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International Journal of Brief Therapy and Family Science

2018 Vol. 8, No.1, 34-48
< Original Paper: Case Report >

Advantage of empty-chair dialogue over emotion-focused couples therapy for a Japanese

couple with marital infidelity: A case study

Kenji Yokotani1)

1) Niigata Seiryo University, Graduate School of Clinical Psychology

ABSTRACT. Couples with marital infidelity have received many therapies, but the effective therapies for them were still unclear.

The present case study utilized Emotion-Focused Couples Therapy (EFCT) and Empty-Chair Dialogue Intervention (ECDI) for a

couple with marital infidelity and aimed to show advantages of ECDI over EFCT. Our case was a Japanese heterosexual couple with

husband’s infidelity. The husband also had alcohol abuse and bipolar disorder, whereas the wife assaulted him physically. During the

first 6 monthly sessions, they were peaceful but wife’s physical assault suddenly occurred and interrupted the therapy. During the

next 5 monthly sessions, EFCT was applied for them, but his hypomanic episode and her physical assault disturbed their

emotionally responsive communication during the sessions. During the last 5 biweekly sessions, ECDI was applied for the wife. She

imaginary dialogued with the husband’s extramarital lovers, rather than the husband. During the ECDI sessions, she had been able

to fall asleep during night and her physical assault on him had been disappeared. Even after the three-year follow up since the ECDI

session, her physical assault and his marital infidelity had not occurred. Comparative advantages of ECDI over EFCT were

discussed.

KEY WORDS: Marital infidelity, Empty-Chair Dialogue Intervention, Wife’s Physical Assault against husband, Bipolar disorder,

Emotion-focused Couples Therapy

Advantage of empty-chair dialogue over were still unclear (Blow & Hartnett, 2005).
emotion-focused couples therapy for a Most of them received the Empty-Chair
Japanese couple with infidelity: A case study Dialogue Intervention (ECDI) (Paivio, 1999;
Marital infidelity is a social problem. One Paivio & Greenberg, 1995) or
partner’s infidelity injured the other partner’s Emotion-Focused Couples Therapy (EFCT)
feeling (Halchuk, Makinen, & Johnson, 2010), (Greenberg & Foerster, 1996; McKinnon &
increased the injured partner’s risk of major Greenberg, 2017). However, direct comparison
depression (Cano & O’leary, 2002), and finally of them was still rare. The present study
ended their marital relationships (Previti & compared the effects of them for a Japanese
Amato, 2004). Couples with infidelity received couple with infidelity.
many therapies, but effective therapies for them
CORRESPONDENCE TO: Yokotani Niigata Seiryo Empty-Chair Dialogue Intervention (ECDI)
University, Graduate School of Clinical Psychology, 1-5939, and Emotion-Focused Couples Therapy
Suidocho, Chuo-ku, Niigata-shi, Niigata, 951-8121, Japan (EFCT) for a couple with infidelity
e-mail: [email protected] The ECDI, in which a client engages in an

34
 Advantage of empty-chair dialogue over emotion-focused couples therapy 35

imaginary dialogue with the person sitting in (Narkiss-Guez, Zichor, Guez, & Diamond,
the empty chair (Paivio, 1999), was originally 2015). Another quasi-controlled study also
from Gestalt therapy (Perls, Hefferline, & found that 7-week group ECDI sessions were
Goodman, 1951) and has been utilized and effective in reducing traumatic experience and
validated in many therapies (Pugh, 2016). avoidant behaviors for wives whose husbands
ECDI encourages clients to access their were either killed or missing during the war
previously avoidant memories/thoughts and to (Hagl, Powell, Rosner, & Butollo, 2015).
reconstruct them in the therapy-provided safety Another longitudinal study indicated the effects
environment (Timulak & Pascual-Leone, 2015). of ECDI in reduction of depressive symptoms
The ECDI exposes clients to their intense for individuals who experienced the death of
emotion, which has been avoided for long term their spouse (Field & Horowitz, 1998). These
(Greenberg & Foerster, 1996), so that ECDI is findings indicated that ECDI could be useful
useful for clients who avoid specific emotions for the unresolved issues with significant other.
for long term, such as those with posttraumatic Marital infidelity can cause an unresolved
stress disorders (Steenkamp et al., 2011). issue with significant other in marital
ECDI is especially effective for people who relationship. One partner’s marital infidelity
had unresolved issues with significant other, injured partner’s feeling (Halchuk et al., 2010)
because they had continued to avoid their and increased the injured partner’s risk of major
primary emotions about the issues (Steinmann, depression (Cano & O’leary, 2002). These
Gat, Nir-gottlieb, Shahar, & Diamond, 2017). findings indicated that the injured partner could
One randomly controlled trial reported have lingering unresolved negative feeling,
comparative efficacy of ECDI for community such as anger, with their partner (Johnson,
sample who had lingering unresolved negative Makinen, & Millikin, 2001). Actually, several
feeling with the significant other, such as individuals reported unresolved issues with
ex-partner, from the past (Paivio & Greenberg, their romantic partner who did infidelity
1995). Those who received 12-week ECDI (Narkiss-Guez et al., 2015; Paivio & Greenberg,
sessions significantly reduced their 1995). One case study also utilized the ECDI
interpersonal distress and resolved their for a husband whose wife had extramarital
unresolved issues than those who received affairs (Paivio, 1999). These findings indicate
12-week psychoeducation sessions about the the applicability of ECDI for marital infidelity.
unresolved issues. Another randomized Based on the ECDI findings, EFCT was
controlled trial also found that single ECDI developed for couples with infidelity, where the
session was more effective in reducing the offending partner repetitively apologizes about
anger for university students who had persistent one’s misconduct and the injured partner finally
anger toward their significant other than single forgives his misconduct (Greenberg, Warwar, &
emphatic listening session regarding their anger Malcolm, 2010). The EFCT is effective if
36 Yokotani.

couples meet following two conditions: (1) 2017) studies: The applicability of EFCT and
offending partner expresses their vulnerable ECDI for couples with these severe problems is
emotion to their partner (McKinnon & unclear. Clarification of these three points
Greenberg, 2017; Meneses & Greenberg, 2011, could extend the clinical scope of EFCT and
2014): (2) the injured partner also forgives the ECDI to an East Asian couple with multiple
partner’s misconduct (Halchuk et al., 2010). Yet, severe problems. Hence, our research question
satisfaction of these two conditions is not easy is that Are ECDI and EFCT effective for a
for many couples (Greenberg & Foerster, 1996). Japanese couple with marital infidelity, alcohol
Forgiving extramarital affair was still the most abuse, marital violence, and bipolar disorders?
difficult task for couples(Kluwer & Karremans, To answer this research question, we utilized
2009). Hence, therapy effects of EFCT on case study for a detailed description of ECDI
marital infidelity are still limited (Blow & and EFCT on the Japanese couple with these
Hartnett, 2005; Wiebe & Johnson, 2016). problems. ECDI findings were more robust
regarding experimental designs than
Aims of the present study EFCT(Paivio & Greenberg, 1995), so we
Previous study showed the effectiveness of hypothesized that ECDI would be more
ECDI and EFCT for couples with marital effective for a Japanese couple with these
infidelity (Greenberg et al., 2010; Paivio & problems than EFCT. Our case study involves
Greenberg, 1995). However, direct comparison four stages. The first stage aims to build couple
of ECDI and EFCT was rare, so alliance and therapeutic alliance as foundation
(dis)advantages of ECDI over EFCT are still of couple therapy (Timulak & Pascual-Leone,
unclear. Further, the effectiveness of ECDI and 2015). The second stage applied EFCT. The
EFCT were mainly confirmed in Caucasian third stage applied ECDI. Although previous
couples (Greenberg & Foerster, 1996; Hagl et study of ECDI focused on actual injured
al., 2015). Marital infidelity patterns were partner (Paivio, 1999), we focused the partner’s
reportedly different from European to East extramarital lovers, rather than the partner. This
Asian couples(Moore, 2010; Schmitt David P., is because physical violence from her to him
2004). Hence, the applicability of ECDI and was severe so that we need to divert the target
EFCT for East Asian couples is also unclear. of her anger from him to other individuals. The
Moreover, couples with alcohol abuse, marital final fourth stage is follow-up sessions for 3
violence and bipolar disorders were excluded years.
from the sample in EFCT (Greenberg &
Foerster, 1996; McKinnon & Greenberg, 2017; Case Description
Meneses & Greenberg, 2011) and ECDI (Field Basic information
& Horowitz, 1998; Narkiss-Guez et al., 2015; Identified patient and client (January X
Paivio & Greenberg, 1995; Steinmann et al., year): Identified Patient was a husband who
 Advantage of empty-chair dialogue over emotion-focused couples therapy 37

was 31 years old and worked for a sake brewer. uterine fibroids but gave birth to her son.
Client was his wife who was 43 years old and During her second pregnancy (August X-1
housewife. They had a son aged 5 years old year), she became anemia and decided to
with Autism spectrum disorder. They lived in abortion. She had never been pointed out any
the P city of Hokuriku district in Japan since special problem so far.
their marriage (X-9 year). The wife’s parents Problem history: In X-4 year, the husband
had a large house and land so that their house had an affair with the married woman (referred
was in the garden of the parents’ house. to as C) in his neighborhood. He repetitively
Main agenda: The wife wanted to talk about came back to home at early morning so his
her husband’s extramarital affair, whereas the neighborhood rumored about him. Finally, his
husband wanted to talk about his wife detected his extramarital affair with the
alcohol-related problem. During initial session, woman. She smashed the husband several times.
main agenda was inconsistent between the wife In June X -1 year, the husband failed the exam
and husband. in the brewery company. In September X-1 year,
he suddenly yelled at his child, which had
Case history never been occurred. He also drank daily until
Family history: The husband’s mother was 3 o’clock in the morning. In November X-1
the last stage of stomach cancer (died in July X year, the husband and wife received one
year). His father also had extramarital affairs therapy session in a local Q hospital. He was
when the father was young. Both of their diagnosed as bipolar disorder type II with
parents and sibling lived in the P city so they hypomanic episodes. During the therapy, he
frequently met with each other. For example, said to her wife that "I do not like you!" and "I
the wife’s sister visited a hospital to see the do not need you!" After the therapy, they
husband's mother. decided not to visit the hospital again because
Life history: The husband lived in the P city his friend worked in the same hospital despite
until his high school days and lived alone in of their positive attitudes to the therapy. After a
Kanto area during his college days. After he while, the wife found that the husband bought a
had graduated from his university, he returned ring to give to his extramarital lover and
to the P city, worked at the sake brewing pointed out it to him. He stopped giving the
company, and got married. He had never been ring to the lover but presented the same ring to
pointed out any particular problem so far. The the wife. When she had not used the ring, he
wife also lived in the P city and had never left got angry. In December X-1 year,
the P city. After graduating from her university, recommended by a local health nurse who
she was doing a few jobs. After marriage, she mainly care about their son, they visited an R
quitted her job and became a housewife. During hospital. A psychiatrist said that the husband
her first pregnancy (X-6 years), she became had no problem and would recover in short. Yet,
38 Yokotani.

in December X-1 year (before New Year's Day), use”. Wife said that “If he returns to the
the husband's brother, the wife's brother, and previous status, I like to continue my
the husband's friend witnessed a scene where relationship with him”. The husband said that
the husband goes to a hotel with another “I do not know how to return to the previous
woman (referred to as B) by chance. With this status. I am nearly forgiving up relationship
incident trigger, his friend also reported the with her”. Although they fought every day, they
wife about his extramarital affair with another confirmed that they cooperated to come here
woman (referred to as A). The wife could not without fight. The therapists asked them to
control her anger and had continued to smash come here again, because their communication
the husband for several hours. He had been to come here was cooperative without fight.
receiving her punch without any counterattack
for the hours. Since then, he frequently reported Therapy Process
lots of things to her. In January X year, the wife Stage 1: Building Couple Alliance
alone visited author’s therapy center and The first case formulation: Any topic could
another therapist met her. Although her friends produce their fight except for the topic about
and family members recommend her to divorce, couple therapy. Hence, first stage tried to
she did not want to divorce because of her child decrease their fight, to increase cooperative
and money. She knew the days when her communication, and to build couple alliance
husband was good, so she wanted to continue between them (Bodenmann, Hilpert, Nussbeck,
her marital relationship with him as far as she & Bradbury, 2014). After the couple built
could. Her husband was also positive about alliance, the therapy can set their main agenda
couple therapy. Then they started to receive consistent between the husband and wife. In
monthly couple joint therapy in charge of the addition, the therapists aimed to build
author. The husband has received medication therapeutic alliance with them, which was
(lithium carbonate and Olanzapine) for his foundation of many psychotherapies (Paivio
hypomanic episode from the S hospital since & Greenberg, 1995; Timulak & Pascual-Leone,
March X, but the wife did not receive any 2015).
medication. #2(February X year): Compared to previous
Initial session [#1] (February X year): session, the wife and husband had eye contact
During couple joint session, they had no eye with each other. Actually, they went out in this
contact with each other so that they had a long weekend with their son. Still, the husband
silence to change their turn. The wife liked to sometime said at home that "I am working hard
talk about his extramarital affair in the therapy. for the child, but not for you." She also said
However, the husband said "I did an affair, but I that she could not trust him because he was
do not feel any guilty. The extramarital affair is nice to her in the therapy room but arrogant to
like a game." ”I like to talk about my alcohol her in their house. The couple communication
 Advantage of empty-chair dialogue over emotion-focused couples therapy 39

seems to be better than the initial session. can take time for extramarital sex!" Then, she
# 3(March X year): The husband said that asked about how he cheated up until 3 and 4
marital relationship became peaceful. The wife o’clock in the morning. The husband tried to
acknowledged her peaceful marital relationship answer at the beginning of discussion, but he
with him, but she was anxious about how long cannot see the end of the discussion, his
this peaceful relationship continued. Both of sleepiness won, and finally he said "I do not
them liked to talk about “peaceful life in their know" "I forgot" and ignored her questions
family (including the husband, wife and son)” suddenly. Then, the wife’s frustration had more
in following session. Their main agenda accumulated. The husband also did little work
consistent between them was decided as “the due to lack of sleep. Destructive
peaceful family life”. communication was too much in the couple so
#4(April X year): Couple was mostly the therapists intervened in the communication
peaceful, but they had a fight one time and she and proposed to restrict their time for
smashed him during driving. The therapists discussion within an hour per day. Further, their
normalized their fight. intervention is necessary to prevent escalating
#5(April X year): The husband drank alcohol their fight to severe physical violence. The
even though he pledged to quit alcohol in front husband accepted their proposal, but the wife
of her. During his drunk, he made a pass at a got angry. The wife’s anger exploded suddenly
woman. Even after he became sober, he did not and damaged their marital communication.
stop making pass at the woman, because he did
not want to miss the opportunity to have a sex Interruption period
with her. The wife said “I cannot understand the After the sixth session, they had made
meaning of your opportunity!” His appointment monthly, but they cancelled the
alcohol-related relapse triggered his fainting, appointment the day before the therapy. Their
rough attitudes, and their fight. cancels continued from July to August X year.
#6(May X year): The first half in the April During these months, husband’s mother and
was peaceful, but the second half got worse for uncle passed away one after another so they
both husband and wife. During the second half, were actually busy preparing for funerals and
the husband started to counterattack to his could not come to the therapy. Still, their
wife’s smash. When their son fell asleep around cancellation was also repeated in middle of the
11 o'clock, the wife every day started to ask the September. Hence, the therapists supposed that
reason why he made marital infidelity. He the wife had hostility toward the therapists who
responded to her for an hour and tried to go to did not understand her anger. Therapists made
bed because of the next day's work. Then, she appointment with her via telephone and
became angry and said "Why you cannot take reported that they felt sorry that they did not
time for our communication even though you help her nicely. Then, they revisited the therapy
40 Yokotani.

center. Greenberg, 2017). When the wife satisfied with

emotionally responsive couple communication
Stage 2: Emotion-focused couples therapy about the husband’s infidelity, the number of
(EFCT) her unresolved issue about the infidelity would
The second case formulation: The first stage decrease and finally resolve (Figure 1)
focused cooperative couple communication, but #7-#8(November X year): The wife's anger
not wife’s unresolved issues caused by her exploded again because she recalled the
husband’s infidelity. To treat her unresolved November X-1 year where his marital infidelity
issue, we utilized EFCT (Figure 1). The second was repeated. When her heart felt rough, she
stage aimed to increase husband’s expression of kept hitting her husband for 1-2 hours. Her
vulnerable emotion and to produce her hitting and rough feeling lasted 3 days and one
week, respectively. She said “My husband does
forgiveness on his infidelity in the context of not understand anything though I feel such a
emotionally responsive couple communication suffering.” He said that he liked to be patient
(Greenberg et al., 2010; McKinnon & for her smash because the smash was caused by

Note: Y and N represent Yes and No, respectively

Figure 1 Wife’s unresolved issues with her husband’s marital infidelity and emotion-focused
couple therapy approach
 Advantage of empty-chair dialogue over emotion-focused couples therapy 41

his infidelity. He also appreciated her every intervene in her aggression directly. Therapists
day’s work in house. The husband tried to keep empathetically listened to her emotion to calm
calm, but the wife did not. Her anger on his down her aggression and to stop her physical
marital infidelity was under-regulated again. violence indirectly.
Although therapists noticed her aggression #9(December X year): Their fight occurred
against him was severe physical violence, in front of their son so that the son had started
therapist intervention on her aggression failed to suffer nightmare since the fight. The husband
in the last session (#6), so therapists did not tried to select his word before he spoke

Note: Y and N represent Yes and No, respectively

Figure 2 Wife’s unresolved issues with her husband’s marital infidelity and
empty-chair dialogue intervention
42 Yokotani.

especially when he was angry. He said “The them.

past is the past. We like to live peacefully in
future.” Still, the wife did not forgive his past Stage 3: Empty-chair dialogue intervention
and could not imagine peaceful future. The (ECDI)
husband and wife had a big gap in their The third case formulation: We thought that
recognition about his infidelity. Although EFCT did not fit well with this couple because
therapists noticed their fight in front of their of two reasons. First, the husband had been
son is psychological violence, therapist received physical and psychological violence
intervention on her aggression failed in the from his wife, so he had difficulty to express
previous session (#6), so therapists did not his weakness in front of her, since his weakness
intervene in their fight directly. Therapists might be a target of her attack. Second, when
empathetically listened to their emotion to calm he became hypomanic, he said “All what I said
down their aggressions and to stop their fight in the therapy is a lie” so that the wife cannot
indirectly. trust his words in the therapy and could be
#10(February X+1 year): The wife reminded difficult to forgive him in the therapy.
that the husband concentrated on TV and To overcome these limitations, we utilized
comics too much to care his son, so she started ECDI for the wife and encouraged her
to attack him in the therapy room. When she imaginary dialogue with her husband’s
heated up, he turned to pale. Her repetitive extramarital lovers, rather than the husband
violence to him might shrink his feelings. His (Figure 2). During her imaginary talk with the
honest expression of his feelings in front of her lovers, her anger could focus on the lovers,
might be difficult. which could reduce the risk of her violence on
#11(May X+1 year): The wife became him. Furthermore, she could express her
anxious about her son’s school life, because his uncontrollable anger as she liked (Paivio, 1999)
classmates might tease him because of his regardless of his hypomanic mood. When the
father’s marital infidelity. When she thought wife is satisfied with aggressive
about the son’s future, she thought “Everything communication with her husband’s extramarital
had no value”. On the other hand, the husband lovers, the number of her unresolved issue
said that he could enjoy weekends so he did not about the husband’s infidelity would decrease
feel any problem. After the last session, he and finally resolve (Figure 2). For ECDI
became hypomanic and said “I tell a lie in the session, therapy structure was changed. The
couple therapy. All what I said in the therapy is first 40 minutes was for wife’s individual ECDI.
a lie”. The wife’s and husband’s expectation The last 10 minutes was for couple joint session
about their family was different from each other, to confirm the effects of ECDI and to keep the
so that the therapy needed to reset another main husband to be cooperative with her. The
agenda, which would be consistent between therapy also held biweekly.
 Advantage of empty-chair dialogue over emotion-focused couples therapy 43

First picture (3-1) Second picture (3-2) Third picture (3-3)

Figure 3 Wife’s drawing pictures regarding her husband’s extramarital lover

#12(July X+1 year): During ECDI, she marital affairs to your ex-partner. I will show
started to attack the woman A verbally. When him your affairs." Then, she would ask the wife
she stopped her verbal attack on A, the to forgive her for paying, but the wife would
therapists said “Your anger is not such a small not forgive her. "I will never forgive your
degree. Please show your anger more.” and misconducts. I will inform your husband about
encouraged her to continue to attack her in your affairs. You will be receiving domestic
order to treat her unresolved issues with A. She violence from him. Then you have been kicked
said "Yankee who lives in the town" "I feel like out from his house and you will die on the
I've been caught for a long time by you" "I street. Die!" She also expressed her anger
want you to avoid us" "I do not want you to see toward B.
us even for one second" "You cannot #13(August X+1 year): The wife had a good
understand us because you are stupid." "Idiot is sleep after a long time. The husbands also
poor thing. Can you understand the meaning of regarded that she calmed down. Her expression
idiot? This idiot (lol)" She expressed her strong of anger in ECDI could work in this couple.
anger toward A. She also started to attack the She was satisfied with her expression toward A
woman B who aged 20’s. She had 5 or 6 and B so she started to imagine the woman C.
extramarital affairs even though she had a child. She was the wife’s sister's colleague. She had
The B would say "Marital infidelity is not done bad things always and been familiar with
always from me. Your husband is also bad". extramarital affair since her school days. The
Then, the wife said “You are always flipping” wife asked her to stop approaching her husband,
"You are absolutely wrong regardless of other but she did not quit. Even though therapists
men’s behavior." "You seem to be hiding asked the wife to have imaginary dialogue with
44 Yokotani.

her, she did not. picture on C (Figure 3-3). The attack on C was
#14(August X+1 year): The wife could sleep going well. The attack was also translated into
well. The frequency of couple fight was also language, such as "die”, “dirty”, “stupid”,
decreasing. During ECDI targeting the woman “your Japanese language is strange”, “sick”,
C, the wife talked to the therapists rather than C. “crazy”, and “hell" (Figure 3-3). After she
“She has children, so I cannot get angry with finished drawing, she said “my angers on A, B,
her.” “I am not good at her. So I cannot get and C were completed.” After this session, the
angry.” Then, finally, she said “Perhaps, I was therapy structure was restructured as to be a
bad (rather than her).” The therapists intervened monthly joint couple therapy.
in the imaginary dialogue and said “It is
impossible that you are bad. This case is 100% Stage 4: Three-year follow up
bad for C, so please be angry with C”. Still, she #17-21(from October X+1 year to March
did not express her anger toward her, and X+2 year): The husband tried not to meet A
finally told “It is difficult." ECDI targeting C (Yankee). The B’s house was his commuting
might not work for her. road, so he decided not to use the road. When
#15(September X+1 year): The frequency of the wife got to meet C by chance, she recalled
their couple fight on marital infidelity became the bad memory and asked the husband about
only one time per month. The fight also lasted his past extramarital affair. Then he answered it
only 10 minutes. She continued to have good calmly. Therefore, they discuss recently, but the
sleep during night. During the wife’s individual discussion never developed into a fight. The
session, we asked her to draw picture about the therapists proposed the end of couple therapy,
Woman C, instead of ECDI. The first picture but they liked to continue the therapy. Hence
was simply painted with black crayon (Figure follow-up sessions were conducted around
3-1). We asked again to draw C. Then, she drew bimonthly.
a colorful figure. Then, we asked her to attack #Follow-up sessions (from September X+2
C. When she stopped the attack, we asked her year to September X+4 year): The therapists
to continue to attack the woman until there is have been following up the couple for three
no space in the paper. Figure 3-2 shows the years and have not confirmed any special
final version of the second picture. The C’s problems since the ECDI sessions. The agenda
neck was cut by her favorite son. She also of their couple therapy is mainly about school
entered in a tomb. The tomb had graffiti and support for their son with Autism spectrum
bird droppings. The tomb smelled around. After disorders. During follow-up, couple requested
she finished drawing, she made a smile and compensation for damages against the
said "It's funny." The therapists told "This is a husband's extramarital sex partner. Even though
very tasty picture" and laughed together. the sex partner and her lawyer took a
#16(October X+1 year): She drew the third high-pressure attitude to them, the couple
 Advantage of empty-chair dialogue over emotion-focused couples therapy 45

successfully responded and succeeded in especially expressed less vulnerable emotions

receiving the consolation fee. (such as fear and sadness) to their wives than
their wives expressed to them (Safdar et al.,
Discussion 2009). When therapist implements EFCT for
The present study compared the effect of this couple, husband’s expression of his
ECDI and EFCT for a Japanese couple with vulnerable emotion is essential (Field &
marital infidelity, alcohol abuse, marital Horowitz, 1998; Hagl et al., 2015;
violence, and bipolar disorders through a case Narkiss-Guez et al., 2015; Paivio & Greenberg,
study. As hypothesized, ECDI were more 1995): His emotional expression is a key in
effective for the Japanese couple with marital many couple therapy (Snyder, Mangrum, &
infidelity and multiple severe problems than Wills, 1993). However, Japanese husband’s
EFCT. This might be from different expression of his vulnerable emotion is
requirements during therapy sessions between culturally restricted (Safdar et al., 2009). Hence,
EFCT and ECDI. EFCT in this case requires Japanese couple with husband’s extramarital
the husband to express his vulnerable emotion sex might be difficult to apply EFCT, even
toward her and the wife to be patience to though the couples with husband’s extramarital
forgive his marital infidelity during sex were dominant in Japan (Moore, 2010).
session(Halchuk et al., 2010; McKinnon & The ECDI also could be useful for distressed
Greenberg, 2017; Meneses & Greenberg, 2011, couples with bipolar disorders. Bipolar
2014). In contrast, ECDI only requires the wife disorders were significantly correlated with
to imagine her husband’s extramarital lover marital distress (Whisman, 2007). Spousal
(Paivio & Greenberg, 1995). Comparison of hypomanic episodes sometime ruins what
these requirements between EFCT and ECDI couple has built up until then. In our case, the
suggest that couple feel easy to receive ECDI husband said to his wife “All what I said in the
rather than EFCT (Greenberg et al., 2010; therapy is a lie”. After listening to these words,
McKinnon & Greenberg, 2017; Meneses & she could not trust his words in the couple-joint
Greenberg, 2014). Hence, ECDI’s applicability therapy and the impact of the therapy on their
for couples might be greater than EFCT. In couple relationship could be minimized.
other words, couples who are not applicable to Effective therapies for family with bipolar
EFCT could be applicable to ECDI, but not the disorders frequently separated the family
other way around. members from the patients with bipolar
Further, Japanese cultures might have disorder, although the patient receive
negative effects on implementation of EFCT. medication individually (Geddes & Miklowitz,
This is because Japanese couples reportedly 2013). In line with these therapies, ECDI
showed less emotion than Caucasian couples separate the wife from the husband with bipolar
(Safdar et al., 2009). Japanese husbands disorder. ECDI might be effective for spouses
46 Yokotani.

who suffered from both their partners’ bipolar their partner’s lover also could treat their
episodes and marital infidelity. uncontrollable anger and reduce the risk of
However, our study has limitations regarding their physical assault on their partner. Actually,
academic and clinical methodology. First, our after the ECDI in our case, wife’s violence
study was single case design so the against her husband was disappeared. Previous
generalizability of our findings was limited. study reported effectiveness of ECDI with a
Further, we did not control the effects of order. few evidence (Paivio, 1999; Paivio &
The order of session (ECDI first or EFCT first) Greenberg, 1995; Pugh, 2016). Accumulation
might have different treatment effects on our of ECDI evidence for couples with marital
couple. Future study needs more couples and infidelity could propose an effective therapy
randomized research design. Second, our case plan for couples with marital infidelity and
also missed risk management of family contribute to reduce their suffering.
violence during EFCT sessions. Actually, wife’s
physical violence against her husband and Acknowledgement
couple’s psychological violence against their We would like to express our deepest
sons frequently occurred during the sessions 7, gratitude to the couple who accepted this case
8 and 9. To stop these kinds of violence, presentation. We also would like to thank
therapists needed an earlier decision to change Professor Keizo Hasegawa and Doctor Tai
their case formulation and interventions. Kurosawa for their clinical and academic
Incidence of family violence should be comments on our case. Part of our study was
considered more severely in future case studies. orally presented in the Japan Association of
Despite these limitations, this study is the Family therapy 34th Annual meeting in Tsukuba,
first approach, at least our knowledge, to and the National Foundation of Brief Therapy
compare the effect of ECDI and EFCT for a 9th Annual meeting in Fukuoka.
Japanese couple with marital infidelity and
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