by Hailey Palmer and Alan J. Hawkins
The Bottom Line (at the Top): Dr. Sue Johnson’s Hold Me Tight relationship education (RE) program is the first RE program to be based on attachment theory and the popular Emotionally Focused Therapy (EFT). It is an new approach to helping couples foster trust and connection. Several evaluation studies on the effectiveness of the program found that couples who engaged in Hold Me Tight generally experienced small-to-moderate improvements in relationship satisfaction, trust, and attachment security, although these positive effects may fade quickly. More rigorous studies in the future will determine the long-term effectiveness of the program.
Dr. Sue Johnson’s research on attachment theory and Emotionally Focused Couple Therapy (EFT) has consistently shown that couples who engage in EFT experience a reduction in attachment anxiety and an increase in relationship satisfaction in their relationships. However, with the subtle stigma of couples therapy, Johnson thought it helpful to develop a relationship education program based on years of empirical research on EFT and attachment theory. She called the program Hold Me Tight (HMT).
Attachment security is rarely the primary focus of most couple RE programs which makes Hold Me Tight innovative in its goal to improve attachment security and help couples regulate and share their emotions in safe ways that foster connection. Rather than a primary focus on improving couple communication skills in couples – the norm in couple RE programs – the HMT program instead seeks first to improve relationship satisfaction, trust, and intimacy by helping participants understand and develop secure attachments with their partners which will then support positive communication patterns. Of course, other RE programs, such as PREP, emphasize creating safety and connection in relationships, but they do not approach this with a clear focus on adult attachment.
The 16-hour HMT curriculum guides couples through what Johnson calls the 7 transforming conversations, a set of conversations couples have to identify negative communication habits in the relationship as well as develop healthy habits that foster connection and emotional responsiveness. Throughout the program, facilitators first teach the principles behind each conversation, emphasizing the necessity for safety and connection in each crucial conversation. Facilitators then show recorded examples of couples engaging in these key conversations, and finally help each participating couple engage in a back-and-forth dialogue centered on responsiveness and respect. There is also a 12-hour online version of the program. Also, there have been some adaptions of the program for special groups, such as couples dealing with serious health challenges.
Facilitators are not required to be therapists or educators trained in EFT; rather, anyone willing to buy the required materials can facilitate a HMT group. While not required to run the program, there are training seminars that facilitators can take. And almost all who are offering the program have been trained in EFT.
But is this HMT approach effective? Can EFT be effectively transferred to an educational setting? Three recent studies of HMT sought to determine if the program and the principles of attachment theory could could strengthen couple relationships in different cultural contexts.
In one study, researchers analyzed changes in relationship satisfaction, attachment security, and overall family harmony for 23 Chinese Canadian couples (generally religious and conservative) participating in a Chinese version of the HMT program.
This study found:
- Significant increases in relationship satisfaction as well as improvements in family harmony among couples who participated in the program. The changes from before to after the program were small-to-medium.
- Researchers also noted significant decreases in attachment avoidance (characterized by evading closeness and connection in a relationship) but not attachment anxiety (characterized by a distressed pursuit of connection in a relationship). They suggested that the educational setting may not may not effectively facilitate the needed emotional exchanges that can foster decreases in attachment anxiety.
A second study study assessed 95 couples who participated in HMT groups around the United States. Researchers monitored changes in relationship satisfaction, trust, and attachment security as couples participated in the program then analyzed any changes at the 3-month follow-up.
This study found:
- Relationship satisfaction and trust in the couple relationship increased significantly as a result of the program. However, this increase did not last. At follow-up, the increased levels of relationship satisfaction and trust had returned to their pre-program levels.
- The results at follow-up also showed no significant changes in attachment security, which may have been a result of the majority of the participants coming into the program with fairly normal levels of attachment anxiety. Previous research on EFT has shown that insecurely attached individuals in distressed relationships see more dramatic increases in attachment security after participating in EFT.
- The authors suggest that because HMT is briefer and less intense than therapy, participants may have lacked adequate time to reach a “sufficient depth of emotional experience to create shifts in attachment” that help to maintain positive changes.
Finally, a third study conducted in the Netherlands studied 129 couples (79 self-referred and 50 therapist-referred). Researchers explored whether the HMT program had significantly different effects for the two groups of participants.
This study found:
- Self-referred couples improved significantly on measures such as relationship satisfaction and security of partner-bond after participating in the HMT These improvements diminished slightly at follow-up about 4 months later but were still solid effects (e.g., d = .57). They also improved in individual psychological functioning over the course of the study.
- Clinician-referred couples, who were less securely attached and at-risk for distress before participating in the program, showed moderate improvements in these same measures. However, these improvements faded to small effects by the follow-up assessment. These individuals did improve somewhat in individual psychological functioning over the course of the program but did not maintain those gains by the end of the study.
- The researchers speculated that a more intensive and personalized treatment may be needed to maintain long-term benefits for more at-risk populations.
So, what are the implications of the mixed findings from these three evaluation studies with very different samples?
- Short- vs. long-term change. Approaching relationship education from an attachment theory perspective, rather than a traditional focus on communication skills (based on cognitive-behavioral theory), is new and seems to make a impact on relationship quality and satisfaction, at least early on. However, this approach still needs to show that it can maintain positive change over time, especially for more distressed, at-risk couples.
- Depth and time. The nature of the program may require participants to become intensely aware of and willing to dig deep into the emotions they feel without the assistance of a trained therapist. The program may also require the confrontation of fears and insecurities, a feat that may be difficult to accomplish in a relatively brief educational intervention. This approach may necessitate added course time for participants to be able to make the changes necessary to promote long-term, positive effects.
Each of these evaluation studies, of course, has limitations. None of the three studies mentioned above included control groups, which leaves open the possibility that change could be attributed to something other than the program itself. (One of the studies, however, used a methodological approach that tries to approximate what would happen in a control group.) Researchers will need to test future programs with more rigorous random assignment studies. In addition, while two of the studies included follow-up assessments, they were not long-term follow-ups. Researchers need to test if HMT can sustain longer-term positive outcomes.
We anticipate that Hold Me Tight will be a popular option for relationship educators as Emotionally Focused Therapy has been for couple therapists. But there is more work needed to examine its effectiveness. We look forward to seeing the progress over the next few years with this new program in the RE world and to more studies of its effectiveness.
 Wiebe, S. A., Johnson, S. M., Lafontaine, M., Burgess Moser, M., Dalgleish, T. L., & Tasca, G. A. (2017). Two‐year follow‐up outcomes in emotionally focused couple therapy: An investigation of relationship satisfaction and attachment trajectories. Journal of Marital and Family Therapy, 43(2), 227–244. https://doi-org.erl.lib.byu.edu/10.1111/jmft.12206
 “What Is Hold Me Tight?” ICEEFT, iceeft.com/what-is-hold-me-tight/
 Her best-selling book is the same title: Johnson, S. (2008). Hold me tight. Seven conversations for a lifetime of love. New York: Little, Brown.
 Of course, other RE programs, such as PREP, emphasize creating safety and connection in relationships, but they do not approach this with a strong focus on adult attachment.
 Kennedy, N., Johnson S. M., Wiebe, S. A., Willett, J. B., Tasca, G. A., (2018) Conversations for connection: An outcome assessment of the Hold-Me-Tight Relationship-Education Program, and recommendations for improving future research methodology in relationship education.” Journal of Marital and Family Therapy, doi:10.1111/jmft.12356.
 Domingue, R., & Mollen, D. (2009). Attachment and conflict communication in adult romantic relationships. Journal of Social and Personal Relationships, 26(5), 678–696. https://doi-org.erl.lib.byu.edu/10.1177/0265407509347932
 Stavrianopoulos, K., (2015) Enhancing Relationship Satisfaction Among College Student Couples: An Emotionally Focused Therapy (EFT) Approach, Journal of Couple & Relationship Therapy, 14:1, 1-16, DOI: 10.1080/15332691.2014.953656
 Wong, T., Greenman, P. S., & Beaudoin, V. (2018) “Hold Me Tight”: The generalizability of an attachment-based group intervention to Chinese Canadian couples, Journal of Couple & Relationship Therapy, 17:1, 42-60, DOI: 10.1080/15332691.2017.1302376
 Note: Sue Johnson was involved in this study of HMT. Kennedy, N., Johnson S. M., Wiebe, S. A., Willett, J. B., Tasca, G. A., (2018) Conversations for connection: An outcome assessment of the Hold-Me-Tight Relationship-Education Program, and recommendations for improving future research methodology in relationship education.” Journal of Marital and Family Therapy, doi:10.1111/jmft.12356.
 Moser, M. B., Johnson, S. M., Dalgleish, T. L., Lafontaine, M., Wiebe, S. A., & Tasca, G. A. (2016). Changes in relationship‐specific attachment in emotionally focused couple therapy. Journal of Marital and Family Therapy, 42(2), 231–245. https://doi-org.erl.lib.byu.edu/10.1111/jmft.12139
 Conradi, H. J., Dingemanse, P., Noordhof, A., Finkenauer, C., Kamphuis, J. H. (2018).
Effectiveness of the ‘Hold me Tight’ relationship enhancement program in a self-referred and a clinician-referred sample: An emotionally focused couples therapy-based approach. Family Process, 57, 613-628. doi: 10.1111/famp.12305
 This study was designed to assess any change from 2-4 weeks before the beginning of the program and found no evidence of change until the intervention began. Kennedy, N., Johnson S. M., Wiebe, S. A., Willett, J. B., Tasca, G. A., (2018) Conversations for connection: An outcome assessment of the Hold-Me-Tight Relationship-Education Program, and recommendations for improving future research methodology in relationship education.” Journal of Marital and Family Therapy, doi:10.1111/jmft.12356.