Journal of Couple & Relationship Therapy

Innovations in Clinical and Educational Interventions

ISSN: 1533-2691 (Print) 1533-2683 (Online) Journal homepage: http://www.tandfonline.com/loi/wcrt20

“Hold Me Tight”: The Generalizability of an

Attachment-Based Group Intervention to Chinese
Canadian Couples

Tat-Ying Wong, Paul S. Greenman & Valérie Beaudoin

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

To link to this article: http://dx.doi.org/10.1080/15332691.2017.1302376

Published online: 03 Apr 2017.

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JOURNAL OF COUPLE & RELATIONSHIP THERAPY
, VOL. , NO. , –
http://dx.doi.org/./..

“Hold Me Tight”: The Generalizability of an

Attachment-Based Group Intervention to Chinese
Canadian Couples
a
Tat-Ying Wong , Paul S. Greenmanb , and Valérie Beaudoinc
a
Grace Health Centre, Toronto, Ontario, Canada; b Department de Psychologie, Université du Québec en
Outaouais, Gatineau, Quebec, Canada, Institut de recherche de l’Hôpital Montfort, Ottawa, Ontario,
Canada, and Ottawa Couple and Family Institute, Ottawa, Ontario, Canada; c Department de Psychologie,
Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada

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.

Emotionally focused therapy (EFT) for couples is an experiential, systemic therapy

based on attachment theory (Johnson, 2004; Johnson & Greenman, 2006). The main
tenets of EFT stipulate that loving, satisfying relationships result from attentiveness
and responsiveness to one’s partner’s and one’s own feelings. A focal point of therapy
therefore involves helping each individual in the couple recognize and express his
or her needs for closeness, comfort, and respect in clear, direct, unequivocal ways
that pull for positive responses from the other person. This attachment perspective
guides therapist interventions at each of the three stages and nine steps of EFT.
According to attachment theory (Bowlby, 1969; 1973), all human beings, without
exception, have an innate, naturally selected need to establish and maintain close
emotional bonds to significant others. This need becomes particularly salient in the
face of perceived threat or times of stress, when people of all ages will seek prox-
imity to “attachment figures” in order to regulate their affect. For this reason, EFT
therapists are particularly keen on helping clients identify and articulate their own
feelings of vulnerability and on helping them respond to such manifestations in their

CONTACT Tat-Ying Wong [email protected] Grace Health Centre,  Keele St., Suite ,
Downsview, Ontario, Canada MME.
©  Taylor & Francis Group, LLC
2 T.-Y. WONG ET AL.

partner in comforting ways. The underlying assumption is that the accumulation of

these engaged responses helps solidify the relationship by creating a sense of safety,
security, and emotional connection (Johnson, 2004, 2008). Couples who achieve this
level of connection are happier in their relationships and more effective at solving
the problems of everyday life than are couples who do not (e.g., Dalgleish et al., 2015;
Feeney, 2007; Li & Chan, 2012).

“Hold Me Tight” Groups

There is a great deal of empirical support for the efficacy of EFT (see Lewandowski,
Ozog, & Higgins, 2015; Snyder, Castellani, & Whisman, 2006, for reviews). In its
standard format, this therapy consists of three stages divided into nine steps, which
unfold across eight to 20 sessions. All but two EFT sessions are usually conducted
with both partners (Johnson, 2004). More recently, however, the basic interventions
of EFT have been modified into a group format (Johnson, 2010) based on the prin-
ciples of attachment, effective dependency, and the sharing and processing of strong
emotion that typify EFT. These groups are known as “Hold Me Tight” (HMT) edu-
cational groups after the book of the same name (Johnson, 2008) that popularized
attachment theory as it relates to couple relationships and EFT. The present study is
one of the first on the efficacy of HMT educational groups and the only one with a
sample of participants of Asian origin.
The typical HMT relationship enrichment program consists of eight two-hour
sessions. According to the HMT manual, “a minimum of 4 and a maximum of 30
couples is recommended. If the group is larger than 6 to 8 couples, then it is rec-
ommended that the facilitator conduct the program with one or more colleagues,
especially to support couples during the in-session exercises” (Johnson, 2010, p. xx).
In the first session, couples introduce themselves and talk about what they would
like to gain from the educational program. Then, the facilitator presents didactic
material on attachment, couple relationships, and the importance of emotional con-
nection. This sets the stage for the sessions that follow, which coincide with the
seven “Conversations for Connection” presented in the HMT text: (a) “Recogniz-
ing the Demon Dialogues,” (b) “Finding the Raw Spots,” (c) “Revisiting a Rocky
Moment,” (d) Hold Me Tight,” (e) “Forgiving Injuries,” (f) “Bonding through Sex
and Touch,” and (g) “Keeping Your Love Alive” (Johnson, 2008). Group participants
view recordings of actual couples engaging in the different conversations, guided
by a facilitator or therapist. As in standard EFT, couples in HMT groups first learn
to identify their negative interaction patterns and the triggers of the emotional and
behavioral responses that shape those patterns (conversations 1 and 2). Then, also
as in EFT, couples learn to talk to each other about their vulnerabilities, insecurities,
and needs for closeness once they recognize how these can be masked by secondary
responses such as anger and frustration (conversations 3 and 4). This leads into a
discussion of any longstanding emotional injuries that might be present in the rela-
tionship; partners learn how to hear and respond in an empathically comforting
manner to the pain that is expressed, in an effort to solidify trust in the relationship
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 3

(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.

HMT and EFT: Underlying Assumptions and Efficacy

The key assumptions of the HMT educational program are the same as those that
form the basis of EFT. Specifically, interventions are based on the premise that
attachment needs are salient and universal and that the awareness and expression
of primary emotions (e.g., sadness, fear) and vulnerability followed by emotionally
attuned, comforting responses from one’s partner will forge a secure bond in the
couple relationship. Process research on EFT indicates a link between greater ther-
apeutic success and the depth of client emotional expression in-session (Greenman
& Johnson, 2013), particularly when partners who historically attempt to engage
their spouse in ineffective ways (e.g., criticism, blaming) “soften” (i.e., learn to
approach their partner from a position of vulnerability) (Dalgleish et al., 2015).
HMT group leaders therefore concentrate their efforts on helping participants iden-
tify and express a wide spectrum of emotions in order to restructure their inter-
actions such that, for example, expression of sadness or fear by one partner pro-
vokes compassion and understanding in the other (Johnson, 2004; 2010). Partners’
expression of and responsiveness to these primary emotional states are essential to
improvements in relationship closeness and satisfaction in both EFT and HMT.
One of the main differences between HMT and EFT is the highly didactic nature
of the HMT groups (i.e., PowerPoint presentations, viewing of DVDs, structured
dyadic exercises). Group facilitators spend a great deal of time teaching, assigning
homework, and giving feedback, whereas EFT therapists focus on tracking, height-
ening, and structuring emotional and relational experiences as they unfold in the
therapy session.
To our knowledge, only two studies of the effectiveness of HMT groups have
been completed to date. In one, Stavrianopoulos (2015) found that the relationship
4 T.-Y. WONG ET AL.

satisfaction of 14 couples who were undergraduates at a university in New York

City increased significantly on completion of the 8-week HMT program. In another,
95 couples across Canada and the United States participated in 16 HMT groups
(Kennedy, Johnson, & Wiebe, 2016). Their relationship satisfaction increased from
pregroup to postgroup points, with little change from the baseline (8 weeks before
the start of the group) to the pregroup measurement point. This suggests that the
HMT groups were helpful in increasing the relationship satisfaction of participants.

Cross-Cultural Considerations of Attachment, Emotion, and EFT-HMT

The premise on which these interventions rest is that people of all cultures and eth-
nic backgrounds have basic needs for emotional connection to attachment figures,
as indicated in the plethora of cross-cultural studies of attachment (Mesman, van
IJzendoorn, & Sagi-Schwartz, 2016). Consequently, the best way for a clinician to
establish and maintain security in a couple relationship would be to encourage the
kind of attention to attachment needs and emotional expression described earlier
(Greenman, Young, & Johnson, 2009). Attachment and emotion would thus be the
sine qua non of effective couple interventions. But this perspective is not without
controversy.
First, the overwhelming majority of participants in virtually all studies of the
efficacy and process studies of EFT have been Whites of European descent, with
only a few exceptions (e.g., Chang, 2014; Hattori, 2014; Honarparvaran, Tabrizy, &
Navabinejad, 2010). Second, attachment theory itself has come under scrutiny for
what some have deemed a cultural bias (Levine, 2014). Developmental psycholo-
gists and anthropologists have recently called into question long-held notions of
attachment security and insecurity; they raise the possibility that Western ideas
about what constitutes secure attachment in children (e.g., active support-seeking
and displays of strong emotion when separated from caregivers) and about the con-
ditions necessary to create and nurture secure attachment (i.e., attentive, responsive
caregiving) might not apply as universally as the original proponents of attachment
theory thought (Keller, 2014). They cite findings that indicate cross-cultural differ-
ences in attachment behavior on the part of both infants and caregivers. In some
collectivist societies, for example, children have been observed to form multiple
attachments of equal emotional intensity and not to exhibit the fear of strangers or
the distress on separation from their mothers that is exhibited by children in more
individualist societies (Gottlieb, 2014). Cross-cultural studies of romantic attach-
ment in adults are scarce, but the results related to attachment in children that have
surfaced in recent years lead to the question: Would an attachment-based interven-
tion that relies heavily on the expression of and responsiveness to emotions such
as fear, longing, and sadness work for people from a non-Western culture that way
that it seems to work for Westerners? The present study of HMT with Canadians of
Chinese origin represents the first steps toward answering this question and perhaps
others related to the universality of attachment needs and their impact. Since the
Chinese collectivist culture values education, learning, and achievement, we believe
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 5

that an educational approach might be more acceptable to Chinese participants

because it reduces the shame, loss of face, and stigma associated with traditional
psychotherapy.
We have adopted a definition of “Chinese origin” similar to the one used by
Wang and Ratanasiripong (2010) to identify Chinese Americans. For the purposes
of this report, “Chinese origin” refers to people who were born in China and moved
to Canada and to people born in Canada whose first language is Mandarin or
Cantonese and who maintain strong cultural and linguistic ties to the Chinese
community in Toronto.

Emotion, Romantic Attachment, and the Chinese Culture

To appreciate the implications of inviting Chinese Canadians to participate in a
relationship-enhancement group that involves talking openly with partners about
emotions, attachment needs, and vulnerability, let us consider some of the empiri-
cal findings in this domain as they relate to Chinese culture.

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

Twenty-three heterosexual couples (N = 46) completed the educational relationship

enhancement program. Participants indicated their age on a range for each decade.
Four of them (8.7%) were between 31 and 40 years of age, 12 of them (26.1%) were
between 41 and 50 years of age, 15 of them (32.6%) were between 51 and 60 years
of age, and 15 of them (32.6%) were over age 60. All participants were of Chinese
origin living in the Greater Toronto area. Their native language was Cantonese or
Mandarin. The course was taught in Cantonese with simultaneous translation into
Mandarin. Chinese subtitles were added to the original HMT videos. The wide range
in ages reflects the intergenerational interest in this sample in improving their cou-
ple relationship. The sample was drawn from the community and included both
Christian and non-Christian participants.

Group Intervention: Cultural Considerations

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.

Group Intervention: Quality Control

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).

Relationship Satisfaction Questionnaire (RSAT)

The RSAT (Burns & Sayers, 1988, 1992) was translated into Chinese for the pur-
poses of this study. Participants responded to questions about their level of sat-
isfaction with various aspects of an important intimate relationship (with either
their romantic partner, other family member, or close friend) using an 11-point
Likert scale. Items pertained to communication and openness, degree of affection
and caring, resolving conflicts and arguments, intimacy, satisfaction with their own
and their partner’s role in the relationship, overall satisfaction with the relationship,
understanding and acceptance of the relationship, understanding and acceptance
of oneself, and understanding and acceptance of the relationship partner. Higher
total scores on the RSAT reflect greater relationship satisfaction. The original RSAT
has good internal consistency (α = .97) and convergent validity with other marital
quality indices (Burns & Sayers, 1988, 1992).

Experiences in Close Relationships Scale-Short Form (ECR)

To measure changes in attachment from the beginning to the end of the HMT
intervention, we administered a Chinese-language version of the ECR. This short
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 11

questionnaire contains 12 items to which respondents indicate their level of agree-

ment using a Likert scale that ranges from 1 (“strongly agree”) to 7 (“strongly
disagree”). Similar to the original, the Chinese version of the ECR discriminates
between attachment anxiety (e.g., “I find that my relationship partner does not want
to get as close as I would like”) and avoidance (e.g., “I try to avoid getting to close to
others”; Wei, Russell, Mallinckrodt, & Vogel, 2007). The Chinese ECR is a reliable
instrument (α = .78 for the anxiety subscale and .84 for the avoidance subscale) with
good face validity (Wei et al., 2007).

Family Assessment Instrument: Chinese (C-FAI)

The purpose of the 33-item C-FAI is to measure various aspects of family function-
ing in Chinese populations, which were derived from semistructured interviews
with 416 families and subsequently validated in a sample of 3649 families (Siu &
Shek, 2013). The following five factors emerged from exploratory and confirmatory
factor analyses of this instrument: mutuality (M) (e.g., “My family members love
each other”), communication and cohesiveness (CC) (e.g., “My family members talk
to each other”), conflict and harmony (CH) (e.g., “There is much friction among
my family members”), parental concerns (PC) (e.g., “Overall, the parents love their
children”), and control by parents (CP) (e.g., “There is frequent fighting among my
family members”). Respondents indicate their level of agreement with each state-
ment on a Likert scale ranging from 1 (“agree strongly”) to 5 (“disagree strongly”);
lower scores thus represent more positive family functioning. The importance and
usefulness of the C-FAI is underscored by the fact that it is the first indigenous mea-
surement of Chinese family functioning at a time when family therapy is becoming
more acceptable. The C-FAI has demonstrated excellent internal consistency and
convergent validity (Siu & Shek, 2013).

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.

Hypothesis 1: Improvement in Couple Relationship Functioning

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.

Table . Chinese Dyadic Adjustment Scale (C-DAS).

DAS Total DC DS DCH AE
M SD M SD M SD M SD M SD

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 = ..

Table . Relationship Satisfaction Questionnaire (RSAT).

Current Satisfaction Projected Satisfaction (in  year)
M SD M SD

Pre . . . .

Post .∗ . .† .

Note: Significant pre–post intervention differences: ∗ 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.

Hypothesis 2: Attachment Insecurity

We detected significant changes in attachment insecurity, as measured by the ECR.
Table 3 contains the means and standard deviations for the ECR. Participants’ scores
on the attachment avoidance [t(45) = 4.36, p = .0001] subscale of this instrument
decreased between the first and final sessions of the HMT program, with a small
effect size (d = .36). These results partially support hypothesis 2, which stipulated
reductions in attachment insecurity over the course of the study.

Hypothesis 3: Family Functioning

As predicted in hypothesis 3, there were significant improvements in participants’
family functioning, as indicated in Table 4 by decreases in their C-FAI total scores
[t(43) = 2.44, p = .02] and their CH subscale scores [t(43) = 2.46, p = .02]. Effect

Table . Experiences in Close Relationships Scale (ECR).

Avoidant Anxious
M SD M SD

Pre . . . .

Post .∗ . . .

Note: Significant pre–post intervention differences: ∗ p = ..

 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 13

Table . Family Assessment Instrument: Chinese (C-FAI).

C-FAI Total M CC CH PC CP
M SD M SD M SD M SD M SD M SD

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.

Potential Efficacy of HMT for Diverse Populations

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.

Universal Salience of Fundamental Attachment Needs

Although there is controversy and debate about how secure and insecure attachment
might manifest themselves in children and adults across cultural contexts (i.e., what
appears to be insecure attachment through one cultural lens might actually be secure
attachment when one considers the cultural context of the attachment bond; Keller,
2014; Levine, 2014; Mikulincer & Shaver, 2007), our results suggest that when work-
ing with couples, the fundamentals of attachment theory may be extremely useful
to clinicians working with people from a variety of cultural backgrounds.
Even some of the most outspoken critics of attachment theory in its current form
(e.g., Gottlieb, 2014; Levine, 2014) acknowledge the universal human need for social
connection and the importance of such connections for social, emotional, cogni-
tive, and even physical development. People need people. Those who recognize and
act upon their innate needs for comfort and closeness and who receive it from sig-
nificant others tend to feel better about themselves and to be in better mental and
physical health than are people who do not (see Lakey & Orehek, 2011; Newman &
Roberts, 2013, for reviews). In fact, there is some evidence that perceived emotional
support might actually be even more strongly linked to health outcomes in Asian
cultures than in European American cultures (e.g., Park et al., 2012), which speaks
to the applicability of attachment concepts such as connection and responsiveness
to people of Asian backgrounds. Our results are commensurate with this idea: A
clinical focus on attachment needs and behaviors was related to positive changes
in relationship satisfaction, family functioning, and attachment security, the way it
tends to be for people of European American backgrounds.

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.

Overcoming Barriers to Accessing EFT-Based Interventions

Despite the proven effectiveness of EFT, this therapy and interventions based on it
are, unfortunately, not widely available to many groups due to cultural, linguistic,
and financial barriers and to the lack of ethnic EFT-trained clinicians. For example,
at the time of the study, there were 594,735 people of Chinese origin in the Greater
Toronto Area (Statistics Canada, 2011), but there was only one Chinese-speaking
certified EFT therapist.
The ability to offer EFT-based group interventions led by lay facilitators with-
out any professional training in psychotherapy or EFT makes this effective resource
available to many groups who would otherwise be deprived of EFT-based interven-
tions. Furthermore, the partnership with a local Chinese faith community was effec-
tive in overcoming barriers related to cost, access, language, and culture. In many
parts of the non-Western world, this model for low-cost service delivery using lay
facilitators, partnerships with local community groups, and linguistic and culturally
sensitive resources is crucial to overcoming social, economic, and cultural inequities
that restrict access (Wong, 2015) to evidence-based interventions.

Limitations and Suggestions for Future Research

There are limitations to the present study. First, there is no control or comparison
group, which some might argue makes it difficult to attribute the observed changes
in relationship satisfaction and attachment security to the intervention alone. This
study was a pilot investigation of a new program, designed to test the program’s fea-
sibility and applicability. It would indeed be informative if future research were to
include a control or comparison condition (e.g., one group of participants would
receive the couple intervention typically offered in the church setting and the other
would receive HMT) in order to isolate the effects of the intervention. However, it
should be noted that the addition of a control condition to an outcome study does
16 T.-Y. WONG ET AL.

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

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