Based Group Intervention to Chinese Canadian
Couples, Journal of Couple & Relationship Therapy, DOI: 10.1080/15332691.2017.1302376
Article views: 28
ABSTRACT KEYWORDS
“Hold Me Tight” (HMT) groups are an adaptation of emotion- CRE program evaluation;
ally focused therapy (EFT) for couples and have emerged out of immigrant couples;
30 years of research into the efficacy and process of EFT. The goal emotional focused therapy
(EFT)
of this study was to test the effects of a Chinese-language ver-
sion of the HMT relationship enrichment program in a sample of
Chinese Canadians. Twenty-three men and 23 women (N = 46)
in committed couple relationships completed an HMT relation-
ship education program with their partners in Toronto, Ontario,
Canada. Results indicated statistically significant improvements
in participants’ satisfaction with their attachment relationships,
in their attachment security, and in their family functioning. The
implications of these findings are discussed in light of relevant
cross-cultural literature on attachment and couple relationships.
CONTACT Tat-Ying Wong [email protected] Grace Health Centre, Keele St., Suite ,
Downsview, Ontario, Canada MME.
© Taylor & Francis Group, LLC
2 T.-Y. WONG ET AL.
(conversation 5). In the final two group sessions, couples learn how to improve their
sex lives through emotional connection (conversation 6) and how to maintain the
gains made in the relationship enrichment group (conversation 7).
In HMT educational groups, clinicians focus primarily on helping partners
become aware of “attachment needs,” which from the attachment-based EFT per-
spective are fundamental longings for emotional closeness and comfort in the con-
text of love relationships (Johnson & Greenman, 2006). Once partners are aware
of their attachment needs, they learn to ask their spouse for the support and reas-
surance they seek in direct, unequivocal ways. Each person in the couple learns
how to remain emotionally accessible and responsive to the other, which fosters a
safe, enduring emotional bond that facilitates relationship satisfaction and effective
problem-solving (Dalgleish et al., 2015; Guerriero & Zavattini, 2015; Johnson, 2013;
Sadeghi, Mazaheri, & Moutabi, 2011). This type of attachment bond is referred to
as “secure,” as opposed to “insecure” bonds that involve either the avoidance and
minimization of closeness or the anxious pursuit of it (Mikulincer & Shaver, 2007).
Attachment bonds in couples are analogous to the attachment “styles” that represent
an individual person’s habitual way of approaching interpersonal relationships.
Emotion
The results of research conducted over the past 10 years suggest that people of
Chinese origin or cultural background tend to display more reserve and modera-
tion in the expression of emotions than do people of European origin or cultural
background. For example, in one study of the emotional reactions of depressed and
nondepressed European Americans and Asian Americans while watching a sad,
neutral, or funny film, Chentsova-Dutton and colleagues found that nondepressed
Asian Americans reported and displayed fewer emotions of less intensity than did
nondepressed European Americans (Chentsova-Dutton et al., 2007). Interestingly,
Asian Americans who were depressed tended to experience and express their
emotions more intensely than did European Americans in this sample. The authors
also found that the more acculturated Asian American participants were, the more
likely they were to experience and report sadness while viewing the sad film. In a
different study of female university students of diverse cultural backgrounds, those
who espoused traditional Asian values such as remaining “reserved and tranquil”
and “not making waves” were more likely to report suppressing their emotions in
daily life than were those who espoused more European values such as “a woman
who is living alone should be able to have children” and “I’m confident in my ability
to handle most things” (Butler, Lee, & Gross, 2007).
The results of a more recent study corroborate and extend these findings. In
this investigation, Chinese undergraduate students in Beijing reported less intense
positive and negative emotions than did their counterparts in the United States
(California) when viewing photographs designed to elicit strong negative emotions
(e.g., pictures of brutality or violence; Davis et al., 2012). American women reported
the strongest negative emotions in the sample, whereas Chinese men reported the
least intense reactions across both groups of students (Davis et al.). These findings
6 T.-Y. WONG ET AL.
are commensurate with the notion that Chinese people, as members of a collectivist
society, tend to favor group cohesion in part by exercising emotional restraint (Uba,
2003), as opposed to Americans of European descent, who tend to favor individual
rights and responsibilities and the open expression of feelings and needs (Gross &
Thompson, 2007). Taken together, these results suggest that it is important for both
men and women to control one’s emotions in the Chinese culture, which might have
a noteworthy effect on the success or failure of an emotionally focused, attachment-
based intervention with people of Chinese origin.
Adult Attachment
Although there are striking cultural differences relative to the experience and
expression of emotion, there also appear to be some similarities in terms of the
dimensions and dynamics of adult attachment between the Chinese culture and the
European American culture, in which EFT was developed. These similarities are
accompanied by some important differences, however. For example, Wei and col-
leagues found in their study of more than 800 undergraduate students that the factor
structure of the Experiences in Close Relationships scale was the same across four dif-
ferent cultural groups: African Americans, Asian Americans, Whites, and Hispanic
Americans, although Asian Americans reported more anxious and avoidant attach-
ment orientations than did Whites (Wei, Russell, Mallinckrodt, & Zakalik, 2004).
Similarly, Ditommaso and associates detected no differences in patterns of attach-
ment security to parents between Canadian students and students visiting Canada
from China, but they did find that Chinese students reported higher levels of attach-
ment insecurity in their romantic relationships than did their Canadian counter-
parts (Ditommaso, Brannen, & Burgess, 2005).
Other researchers have also identified patterns of attachment whose psychoso-
cial repercussions mirror those typically found in North American samples. For
instance, Wang and Ratanasiripong (2010) found in their study of 112 American
students of Chinese origin that lower levels of attachment anxiety and avoidance
predicted better psychosocial adjustment, as measured by standardized scales of
psychological and interpersonal constructs (e.g., the Beck Depression Inventory–II,
the Independence Self-Construal Scale). In a similar vein, Wang and Scalise (2010)
discovered in an investigation of 275 Taiwanese university students that those who
reported greater attachment security were less likely to report interpersonal prob-
lems. Finally, Jinyao and colleagues reported that anxious and avoidant attachment
orientations in their sample of 662 Chinese university students predicted symptoms
of depression following periods of stress, as would be expected in the West (Jinyao
et al., 2012). The findings from these studies suggest that attachment theory, as it
was conceptualized in the West, might indeed apply to Asian Americans and to
Asian Canadians; that people of Chinese origin might experience emotional uncer-
tainty in their romantic relationships; and that tendencies to worry about or avoid
closeness in personal relationships are related to psychological dysfunction, as they
are in North American samples. For these reasons, EFT or EFT-based interventions
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 7
might be just as useful for people of Asian origin as they are for people in Western
cultures, because they address attachment concerns directly in an effort to
strengthen the emotional tie between partners.
Study Objectives
Given the novelty of EFT-based educational groups and the aforementioned ques-
tions about whether this intervention would be applicable to a cultural group other
than Whites, the purpose of this study was twofold. First, we wanted to gather infor-
mation on the potential efficacy of HMT groups, as there is very little informa-
tion about this in the clinical literature and the two studies of HMT educational
groups that do exist (Kennedy, Johnson, & Wiebe, 2016; Stavrianopoulous, 2015)
were conducted with predominantly White populations. Second, we hoped to dis-
cover whether an attachment-based intervention whose principal aim is to develop
a secure bond between partners through attuned responses to expressions of strong
emotion would appear to be effective at improving relationship functioning in cou-
ples of Chinese origin. This is uncertain in light of the differences vis-à-vis attach-
ment and the experience of strong emotions between North American and Chinese
cultures. However, the basic tenets of attachment theory, EFT, and HMT groups
stipulate that the underlying need for emotional closeness to significant others is a
cross-cultural phenomenon.
Hypotheses
Given the HMT program’s emphasis on the primacy of openness, accessibility, and
responsiveness on the part of partners in a couple relationship and on the idea that
longing for emotional connection represents a human need rather than a culture-
specific one, we formulated the following hypotheses:
H1: People of Chinese origin participating in the HMT program would demonstrate signif-
icant improvements in overall couple relationship functioning, as measured by the Chinese
versions of the Dyadic Adjustment Scale and the Relationship Satisfaction Questionnaire.
H2: People of Chinese origin participating in the HMT program would exhibit significant
decreases in attachment insecurity, as measured by the Chinese version of the Experiences
in Close Relationships Scale-Short Form.
H3: People of Chinese origin participating in the HMT program would show signifi-
cant improvements in family functioning, as measured by the Chinese Family Assessment
Instrument.
Method
This exploratory study featured a pre–post design with the aim of detecting changes
in participants’ scores on a variety of measures that tapped attachment quality and
relationship functioning.
8 T.-Y. WONG ET AL.
Procedure
Participants were recruited through community event announcements in Chinese-
language newspapers, on local television stations, and on the radio in Toronto,
Canada. Recruitment also took place through the network of a local Chinese faith
community. Interested potential participants were invited to attend an introductory
session in which informed consent was obtained and participants had the oppor-
tunity to ask questions. Participants who agreed to participate in the study signed
the consent form to use data from their preintervention and postintervention self-
assessments for outcome studies and to agree to strict confidentiality in the group.
A small fee was paid to cover the cost of printing the course material and the admin-
istration of the course. Participants were free to withdraw from the study any time.
The study and course material were reviewed and approved by the director of the
faith community responsible for the courses. This individual had professional train-
ing in ethics and was frequently consulted for ethical issues in the faith community.
Participants completed all assessment instruments at the conclusion of the first
and final group sessions using a link to the online instruments with all personal and
identifying information encrypted.
Participants
The HMT program in the present study was modified due to logistic and cultural
considerations. Group meetings took place on Sunday mornings at a church in a
Chinese community whose administration offered free facilities, lay group leaders
fluent in Cantonese without any psychotherapy or EFT training but who were will-
ing to learn the HMT model, and childcare during the group. In return, the church
administration asked for 30 courses that were 90 minutes in length each, spread
out over a 9-month period. This arrangement assured maximum participation in
the group due to its very low cost (participants were asked only to purchase the
Chinese version of Hold Me Tight and a workbook, developed by the first author in
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 9
Chinese, to go along with it), its convenient time slot, and the opportunity it afforded
for participants’ children to engage in other supervised activities while their parents
focused on their relationship. In addition, participants included couples of differ-
ent ages and in different family life stages. It was therefore decided to show all of
the conversations on the HMT DVDs (with Chinese subtitles), instead of selecting
only one for each conversation. This reinforced the participants’ experience of each
conversation; they were able to observe both young and older couples talking about
attachment need and fears.
Because most Asian Canadians have minimal exposure to and understanding of
attachment as it is presented and discussed in session 1 of HMT educational groups,
the developers of this version of the HMT program decided to spend much more
time describing attachment theory and discussing its relevance to couple relation-
ships than do facilitators of the traditional HMT group program. Overall, facilitators
of the Chinese version of HMT used the first 10 sessions to cover attachment the-
ory from part 1 of the HMT text, “A New Light on Love.” Sessions 11 to 20 covered
conversations 1 to 3 and sessions 21 to 30 covered conversations 4 to 7 in HMT. The
church administration that sponsored this activity also asked for the inclusion of
some religious content in the groups; attachment- and couple-related concepts were
therefore linked to relevant passages from Scripture.
The Chinese faith community in Toronto is generally conservative and somewhat
suspicious of mainstream North American and European psychological concepts;
the integration of excerpts from the Bible (e.g., “The Lord God said, ‘It is not good
for the man to be alone. I will make a helper suitable for him.’ ” [Genesis 2:18]) were
included to help foster a theological understanding of attachment and to address
any mistrust that participants might have had about the theory that underlies the
majority of HMT interventions. Thus, the goal of these additions was to help partic-
ipants become more readily able to accept and be comfortable with new attachment
concepts such as the fundamental human need for closeness and connection, the
tendency to seek out support and reassurance in times of emotional stress, and the
importance of responding to vulnerability cues in one’s relationship partner.
Finally, as mentioned, people of Chinese background have less of a tendency than
do those of European American background to be aware of and to share deep, vul-
nerable emotions, attachment needs, and fears (Davis et al., 2012; Uba, 2003). This
is due to the fear of the loss of face and the focus in the Chinese culture on the group
rather than on the individual. For this reason, the designers of this version of the
HMT program deemed it useful to slow down the pace of the group and to allow
participants to become more comfortable with one another before asking them to
engage in the expression of emotions such as fear, loneliness, and sadness.
The training of the lay group leaders followed the facilitator’s guide for the HMT pro-
gram (Johnson, 2010). The goals, format, assumptions, and values of the program;
the role of the facilitators; and examples of validating and supportive responses were
10 T.-Y. WONG ET AL.
reviewed during the first 90-minute training session. Skills for facilitating a group,
mapping out the couples’ cycles, and engaging and working with emotions were
reviewed during a second and third 90-minute training session for group leaders.
The first author, who is a certified EFT therapist, supervisor, and trainer, closely
monitored and supervised the group facilitators’ teaching and structuring of prac-
tical exercises. The first author attended the groups, observed and gave feedback
on facilitators’ presentations, and circulated during the practical exercises to offer
direct, immediate assistance to group facilitators with any difficulties. It is important
to note that the HMT program was designed for implementation by nonprofessional
group leaders with minimal, if any, exposure to the techniques of formal counseling
or psychotherapy. This is an educational group; all of the key concepts are detailed
in the manual in such a way as to be accessible to a large cross section of potential
facilitators (Johnson, 2010).
Instruments
Chinese Version of the Dyadic Adjustment Scale (C-DAS)
We used the C-DAS to measure relationship functioning. The DAS is widely consid-
ered to be the gold standard for assessing relationship satisfaction and closeness, and
the Chinese version has been developed and validated with Chinese-speaking popu-
lations (Shek, 1994, 1995). The C-DAS has excellent internal consistency and it cor-
relates with other measures of relationship satisfaction, which testifies to its validity
(Shek, 1994, 1995). A factor analysis revealed that the C-DAS has the same essen-
tial factor structure as the original DAS (Spanier, 1976): dyadic consensus, dyadic
cohesion, dyadic satisfaction, and affectional expression (Shek & Cheung, 2008).
Results
The results of this study support the three main hypotheses regarding improve-
ments in participants’ satisfaction with their couple and family relationships. We
conducted paired t-tests on the data collected at the first and last HMT educational
group sessions.
Table 1 contains the means and standard deviations for the C-DAS. As predicted,
participants demonstrated significant increases in overall relationship satisfaction,
as measured by the C-DAS [t(45) = 5.75, p < .0001], with a small but appreciable
effect size (d = .42). They also exhibited statistically significant increases on all of
the C-DAS subscales: dyadic consensus [t(45) = 2.09, p = .04), dyadic satisfaction
(t(45) = 3.61, p = .008], dyadic cohesion [t(45) = 2.57, p = .01], and affectional
expression [t(45) = 4.14, p = .002]. Effect sizes were in the small range for these
12 T.-Y. WONG ET AL.
Pre . . . . . . . . . .
Post .∗ . .† . .∗ . .‡ . .∗ .
Notes: DAS Total = DAS total score, DC = dyadic consensus, DS = dyadic satisfaction, DCH = dyadic cohesion, AE =
affectional expression. Significant pre–post intervention differences: ∗ p < ., † p = ., ‡ p = ..
subscales (d = .24, 32, 34, and .30 for dyadic consensus, dyadic satisfaction, dyadic
cohesion, and affectional expression, respectively).
Also as predicted, our analyses revealed significant increases in current [t(45) =
2.96, p = .005] and projected future [t(45) = 2.56, p = .01] relationship satisfaction
as measured by the RSAT. Effect sizes were in the small range for both of these sub-
scales (d = .34 and .32 for current and future relationship satisfaction, respectively).
Table 2 contains the means and standard deviations for the RSAT.
Pre . . . . . . . . . . . .
Post .∗ . .† . . . .‡ . . . . .
Note: C-FAI Total = C-FAI total score, M = mutuality, CC = communication and cohesiveness, CH = conflict and
harmony, PC = parental concerns, CP = control by parents. Significant pre–post intervention differences: ∗ p < .,
† p = ., ‡ p = ..
sizes were in the small range for C-FAI total scores (d = .25) and for CH subscale
scores (d = .26). These findings offer partial support for hypothesis 3.
Discussion
This is one of the first studies of the potential efficacy of any type of HMT educa-
tional group and the first to include an Asian population. It is also one in a small
handful of studies of EFT-derived interventions that have been conducted with a
non-White sample.
Overall, the results of our study indicate that participants’ satisfaction with
their couple relationships increased (hypothesis 1), their attachment avoidance
decreased (hypothesis 2), and their family harmony increased (hypothesis 3) after
completing the Chinese HMT program. These pre–post intervention effects were
significant with nontrivial effect sizes. The increased number of sessions might have
contributed to the apparent success of the program due to the added educational
components on attachment. The request by the faith community where the groups
took place to add relevant passages from Scripture appeared to promote acceptance
by Christian participants but did not seem affect the participation of non-Christians
since the selected passages from the Bible reinforced basic attachment concepts.
Our findings have implications for the development of future interventions of
this kind for people of diverse cultural backgrounds and it helps answer some of the
questions raised about the applicability of emotionally focused, attachment-based
programs to a wide range of sociocultural groups.
Our results show that people of Chinese background who were struggling in their
couple and family relationships made notable improvements in these areas after par-
ticipating in the Chinese HMT program. Although these results are preliminary and
need to be corroborated (see “Limitations” section), they suggest that HMT can be
successfully adapted to the needs of people from a particular cultural background
and that it can have the desired effects of improving relationship satisfaction and
increasing attachment security. In addition, our findings suggest that, despite impor-
tant cultural differences concerning the expression of strong emotion (e.g., Davis
et al., 2012) and levels of attachment insecurity in couples that appear to be higher
14 T.-Y. WONG ET AL.
in some Asian samples (Ditommaso et al., 2005), Chinese Canadians can indeed
benefit from an educational program that teaches them to recognize and to express
their sadness, their fears, and their vulnerability to their relationship partners. For
those who participated in this study, as for those who have benefitted from EFT
through the years, learning to identify primary emotions, to link them to attach-
ment needs, to ask partners directly for what they need, and to respond to clear signs
of attachment distress in their partners seems to have helped them feel happier in
their relationships (Wiebe et al., in press) with their spouses and with their fami-
lies in general. This is a notable finding and it speaks to the universality of certain
aspects of adult attachment.
Malleability of Attachment
The findings from the present study also reflect a growing trend in the attach-
ment literature to acknowledge that attachment orientations might be more mal-
leable and relationship-specific than originally thought (Burgess Moser et al., 2016;
Cozzarelli, Hoekstra, & Bylsma, 2000; Fraley, Heffernan, Brumbaugh, & Vicary,
2011). Participants in the Chinese HMT groups that we conducted demonstrated
greater attachment security by the end of the study, as indicated by significant
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 15
decreases in attachment avoidance over time. This result is similar to the one
reported by Burgess Moser and colleagues (2016) for standard EFT. They found,
as we did for our HMT group, that attachment avoidance tended to decrease in
clients over the course of EFT. They also found that changes in attachment anxiety
depended on the completion of what are known as “softenings” in therapy. A soften-
ing occurs when the partner who usually tends to criticize or blame when the couple
gets caught in a negative interaction cycle begins to access and express vulnerabil-
ity and need, to which his or her partner learns to respond with empathy and caring
instead of defensiveness or emotional stonewalling (Burgess Moser et al., 2016). This
might explain why attachment anxiety did not change after the HMT intervention
in our study. It is possible that the educational group format, while useful and related
to increases in relationship satisfaction, may not be conducive to the kind of intense,
repeated emotional exchanges that typify softenings in EFT (Bradley & Furrow,
2004; Johnson, 2004) and usually take place in the privacy of the therapist’s office.
not in and of itself ensure, in any meaningful fashion, reliable conclusions about the
clinical usefulness of a particular therapeutic approach, as pointed out by Jacobson
and Truax (1991) so cogently. We argue that future research on HMT groups ought
to focus on the clinical significance of the intervention, which involves taking into
account the norms of a high-functioning population and comparing them to prein-
tervention and postintervention outcomes (Jacobson & Truax).
Next, the present results preclude conclusions about the stability of the HMT pro-
gram’s effects over time. It would be useful, in a future project, to include a follow-up
assessment perhaps at 6 months and 1 year after the completion of the program. This
would help determine whether the impact of the program endures and it might pro-
vide insight into elements that could be adjusted in order to ensure the durability of
its effects.
Generalizability is also a concern. This HMT program was conducted in a reli-
gious setting in a Chinese community in Toronto, Canada. The program was much
longer than typical HMT groups because it was deemed important to sensitize the
Chinese population in Toronto to the notions of attachment theory more intensively
than elsewhere, in order to ensure their acceptance of the fundamental principles of
and their full participation in the intervention. The addition of religious material
might also have affected the outcome. For these reasons, although the results of the
present study are promising, it will be necessary to replicate them in other Asian
populations in nonreligious settings before making stronger claims about the pro-
gram’s applicability.
Finally, contrary to EFT, there is no process research on HMT at this time. For this
reason, specific change mechanisms have yet to be empirically identified. It would
be good for future research on HMT groups to examine whether the change mecha-
nisms in HMT, particularly the primacy of emotional experience in session, are the
same, similar to, or different from those that form the backbone of EFT.
Conclusion
Despite these limitations, the present study represents the first empirical evidence of
the potential efficacy and applicability of an attachment-based group intervention
to couples of Chinese origin. Participants in the Chinese HMT program appeared
to improve at the conclusion of their course in various aspects of their interper-
sonal functioning. This is the first study of HMT educational groups with a non-
American sample and one of the only studies of an EFT-based intervention with a
non-American sample. Our results pave the way for larger research programs that
will investigate the effects of changes in attachment and emotional connection on
the relationship satisfaction of people of diverse backgrounds.
ORCID
Tat-Ying Wong http://orcid.org/0000-0001-6615-9450
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 17
References
Bowlby, J. (1969). Attachment and loss: Vol. 1 Attachment. New York, NY: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety & anger. New York, NY: Basic
Books.
Burns, D. D., & Sayers, S. L. (1988). Cognitive and affective components of marital satisfaction:
Development and validation of a brief relationship satisfaction scale. Unpublished manuscript.
Burns, D. D., & Sayers, S. L. (1992). Development and validation of a brief relationship satisfaction
scale. Unpublished manuscript.
Butler, E. A., Lee, T. L., & Gross, J. J. (2007). Emotion regulation and culture: Are the social
consequences of emotion suppression culture-specific? Emotion, 7, 30–48. doi:10.1037/1528-
3542.7.1.30
Chang, S.-F. (2014). Infidelity among Chinese married couples: An emotionally focused approach to
treatment. Unpublished doctoral dissertation, Alliant University, Los Angeles, CA.
Chentsova-Dutton, Y. E., Chu, J. P., Tsai, J. L., Rottenberg, J., Gross, J. J., & Gotlib, I. H. (2007).
Depression and emotional reactivity: variation among Asian Americans of East Asian descent
and European Americans. Journal of Abnormal Psychology, 116, 776–785. doi:10.1037/0021-
843X.116.4.776
Cozzarelli, C., Hoekstra, S. J., & Bylsma, W. H. (2000). General versus specific mental models of
attachment: Are they associated with different outcomes? Personality and Social Psychology
Bulletin, 26, 605–618. doi:10.1177/0146167200267008
Dalgleish, T. L., Johnson, S. M., Burgess Moser, M., Wiebe, S. A., & Tasca, G. A. (2015). Predict-
ing key change events in emotionally focused couple therapy. Journal of Marital and Family
Therapy, 41, 260–275. doi:10.1111/jmft.12101
Davis, E., Greenberger, E., Charles, S., Chen, C., Zhao, L., & Dong, Q. (2012). Emo-
tion experience and regulation in China and the United States: How do culture and
gender shape emotion responding? International Journal of Psychology, 47, 230–239.
doi:10.1080/00207594.2011.626043
DiTommaso, E., Brannen, C., & Burgess, M. (2005). The universality of relationship char-
acteristics: A cross-cultural comparison of different types of attachment and loneliness
in Canadian and visiting Chinese students. Social Behavior and Personality, 33, 57–68.
doi:10.2224/sbp.2005.33.1.57
Feeney, B. C. (2007). The dependency paradox in close relationships: Accepting depen-
dence promotes independence. Journal of Personality and Social Psychology, 92, 268–285.
doi:10.1037/0022-3514.92.2.268
Fraley, R. C., Heffernan, M. E., Vicary, A. M., & Brumbaugh, C. C. (2011). The experi-
ences in close relationships—Relationship Structures Questionnaire: A method for assess-
ing attachment orientations across relationships. Psychological Assessment, 23, 615–625.
doi:10.1037/a0022898
Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT)
for couples: Linking theory to practice. Family Process, 52, 46–61. doi:10.1111/famp.12015
Greenman, P. S., Young, M. Y., & Johnson, S. M. (2009). Emotionally focused therapy with inter-
cultural couples. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 143–
165). New York, NY: Sage.
Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. In
J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–24). New York, NY: Guilford
Press.
Gottlieb, A. (2014). Is it time to detach from attachment theory? Perspectives from the West
African rain forest. Different faces of attachment: Cultural variations on a universal human
need (pp. 187–214). Cambridge, UK: Cambridge University Press.
18 T.-Y. WONG ET AL.
Guerriero, V., & Zavattini, G. C. (2015). Questioni d’amore: Teoria dell’attaccamento e relazioni
sentimentali [Questions of love: Attachment theory and romantic relationships]. Attacca-
mento e Sistemi Complessi, 2, 27–44.
Hattori, K. (2014). Emotionally focused therapy for japanese couples: Development and empirical
investigation of a culturally-sensitive EFT model. Unpublished doctoral dissertation, Univer-
sity of Ottawa, Ottawa, ON, Canada.
Honarparvaran, N., Tabrizy, M., & Navabinejad, S. (2010). The efficacy of emotionally focused
couple therapy (EFT-C) training with regard to reducing sexual dissatisfaction among cou-
ples. European Journal of Scientific Research, 43, 538–545.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining mean-
ingful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59,
12–19. doi:10.1037/0022-006X.59.1.12
Jinyao, Y., Xiongzhao, Z., Auerbach, R. P., Gardiner, C. K., Lin, C., … Shuqiao, Y. (2012). Insecure
attachment as a predictor of depressive and anxious symptomology. Depression and Anxiety,
29, 789–796. doi:10.1002/da.21953
Johnson, S. (2008). Hold me tight: Seven conversations for a lifetime of love. New York, NY: Little,
Brown and Co.
Johnson, S. (2010). Facilitator’s guide for Hold Me Tight groups (2nd ed.). Ottawa, Canada:
ICEEFT.
Johnson, S. (2013). Love sense: The revolutionary new science of romantic relationships. New York,
NY: Little, Brown and Co.
Johnson, S. M. (2004). The practice of emotionally focused coupled therapy (2nd ed.). New York,
NY: Brunner-Routledge.
Johnson, S. M., & Greenman, P. S. (2006). The path to a secure bond: Emotionally focused couple
therapy. Journal of Clinical Psychology, 62, 597–609. doi:10.1002/jclp.20251
Keller, H. (2014). Introduction: understanding relationships—what we would need to know to
conceptualize attachment as the cultural solution of a universal developmental task. In H.
Otto & H. Keller (Eds.), Different faces of attachment: Cultural variations on a universal human
need (pp. 1–24). Cambridge, UK: Cambridge University Press.
Kennedy, N., Johnson, S. M. & Wiebe, S. A. (2016). The Hold Me Tight Relationship Enhancement
Program: Short-term and long-term effectiveness. Manuscript in preparation.
Lakey, B., & Orehek, E. (2011). Relational regulation theory: A new approach to explain the
link between perceived social support and mental health. Psychological Review, 118, 482–495.
doi:10.1037/a0023477
Levine, R. A. (2014). Attachment theory as cultural ideology. In H. Otto & H. Keller (Eds.), Dif-
ferent faces of attachment: Cultural variations on a universal human need (pp. 50–65). Cam-
bridge, UK: Cambridge University Press.
Lewandowski, G. W., Ozog, V., & Higgins, H. (2015). The science of improving relationships. In
A. Rennolds (Ed.), Psychology of interpersonal perception and relationships (pp. 1–36). Haup-
pauge, NY: Nova Science Publishers.
Li, T., & Chan, D. K.-S. (2012). How anxious and avoidant attachment affect romantic relationship
quality differently: A meta-analytic review. European Journal of Social Psychology, 42, 406–
419. doi:10.1002/ejsp.1842
Mesman, J., van IJzendoorn, M. H., & Sagi-Schwartz, A. (2016). Cross-cultural patterns of attach-
ment: Universal and contextual dimensions. In J. Cassidy & P. R. Shaver (Eds.), Handbook of
attachment: Theory, research, and clinical applications (3rd ed., pp. 790–815). New York, NY:
Guilford Press.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change.
New York, NY: Guilford Press.
Newman, M. L., & Roberts, N. A. (2013). Health and social relationships: The good, the bad, and
the complicated. Washington, DC: American Psychological Association.
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 19
Park, J., Kitayama, S., Karasawa, M., Curhan, K., Markus, H. R., Kawakami, N., … Ryff, C. D.
(2013). Clarifying the links between social support and health: Culture, stress, and neuroti-
cism matter. Journal of Health Psychology, 18, 226–235. doi:10.1177/1359105312439731
Sadeghi, M. A., Mazaheri, M. A., & Moutabi, F. (2011). Adult attachment and quality of couples’
communication based on observed couple interactions. Journal of Psychology, 15, 3–22.
Shek, D. T. L. (1994). Psychometric properties of the Chinese version of the Dyadic Adjustment
Scale. Psychologia: An International Journal of Psychology in the Orient, 37, 7–17.
Shek, D. T. L. (1995). The Chinese version of the Dyadic Adjustment Scale: Does language make
a difference? Journal of Clinical Psychology, 51, 802–811. doi:10.1002/1097-4679
Shek, D. T. L., & Cheung, C. K. (2008). Dimensionality of the Chinese Dyadic Adjust-
ment Scale based on confirmatory factor analyses. Social Indicators Research, 86, 201–212.
doi:10.1007/s11205-007-9108-4
Siu, A., & Shek, D. (2013). Family assessment instrument: Chinese (C-FAI). In K. Corcoran
& J. Fischer (Eds.), Measures for clinical practice and research—A sourcebook. Fifth edition,
volume 1: Couples, families, and children (pp. 221–224). New York, NY: Oxford University
Press.
Spanier, G. B. (1976). Dyadic Adjustment Scale (DAS): Manual. New York, NY: Multi-Health Sys-
tems.
Statistics Canada (2011). Census profile. Available: http://www12.statcan.gc.ca/census-
recensement/2011/dp-pd/prof/details/page.cfm?Lang=E&Geo1=CMA&Code1=535&
Geo2=PR&Code2=35&Data=Count&SearchText=Toronto&SearchType=Begins&Search
Stavrianopoulos, K. (2015). Enhancing relationship satisfaction among college student couples:
An emotionally focused therapy (EFT) approach. Journal of Couple & Relationship Therapy,
14, 1–16. doi:10.1080/15332691.2014.95365
Uba, L. (2003). Asian Americans: Personality patterns, identity, and mental health. New York, NY:
Guilford Press.
Wang, C. C. D., & Ratanasiripong, P. (2010). Adult attachment, cultural orientation, and psy-
chosocial functioning of Chinese American college students. Cultural Diversity and Ethnic
Minority Psychology, 16, 101–109. doi:10.1037/a0018634
Wang, C. C. D., & Scalise, D. A. (2010). Adult attachment, culturally adjusted attachment,
and interpersonal difficulties of Taiwanese adults. The Counseling Psychologist, 38, 6–31.
doi:10.1177/0011000009338950
Wei, M., Russell, D. W., Mallinckrodt, B., & Vogel, D. L. (2007). The experiences in Close Relation-
ship Scale (ECR)-Short Form: Reliability, validity, and factor structure. Journal of Personality
Assessment, 88, 187–204. doi:10.1080/00223890701268041
Wei, M., Russell, D. W., Mallinckrodt, B., & Zakalik, R. A. (2004). Cultural equivalence of
adult attachment across four ethnic groups: Factor structure, structured means, and associa-
tions with negative mood. Journal of Counseling Psychology, 51, 408–417. doi:10.1037/0022-
0167.51.4.408
Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish, T. L., Lafontaine, M. & Tasca, G.
(in press). Two-source follow-up outcomes in emotionally focused couple therapy. Journal of
Marital and Family Therapy.
Wong, T.-Y. (2015, May). Expanding the reach and multiplying the impact of mental health pre-
vention and intervention where resources are scarce: Empowering faith communities to deliver
mental health psycho-education in a spiritual context. Presentation at the 168th American Psy-
chiatric Association Annual Meeting, Toronto, Canada.