IJBCT
Volume 7 Issues 2 & 3 2012
The INTERNATIONAL JOURNAL of BEHAVIORAL CONSULTATION and THERAPY
ISSN: 1555-7855 © 2012 ‑ All rights reserved.
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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
International Journal of Behavioral Consultation and Therapy CONTENTS Introduction to the Special Issue Robert J. Kohlenberg, Editor of Special Issue
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Acknowledgements Jack Apsche, Editor in Chief, IJBCT
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Functional Analytic Psychotherapy is a Framework for Implementing Evidence-Based Practices: The Example of Integrated Smoking Cessation and Depression Treatment Gareth Holman, Robert J. Kohlenberg, Mavis Tsai, Kevin Haworth, Emily Jacobson, & Sarah Liu 58 Promoting Efficacy Research on Functional Analytic Psychotherapy Daniel W.M. Maitland & Scott T. Gaynor
The Challenge of Developing a Universal Case Conceptualization for Functional Analytic Psychotherapy Jordan T. Bonow, Alexandros Maragakis, and William C. Follette 2 Interpersonal Mindfulness Informed by Functional Analytic Psychotherapy: Findings from a Pilot Randomized Trial Sarah Bowen, Kevin Haworth, Joel Grow, Mavis Tsai, and Robert Kohlenberg
First Steps in FAP: Experiences of Beginning Functional Analytic Psychotherapy Therapist with an ObsessiveCompulsive Personality Disorder Client Katia Manduchi, & Benjamin Schoendorff 72 Functional Analytic Psychotherapy (FAP): A review of publications from 1990 to 2010 Victor Mangabeira, Jonathan Kanter, & Giovana Del Prette 78
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An Empirical Model of Body Image Disturbance Using Behavioral Principles found in Functional Analytic Psychotherapy and Acceptance and Commitment Therapy Glenn M. Callaghan, Julissa A. Duenas, Sarah E. Nadeau, Sabrina M. Darrow, Jessica Van der Merwe, & Jennifer Misko 16
Expanding the Cognitive Behavioural Therapy Traditions: An Application of Functional Analytic Psychotherapy Treatment in a Case Study of Depression Catherine McClafferty 90 Functional Analytic Psychotherapy (FAP) in IberoAmerica: Review of current status and some proposals Amanda Muñoz-Martínez, Mónica Novoa-Gómez, & Rochy Vargas Gutiérrez 96
Promoting Appropriate Behavior in Daily Life Contexts Using Functional Analytic Psychotherapy in EarlyAdolescent Children Roberto Cattivelli, Valentina Tirelli, Federica Berardo and Silvia Perini 25 An Example of a Hakomi Technique Adapted for Functional Analytic Psychotherapy Peter Collis Equifinality in Functional Analytic Psychotherapy: Different Strokes for Different Folks Sabrina M. Darrow, Georgia Dalto, & William C. Follette
Functional Analytic Psychotherapy with Juveniles who have Committed Sexual Offenses Kirk A. B. Newring and Jennifer G. Wheeler 102 A Single-Case Experimental Demonstration of Functional Analytic Psychotherapy with Two Clients with Severe Interpersonal Problems Claudia Kami Bastos Oshiro, Jonathan Kanter, & Sonia Beatriz Meyer 111
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Functional Analytic Psychotherapy (FAP) for Cluster B Personality Disorders: Creating Meaning, Mattering, and Skills Julieann Pankey 117
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Treatment of a Disorder of Self through Functional Analytic Psychotherapy Rafael Ferro-Garcia, Miguel Angel Lopez-Bermudez, & Luis Valero-Aguayo
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Development and Preliminary Evaluation of a FAP Protocol: Brief Relationship Enhancement Gareth Holman, Robert J. Kohlenberg, & Mavis Tsai
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Functional Analytic Psychotherapy as an Adjunct to Cognitive-Behavioral Treatments for Posttraumatic Stress Disorder: Theory and Application in a Single Case Design Eric R. Pedersen, Glenn M. Callaghan, Annabel Prins, Hong Nguyen, & Mavis Tsai 125 i
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Using Functional Analytic Therapy to train therapists in Acceptance and Commitment Therapy, a conceptual and practical framework Benjamin Schoendorff, MA, MSc MPs & Joanne Steinwachs, LCSW 135 Therapists’ Attitudes about and Preferences to Use Relationship Focused Interventions: New Tools to Measure a Critical Component of Functional Analytic Psychotherapy (FAP) Christeine M. Terry & Robert J. Kohlenberg 138 Working In-Vivo with Client Sense of Unlovability Mavis Tsai & Richard Reed
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Reliability and Validity of the Spanish Adaptation of EOSS, Comparing Normal and Clinical Samples Luis Valero-Aguayo, Rafael Ferro-Garcia, Miguel Angel Lopez-Bermudez, and Mª Angeles Selva-Lopez de Huralde 151 The Trouble with the Short-Term Therapist-Client Relationship and What Can Be Done About It Luc Vandenberghe and Jocelaine Martins da Silveira
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Intimacy is a Transdiagnostic Problem for Cognitive Behavior Therapy: Functional Analytical Psychotherapy is a solution Chad T. Wetterneck, Ph.D. and John M Hart, Ph.D. 167 FAP Group Supervision: Reporting Educational Experiences at the University of São Paulo, Brazil Regina Christina Wielenska and Claudia Kami Bastos Oshiro 177 Transitional Probability Analysis of Two Child Behavior Analytic Therapy Cases Rodrigo Nunes Xavier, Jonathan William Kanter, and Sonia Beatriz Meyer 182
PUBLISHER’S STATEMENT The International Journal of Behavioral Consultation and Therapy (IJBCT), is published quarterly by Joseph Cautilli and BAO Journals. IJBCT is an online, electronic publication of general circulation to the scientific community. IJBCT’s mission is to provide a focused view of behavioral consultation and therapy for the general behavioral intervention community. Additionally, IJBCT hopes to highlight the importance of conducting clinical research from a strong theoretical base. IJBCT areas of interest include, but are not limited to: Clinical Behavior Analysis, Behavioral Therapy, Behavioral Consultation, Organizational Behavior Management, Human Performance Technology, and Cognitive Behavior Therapy. IJBCT is an independent publication and is in no way affiliated with any other publications. The materials, articles, and information provided in this journal have been peer reviewed by the review board of IJBCT for informational purposes only. The information contained in this journal is not intended to create any kind of patient-therapist
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SCOPE AND PURPOSE The International Journal of Behavioral Consultation and Therapy (IJBCT) publishes original research, topical reviews, theoretical and conceptual work, clinical case studies, program descriptions, and organizational and community focused evaluations within the disciplines of behavior therapy, applied and clinical behavior analysis, behavioral psychology, and organizational behavior management. Our purpose is to publish empirical research, theoretical papers, and clinical demonstrations that advance therapy and consultation with children, adolescents, and adults within school, clinic, home, and community settings. Furthermore, IJBCT has the purpose of increasing communication among practitioners, researchers, and academic professionals.
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EDITORIAL STAFF EDITOR IN CHIEF
Jack Apsche, Ed.D, ABPP North Spring Behavioral Healthcare Leesburg, VA
SENIOR ASSOCIATE EDITOR
Christopher Bass Clark Atlanta University Atlanta, GA
SENIOR ASSOCIATE EDITORS
Robert Kohlenberg, Ph.D. University of Washington
Steven C. Hayes, Ph.D. University of Nevada, Reno
EDITORIAL ASSISTANT TO DR. APSCHE
Melissa Apsche CO-FOUNDING EDITORS
Joe Cautilli, Ph.D., BCBA Behavior Analysis & Therapy Partners Bala Cynwyd, PA
Jack Apsche, Ed.D, ABPP North Spring Behavioral Healthcare Leesburg, VA
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EDITORIAL REVIEW BOARD
John Austin, Ph.D.
Western Michigan University USA
John Blackledge, Ph.D. University of Wollongong New South Wales, Australia
Teri Burcroff, Ph.D. East Strausburg University USA
Ken Carpenter, Ph.D.
New York State Psychiatric Institute Division - CPMC USA
Arthur Freeman, Ed.D. Governors State University USA
Simon Dymond, Ph.D., B.C.B.A. University of Wales, Swansea United Kingdom
Patrick Friman, Ph.D. Boys Town USA
Lee Kern, Ph.D. Lehigh University USA
Marsha Linehan, Ph.D., ABPP University of Washington USA
Shari Manning , Ph.D. President/CEO Behavioral Tech USA
Smita Mehta, Ph.D. University of Texas USA
Cheryl McNeil, Ph.D. West Virginia University USA
Arthur M. Nezu, Ph.D., ABPP President ABPP Department of Psychology Drexel University
Christine Maguth Nezu, Ph.D., ABPP Professor of Psychology Associate Professor of Medicine Drexel University USA
Paul H. Pittman, Ph.D. Indiana University Southwest USA
Phil Reed, Ph.D. University of Wales Swansea, United Kingdom
David M. Richman, Ph.D. University of Maryland Baltimore County USA
Kimberly Schreck, Ph.D. Penn State University USA
James Snyder, Ph.D. Wichata University USA
Peter Sturmey, Ph.D. Queens College and The Graduate Center City University of New York
Adam Weaver Mississippi State University USA
David Wilder, Ph.D. Florida Institute of Technology USA
Kelly Wilson University of Mississippi USA
R.D Zettle, Ph.D. Witchita University USA
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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
INTRODUCTION TO THE SPECIAL ISSUE
Integration:
ACT (Callaghan & colleagues; Pankey; Schoendorff & colleague); Hakomi (Collis); Mindfulness (Bowen & colleagues); Behavioral Activation (McClafferty); EST for PTSD (Pederson & colleagues); ACT, CBT, Behavioral Activation, EST for Smoking (Holman1 & colleagues); ESTs for Sexual Offense Behavior (Newring & colleagues).
Robert J. Kohlenberg Editor of the Special Issue Functional Analytic Psychotherapy (FAP) is a behavioral approach to therapy that brings a laserlike focus on the curative aspects and implementation of a close and intense therapist client relationship. FAP entered the cognitive behavior therapy literature with a chapter (Kohlenberg & Tsai, 1987) published in Neil Jacobson’s edited volume – – interestingly that same book included Steve Hayes’s chapter that introduced ACT (Hayes 1987 ). Now 25 years, four books, and some 200 publications later (many of which are included in the literature reviews by Mangabeira, Kanter, & Del Prette and Munoz-Martinez, Nova-Gomez, & Vargas Guitierrez), the papers in this special issue provide a snapshot of the impact, scope , international representation, and trends engendered by this history. Just as FAP underscores establishing meaningful relationships with clients, the same holds true for the relationships between supervisors and supervisees and the connection among the members of our small but growing professional community of therapists, researchers, and trainers. This group came into play in the unanticipated and enthusiastic response to our call for papers. We are very appreciative of the effort and creativity of our colleagues who submitted their work. At the expense of not doing justice to the comprehensive nature of the papers, here is a brief overview of the topics and issues addressed by our authors.
Literature Reviews:
(Mangabeira & colleagues; Munoz & colleagues). Intensive Single Subject Design and Case Studies:
(Xavier & colleagues; McClafferty; Pederson & colleagues; Oshiro & colleagues). I want to thank Jack Apsche who conceived this project and gently and tirelessly encouraged its completion. I wish to extend my deepest gratitude to the associate editors Glenn Callaghan, Bill Follette, Jonathan Kanter, Barbara Kohlenberg, and Mavis Tsai who put in a great deal time and effort in offering insightful and constructive criticism to our contributors. I am moved by the care, creativity, enthusiasm, patience and persistence of the authors, and am deeply thankful for their contributions to this special issue and the development of FAP. Robert J. Kohlenberg
ACKNOWLEDGEMENTS Jack Apsche Editor in Chief, IJBCT
Populations and Disorders/Problems
PTSD (Pederson & colleagues); Personality Disorders (Pankey; Manduchi & colleague; Oshiro & colleagues); Unlovability (Tsai & colleague); Body Dysmorphic Disorder (Callaghan and colleagues); Self Problems (Ferro & colleagues); Adolescents (Cattivelli & colleagues); Smoking and Depression (Holman1 & colleagues); Adolescents with Sexual Offense Behaviors (Newring & colleagues); Children (Xavier & colleagues).
I am so thrilled to see this double edition of IJBCT completed. Over a year ago I asked Robert Kohlenberg if he would consider editing an all Functional Analytic Psychotherapy (FAP) edition of IJBCT. Bob accepted the idea and he and his FAP editors and authors responded with a double edition of the best group of articles ever offered in IJBCT or any print or online journals. I want to thank Bob and the following colleagues from my heart for IJBCT 7.2 and 7.3; Jonathan Kanter, University of Wisconsin – Milwaukee, M. Callaghan (San Jose State University), William C. Follette University of Nevada-Reno), Barbara Kohlenberg (University of Nevada Medical School, Reno), Mavis Tsai (Independent Practice and Director of the FAP Clinic, University of Washington).
Clinical Technique and Solving Clinical/Theoretical Problems
(Vandenberghe & Colleague; Tsai & colleague; Bowen & colleagues; Pankey). Theoretical and Conceptual Issues:
(Vandenberghe & Colleague; Pankey; Wetterneck & colleague; Maitland & colleague). Facilitating Dissemination and Issues Concerning Ideographic Versus Functional Analysis and Generalization to Daily Life:
Jack Apsche
(Bonow & colleagues; Darrow & colleagues; Wetterneck & colleague; Maitland & colleague; Cattivelli & colleagues).
REFERENCES
Supervision and Training:
(Manduchi & colleague; Darrow & colleagues; Wielenska & colleagues; Schoendorff & colleague).
Hayes, S. C. (1987). A contextual approach to therapeutic change. Psychotherapists in clinical practice: Cognitive and behavioral perspectives. N. Jacobson. New York, Guilford: 327-387. Kohlenberg, R. J. and M. Tsai (1987). Functional analytic psychotherapy. (1987). Psychotherapists in clinical practice: Cognitive and behavioral perspectives. N. S. Jacobson. New York, NY, Guilford Press: 388-443.
Basic Research and/or Mechanisms of Action, Methodology:
(Terry & colleague; Bowen & colleagues; Holman2 & colleagues; Callaghan & colleagues; Valero & colleagues, Rodrigo & colleagues; Wetterneck & colleague).
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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
The Challenge of Developing a Universal Case Conceptualization for Functional Analytic Psychotherapy Jordan T. Bonow, Alexandros Maragakis, and William C. Follette University of Nevada, Reno Abstract Functional Analytic Psychotherapy (FAP) targets a client’s interpersonal behavior for change with the goal of improving his or her quality of life. One question guiding FAP case conceptualization is, “What interpersonal behavioral repertoires will allow a specific client to function optimally?” Previous FAP writings have suggested that a therapist must consider two issues when answering this question: (1) the client’s values and (2) the interpersonal behaviors that will be supported by the client’s social community. This paper discusses the potential for a single “universal” case conceptualization that can be successfully used with all FAP clients. A number of possible universal conceptualizations are reviewed but ultimately rejected as legitimate candidates. As an alternative, the authors suggest the use of a foundational framework for FAP case conceptualization focused on developing goal-directed interpersonal flexibility in clients. This framework has the benefits of: (1) identifying target repertoires that may be necessary but are not sufficient for the successful interpersonal functioning of all clients, (2) allowing for a functional, principle-based conceptualization of a client’s specific target behaviors, and (3) encouraging consideration of a client’s unique values and social community.
Keywords Functional Analytic Psychotherapy, Case Conceptualization, Values, Social Community
W
hile Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, Kanter, et al., 2009) has been used as an enhancement to other psychotherapy approaches (see e.g., Kohlenberg, Kanter, Bolling, Parker & Tsai, 2002), it is also, and perhaps most commonly, used as a standalone treatment. When employed in this manner, a FAP therapist attempts to improve a client’s interpersonal functioning through in-vivo contingent responding in order to ultimately increase that client’s quality of life. This contingent responding by a therapist is guided by a FAP case conceptualization (Kanter et al., 2009). Kanter and colleagues (2009) provide an excellent overview of FAP assessment processes, including the development and ongoing revision of a case conceptualization. The present paper is designed to supplement earlier discussions of FAP assessment and case conceptualization by discussing the possibility of a FAP case conceptualization applicable to all clients. This paper assumes a basic knowledge of FAP, which readers can obtain from the texts summarizing FAP (Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, Kanter, et al., 2009). An attempt to identify a case conceptualization applicable to all clients initially seems completely contradictory to FAP’s behavior analytic foundation, which emphasizes the importance of an idiographic understanding of a client’s behavior and the environment in which it is emitted (see, e.g., Callaghan, 2006; Kanter et al., 2009). From this perspective, given that each client has a unique learning history and behaves within a unique context, his or her behavior should be analyzed in an individualistic
manner. Thus, each client should have his or her own unique case conceptualization.1 Ongoing discussions of FAP, however, have noted that it, as a principle-based psychotherapy, is typically very difficult to implement (Weeks, Kanter, Bonow, Landes, & Busch, 2011). This difficulty in implementation has led to calls for descriptions of the practice of FAP that are as clear and specific as possible, allowing for easier dissemination and competent practice of FAP (Weeks et al., 2011). The present paper provides one response to this call. It specifically attempts to identify a universal case conceptualization applicable to all FAP clients that will allow therapists to more efficiently and effectively implement FAP. There are many possible components of a FAP case conceptualization. These include but are not limited to: (1) a summary of historical variables potentially influencing a client’s behavior, (2) a summary of a client’s goals and values, (3) a description of a client’s problem behaviors in session and more effective alternative behaviors (CRB1s and CRB2s), (4) a description of a client’s problem behaviors outside of session and more effective alternative behaviors (O1s and O2s), and (5) a description of therapist problem behaviors and more effective alternative behaviors (T1s and T2s; for further discussion of typical contents of a FAP case conceptualization see Kanter et al., 2009). Before proceeding it is essential to emphasize that a widely applicable, universal case conceptualization is generally not possible with respect to these specific components. For example, it is obvious that historical variables uniquely influence each client’s behavior and thus need 1 This uniqueness should extend beyond any other factors that might contribute to variety in case conceptualizations (e.g., level technicality in the language used, individual differences in therapist styles in forming the conceptualization).
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THE CHALLENGE OF DEVELOPING A UNIVERSAL CASE CONCEPTUALIZATION FOR FUNCTIONAL ANALYTIC PSYCHOTHERAPY
to be described idiographically. Likewise, the unique interaction between a specific client’s learning history and current context must be captured in a case conceptualization’s identification of both the function and form of that client’s behavioral targets. As a result, the specific proximal behaviors identified in a FAP case conceptualization, including client CRB1s, CRB2s, O1s, and O2s need to be idiographically defined (Kohlenberg & Tsai, 1991; Kanter et al., 2009). In contrast, a widely applicable FAP case conceptualization may be possible, appropriate, and useful at more foundational level. As already noted, the primary outcome sought in FAP is the improvement of a client’s quality of life. From a behavioral perspective, improvement in an individual’s quality of life is primarily defined by increased access to positive reinforcement (Follette, Linnerooth, & Ruckstuhl, 2001). FAP is most fundamentally a process of shaping a client’s interpersonal reportoires such that they allow the client to access more socially-mediated positive reinforcement. Because of this, a FAP case conceptualization must at least implicitly identify interpersonal repertoires2 that are likely to be maintained by consistent positive reinforcement delivered by individuals the client contacts outside of the therapeutic environment. In general, these repertoires are the goal of the shaping process that is at the core of FAP. For example, a specific client improvement of attempting to describe one’s emotional state is likely one step toward the broader repertoire of the client consistently and accurately expressing his or her emotions. Theoretically, if a client were to consistently display the identified goal repertoires, he or she would contact the maximum amount of interpersonally-mediated positive reinforcement potentially available to him or her.3 Therefore, these repertoires represent a client’s maximal level of interpersonal functioning. It is at this level (i.e., end goal client interpersonal repertoires) that a broadly applicable, universal FAP client case conceptualization (hereafter referred to as a universal case conceptualization) might be possible. The question under consideration in the present paper is whether such a universal case conceptualization actually exists. In particular, the present paper addresses the question of whether there is a set of interpersonal repertoires that should be promoted in all FAP clients. FAP writings have traditionally stated that, like his or her proximal therapy targets, the behavioral repertoires promoted in FAP should be idiographically determined (see, e.g., Kohlenberg & Tsai, 1991; Kanter et al., 2009). The FAP literature has identified two issues that a therapist must consider when identifying these repertoires: (1) the client’s values and (2) the client’s social community. Both of these will now be discussed in turn with particular emphasis on their implications for case conceptualization, including the possibility of a universal case conceptualization. 2 For the present purposes, these repertoires should be understood as involving both the capacity to emit a functional form of behavior in the moment and the appropriate discrimination of when to emit that particular behavior. 3 This represents cases in which therapy is unlimited by any constraints (e.g., time, cost to client, client willingness to engage the change process). More typically, a client has a specific goal for therapy (e.g., improved functioning in a romantic relationship, reduced depression) that is much more constrained when compared to the broad changes in interpersonal functioning suggested here. It is still the case, though, that treatment targets in these more constrained therapeutic contexts would be based on a conceptualization of these broad changes.
VALUES According to the behavior analytic perspective underlying FAP, values are broadly defined as “verbal statements specifying reinforcers and the activities that produce them” (Baum, 2005; Skinner, 1971; as cited by Tsai, Kohlenberg, Bolling, & Terry, 2009; p. 199-200). When clients enter therapy they often make a number of idiographic statements of values (e.g., what is personally important to them, their individual goals for therapy). The general consensus in the FAP literature is that these statements should be used by a therapist to identify the general direction of therapy and prioritize what behaviors should be targeted first in therapy (see, e.g., Kanter et al., 2009). This activity is directly related to the identification of the interpersonal repertoires targeted for a specific client in FAP. This is a common approach to client values and reflects the most common interpretation of the American Psychological Association (APA) Code of Ethics (2002; see Bonow & Follette, 2009). However, we (Bonow & Follette, 2009) have argued that this approach is untenable within a behavior analytic approach to psychotherapy. When defined operationally (see Skinner, 1945), values can be understood as: (1) one’s behavior (i.e., valuing), (2) the functional consequences maintaining that behavior (i.e., functional values), and (3) statements identifying those functional consequences and the behaviors that are likely to be met with those consequences (i.e., statements of values; Bonow & Follette, 2009). Given this understanding of values, successful therapy (i.e., therapy leading to meaningful client behavioral change) by necessity influences and changes a client’s values. As a result, it is not logical to rely solely on a client’s pre-therapy values to direct the full course of psychotherapy. This is especially true if a client has previously had limited contact with potential reinforcers and is likely to experience dramatic changes in behavior when exposed to new learning histories during the course of therapy (i.e., his or her values are likely to evolve during the course of therapy). Because of this, a therapist should attempt to influence a client’s values in the service of allowing that client to access additional potential sources of positive reinforcement (especially in novel forms) so that a client will be able to behaviorally “choose” among sources of reinforcement (Bonow & Follette, 2009). Thus, when identifying a client’s ultimate therapy targets, a therapist must attempt to determine what values will be functional for a client in the longterm and support the evolution of these values in a client.4 Arguments by Tsai, Kohlenberg, Bolling, and Terry (2009) extend even further the bounds of the appropriate influence of a therapist on a client’s values. They note that a therapist’s own personal values typically influence the therapeutic process in ways that may not be apparent to the therapist or the client. As a result, they encourage greater transparency in the therapist’s own personal values and the manner in which they influence interactions with a client. This includes allowing, with a client’s consent, an individual therapist’s personal values to influence the process of identifying the values that should be espoused by a client (Tsai, Kohlenberg, Bolling, & Terry, 2009). 4 Bonow and Follette (2009) argue that the influencing of a client’s values in this manner should only be undertaken when the consequences of holding particular values is known (i.e., can reasonably be predicted based on empirical evidence).
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The above arguments suggest that it may be appropriate for FAP therapists to promote universal values that are functional for all clients (or even all people) in the long-term. Identifying a set of universal values (i.e., a universal set of therapeutic goals) would obviously have a consistent, direct impact on each client’s individual case conceptualization. At the same time, a set of universal values has yet to be identified.5 Two general assumptions underlying FAP may suggest universal values to be engendered in clients. These assumptions are that: (1) socially-mediated events are consequences functioning to influence a client’s behavior, and (2) clients are motivated to learn more effective interpersonal repertoires. Based on these assumptions, one might conclude that a client should value interpersonal relationships and should want to be interpersonally adept. This would be an incorrect conclusion. According to the original FAP book, “there are no models of what a healthy person should be like or what kinds of goal behaviors should be in his or her repertoire” (Kohlenberg & Tsai, 1991; p. 192). Any assumptions regarding the necessity of a client valuing interpersonal interaction for the success of FAP are generally descriptive rather than prescriptive; they identify conditions contributing to successful courses of FAP and do not identify values that clients should be encouraged to hold. In reality, some clients find interpersonal interaction reinforcing and others do not (i.e., some value interpersonal relationships while others do not). Kohlenberg and Tsai (1991) noted this in the earliest FAP writings, indicating that, for this reason, there are clients who are more or less appropriate for FAP. Thus, FAP is to be employed with clients who meet its assumptions, which is very different than making clients appropriate for FAP by manipulating their values. To summarize, it is clear that FAP therapists typically hold to the principle that a client’s values should direct therapy, including the identification of the specific client repertoires targeted in therapy. At the same time, there are convincing arguments that it is often in a client’s best interest to influence him or her to hold or at least explore particular values. Because of this, it is currently concluded that a universal client case conceptualization based on an identified set of universal values is theoretically plausible, even if there is currently no agreement upon what those universal values might be. Until such a set of universal values has been identified, though, it seems advisable that therapists continue to adhere to the common practice of primarily relying on the client’s wishes when determining the ultimate targets of therapy (realizing that those values may morph and expand as the client’s improved interpersonal repertoire is likely to expose him or her to novel potential reinforcers, including those that he or she previously considered inaccessible).
SOCIAL COMMUNITY One’s social community refers to all individuals with whom one interacts. These individuals are the mediators of reinforcement for one’s interpersonal behavior (more technically referred to as one’s verbal community; Skinner, 1957), so it is essential that one is able to effectively interact with one’s social community. 5 One example of a proposed set of universal values will be discussed below under the subheading “Green FAP” (Tsai, Kohlenberg, Bolling, & Terry, 2009).
While a client’s social community technically includes the FAP therapist (during the course of therapy), the present discussion focuses on a client’s social community outside of the therapy room (e.g., a client’s family, friends, coworkers, etc.). This is because the FAP therapist is not intended to be a lasting member of an individual’s social community. It is hoped that, at the termination of therapy, a FAP client will be able to effectively interact with his or her social community without continued interaction with a therapist. Thus, ultimate therapy targets in FAP should consist of interpersonal repertoires that are likely to be functional as a client has ongoing interactions with his or her social community outside of the therapeutic environment. The importance of considering a client’s social community was noted in early FAP writings. Kohlenberg and Tsai (1991) specifically highlighted the issue when discussing the distinction between natural and arbitrary therapist responding. They specifically encouraged therapists to consider the question, “How typical and reliable is the reinforcer in the natural environment for the behavior being exhibited [in the therapy session]?” (Kohlenberg & Tsai, 1991; p. 12). This question emphasizes the importance of the FAP therapist’s awareness of the client’s social community. If a therapist shapes behavioral repertoires that will not be reinforced by a client’s social community, the client’s gains in the therapy room will not be maintained and therapy will have been of minimal benefit to the client. As is the case with a client’s values, the FAP literature encourages therapists to idiographically assess a client’s social community when identifying repertoires to be targeted in therapy. Overall, this is a reasonable approach, as it seems likely that all people have social communities that are unique in some meaningful way (e.g., no two romantic partner’s are completely identical). At the same time, much of the discussion of a client’s values with respect to the identification of therapy targets is pertinent to the topic at hand. For example, it is quite plausible that a client’s social community will change during the course of therapy. This is especially likely if a client’s values and interpersonal repertoires change in a manner that makes them in some way incompatible with the values and repertoires of his or her initial pre-therapy social community. It could even be argued that a therapist should encourage a client to expand or modify his or her social community so that it includes individuals who more readily provide socially-mediated reinforcement. Thus a therapist, after an initial assessment of a client’s social community, should continue the assessment of that community throughout the course of therapy. This will allow the therapist to track any changes in the client’s social community, including the entrance of novel persons into that community and changes exhibited by initial members of that community (e.g., changes exhibited by those in long-term relationships with the client such as the spouse or children of the client). A separate issue to consider is whether there really are meaningful differences between the social communities of various clients. There certainly are a number of potential social communities that require different interpersonal repertoires. In fact, the clinical experiences of the present authors suggest that clients frequently enter therapy because they inappropriately exhibit a repertoire that is very effective in one social community when interacting with individuals in another social community (e.g.,
THE CHALLENGE OF DEVELOPING A UNIVERSAL CASE CONCEPTUALIZATION FOR FUNCTIONAL ANALYTIC PSYCHOTHERAPY
a police officer’s “controlling” repertoire keeps him safe when he interacts with criminal offenders but feels overbearing to his romantic partner, a salesperson’s storytelling repertoire allows him to quickly build trust with customers but hampers intimacy-building with his close friends). Nevertheless, for purposes of the present discussion of the plausibility of a universal client case conceptualization, it is important to consider whether there is an identifiable set of interpersonal repertoires that, if exhibited by a client, would be sufficient for him or her to successfully interact with any person with whom he or she could come into contact. It certainly seems that there are a number of interpersonal repertoires that are universally functional across social communities (e.g., accurately expressing one’s desires, showing an interest in the experiences of others, discriminating opportunities to build closeness). This means that a universal case conceptualization is still a theoretically plausible consideration. As was the case with client values, though, no such set of universally effective repertoires has been unanimously identified.6 Therefore, it currently seems advisable for therapists to continue to take an idiographic approach to the assessment of a client’s social community when determining his or her therapy targets.
POSSIBLE UNIVERSAL CASE CONCEPTUALIZATIONS The above discussions generally suggest that FAP therapists should continue to idiographically identify a specific client’s values, social communities, and target repertoires. Yet, the above discussions also demonstrate that a universal FAP client case conceptualization is theoretically plausible. At this time, the primary barrier to the identification of a universally applicable case conceptualization appears to be the relative lack of thorough discussion and empirical investigation of the topic. The following attempts to promote such efforts by presenting a number of possible universal case conceptualizations. Each will be summarized and evaluated with respect to the issues highlighted above. GREEN FAP Tsai, Kohlenberg, Bolling, and Terry (2009) provide a possible universal case conceptualization for what they term Green FAP, a form of FAP in which a therapist directly promotes client’s behavior in the service of the values of “caring and helping of others, social consciousness and responsibility, and using one’s talents and passions to contribute to the world” (p. 199). According to this approach, a case conceptualization should universally target the following repertoires: (1) being more altruistic, (2) developing a sense of universal responsibility, (3) cultivating an open heart, (4) advancing a sense of purpose and personal mission, and (5) engaging in a daily practice. Within this approach, Tsai, Kohlenberg, Bolling, and Terry (2009) argue that the world as a whole would benefit from all of its citizens behaving with respect to a specific set of values (e.g., altruism, universal responsibility). As a result, this case conceptualization should be universally applicable to clients. The specificity with which this approach identifies ideal client values, however, indicates that this would not be an appropri6 Possible universally effective repertoires will be presented below.
ate or useful universal case conceptualization. In particular, the values that are promoted are far too constrained. In presenting this approach, the authors demonstrate recognition of this fact when they suggest that Green FAP caters to a specific clientele and that it should be employed only with the explicit consent of the client (Tsai, Kohlenberg, Bolling, & Terry, 2009). Given this clear limitation in this approach as a universal case conceptualization, it will not be discussed further. EXPERIENTIAL AVOIDANCE AND INTIMACY-BUILDING While not intending to describe a possible universal case conceptualization, Tsai, Kohlenberg, Bolling, and Terry (2009) provide a list of client repertoires that are regularly promoted in FAP. These have been selected for discussion here as a possible universal case conceptualization because they provide an example of the target repertoires implied by many FAP-focused presentations and publications.7 Four separate behavioral repertoires of focus are included in this potential universal conceptualization: (1) reducing experiential avoidance, (2) improving attachment repertoires, (3) giving and accepting care, and (4) increasing a stable sense of self (pp. 202-203). One positive aspect of this case conceptualization is that it targets the most common deficits observed in FAP clients (i.e., deficits in intimacy-building). Moreover, it follows FAP’s assumption regarding client values (i.e., that all clients who would present for FAP value socially mediated reinforcement). As a result, this is very much a universal case conceptualization. At the same time, there are two potentially problematic aspects of this approach that make it untenable. First, the target repertoires within this conceptualization may be too constrained. By placing focus on what could be considered more “advanced” interpersonal repertoires related to mattering to others and allowing others to matter to oneself, it may cause a therapist to overlook more foundational interpersonal repertoires (i.e., basic social skills). Second and more important, the ultimate therapy targets identified in this conceptualization may not be functional for a given client. For example, a client may not actually find an intense intimate relationship to be reinforcing, or the client’s long-term romantic partner may not appreciate a client’s more expressive repertoire. Thus, while this case conceptualization may frequently be worth considering for use in FAP, it is not truly universal. FIAT-DERIVED An alternative possible universal case conceptualization can be derived from the Functional Idiographic Assessment Template (FIAT; Callaghan, 2006), an assessment system specifically designed for FAP and other interpersonally-focused psychotherapies. In order to streamline functional behavioral assessment of client interpersonal functioning, the FIAT broadly organizes client interpersonal behaviors into five different topographically-defined areas. Tsai, Callaghan, Kohlenberg, Follette, and Darrow (2009; p. 170) identify optimal repertoires for daily interpersonal functioning within each of the five areas of the FIAT: (1) “To identify and authentically assert one’s thoughts, feelings, and needs. To speak truths compassionately and to 7 Any critical discussion of this list as a possible universal case conceptualization should be read with the understanding that the authors’ points have been adapted for the present purposes and does not reflect a criticism of their original work.
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take risks appropriately.” (Assertion of Needs), (2) “Ability to discriminate one’s impact on others and vice versa.” (Bi-Directional Communication), (3) “Engaging in healthy conflict and conflict resolution effectively with others.” (Conflict), (4) “Appropriately engaging in disclosure and interpersonal closeness with others. To be interpersonally intimate and effective. To create close relationships, to give and receive love.” (Disclosure and Interpersonal Closeness), and (5) “To discriminate, experience and express one’s feelings with others.” (Emotional Experience and Expression). While the authors were primarily focused on therapist self-development (i.e., were identifying optimal therapist daily life interpersonal repertoires), these recommendations can be applied to clients as well. Thus, from within this approach, a client’s target repertoires would consist of those listed above. This FIAT-based case conceptualization provides a comprehensive framework for identifying a client’s ultimate therapy targets. By design, any possible client dysfunctional repertoires (and more functional alternative behaviors) could be incorporated into this framework. As a result, this case conceptualization is universally applicable. An additional positive aspect to this approach to case conceptualization is that it allows for more flexibility with respect to a client’s goals for particular interactions (as demonstrated by the use of words such as “appropriately” and “effectively”). While this flexibility is present, there are still undertones that a client should generally behave in a manner that creates intimacy with others. This implication makes this approach subject to the criticisms of the previously presented possible universal case conceptualization. In other words, it may promote repertoires that may not be functional for particular clients (e.g., an intense intimacy-building repertoire that is not supported by close members of one’s social community). Related to this, successful use of this FIAT-based conceptualization seems to depend upon a client already having a relatively rich and responsive social community available. For example, this approach generally assumes that a client’s expressed needs will be met by the environment and fails to provide guidance for a client’s behavior under circumstances in which his or her current social community is unresponsive to these requests (e.g., dissolution of unsupportive relationships and forming a social community more likely to reinforce one’s new repertoires). This limitation prevents this FIAT-based case conceptualization from being considered truly universal, as not all clients will have contact with a rich and responsive social community. GOAL-DIRECTED FLEXIBILITY A final possible universal case conceptualization has been derived from the clinical practice and experience of the present authors (i.e., the target repertoires typically underlying the authors’ FAP case conceptualizations). According to this approach, the goal of FAP is to teach a client three broadly applicable behavioral repertoires: (1) the accurate identification of one’s values and goals in a given situation, (2) engaging in interpersonal behavior that attempts to enact those values or achieve those goals, (3) noticing the degree of success of one’s behavior with respect to one’s values and goals and adjusting accordingly (e.g., discriminating opportunities to engage in particular kinds
of interpersonal behavior, changing the form of one’s behavior to increase the likelihood it will be reinforced). This approach to case conceptualization adequately addresses the two issues related to the identification of target client repertoires: a client’s values and a client’s social community. Teaching clients to accurately assess their own values promotes their engagement in values-consistent behavior (regardless of what their values are) and is respectful of a client’s autonomy (i.e., does not assume or promote specific values). The promotion of client behavioral flexibility allows clients to effectively interact with their individual social communities (i.e., does not prescribe particular behaviors in which clients should always engage). Thus, this case conceptualization uniquely focuses on repertoires that are likely to allow most clients to access additional and novel positive reinforcement, which the reader will recall is the ultimate goal of FAP. While this proposed universal case conceptualization has many benefits, it has some important limitations. The primary of these is that it may be difficult for a FAP therapist to practically implement. The three repertoires highlighted in this case conceptualization are extremely broad and potentially very complex. For example, if a client is to successfully adapt to his or her environment, he or she must be able to identify his or her specific goal in a given situation, identify a behavior that is likely to meet that goal within that situation, and skillfully emit that behavior. Thus, this approach to case conceptualization requires a FAP therapist to have a sophisticated assessment repertoire. Unfortunately, rather than being easily remedied, this issue is primarily a reflection of the difficulty in the manualization or dissemination of a principle-based therapy like FAP. In order to prevent a therapist’s inflexible engagement in rule-governed behavior (Hayes, 1989), the therapy must be described in terms of principles, the application of which are not always readily apparent.8 Readers interested in strategies for developing a clientspecific case conceptualization are encouraged to reference previous works related to that topic (e.g., Callaghan, 2006; Kanter et al., 2009). A second potential limitation of this proposed universal case conceptualization is that it may create a context in which a client is not exposed to novel forms of potential positive reinforcement. While some of the approaches discussed above were criticized for their assumptions regarding the reinforcing qualities of particular kinds of behaviors and relationships (e.g., intense intimate interactions, altruism), one strength stemming from those assumptions is that they are likely to promote client exposure to novel ways of interacting, which the client may indeed find reinforcing.9 If, as is the case with the specific case conceptualization currently under discussion, the client is given the responsibility of identifying his or her own values and goals, then the therapist must be responsible for exposing the client to interpersonal contexts that will allow that client to make informed “choices” regarding his or her values and goals. 8 See, however, Weeks and colleagues (2011) for an example of an attempt to describe the application of FAP principles using concrete examples. 9 An obvious but important point related to this is that if there is a specific set of universal client values (e.g., intimacy) or a specific set of behaviors functional in all social communities, then a universal case conceptualization would be best if it directly incorporated them.
THE CHALLENGE OF DEVELOPING A UNIVERSAL CASE CONCEPTUALIZATION FOR FUNCTIONAL ANALYTIC PSYCHOTHERAPY
The third and most important limitation of the proposed universal conceptualization is that, while it focuses on interpersonal repertoires that are necessary (i.e., identifies repertoires that are universally required for a client’s successful functioning), these repertoires may not be universally sufficient for successful functioning. Many of the repertoires specifically targeted within the frameworks of the other possible universal case conceptualizations could be essential therapy targets for particular clients. For example, a client’s consistent engagement in experiential avoidance could consistently impair his or her interpersonal functioning, making this an important specific target on his or her case conceptualization. As a result, there is potential that this proposed universal case conceptualization may need to be supplemented by other approaches, preventing it too from being considered truly universal. While this case conceptualization has some important limitations (in particular, that it may not provide a case conceptualization sufficient for all clients), it does identify broad target repertoires essential for all clients. It also encourages therapists to appropriately address two key considerations in the development of a FAP case conceptualization: a client’s values and social community. As a result, it might best be considered a foundational framework for FAP case conceptualization that can assist therapists in their development of a functional, idiographic case conceptualization to guide their work with individual clients.
FURTHER CONSIDERATIONS AND CONCLUSIONS There are a number of issues related to the evaluation of possible universal case conceptualizations worth considering at this time. The first of these is a caution that individuals need to be aware of the influence of their values and social community on their evaluations of potential universal case conceptualizations. As noted by Tsai, Kohlenberg, Bolling, and Terry (2009), a therapist’s own learning history significantly impacts what he or she considers “good” or “effective.” Just as these variables influence a therapist’s assessment activities (Kanter et al., 2009), they are likely to influence any individual’s (including the present authors and the reader) evaluation of components of a universal case conceptualization. Thus, it is important for there to be a wide variety of individuals participating in any ongoing or future discussions of possible universal FAP client case conceptualizations. Related to this, clients should always be involved in the process of identifying their treatment targets (Kohlenberg & Tsai, 1991; Kanter et al., 2009). Just as therapists and FAP theorists are likely to display wide variety in their evaluation of possible treatment targets, so too will clients display this type of variety. A client will likely have his or her own unique values and goals as well as a unique language for talking about those values and goals. Moreover, a client’s ideas about treatment targets are especially likely to initially differ from a FAP therapist’s given that the client may have had no prior exposure to psychotherapy and, more specifically, a behavior analytic approach to psychotherapy. As a result, it is important to gain a client’s fully in-
formed consent to the therapist’s treatment plan, particularly if it is based upon a “universal” case conceptualization.10 A final issue worth considering is the possibility that there are relatively specific case conceptualizations specially suited for use with particular client populations (i.e., universal case conceptualizations for specific client populations).11 Consider as an example clients who meet diagnostic criteria for Asperger’s Syndrome, a pervasive developmental disorder characterized by significant deficits in interpersonal functioning (American Psychiatric Association, 2000). It is possible that there is a set of relatively specific repertoires (e.g., showing interest by attending to and directly responding to the communications of others, discriminating one’s impact on others in the moment) that should always be targeted in these clients. Further consideration of the appropriateness12 and feasibility of population-specific conceptualizations is prevented by present space limitations, but future discussion of universal case conceptualizations and development of FAP interventions targeting specific client populations should pursue this possibility further. This serves as one final reminder of the primary function of the case conceptualization, namely, guiding therapist contingent responding to client behavior. The case conceptualization is an essential part of FAP, and it must be accurate enough to usefully contribute to successful therapy. Given its importance, much time is often spent in the process of FAP assessment (see Kanter et al., 2009). Because of this, development of a universal case conceptualization would have the primary benefit of the more efficient assessment of client functioning (in addition to the benefit of better outcomes for clients), making this an important topic for future discussion. In conclusion, while the possibility of a universal client case conceptualization is a novel consideration, the issues related to it (a client’s values and social community) have been discussed since the earliest of FAP writings (cf. Kohlenberg & Tsai, 1991). It is very likely that the discussion of all of these issues will continue for some time. Currently, it is concluded that a universal FAP client case conceptualization is theoretically plausible. However, because FAP involves the functional idiographic application of behavioral principles, the identification of a truly universal FAP case conceptualization will continue to be extremely difficult (and may even be impossible). The difficulty of this task has been demonstrated by the present failure to identify a truly universal case conceptualization. Despite the generally negative results of the above consideration of possible universal FAP case conceptualizations, the present evaluation of various possible approaches has been fruitful in its identification of what is best thought of as a foundational framework for FAP case conceptualization. Overall, it is hoped that the present paper will spark continued theoretical debate on this important topic. Not only that, it is hoped that these discussions can serve 10 During this process therapists are cautioned to consider whether a particular client is especially deferential to the expressed wishes of others (e.g., because of a cultural heritage). In such a case, a client’s verbal agreement to a presented treatment plan may not actually represent informed consent as it is typically defined. 11 For specific discussions of the application of FAP with a wide variety of client populations, see Kanter, Tsai, & Kohlenberg (2010). 12 Particularly given the behavioral foundations of FAP, which emphasize building functional repertoires rather than reducing psychopathology (see Follette et al., 2001).
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as the starting point for an empirical investigation of the utility of this foundational framework for FAP client case conceptualization and, more generally, the potential for a truly universal FAP client case conceptualization.
REFERENCES American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th Ed., Text Rev.). Washington, D. C.: American Psychiatric Association. American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073. DOI:10.1037/0003066X57121060 Bonow, J. T., & Follette, W. C. (2009). Beyond values clarification: Addressing client values in clinical behavior analysis. The Behavior Analyst, 32, 69-84. Callaghan, G. M. (2006). The functional idiographic assessment template (FIAT) system: For use with interpersonally-based interventions including functional analytic psychotherapy (FAP) and FAP-enhanced treatments. The Behavior Analyst Today, 7, 357-398. Retrieved from http://www.baojournal.com/BAT%20Journal/BATJournals-2009.html Follette, W. C., Linnerooth, P. J. N., & Ruckstuhl, L. E. (2001). Positive psychology: A clinical behavior analytic perspective. Journal of Humanistic Psychology, 41, 102-134. DOI: 10.1177/0022167801411007 Hayes, S. C. (Ed.). (1989). Rule-governed behavior: Cognition, contingencies, and instructional control. Reno, NV: Context Press. Kanter, J. W., Tsai, M., & Kohlenberg, R. J. (Eds.). (2010). The practice of functional analytic psychotherapy. New York, NY: Springer. DOI:10.1007/9781441958303 Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: A guide for creating intense and curative therapeutic relationships. New York: Plenum. Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C. R., & Tsai, M. (2002). Enhancing cognitive therapy for depression with functional analytic psychotherapy: Treatment guidelines and empirical findings. Cognitive and Behavioral Practice, 9, 213-229. DOI:10.1016/S1077722902800517 Leigland, S. (2005). Variables of which values are a function. The Behavior Analyst, 28, 133-142. Skinner, B. F. (1945). The operational analysis of psychological terms. Psychological Review, 52, 270-277. DOI:10.1037/h0062535 Skinner, B. F. (1957). Verbal behavior. New York: Appleton-Century-Crofts. DOI:10.1037/11256000 Skinner, B. F. (1969). Contingencies of reinforcement: A theoretical analysis. New York: Appleton-Century-Crofts.
Skinner, B. F. (1971). Beyond freedom and dignity. Indianapolis, IN: Hackett Publishing Company. Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B., Follette, W. C., & Callaghan, G. M. (Eds.). (2009). A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism. New York: Springer. DOI:10.1007/9780387097879 Tsai, M., Callaghan, G. M., Kohlenberg, R. J., Follette, W. C., & Darrow, S. M. (2009). Supervision and therapist self-development. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. C. Follette, & G. M. Callaghan (Eds.), A guide to functional analytic psychotherapy: Awareness, courage, love and behaviorism in the therapeutic relationship (pp. 167-198). New York: Springer. DOI:10.1007/97803870978798 Tsai, M., Kohlenberg, R. J., Bolling, M. Y., & Terry, C. (2009). Values in therapy and green FAP. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. C. Follette, & G. M. Callaghan (Eds.), A guide to functional analytic psychotherapy: Awareness, courage, love and behaviorism in the therapeutic relationship (pp. 199-212). New York: Springer. DOI:10.1007/97803870978799 Weeks, C. E., Kanter, J. W., Bonow, J. T., Landes, S. J., & Busch, A. M. (2011). Translating the theoretical into practical: A logical framework for functional analytic psychotherapy interactions for research, training, and clinical purposes. Behavior Modification. Advanced online publication. DOI:10.1177/0145445511422830
AUTHOR CONTACT INFORMATION: JORDAN T. BONOW
Department of Psychology/298 University of Nevada, Reno Reno, NV 89557
[email protected] ALEXANDROS MARAGAKIS
Department of Psychology/298 University of Nevada, Reno Reno, NV 89557
[email protected] WILLIAM C. FOLLETTE
Department of Psychology/298 University of Nevada, Reno Reno, NV 89557
[email protected]
INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Interpersonal Mindfulness Informed by Functional Analytic Psychotherapy: Findings from a Pilot Randomized Trial Sarah Bowen, Kevin Haworth, Joel Grow, Mavis Tsai, and Robert Kohlenberg University of Washington Abstract Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991) aims to improve interpersonal relationships through skills intended to increase closeness and connection. The current trial assessed a brief mindfulness-based intervention informed by FAP, in which an interpersonal element was added to a traditional intrapersonal mindfulness practice. Undergraduate students (N=104) were randomly assigned to a basic intrapersonal meditation, the same meditation with the addition of a FAP-informed interpersonally-based exercise, or a control group. Follow-up assessments were given at post-intervention, and 48 hours and 2 weeks. Results indicated that for those in the interpersonal group, self-reported connectedness with others in the room increased, and experiential avoidance decreased. However, there were no significant changes in general connectedness with others, mindfulness or intimacy. Future studies might increase the length and depth of this intervention, and assess clinical benefits of adding an interpersonal element to mindfulness-based interventions.
Keywords mindfulness, meditation, interpersonal, functional analytic psychotherapy, experiential avoidance, relationship, intimacy
T
he literature of the past decade has seen a dramatic increase of studies on clinical benefits of mindfulness practice (Chiesa & Serretti, 2009, 2011; Zgierska et al., 2009) in treating a range of psychological problems, including chronic pain (e.g., Kabat-Zinn, 1990), anxiety (e.g., Orsillo, Roemer, & Barlow, 2003; Hofmann, Sawyer, Witt, & Oh, 2010; Miller, Fletcher, & Kabat-Zinn, 1995), depressive relapse (e.g., Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000), and addictive behaviors (e.g., Bowen & Marlatt, 2009; Brewer, Bowen, Smith, Marlatt, & Potenza, 2010; Vieten, Astin, Buscemi, & Galloway, 2010). Although there are varied definitions and practices based on both historical and contemporary traditions, mindfulness has been described as, “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (KabatZinn, 1994). Meditation instructions typically involve sitting or walking in silence, either in group or individual settings, and attending to one’s own immediate, primarily intrapersonal, experience. The current pilot randomized trial assessed the feasibility and efficacy of a brief mindfulness-based intervention informed by Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et. al., 2009) in which an interpersonal element was added to traditional practice. FAP aims to improve interpersonal relationships through an experiential teaching of skills intended to increase closeness and connection with others. FAP focuses on interpersonal factors, positing that a major cause of psychopathology stems from problematic interpersonal relationships (e.g., Horowitz, 2004). One hindrance to improving closeness and connection is avoidance of openness and honesty in interactions with others. From a behavioral perspective, overcoming this avoidance often involves taking a risk by being more honest and open with others (Cor-
dova & Scott, 2001). Termed “courage” in the FAP literature, this risk taking creates the possibility of improved and more satisfying relationships (e. g. Reis & Shaver, 1988; Rubin, Hill, Peplau, & Dunkel-Schetter, 1980). FAP also seeks to increase awareness, which includes the ability to view interpersonal interactions from multiple perspectives, allowing new interpersonal skills to emerge. The present study used a two-phase intervention to evaluate a brief FAP-informed interpersonal meditation (FAP-IM). FAP-IM integrates intrapersonal mindfulness meditation practices, based on contemporary, secularized mindfulness practices used in therapies such as Mindfulness-Based Stress Reduction (Kabat-Zinn, 1990) and Mindfulness-Based Cognitive Therapy (Teasdale, et al., 2000), with Benson’s Relaxation Response (Benson, 1975). Although there is some variation in these practices and their foci, we will refer to here them as “traditional meditation.” Phase 1 of the current study focused primarily on breath meditation and relaxation techniques. Instructions included a body scan (becoming aware of physical sensations in the body), and attending to breath (noticing the sensations of the rising and falling of the chest or abdomen). Participants were instructed to notice internal and external stimuli, such as thoughts, feelings, bodily sensations, and sounds. It was suggested that, as best they could, they refrain from judgment, and allow experiences to naturally arise and pass, repeatedly returning attention to the chosen target when their attention wandered. For example, participants practiced bringing attention to the process of thinking. Rather than identifying with the content of thoughts, they were instructed to view them as leaves floating down a stream, observing them as they float in and out of awareness. If their attention was carried away by the content of a thought, they were 9
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instructed to notice the mind had wandered, allow their attention to remain with it for a moment, and then gently return their focus to the chosen focus. Based on a behavioral analysis of this process, Kohlenberg, Tsai, Kanter, & Parker (2009) concluded that this type of meditation can affect an individual’s awareness and shift it to include “being aware that you are aware.” In this process, the perception of a given stimulus shifts; in behavioral terms, its discriminative stimulus functions have been altered. If this type of awareness occurs during daily life, the altered stimulus control allows new behavior to occur in situations that have previously elicited a given habitual response. For example, an individual might have the thought, “I am stupid” and respond to its content. As a result of mindfulness training, the same thought might now evoke the realization that, “a thought is arising that is saying ‘I’m stupid.’” The stimulus has changed, providing an opportunity to respond differently. In everyday language, it places the individual in the position of responding to a situation as if it is simply a passing phenomenon, and not necessarily a reflection of the truth, thus providing an opportunity for new learning to occur. Roemer and Orsillo (2002) explain this process as an altering of habitual or automatic maladaptive patterns of behavior due to a shift in perspective that has been called “reperceiving” (Shapiro, Carlson, Astin, & Freedman, 2006) or “decentering” (Teasdale et al.,
2000). Kohlenberg and colleagues (2009) suggest that many of the clinical benefits of mindfulness are due to this process. Phase 2 consisted of FAP-informed instructions intended to bring awareness to the presence of others in the room, in much the same way that perception of thoughts, bodily sensations and sounds were the foci in Phase 1. Participants were guided through an exercise in which they were asked to focus on a close relationship in their life, and bring awareness to ways they tend to communicate in this relationship. They were then asked to expand their awareness to include the others in the room who were engaging in the same practice. They were asked to notice this awareness of others, and then return to focusing on their breath. This was presented as a back-and-forth iterative process, alternating between awareness of others in the room and awareness of inner stimuli. After about 5 minutes, they were given further instructions based on a behavioral cosmology (Tsai et al., 2009, pp 3-14) that describes present experience as being heavily influenced by past interactions with others, going back as far as infancy. Participants were asked to include in their awareness the fact that the others, like themselves, have histories that have shaped who they are and how they perceive themselves and the world. They were asked to contemplate the notion that their peers in the room, like themselves, all have had happiness, sorrow, failures and successes. The intention of this instruction was to facilitate the participants’ abilities to take on
Table 1. Participant Demographics by Condition
Control
Interpersonal
Intrapersonal
Total Sample
(n = 39)
(n = 34)
(n = 31)
(N = 104)
19.18 (.85)
20.44 (6.76)
19.13 (1.26)
19.58 (3.97)
Male
41.03% (16)
41.18% (14)
48.39% (15)
43.3% (45)
Female
58.97% (23)
58.82% (20)
51.61% (16)
56.7% (59)
46.15% (18)
44.12% (15)
51.61% (16)
47.1% (49)
African-American
0.00% (0)
2.94% (1)
6.45% (2)
2.9% (3)
Latino/a
7.69% (3)
5.88% (2)
6.45% (2)
6.7% (7)
Asian-American
28.21% (11)
38.24% (13)
32.26% (10)
32.7% (34)
Native American
2.56% (1)
0.00% (0)
0.00% (0)
1% (1)
Other
15.38% (6)
8.82% (3)
3.23% (1)
9.6% (10)
Single
64.10% (25)
64.71% (22)
64.52% (20)
64.4% (67)
In a Relationship
35.90% (14)
35.29% (12)
35.48% (11)
35.6% (37)
Yes
10.26% (4)
14.71% (5)
9.68% (3)
11.5% (19)
No
89.74% (35)
85.29% (29)
90.32% (28)
88.5% (92)
Yes
15.38% (6)
14.71% (5)
22.58% (7)
18.3% (19)
No
84.62% (33)
85.29% (29)
77.42% (24)
81.7% (85)
Age M (SD) Gender (Frequency)
Ethnicity (Frequency) Caucasian
Relationship Status
Mindfulness Experience Historical Experience
Current Experience
INTERPERSONAL MINDFULNESS INFORMED BY FUNCTIONAL ANALYTIC PSYCHOTHERAPY: FINDINGS FROM A PILOT RANDOMIZED TRIAL
the perspective of others, and to place themselves in the others’ shoes. This process, according to theory of mind (Flavell, 1999), accounts for such traits as empathy and compassion. In FAP, these latter are subsumed in the category of “love.” In the final part of phase 2, it was suggested to participants that everyone tends to have “comfort zones” when interacting with others that set the boundaries for openness and honesty, and that vary based on contextual factors (e.g., the person with whom they are interacting). Participants were asked to consider that relationships may improve and become more satisfying with increased openness, but that it often takes courage to step outside of habitual patterns of interaction. This “stepping outside” may be experienced as “risky;” thus many people tend to stay within their comfort zones. Participants were then asked to think about a particular relationship in their lives and what they might say to this person that would constitute a small step or a risk, i.e., something just outside of their comfort zone. The attention to context and “small steps” in this process is based on the behavioral principles of shaping and functional analysis. After approximately 5 minutes of participating in this contemplation, they were asked to return awareness to their breath for several minutes, and then to gradually allow their eyes to open, and, if they wished to do so, briefly speak (for about 30 seconds to a minute) to one another in small groups about the relationship they had thought about, and what “small step” they envisioned taking, acknowledging that speaking to the group might be a risk or step outside their comfort zone. This last step is based on the FAP principle that in-vivo practice of a target behavior, i.e., taking small risks, can have generalized clinical benefits in behavior outside of session. We hypothesized that participants in both the intrapersonal and interpersonal groups would have significantly higher scores on mindfulness as measured by the MAAS than those in the control group. We predicted that scores in the interpersonal group would be higher than both the intrapersonal and control groups on measures of social connectedness, intimacy, and post-intervention ratings of connectedness with others in the room. Finally, having participated in an imaginal rehearsal of interpersonal risk taking, and having interacted with others in the groups in a way that potentially challenged their comfort zones, we predicted that participants in the interpersonal group would score significantly lower than the intrapersonal and control groups on experiential avoidance as measured by the AAQ. Measures of positive and negative affect were included for exploratory purposes.
METHODS PARTICIPANTS Participants in the current study were undergraduate students (N=104), at least 18 years old, who were enrolled in a lower level psychology class at a major university. They were recruited through a departmental online posting board. All procedures were approved by the university Institutional Review Board. See Table 1 for a detailed description of participant characteristics.
PROCEDURE Participants signed up for one of several prescheduled time slots, with 6 to 11 participants included in each slot. Slots were then randomized to 1 of 3 treatment conditions: interpersonal, intrapersonal, or control. Conditions were balanced across time of day and day of the week. Participants were unaware of which condition the time slots represented when they arrived at the lab. They received up to 3 hours of course credit for their participation. Groups of 6 to 11 participants met a research assistant in the waiting room during the pre-established time slot. The research assistant then guided the group of participants to a nearby group room where they were checked in, seated, and provided with a consent form. Once formal consent was obtained, paper-andpencil baseline measures were administered. After completion of the baseline assessment, which lasted approximately 30 minutes, participants were introduced to the session interventionist and participated in 1 of the 3 conditions. Following the laboratory session, participants completed a post-course assessment, which lasted approximately 30 minutes, and were reminded of the upcoming web-based follow-up surveys. Follow-up assessments were administered online 48 hours and 2 weeks following the laboratory session. Participants were sent an email containing a website link to the follow-up assessment, designed to take less than 30 minutes to complete. INTERVENTIONS The intrapersonal and interpersonal groups both included Phase 1, described above, consisting of intrapersonally-based meditation instructions. Participants in the interpersonal group were then given Phase 2 instructions, in which they reflected on an interpersonal relationship, imagined taking a small step out of their comfort zones in communicating with this person, and then participated in a small group discussion about their experience. Participants assigned to the control group watched a 50-minute nature video on the topic of trees. MEASUREMENT A variety of assessments were used in the study to measure changes in connectedness, intimacy, acceptance, well-being and mindfulness among the three conditions. All assessments were completed at baseline, post-course, 48 hours and 2 weeks after the intervention unless otherwise noted. Descriptives. At baseline, participants provided demographic and background information such as age, gender, ethnicity and relationship status. The Mindfulness Experiences Questionnaire was used to assess past and current experience with mindfulness meditation. Affect. The Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) was used to monitor change in affect at all 4 assessment time points (baseline, post-course, 48 hour and 2 week follow-up). The PANAS consists of 20 emotion words: 10 positive (e.g. “proud”) and 10 negative (e.g. “nervous”). Participants rated their present experience of each emotion on a scale from 1 (“very slightly/not at all”) to 5 (“extremely”). The PANAS has strong psychometric properties and high reliability (Molloy, Pallant & Kantas, 2001). Reliability in the current study was alpha .82.
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12
Table 2. Means (SDs) on Assessment Measures at Four Time Points by Treatment Groups and Control Control (n = 39) Mean (SD)
Interpersonal (n = 34) Mean (SD)
Intrapersonal (n = 31) Mean (SD)
Total Sample (N = 104) Mean (SD)
Baseline
3.83 (.66)
3.77 (.71)
3.92 (.72)
3.84 (.69)
Post Course
3.84 (.69)
3.70 (.73)
3.89 (.83)
3.81 (.75)
48 Hour
3.85 (.73)
3.99 (.79)
4.13 (.68)
4.00 (.73)
Two Week
3.77 (.70)
4.12 (.99)
4.30 (.80)
4.04 (.85)
Baseline
5.20 (1.14)
4.61 (1.25)
5.12 (.96)
4.98 (1.15)
Post Course
5.20 (1.12)
4.98 (1.33)
5.28 (.99)
5.15 (1.15)
48 Hour
4.95 (1.12)
4.90 (1.16)
5.28 (.88)
5.05 (1.04)
Two Week
5.18 (1.08)
4.85 (1.26)
5.46 (.61)
5.14 (1.06)
Baseline
3.07 (.77)
3.13 (.69)
3.06 (.69)
3.09 (.72)
Post Course
2.96 (.88)
3.14 (.69)
3.10 (.82)
3.06 (.80)
48 Hour
3.16 (.86)
3.19 (.77)
3.15 (.82)
3.17 (.80)
Two Week
3.18 (.61)
3.09 (.69)
3.46 (.90)
3.22 (.73)
Baseline
2.06 (.69)
2.18 (.81)
2.05 (.74)
2.10 (.73)
Post Course
1.95 (.67)
1.81 (.72)
1.83 (.80)
1.87 (.72)
48 Hour
2.04 (.59)
2.04 (.75)
1.95 (.78)
2.01 (.71)
Two Week
2.07 (.61)
2.05 (.93)
1.97 (.89)
2.04 (.80)
Baseline
4.82 (.95)
4.30 (1.07)
4.62 (1.05)
4.59 (1.04)
48 Hour
4.25 (.90)
4.19 (1.32)
3.94 (1.22)
4.12 (1.16)
Two Week
4.36 (1.26)
4.21 (1.24)
4.66 (1.22)
4.39 (1.23)
Baseline
4.60 (.77)
4.35 (.83)
4.66 (.78)
4.53 (.80)
Post Course
4.71 (.72)
4.55 (.79)
4.70 (.75)
4.65 (.75)
48 Hour
4.45 (.85)
4.48 (.84)
4.54 (.83)
4.49 (.83)
Two Week
4.60 (.83)
4.41 (.98)
4.69 (.79)
4.56 (.87)
Baseline
3.21 (.76)
3.31 (1.00)
2.97 (.78)
3.17 (.85)
Post Course
3.35 (.83)
3.65 (.98)
3.17 (.92)
3.39 (.92)
MAASa
AAQb
PANAS
c
Positive
Negative
Intimacy Scale*
SCS
d
BMSSCSe**
MAAS = Mindfulness Attention Awareness Scale, b AAQ = Acceptance and Action Questionnaire, c PANAS = Positive and Negative Affect Schedule, d SCS-R = Social Connectedness Scale – Revised, e BMSSCS = Brief Mindfulness Study Social Connectedness Scale * The Intimacy Scale was not given at post course ** The BMSCS was only given at baseline and post course a
Experiential Avoidance. The Acceptance and Action Questionnaire
tion of or unwillingness to maintain contact with internal expe-
(AAQ-2, Bond et al., 2011) is a 10-item was used to measure
riences. Participants rate each statement (e.g., “I am in control
experiential avoidance, which can be defined as negative evalua-
of my life”) on a scale from 1 (“never true”) to 7 (“always true”).
INTERPERSONAL MINDFULNESS INFORMED BY FUNCTIONAL ANALYTIC PSYCHOTHERAPY: FINDINGS FROM A PILOT RANDOMIZED TRIAL
The AAQ-2 has strong psychometric and reliable properties (Bond et al., 2011). The current study demonstrated a high reliability (alpha = .89). Mindfulness. The Mindfulness Attention Awareness Scale (MAAS, Brown & Ryan, 2003) is a 15-item scale used to assess trait mindfulness, defined as an open or receptive awareness to present moment experiences. Participants rated the frequency of each mindfulness statement (e.g., “I find it difficult to stay focused on what’s happening in the present”) on a scale from 1 (“almost always”) to 6 (“almost never”). The MAAS has exhibited strong psychometric properties (MacKillop & Anderson, 2007), also demonstrated in the current study (alpha = .84). Intimacy. The two-part Intimacy Scale (Kanter, unpublished) was used to monitor change in intimacy as it relates to the participant and the “target person.” Part one includes a series of questions used to help the participant select the “target person” and provide background information on the relationship. Part 2 is comprised of 14 items related to the intimacy between the participant and the “target person.” Participants rated intimacy items (e.g., “I expressed loving, caring feelings toward this person”) on a scale from 0 (“not at all”) to 6 (“completely”) based upon interactions with the “target person” in a given time frame (e.g., past 48 hours). The scale demonstrated high reliability in the current study (alpha = .82). Connectedness. Two versions of a social connectedness scale were used. The Social Connectedness Scale – Revised is a 20-item scale assessing a person’s feelings of connectedness to society as a whole. Participants rated statements (e.g., “I feel comfortable in the presence of strangers”) on a scale from 1 (“strongly disagree) to 6 (“strongly agree”). SCS-R has demonstrated high reliably and has strong psychometric qualities (SCS-R, Lee, Draper & Lee, 2001). The scale demonstrated high reliability in the current study (alpha = .91). The Brief Mindfulness Study Social Connectedness Scale (BMSSCS) is a 14-item scale that examines connectedness to the other participants in the room. It was derived from the Campus Connectedness Scale (CCS, Lee, Draper & Lee, 2001), modifying the CCS items to relate to “in room” experiences, rather than experiences of campus life. Participants rated statements (e.g., “I can relate to other people in this room”) on a scale from 1 (“strongly disagree) to 6 (“strongly agree”). The BMSCS also demonstrated high reliability in the current study (alpha = .89). On the Single Item Connectedness Scale (SICS, Kohlenberg, unpublished) participants rated one question, “How connected do you feel to others in the room?” on a scale ranging from 0 (“not at all”) to 6 (“completely”). The SICS was administered at baseline and post-course. Manipulation check. The manipulation check was administered post-intervention, and consisted of a single item (“To what extent do you feel were you engaged in the session’s activities?”) and was asked at post-course. DATA ANALYSES Descriptive analyses were conducted to assess demographic characteristics of the sample. Baseline differences on key demographic and outcome variables were assessed using independent sample t-tests. ANCOVAS were used to assess differences
between groups at the post-intervention and follow-up time points on connectedness, mindfulness, intimacy, positive and negative affect, and experiential avoidance, with baseline levels of outcome variables covaried. Where omnibus tests were significant, post hoc multiple comparisons were used to determine between which groups the significant differences occurred. Only cases with complete data for the relevant time points were included in analyses. All analyses were conducted using SPSS 16.0.
RESULTS Sixty-nine participants completed 48-hour follow-up assessment, and 54 participants completed the final 2-week followup assessment. Forty-two participants completed all phases of the study. Tests for outliers and normality of distributions for primary variables of interest showed all variables were in the acceptable range. Comparisons between groups revealed no significant differences at baseline on key demographic or primary outcome variables, with the exception of a trend towards baseline differences on the Intimacy Scale F(2, 99)=2.36, p=.099. Tukey HSD test revealed a trend (p = .082) towards higher scores in the control (M=4.82, SD=.945) versus the interpersonal group (M=4.30, SD=1.07). As a conservative measure, this variable was covaried in all subsequent analyses. Omnibus tests revealed significant between-group differences on measures of connectedness and experiential avoidance. Significant differences were found on the single-item postcourse measure of connectedness, F(2.97) = 5.34, p = .006. Specifically, post hoc Tukey HSD test revealed differences between control and both the intrapersonal (p = .018) and interpersonal group (p = .003). Significant differences were found on the AAQ at post-intervention, F(2, 97) = 5.65, p = 005, specifically between the control and interpersonal group (p = .001). Between group differences remained significant at the 48-hour follow-up F(2, 61) = 4.67, p = .013, with differences maintained between the control and interpersonal group (p = .031). Although trending towards significance, significant differences were not retained at the 2-week follow-up (p = .068). No significant between-group differences were found on follow-up measures of Intimacy, Mindfulness or Social Connectedness (see Table 2 for means on all outcome variables).
DISCUSSION The current study was designed to develop and test a brief interpersonally-informed mindfulness-based intervention intended to improve communication and intimacy in primary relationships by reducing interpersonal risk avoidance and expanding participants’ interpersonal boundaries. Contrary to hypotheses, results did not reveal significant between-group differences in mindfulness as measured by the MAAS, nor for measures of social connectedness or intimacy. However, post-intervention ratings on the self-report assessment of connectedness to others in the room were significantly higher for both the intra- and interpersonal groups as compared to the control group. Additionally, the control and interpersonal groups differed significantly
13
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BOWEN, HAWORTH, GROW, TSAI, & KOHLENBERG
on AAQ at post-intervention and 48-hour follow-up, with the interpersonal group scoring lower on experiential avoidance. The lack of between-group differences on measures of mindfulness, social connectedness and intimacy may be due to the brevity of the intervention. Lengthening the intervention or providing multiple sessions might allow participants more extensive in-session practice, and provide opportunities and support to practice outside of session. Reports of connectedness to others in the room were significantly higher for participants in both intra- and interpersonal groups as compared to those in the control group. Although participants in the intrapersonal group did not engage with one another in the same fashion as those in the interpersonal group, having an intrapersonally-based experience in the company of others may increase a sense of connectedness with them, even if there is no interpersonal interaction, per se. The significant between-group differences in experiential avoidance between the interpersonal and control groups might be reflective of either the imaginal interpersonal risk-taking in Phase 2 of the intervention, or of the group discussions wherein participants took in-vivo risks with their peers by sharing their experiences. Future studies would benefit by isolating and testing these components separately to determine if either is predicting changes in avoidance. The current study has several limitations to consider. First, baseline and post-intervention measures were given in person via paper-and-pencil administration, whereas the follow-up measures were given online. Although research suggests these methods yield similar outcomes (Fouladi, 2002), consistency in administration would limit potential confounds. Secondly, because the sample was drawn from non-treatment seeking undergraduate students, who may differ in important ways from the population at large, findings may not generalize to other populations. Future research utilizing this intervention design with larger and diverse samples is warranted. Despite the limitations and its pilot nature, the current study offers a novel contribution to the literature. Although research on meditation has included a focus on several intrapersonal practices and outcomes, only a handful of studies have included a focus on interpersonal practices and factors. For example, Carson, Gil, & Baucom (2004) taught meditation practices in a couples context, and Cohen and Miller (2009) included interpersonal awareness and dyadic interactions in a study of a cohort of clinical psychology graduate students. In both cases, the training was far more extensive than the one-hour FAP-IM in the current study, exceeding 20 hours of mindfulness training. Further, research suggests that traditional intrapersonal meditation alone is related to improved interpersonal functioning (Barnes, Brown, Krusemark, Campbell, & Rogge, 2007; Block-Lerner, Adair, Plumb, Rhatigan, & Orsillo, 2007; Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008; Wachs & Cordova, 2007). Finally, it is of interest to note that the Buddhist practice of Insight Dialogue (Kramer, 2007) combines standard intrapersonal meditation with mindful engagement in dialogue with others, although the methods of Insight Dialogue are not intended to be a clinical treatment; instead they are taught in the context of a spiritual path cultivating wisdom and compassion.
Future studies might assess whether increasing the length and depth of the current intervention would yield positive effects on mindfulness, intimacy and connectedness, and lead to a long-term decrease in experiential avoidance. Similarly, future research on mindfulness-based interventions might assess clinical benefits of adding an interpersonal element to an intrapersonally-based meditation protocol. Although the study of interpersonally-based mindfulness interventions is in its early stages, the decreases in experiential avoidance following a one-hour intervention suggests potential for brief interpersonal mindfulness interventions to affect the willingness of individuals to engage in behaviors that may lead to more satisfying intraand interpersonal experiences.
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INTERPERSONAL MINDFULNESS INFORMED BY FUNCTIONAL ANALYTIC PSYCHOTHERAPY: FINDINGS FROM A PILOT RANDOMIZED TRIAL Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulnessbased therapy on anxiety and depression: A meta-analytic review. Journal Of Consulting And Clinical Psychology, 78(2), 169-183. doi:10.1037/a0018555 Horowitz, L. M. (2004). Interpersonal foundations of psychopathology. Washington, DC: American Psychological Association. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York: Dell. Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. Kanter, J. W. (2011). The FAP Intimacy Scale. Unpublished document. University of Wisconsin-Milwaukee. Kohlenberg, R. J. (2011). Single Item Connectedness Scale. Unpublished document. University of Washington. Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press. Kohlenberg, R. J., Tsai, M., Kanter, J. W., & Parker, C. R. (2009). Self and mindfulness. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. C. Follette & G. M. Callaghan (Eds.), A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism. (pp. 103-130). New York, NY US: Springer Science + Business Media. Kramer, G. (2007). Insight Dialogue. Boston: Shambhala. Lee, R. M., Draper, M., & Lee, S. (2001). Social connectedness, dysfunctional interpersonal behaviors, and psychological distress: Testing a mediator model. Journal of Counseling Psychology, 48(3), 310-318. doi:10.1037/0022-0167.48.3.310 MacKillop, J., & Anderson, E. (2007). Further Psychometric Validation of the Mindful Attention Awareness Scale (MAAS). Journal of Psychopathology and Behavioral Assessment, 29(4), 289-293. doi:10.1007/s10862-007-9045-1 Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17(3), 192-200. doi:10.1016/0163-8343(95)00025-M Molloy, G. N., Pallant, J. F., & Kantas, A. (2001). A psychometric comparison of the positive and negative affect schedule across age and sex. Psychological Reports, 88(3 Pt 1), 861-862. Orsillo, S. M., Roemer, L., & Barlow, D. H. (2003). Integrating Acceptance and Mindfulness Into Existing Cognitive-Behavioral Treatment for GAD: A Case Study. Cognitive and Behavioral Practice, 10(3), 222-230. doi:10.1016/S10777229(03)80034-2 Reis, H. T., & Shaver, P. (1988). Intimacy as an interpersonal process. In S. Duck, D. F. Hay, S. E. Hobfoll, W. Ickes & B. M. Montgomery (Eds.), Handbook of personal relationships: Theory, research and interventions. (pp. 367-389). Oxford England: John Wiley & Sons. Roemer, L., & Orsillo, S. M. (2002). Expanding Our Conceptualization of and Treatment for Generalized Anxiety Disorder: Integrating Mindfulness/Acceptance-Based Approaches With Existing Cognitive-Behavioral Models. Clinical Psychology: Science and Practice, 9(1), 54. doi:10.1093/clipsy.9.1.54 Rubin, Z., Hill, C. T., Peplau, L. A., & Dunkel-Schetter, C. (1980). Self-disclosure in dating couples: Sex roles and the ethic of openness. Journal of Marriage & the Family, 42(2), 305-317. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 63(3), 373-86. doi:10.1002/ jclp.20237 Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of Relapse/Recurrence in Major Depression by Mind-
fulness-Based Cognitive Therapy. Journal of Consulting and Clinical Psychology, 68(4), 615-623. doi:10.1037/0022-006X.68.4.615 Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B., Follette, W. C., & Callaghan, G. M. (2009). A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism. New York, NY US: Springer Science + Business Media. Vieten, C., Astin, J. A., Buscemi, R., & Galloway, G. P. (2010). Development of an acceptance-based coping intervention for alcohol dependence relapse prevention. Substance Abuse, 31(2), 108-116. doi:10.1080/08897071003641594 Wachs, K., & Cordova, J. V. (2007). Mindful relating: Exploring mindfulness and emotion repertoires in intimate relationships. Journal of Marital and Family Therapy, 33(4), 464-481. doi:10.1111/j.1752-0606.2007.00032.x Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology, 54(6), 1063-70. doi:10.1037/0022-3514.54.6.1063 Zgierska, A., Rabago, D., Kushner, K., Chawla, N., Marlatt, A., & Koehler, R. (2009). Mindfulness meditation for substance use disorders: A systematic review. Substance Abuse, 30(4), 266-294.
AUTHOR CONTACT INFORMATION: SARAH BOWEN, PHD
Center for the Study of Health and Risk Behaviors - Department of Psychiatry University of Washington Box 354944, 1100 NE 45th St, Suite 300 Seattle WA 98105 USA
[email protected], phone: 206-685-2995 JOEL GROW, MS
Center for the Study of Health and Risk Behaviors University of Washington 1100 NE 45th St, Suite 300 Seattle, WA 98105
[email protected] KEVIN HAWORTH, B.A., B.S.
Department of Psychology 351629 University of Washington Seattle, WA 98195
[email protected], phone: 206-321-5331 MAVIS TSAI, PH.D.
Independent Practice and University of Washington 3245 Fairview Ave. East, Suite 301, Seattle WA 98102.
[email protected] 206-322-1067 ROBERT J. KOHLENBERG, PH.D., ABPP
Department of Psychology 351629 University of Washington Seattle, WA 98195 Voice- 206-543-9898
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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
An Empirical Model of Body Image Disturbance Using Behavioral Principles found in Functional Analytic Psychotherapy and Acceptance and Commitment Therapy Glenn M. Callaghan1, Julissa A. Duenas1, Sarah E. Nadeau1, Sabrina M. Darrow2, Jessica Van der Merwe1, & Jennifer Misko1 1 San José State University & 2University of California San Francisco Abstract The literature examining body image disturbance and Body Dysmorphic Disorder (BDD) is fraught with competing theoretical constructions of the etiology and nosology of these problems. Recent studies on various forms of psychopathology suggest that intrapersonal processes, including experiential avoidance, and interpersonal processes such as difficulties identifying and expressing emotions with others, correlate with higher levels of psychopathology. The present study aimed to investigate the relationship of body image disturbance and diagnosable BDD to the contemporary behavioral variables of experiential avoidance and interpersonal expression of affect. A large sample of participants including those who are diagnosable with BDD were examined. Results indicate that both intrapersonal and interpersonal variables are significant predictors of both body image disturbance in a large population and of BDD as a subsample and that these variables may be important targets for treatment. This principle-based conceptualization has parsimony and potential utility for clinical interventions of these problems. Implications are discussed for the use of contemporary behavioral treatments such as Functional Analytic Psychotherapy and Acceptance and Commitment Therapy to address both body image disturbance and BDD.
Keywords Body image disturbance, body dysmorphic disorder, Functional Analytic Psychotherapy (FAP), Acceptance and Commitment Therapy (ACT), assessment
T
he concept of body image disturbance encompasses a variety of psychological factors including general body dissatisfaction, distressing emotions over one’s body image, overinvestment in one’s appearance, and poorer quality of life (Cash & Grasso, 2005; Cash, Phillips, Santos, & Hrabosky, 2004). Cash and colleagues (2004) propose that body image disturbance lies on a continuum where less severe negative body image can be considered body image dissatisfaction, while the extreme end of the continuum contains greater distress consistent with Body Dysmorphic Disorder (BDD). BDD is characterized by an excessive preoccupation with an imagined or slight physical defect leading to significant distress or impairment in functioning (American Psychiatric Association, 2000). According to the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000), BDD is present if these criteria are met and cannot be attributed to an eating or other psychological disorder. Aside from preoccupation and impairment in functioning, typical characteristics demonstrated by individuals suffering from BDD include concern about several body parts, high frequency of suicidal thoughts and attempts, and comorbidity with other disorders (Phillips, Menard, Fay, & Weisberg, 2005).
Prevalence rates for BDD have been examined for different populations and range from 0.7 to 1.1% in community samples (Faravelli et al., 1997; Otto, Wilhelm, Cohen, & Harlow, 2001; Phillips et al., 2005). College student samples have slightly higher rates (ranging from 4.8 -13%; Biby, 1998; Bohne et al., 2002; Cansever, Uzun, Donmez, & Ozsahin, 2003), and Phillips et al. (2005) found similarly elevated rates (13%) among psychiatric inpatients. The prevalence of BDD is likely higher but may be underreported for a variety of reasons including individual shame and hesitancy to seek treatment (Fuchs, 2002), seeking cosmetic procedures in an attempt to fix the perceived defects (Cansever et al., 2003), and misdiagnosis of other disorders (Zimmerman & Mattia, 1998; see Pavan et al., 2008, for a review). Because it is relatively common in the general population, researchers continue to investigate possible causal variables to further understand and treat both body image disturbance and BDD. CATEGORIZATION AND CONCEPTUALIZATION OF BDD The current DSM-IV-TR categorizes BDD as a somatoform disorder (APA, 2000; see Phillips et al., 2010, for a review of the history of BDD classification). Due to shared topographical characteristics (i.e., symptoms), there have been efforts to reclassify BDD with other disorders including mood and anxiety disorders (Toh, Russell, & Castle, 2009), as part of the Obsessive-Compulsive Disorders spectrum (McKay, Neziroglu, & Yaryura-Tobias, 1997; Phillips et al., 2010), and as an eating disorder (Grant &
This research was supported in part by a grant from the McNair Scholars Program at San José State University and a College of Social Sciences Foundation Research Grant. Dr Darrow was supported in part by NIH T32 MH018261 at the University of California, San Francisco.
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AN EMPIRICAL MODEL OF BODY IMAGE DISTURBANCE USING BEHAVIORAL PRINCIPLES
Phillips, 2004; Rosen & Ramirez, 1998). Additionally, the DSMIV-TR inclusion of Delusional Disorder, Somatic Type, as a psychotic variant of BDD has prompted research on comparisons of delusional versus nondelusional types of the disorder (Phillips, 2004; Phillips, Menard, Pagano, Fay, & Stout, 2006; Phillips et al., 2010). Thus, multiple arguments have been posed in the literature about how best to categorize or frame BDD. While there are merits to re-categorizing BDD, it is unclear this effort will serve to clarify its etiology or suggest appropriate intervention strategies. What results, then, is a nosological endeavor in typology without clinical application. It may be more useful to focus on psychological variables related to etiology and maintenance of body image disturbance. This paper describes a behavior analytic model of body image disturbance. An empirical test of the model is also reported. Inasmuch as BDD represents the more extreme end of the continuum of suffering, this same core conceptualization could be applied to less severe struggles with body image disturbance. This approach to understanding BDD and other less severe forms of suffering from a learning perspective should demonstrate improved treatment utility; understanding how behaviors are shaped and maintained in a social context provides a direct link to shaping more effective behavior in treatment. Within contemporary behavior analysis, there are two different approaches to understanding mental health: intrapersonal and interpersonal. However, there may be reason to include both of these conceptualizations in understanding body image disturbance. INTRAPERSONAL FACTORS Intrapersonal factors can include psychological processes such as cognitions and emotional experience. Much of the research on intrapersonal processes and body image has focused on the role of cognitive variables. This research has demonstrated a relationship between negative cognitive processes and body image disturbance (Altabe & Thompson, 1996; Jakatdar, Cash, & Engle, 2006).Veale et al. (1996) and Cash (2002) suggested that avoidant behaviors are used in response to distressing thoughts and feelings regarding body image. They describe these behavioral strategies as becoming negatively reinforced in that they temporarily reduce discomfort, though they often ultimately lead to greater distress. Additionally, Cash, Santos, and Williams (2005) found that individuals who engaged in avoidance coping strategies experienced higher degrees of body image disturbance, believed their appearance influenced their self-worth, and had poorer quality of life. As predicted by the researchers, those who showed alternative strategies, including acceptance, had a more positive body image and better quality of life. This understanding of the role of negative reinforcement in reducing distress is conceptually similar to constructions of ObsessiveCompulsive spectrum problems (e.g., Franklin & Foa, 2008) as well as Bulimia Nervosa (Hilbert & Tuschen-Caffier, 2007). These findings align with previous research suggesting that avoidant coping strategies exacerbate psychological struggles (Chawla & Ostafin, 2007; Neziroglu, Khemlani-Patel, & Veale, 2008; Rosen, Reiter, & Orosan, 1995). One principle-based understanding of avoidance of emotions and thoughts can be found in contemporary behavioral mod-
els of language and cognition (e.g., Hayes, Strosahl, & Wilson, 1999). From this perspective, the inability to experience these intrapersonal processes (e.g., distressing emotional states) leads to engaging in behaviors that attempt to get rid of or ignore them (Blackledge & Hayes, 2001). These strategies, while temporarily effective and negatively reinforced, often result in creating more problems for the person, and, hence, more suffering. That is, while the desire to escape or avoid an aversive emotion makes some sense, the ways to do that (e.g., leaving a relationship, using drugs or alcohol) are often only temporary solutions and simply add more distress (e.g., loneliness, substance abuse or dependence). On the other hand, learning to experience those events and abandoning attempts to control or eliminate thoughts and feelings provides an opportunity to lessen psychological suffering. In the case of body image disturbance and BDD, it can be argued that a person has distinct experiences such as aversive affect following self-evaluative statements (about one’s appearance) that then prompt attempts to escape or otherwise “neutralize” those intrapersonal events (for an analysis using relational frame theory as a model of developing and maintaining BDD, see Neziroglu et al., 2008). These attempts, however, do not decrease the rate of occurrence of those thoughts or feelings and may in fact increase them over time. The strategy of experiential avoidance becomes unworkable and can escalate into a variety of problematic behaviors. Acceptance and Commitment Therapy (ACT) is a contemporary behavioral therapy based on the idea that individuals commonly label their internal processes as aversive and make ineffective attempts to change them (Hayes, Strosahl, & Wilson, 1999). ACT assists individuals with realizing that experiential avoidance is ineffective and helps them to develop more effective ways of experiencing unpleasant internal processes through emotional acceptance and living in accordance with one’s values (Hayes et al., 1999). Thus, it appears that a behavioral conceptualization of body image disturbance should include intrapersonal factors. For an application of ACT with a broad set of problems related to body image dissatisfaction and disturbance see Pearson, Heffner, and Follette (2010). INTERPERSONAL FACTORS In addition to intrapersonal factors, the manner in which people engage others may also be an essential factor in understanding BDD and related problems. Several researchers point out the importance of examining body image disturbance in the context of interpersonal processes to further understand the variables that cause distress (Boyes, Fletcher, & Latner, 2007; Cash, Theriault, & Annis, 2004; Davison & McCabe, 2005; TantleffDunn & Gokee, 2002). Research has linked higher body image disturbance with higher levels of social withdrawal, increased reassurance seeking, increased concern for social approval, and increased sensitivity to rejection (Boyes, Fletcher, & Latner, 2007; Calogero, Park, Rahemtulla, & Williams, 2010; Cash et al., 2004). Behavioral processes within interpersonal reactions can explain these findings. For example, the frequency or manner in which a person seeks support or reassurance will impact the likelihood of receiving said support or other social reinforce-
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CALLAGHAN, DUENAS, NADEAU, DARROW, MERWE, & MISKO
ment. Similarly, if a person ineffectively expresses his or her emotions about body image concerns to another, he or she will likely not receive support or compassion, or more plainly, social reinforcement. This may then increase the concern the person has about his or her perceived defect and could even result in social isolation. In any case, interpersonal factors such as these can exacerbate aversive feelings and decrease the likelihood of seeking support or being socially engaged in the future. Interpersonally problematic repertoires have been addressed from a contemporary behavioral perspective using both basic operant and modern verbal behavior analyses (e.g., Follette, Naugle, & Callaghan, 1996). Problems identifying and expressing emotions may lead to ineffective social interactions and engaging in problematic behaviors that reduce the likelihood of attaining social reinforcement (Callaghan, 2006; Kohlenberg, Hayes, & Tsai, 1993). In contrast, an effective repertoire for expression of feelings helps individuals obtain social reinforcement in the form of getting their needs met and maintaining fulfilling relationships with others (Kohlenberg & Tsai, 1991). These ideas are realized in the behavioral therapy, Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; see also Kanter, Tsai, Kohlenberg, 2010; Tsai et al., 2009). FAP is an interpersonal-based approach rooted in behavior analytic theory that uses the therapeutic relationship to help develop more effective interpersonal skills. COMBINATION OF FACTORS While numerous studies support the idea that both intrapersonal and interpersonal processes play a role in body image disturbance, the literature is scant with empirical investigations of the integration of these factors and how they affect body image disturbance or BDD. One example of an empirical study of BDD that highlights the role of both interpersonal and intrapersonal factors can be found in Kelly, Walters, and Phillips (2010), who note the impact of both experiential and social factors on functional impairment. In their empirical research, Calogero and colleagues (2010) emphasized the importance of addressing interpersonal variables in the context of intrapersonal processes surrounding body image concerns. From a behavioral framework, there are advantages to assuming either an ACT approach for intrapersonal factors or a FAP perspective to focus on the interpersonal variables. Still, there are limitations to conceptualizations from either approach when used independently. The focus on intrapersonal factors such as experiential avoidance in ACT does not fully account for the impact this avoidance repertoire has on the individual’s interpersonal relationships with others (Callaghan, Gregg, Marx, Kohlenberg, & Gifford, 2004). Likewise, the therapist may unintentionally neglect problematic intrapersonal factors while focusing on interpersonal repertoire skills in FAP (Kohlenberg & Callaghan, 2010). The integration of intrapersonal and interpersonal conceptualizations is suggested as a more effective way of understanding body image disturbance and BDD. The present study investigated the relationship of intrapersonal and interpersonal factors in body image disturbance and Body Dysmorphic Disorder (BDD) using behavioral principles and assessment approaches from these contemporary therapies. Specifically, intrapersonal variables were assessed from an
experiential avoidance perspective as seen in ACT. Interpersonal variables were assessed examining the ability to identify and express emotions with other people consistent with FAP. It was hypothesized that higher levels of body image disturbance would be related to both (1) greater levels of experiential avoidance, and (2) increased difficulties in participants’ interpersonal expression of emotions with others. It was also predicted that experiential avoidance and problems with interpersonal expression of emotions would predict meeting criteria for being diagnosable with BDD as well as the severity of BDD symptomatology.
METHOD PARTICIPANTS A sample of convenience consisting of 544 undergraduate students at a diverse university participated in this study, which was conducted in classrooms on campus. The sample included 373 women and 171 men aged 18 to 52 years (M = 19.32, SD = 3.1). The participants identified themselves as White/Caucasian (n = 132; 24.3%); Asian (n = 186; 34.2%); Black/African-American (n = 29; 5.3%); Hispanic/Latino/Spanish (n = 105; 19.3%); American Indian (n = 1; 0.2%); Pacific Islander (n = 8; 1.5%); Other (n = 11; 2%); or multiple ethnicities (n = 72; 13.2%). All participants gave their informed consent before completing the questionnaire. Before data collection, this study received approval by a university Human Subjects Institutional Review Board. Participants received university course credit without any other compensation. This study was part of a larger research effort; see Callaghan, Lopez, Wong, Northcross, & Anderson (2011) for further methodological details. MATERIALS AND DEVICES Participants completed a questionnaire packet containing: (a) a brief demographic questionnaire; (b) the Functional Idiographic Assessment Template Questionnaire-E (FIAT-Q-E; Callaghan, 2006); (c) the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011); (d) the Body Image Disturbance Questionnaire (BIDQ; Cash et al., 2004); and (e) the Body Dysmorphic Disorder Questionnaire (BDDQ; Phillips, 2005). Participants who met criteria for and participated in the interview portion of the study were interviewed using the Body Dysmorphic Disorder Module for Adults (Phillips, 2005) and the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS; Phillips et al., 1997). Brief demographic questionnaire. A demographic questionnaire constructed by the researchers consisted of questions about the participants’ age, height, weight (used to calculate body mass index [BMI; Keys, Fidanza, Karvonen, Kimura, & Taylor, 1972]), gender, ethnicity, and past or current diagnosed eating disorders. Functional Idiographic Assessment Template Questionnaire-E (FIAT-Q-E).
The Functional Idiographic Assessment Template (FIAT; Callaghan, 2006) is an assessment system designed for use with FAP (Kohlenberg & Tsai, 1991). The FIAT organizes behavior into five classes that are often targets of change in FAP and other interpersonally based psychotherapies. Each of these five domains of responding is assessed using the corresponding subscales of the FIAT-Questionnaire. One of those subscales, the
AN EMPIRICAL MODEL OF BODY IMAGE DISTURBANCE USING BEHAVIORAL PRINCIPLES
FIAT-Q-E, assesses the expression of emotional experiences to others. While the FIAT-Q-E does have several items assessing a client’s ability to identify an emotional experience, the majority of items help determine how those emotions are expressed in the context of a variety of relationships. Respondents react to a series of 24 statements using a Likert scale consisting of six options ranging from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate higher levels of these problematic behaviors. Studies on the psychometric properties of the FIAT-Q and its subscales show promising data supporting the reliability and validity of this assessment. A reliability study using an ethnically diverse nonclinical sample of 619 participants demonstrated high internal consistency and good test-retest reliability for both the FIAT-Q’s overall assessment of interpersonal effectiveness and the FIAT-Q-E subscale (Gummeson, Callaghan, Weidman, Nzerem, & Kirby, 2004). In the current study, the internal consistency was also good (a = .83). Furthermore, convergent validity has been demonstrated for both the FIAT-Q and its subscales (Gummeson et al., 2004). Acceptance and Action Questionnaire-II (AAQ-II). The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) is based on the AAQ (Hayes et al., 2004). It was developed as a broad measure of experiential avoidance and psychological inflexibility, the proposed mechanism of change in ACT. These constructs include the need to control thoughts and emotions, avoidance of private experiences, and immobility in taking action (Hayes et al., 2004). The AAQ-II is predominantly a measure of a respondent’s ability to experience emotions and it does not focus on the interpersonal expression of those experiences to others. The AAQ-II consists of 10 items on a 7-point Likert scale ranging from 1 (never true) to 7 (always true). The measure can be scored so that higher scores indicate greater acceptance and action or, conversely, with higher scores indicating higher avoidance and psychological inflexibility (Hayes et al., 2004). This study used the latter scoring method where higher scores indicate greater levels of experiential avoidance or psychological inflexibility. In the preliminary study on the psychometric properties of the measure, the AAQ-II demonstrated good internal consistency ranging from .81 to .87 (Bond et al., 2011). In the current study, internal consistency was high (a = .87). Body Image Disturbance Questionnaire (BIDQ). The Body Image Disturbance Questionnaire (BIDQ) is a self-report measure developed to assess body image disturbance on a continuum including body image dissatisfaction, distress, and dysfunction (Cash & Grasso, 2005). It was derived from Phillips’ (2005) Body Dysmorphic Disorder Questionnaire (BDDQ), a clinical screening instrument used as an aid in diagnosing BDD (described in the following section). The BIDQ contains seven questions measuring preoccupation, distress, impairment in functioning, and behavioral avoidance in relation to body image. Each question contains a 5-point rating scale and is scored by calculating the mean of all seven questions (Cash & Grasso, 2005). In the main study on the psychometric properties of the BIDQ, Cash and colleagues (2004) found good internal consistency for both women and men (a = .89). They found that the BIDQ correlates with other measures of body image dissatisfaction, dysphoria,
and quality of life. Additionally, the BIDQ demonstrates good test-retest reliability (r = .88; Cash & Grasso, 2005). Overall, the BIDQ demonstrates adequate validity and reliability in measuring body image disturbance in nonclinical samples. Internal consistency in the present study was also good (a = .88). Body Dysmorphic Disorder Questionnaire (BDDQ). The Body Dysmorphic Disorder Questionnaire (BDDQ; Phillips, 2005) is a selfreport screening measure developed to determine whether a person meets DSM-IV-TR criteria for BDD. The BDDQ was used in the present study to help screen participants for interviews for the presence of BDD. The BDDQ uses a yes/no format to establish whether the respondent experiences a preoccupation with a perceived physical defect and whether the preoccupation causes distress or impairment in functioning. However, even if a respondent meets the criteria on the BDDQ, a faceto-face interview is necessary to make a diagnosis of BDD by visually confirming whether the perceived defect actually exists, whether the distress or impairment is significant, and to rule out the presence of an eating disorder (Phillips, 2005). Published psychometric data on the BDDQ is limited. Phillips and her colleagues have found the BDDQ has high sensitivity and specificity for BDD (Phillips, 2005). Overall, the BDDQ appears to be an acceptable screening measure to determine which participants to invite for an in-person interview. Body Dysmorphic Disorder Diagnostic Module for Adults. The Body Dysmorphic Disorder Diagnostic Module for Adults (Phillips, 2005) is a clinician-administered in-person interview developed to confirm the diagnosis of BDD in individuals whose self-report responses on the BDDQ indicate the possible presence of BDD. The BDD Diagnostic Module was used for the interview portion of this study. It is based on the DSM-IV-TR criteria for BDD and constructed in a format similar to that of the Structured Clinical Interview for DSM (First, Spitzer, Gibbon, & Williams, 1996). The DSM-IV-TR criteria are listed next to each question to determine if a criterion is met before continuing with the subsequent questions. An individual must have a preoccupation with an imagined physical defect to meet criterion A and significant distress or impairment to meet criterion B. In order to meet criterion C, the preoccupation must not be attributed to an eating disorder. Clinical judgment is necessary for this assessment, particularly when determining the presence of a real or imagined physical defect and whether the distress or impairment reported for criterion B is significant enough to meet threshold for a diagnosis. The BDD Diagnostic Module shows high inter-rater reliability (k = .96; Phillips, 2005). Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). Phillips and colleagues (1997) developed
the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) to measure BDD severity, based on the Yale-Brown Obsessive Compulsive Scale, a measure of Obsessive-Compulsive disorder (OCD) severity (Goodman et al., 1989). This measure was modified for BDD based on the similarities in behavioral patterns between BDD and OCD. The BDD-YBOCS is a measure of BDD symptom severity when a diagnosis is already established (Phillips et al., 1997). This semi-structured clinical interview contains 12 items assessing obsessive thoughts and behaviors, including
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resistance and control of thoughts, insight, and avoidance regarding a physical defect, during the past week (Phillips et al., 1997; Phillips, 2005). Each item’s score ranges from 0 to 4, with 0 indicating an absence of symptoms and 4 indicating severe symptoms. The sum of the 12 items indicates severity of symptoms, with scores over 20 indicating mild to moderately severe BDD, scores over 30 indicating moderate to severe BDD, and scores over 40 indicating very severe BDD (Phillips, 2005). In a psychometric study (Phillips et al., 1997), the BDD-YBOCS demonstrated good internal consistency (a = .80). Test-retest reliability was also high (r = .88), and inter-rater reliability was extremely high (r = .99). Additionally, the BDD-YBOCS is significantly correlated with global measures of severity of distress and demonstrates discriminant validity with measures of general psychopathology (Phillips et al., 1997). In the current study, the internal consistency was also good (a = 84.). PROCEDURES At least two experimenters were present at each session. Once an individual completed the questionnaire packet, a researcher checked the packet for completeness and quickly scored the BDDQ. Participants who answered “yes” to select questions met threshold criteria and were invited to the subsequent interview portion (Phillips, 2005). Those who did not meet criteria received proof of participation. Of those who met criteria using the BDDQ, participants whose primary concern was weight and were overweight (i.e., BMI > 25) were excluded from the interview portion. Participants who listed weight as the main concern but were not overweight according to the BMI scale were eligible for the interview. Interviews were conducted using the BDD Module for Adults and the BDD-YBOCS. In the interview, an evaluation was made to determine whether the areas of concern were imagined or disproportionate (e.g., concern of acne with no visible blemishes). At the end of the interview, the researcher answered any questions and debriefed participants. Eligible participants received proof of participation if applicable. To assess for imaginary or minimal defects required of a possible BDD diagnosis, a clinical psychologist instructed interviewers to visually examine participants and to focus the interview questions on the participants’ body part(s) of concern. Following each interview, research assistants discussed potentially diagnosable cases with the research team about the presence or absence of a perceived defect. In cases where the body part was not visible or could not be made visible easily and appropriately, the possible defect could not be verified, and the participant was not considered a BDD case. In situations where Table 1. Means, Standard Deviations, and Correlations Among Measures for all Participants Measures
n
M
SD
1
2
1. BIDQ
542
1.81
0.67
–
2. FIAT-Q-E
543
66.71
15.45
.38**
–
3. AAQ-II
544
29.58
10.55
.46**
.67**
3
–
Note: BIDQ = Body Image Disturbance Questionnaire; FIAT-Q-E = Functional Idiographic Assessment Template Questionnaire-E; AAQ-II = Acceptance and Action Questionnaire-II. **p < .001.
the defect was possible to visually verify, but was not perceptible to the interviewer, the defect was considered imaginary (i.e., a perceived defect). If the perceived defect was visible to the interviewer, it was judged minor if it was present but not severe (e.g., minimally noticeable scaring or acne). Throughout the study, interviewers discussed questionable cases with the clinical psychologist and research team to make final judgments about possible BDD cases. DATA ANALYSIS Analyses were conducted to examine the relationship between intra- and interpersonal factors and body image disturbance and BDD. First, basic correlations were run for the total sample and the subsample of those participants who met criteria for BDD to demonstrate the relationship between the variables of interest. A backward stepwise regression analysis was conducted on the total sample to demonstrate the ability of intraand interpersonal variables to predict body image disturbance. Next, a backward logistic regression analysis was conducted to determine which of these variables (FIAT-Q-E, AAQ-II) predicted a diagnosis of BDD. Finally, a backward regression analysis was run on the subsample of BDD cases to determine what variables predicted the severity of BDD symptomatology (BDD –YBOCS). To briefly explain, a logistic regression is a type of regression analysis that is used with dichotomous variables. In this study, scores on the AAQ-II and the FIAT-Q-E were entered into one equation to predict the dichotomous variable of meeting criteria for BDD (“yes” or “no”). In a backward stepwise regression, scales are eliminated one at a time and the model is retested for significance as each is removed, and the final model includes only those scales that are statistically significant.
RESULTS Eighty participants met screening criteria and participated in the interview. A total of 55 participants (42 females and 13 males) met criteria for a formal diagnosis of BDD (total prevalence for the sample was 10.1%). While the initial population was non-clinical, this subsample of 55 represents those who are diagnosable with BDD and, thus, can serve as an identified clinical population. The remaining interviewees were excluded from analysis as a BDD case on the basis of not meeting diagnostic criteria of BDD (n = 14), meeting criteria for or reporting a current eating disorder (n = 3), concerns of physical defects that could not be verified (n = 2), and presenting real (not imagTable 2. Means, Standard Deviations, and Correlations Among Measures for Participants Meeting BDD Diagnostic Criteria Measures
n
M
SD
1
2
1. BDD-YBOCS
55
20.64
6.25
–
2. FIAT-Q-E
55
74.12 12.75
.27*
–
3. AAQ-II
55
36.65 10.13
.26
.65**
3
–
Note: FIAT-Q-E = Functional Idiographic Assessment Template Questionnaire-E; AAQ-II = Acceptance and Action Questionnaire-II; BDD-YBOCS = Yale Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder. *p < .05; **p < .001.
AN EMPIRICAL MODEL OF BODY IMAGE DISTURBANCE USING BEHAVIORAL PRINCIPLES
Table 3. Summary of the Regression Analysis on body image disturbance (BIDQ) Variables
β
S.E.
Standardized β
t-value
p
AAQ-II
.023
.003
.367
7.152
.000
FIAT-Q-E
.006
.002
.135
2.623
.009
Note. BIDQ = Body Image Disturbance Questionnaire . FIAT-Q-E = Functional Idiographic Assessment Template Questionnaire-E. AAQ-II = Acceptance and Action Questionnaire-II.
ined) defects (e.g. scarring; n = 6). Data from these participants remained in the larger data set. RELATIONSHIP BETWEEN INTRA- AND INTERPERSONAL VARIABLES AND BODY IMAGE DISTURBANCE The means and standard deviations for these measures and their correlation coefficients are presented in Tables 1 and 2. In Table 1, it can be observed that, for all participants in the sample, there is a significant relationship between increased levels of body image disturbance (BIDQ) and both intrapersonal levels of avoidance (AAQ-II) and interpersonal expression of emotions with others (FIAT-Q-E). Table 2 shows that for the 55 participants diagnosable with BDD, increased levels of interpersonal expression problems (FIAT-Q-E) was significantly related to severity of BDD (BDD-YBOCS), while experiential avoidance (AAQ-II) was not. REGRESSION ANALYSES AND PREDICTION OF MEETING DIAGNOSTIC CRITERIA AND BDD SEVERITY A backward regression analysis on the ability of the AAQ-II and the FIAT-Q-E to predict body image distress revealed that both were statistically significant predictors, with the AAQ-II accounting for slightly more variance than the FIAT-Q-E. These results are presented in Table 3. These findings suggest that both intrapersonal and interpersonal variables contribute to and predict the level of severity of body image disturbance. A backward logistic regression examined whether the psychological variables of experiential avoidance or interpersonal problems with expression of emotions could predict meeting diagnostic criteria for BDD using a backward procedure with diagnosis of BDD (case or non-case; where “case” refers to meeting diagnostic criteria) as the outcome variable. Table 4 presents the results of this analysis. Only the AAQ-II significantly predicted that participants met diagnostic criteria for BDD. The final model was statistically significant, χ2 (1) = 25.76, p < .001, Nagelkerke R2 = .096. Overall the prediction success was 89.7%. These results indicate that higher levels of experiential avoidance predicted meeting diagnostic criteria of BDD, while problems in interpersonal expression of emotions did not. For the subsample of BDD cases, an additional backwards procedure regression analysis examined whether experiential avoidance or interpersonal problems with expression of emotions predicted severity of BDD symptomatology (BDD-
YBOCS). Table 5 presents the results of this analysis. In the final model, elimination of the AAQ-II left the FIAT-Q-E as the only significant predictor of BDD severity (b = .27, t = 2.0, p = .045). This indicates that difficulties in interpersonal expression of emotions were a significant predictor of BDD severity, while experiential avoidance was not.
DISCUSSION The present study examined the relationship between body image disturbance, experiential avoidance, and interpersonal expression of emotions. The basic correlation data support the hypothesis that there is a relationship between body image disturbance and intrapersonal experiential avoidance as well as interpersonal expression of emotions for all participants. However, when considering those meeting criteria for a diagnosis of BDD as a subsample, only interpersonal problems are related to increased severity of BDD symptoms. This suggests that while experiential avoidance is important in understanding body image disturbance, interpersonal problems are essential to consider in looking at both disturbance and more severe forms of suffering. The basic regression analysis also showed that higher body image disturbance for the entire sample is associated with both higher levels of experiential avoidance and problems with interpersonal expression of emotions. The present findings are consistent with previous research investigating the relationship between body image disturbance, the intrapersonal process of avoidance (Cash, 2002; Cash et al., 2005), and interpersonal processes (Cash, Theriault, & Annis, 2004). These data provide some initial support for understanding these problems with behavioral principles of negatively reinforced repertoires including both the escape and avoidance of intrapersonal experiences and the skill of interpersonal expression of affect in a social context. This theory-based and empirically supported perspective lends itself to a conceptualization of body image disturbance for non-clinical populations (i.e., those not diagnosed with BDD) not seen previously in the literature. At the more extreme end of the continuum of body image disturbance, 10% of participants met criteria for diagnosable Body Dysmorphic Disorder, a prevalence rate consistent with other reports in the literature (Biby, 1998; Bohne et al., 2002; Cansever, Uzun, Donmez, & Ozsahin, 2003). Experiential avoidance, based on scores on the AAQ-II, served as the only significant predictor for meeting the diagnostic criteria of BDD,
Table 4. Summary of the Logistic Regression Analysis on BDD Status Variables
β
S.E.
Wald
Odds Ratio
p
FIAT-Q-E
.011
.014
.617
1.011
.432
AAQ-II
.066
.013
25.001
1.068
95%. Approximately 10% of the parent report - OSs Observations were collected also in the presence of two researchers who registered the same IOA results, i.e., with agreement percentages ranging from 85% to 100%. Daily-life context behaviors data were measured as accurately as possible, although via parental report. The observed and reported behaviors, however, had been carefully operationalized in the weekly frequency sheet. About 10% of the OS observations were conducted in-vivo with the co-presence of two therapists, to verify the agreement between parental and professional observations. In these instances, as reported above, researcherparent agreement was satisfactory. Nonetheless, our choice to use two data collection procedures, one for directly observed behavior frequencies and the other for referred presence/absence of a given behavior represents one of the study’s main limits. The behavioral programs, developed from a FAP perspective, mostly consisted of providing opportunities for the participants to emit appropriate or inappropriate behavior, and by using verbal cues and prompts to direct them in some specific interactions. For examples, therapists could shape directly appropriate behavior in some contexts. Contingent responses of the thera-
pist, combined with prearranged social situations suitable for evoking CRBs, were the main mechanisms of change employed. In technical terms, the programs consisted in the setting up of directly present and verbally mediated reinforcements suitable for each participant, by analyzing and planning discriminative stimuli to be used during sessions to evoke CRB, promoting CRB2 and weakening CRB1 responses. Parallels were repeatedly made between in-session context and daily life(and vice-versa) as a relevant part of the intervention to extend the improvements from the center to the participants’ ecological setting. In addition to these specific procedures, participants also underwent both individual and group mindfulness training weekly. We implement multiple example strategies (MET - Multiple Exemplar Training) to obtained better stimulus control and a careful variation of contextual aspects, so as to allow for true autonomy. This meant previously inserting significant topographical differences in both discriminative stimuli and in general context aspects. These procedures helped foster participant learning and promote behaviors that were already partially or completely acquired, but more effectively so (Rehfeldt & Barnes, 2009). For example, the request for a participant to “open up more” emotionally and cope with emotional content he tends to avoid in a topographically various (but mostly inappropriate) way is repeated in different moments, in different contexts, and in different ways. For instance, the therapist’s contingent response to CRB2 for example, could consist in social reinforcement previously identified as being effective for that person. Moreover, FAP emphasizes the importance of using the most “natural” consequences possible to ensure more effective generalization and to exclude or limit the use of artificially provided reinforcers. The latter can sound “empty” for more verbally sophisticated participants and can therefore be ineffective (not actually serving as a reinforcer). Both the more recent and traditional literature suggest that broad-based and flexible repertoires are a fundamental pre-requisite for improving people’s quality of life and well-being. This occurred in our own study because part of the consequences of the participants’ behavior were social reinforcement (therapist approval); another part were directly provided in the environment (non-social); and lastly, one part of the consequences was social but not pre-arranged by researchers. For example, in asking a boy to ask the time of a passerby, part of the consequences of this action will be praise by the researcher present; one part will be dialogue with the passerby, who remains unaware of the program; and another still will be direct consequences of the action itself (in this instance, minimal). If we conversely ask a boy to go for a walk wearing a funny hat, the social consequences, therapists’ praise and encouragement, would not vary. Other social consequences would be provided by other passersby glancing at the boy and unaware he is implementing these behavioral strategies. Lastly, other consequences would be linked to the action itself. Providing an interactional history aimed to promote derived relational responses presents several advantages, as the creation of more ample and flexible repertoires than more traditional expositions. In most of the common trainings including variability is not a conscious therapist choice, but simply the result of a
PROMOTING APPROPRIATE BEHAVIOR IN DAILY LIFE CONTEXTS USING FUNCTIONAL ANALYTIC PSYCHOTHERAPY IN EARLY-ADOLESCENT CHILDREN
Figure 1. Experimental design
lack of operationalizaton of the variables, and, as consequence, leads to ineffective procedures. For example, directly planning MET training allows for the more rapid development of flexible verbal and direct contingency shaped repertoires which are therefore more quickly adaptable to new situations. Promoting appropriate responses with multiple exemplars of antecedents and by varying response topographies, inducing new but “similar” responses, as an effect of the emergence of DRR. These responses are selected by consequences, just as any other behav-
ior, with the exclusive but important advantage of leading to the emergence of more new responses. Special attention was dedicated to experiential-avoidance repertoires and to conversely promoting willingness strategies; the aim was to promote the emergence of more functional tacts and, more generally, more adaptive verbal descriptions, in relation to participants’ own internal experiences, easily measureable via self-report.
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Figure 2. Pre - Post probes Experimental design. Figure 1 suggests that the improvements in
CRB2s can effect the behaviors of the participants in daily life contexts. On the left are reported data on CRB2s, with a multiple baseline across subjects. The introduction of the independent variable seems to induce an emersion of CRB2s for all the participants. On the right we can see the Pre-Post Probes of the OS2s. For all participants, Pre-Probes were conducted in the baseline phase, and Post Probes after the end of the intervention. Pre - Post probes. Figure 2 shows the results of the Pre-Post probes - frequency of OS2s behaviors collected by parents of all the 5 participants (OS2s = appropriate social relevant behaviors in daily life contexts).
RESULTS The results showed a significant increase in identified prosocial behaviors implemented in the natural context (OS2). The anecdotal reports of parents, teachers, and participants themselves were consistent. In the baseline-phase session, none of the behaviors identified was emitted with a relevant frequency, but they were emitted with greater frequency during the intervention phase, indeed, with the emergence of in-session multiple behaviors. Obviously one of the reasons for the CRB2 increase observed during the entire treatment period could be due to a greater number of opportunities for emitting these behaviors, as outcomes of the process itself. The OS2 increase, not directly related to a specific in session training as CRBs, although less marked, was in any event relevant. In particular, participants 1, 2, and 3 demonstrated a significant increase in OS2, and the effect was smaller, though always present, for participants 4 and 5. They are older than other cli-
ents, and could be more difficult assess and provide relevant reinforcers for them and this can affect the efficacy of the whole treatment for these subjects. Further study are needed to focus on strategy to identify reinforcers for this population, according with developmental age studies. With respect to CRB, all participants showed an increase in socially relevant in-session behaviors (CRB2s), and demonstrated inappropriate behaviors such as emotional or experiential avoidance, aggressiveness, challenging behaviors, or escape (CRB1s) only rarely. The CRB2s frequency did not reach higher levels, as it was difficult to prearrange conditions for more than 3 to 5 meaningful activities in an hour of intervention.
DISCUSSION The graphic analysis seems to support how direct action on CRB2s can produce indirect modifications on OS2s, consistently with the FAP approach and knowledge gained from research in the field of derived relational responses - DRR (Tsai, Kohlemberg, Kanter et al, 2009; Rehfeldt & Barnes, 2009; Hayes, Strosahl & Wilson). A detailed explanation of the mechanisms implicated in these modifications goes beyond the scope of the present work. Although the study conducted with these procedures made it possible to control a certain amount of variability, we underscore that the study participants were already participating in some form of intervention, although mostly focused on school achievement problems. Indeed, the experimental design adopted allowed us to exclude that an intervention based on academic skills can be itself effective in diminishing dysfunctional behavior and promoting appropriate behavior in the participants selected. This type of design, and the characteristics of the Research Center in which the study was carried out, however,
PROMOTING APPROPRIATE BEHAVIOR IN DAILY LIFE CONTEXTS USING FUNCTIONAL ANALYTIC PSYCHOTHERAPY IN EARLY-ADOLESCENT CHILDREN
does not allow us to exclude the possibility that an intervenion based on promotions of academic skills represents an important prerequisite for achieving the results reported herein. In fact, the teacher-student relationship at the center is based on a high frequency of praise for desired behavior implemented during sessions (in general, mostly teaching sessions, and therefore not pertaining to the present experiment as mentioned previously). Although this type of interaction model cannot be defined in any way as a “therapeutic relationship”, it can represents a mechanism of change even though it appears incidental when compared to a FAP based approach, in which the therapist consciously, spontaneously and simultaneously provides a series of differential consequences for the various participants’ CRBs. Although numerous studies highlight the efficacy of positive reinforcement-based relational strategies in promoting various appropriate behavioral repertoires in teens and preteens (e.g., Levine, 2006), the role of this training may influencing the efficacy of a subsequent experimental intervention phase conducted with FAP procedures. The emission of a behavior that is appropriate but already in the repertoires of each specific participant also poses various questions that cannot properly be dealt with herein. On one hand, participants must be helped to face, acknowledge and modify their problematic behavior and to acquire more adaptive responses. On the other, appropriate behavior already in repertoire, although not subject to data collection, could have influenced the emission of new responses, as suggested by research on behavioral momentum (Nevin & Grace, 2000). Nonetheless, the experimental design used herein and the lack of data on the topic does not make further analyses possible, but the adequate social behaviors promoted by intervention were probably not completely new responses, and the effect of behavioral momentum probably could be negligible. Moreover, the emission of appropriate responses during intervention, although not to be underestimated, cannot alone be considered a significant result, but only in relation to variations in participants’ meaningful daily life repertories. Yet, the OS2s data collected via parent report does not satisfy the same scientific ABA criteria. The use of normative tests could in part obviate these problems, but selecting tests that are sufficiently sensitive to change and which can be re-administrated even after brief time periods is a complex challenge. We therefore opted to rely on behavioral (although parent report) frequency measures to gather the OS data. Further research could be conducted supplementing direct in-session CRB measures with daily life (OS) observed behavior measures of similar reliability. These results have to be interpreted with caution, but we think that could be interesting to continue in this direction, improving methods and data collection to better explain mechanism of change and to build more efficient treatment for preadolescents, a population usually less studied. For example, the therapists use mindfulness as an important part of the intervention with all the participants, to help them to reframing unpleasant events referring to values, with a verbal mediated exposure through interpersonal relationship. The researchers use mindfulness in a FAP-oriented way, but the impact of these procedure is not so easy to assess in whole package of this intervention.
Moreover, de-constructing the intervention “package” into its various components could represent a further step towards better understanding the process of significant behavioral change, and an important advancement toward the development of even more effective applicative forms of intervention to promote prosocial behavior in adolescents.
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AUTHORS INFORMATION ROBERTO CATTIVELLI, PHD
University of Parma – Fondazione Sospiro (CR - Italy)
[email protected] Via Gregorio X n. 34 – 29121 Piacenza PC - Italy
VALENTINA TIRELLI
University of Parma – Learning Centre TICE
[email protected] via Fratelli Bandiera, 30/B - 29015 Castel San Giovanni (PC) - Italy FEDERICA BERARDO, PHD
University of Parma – Learning Centre TICE
[email protected] via La Primogenita, 25 - 29122 - Piacenza (PC) Italy SILVIA PERINI, PHD
University of Parma -
[email protected] Borgo Carissimi, 10 - 43121 - Parma (PR) Italy
INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
An Example of a Hakomi Technique Adapted for Functional Analytic Psychotherapy Peter Collis University of Canberra Abstract Functional Analytic Psychotherapy (FAP) is a model of therapy that lends itself to integration with other therapy models. This paper aims to provide an example to assist others in assimilating techniques from other forms of therapy into FAP. A technique from the Hakomi Method is outlined and modified for FAP. As, on the whole, psychotherapy techniques are evocative; there is a potential menu of techniques to be drawn from in most therapists’ history.
Keywords Functional Analytic Psychotherapy, Hakomi, Integration
F
THE HAKOMI METHOD
unctional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991) is well positioned as an integrative model of psychotherapy through its focus on function rather than rigid adherence to technique (Kohlenberg & Tsai, 1994). Integration of a range of psychotherapy models with FAP has been previously discussed; this has included Psychodynamic approaches (Kohlenberg & Tsai, 1991; Kohlenberg & Tsai, 1994; Rosenfarb, 2010), Cognitive Behavioural Therapy (Kohlenberg & Tsai, 1991; Kohlenberg & Tsai, 1994; Kohlenberg, Kanter, Tsai, & Weeks, 2010), Acceptance and Commitment Therapy (Callaghan, Gregg, Marx, Kohlenberg, & Gifford, 2004; Baruch, Kanter, Busch, & Juskiewicz, 2009; Kohlenberg & Callaghan, 2010), Dialectical Behaviour Therapy (Waltz, Landes, & Holman, 2010) Behavioural Activation (Busch, Manos, Rusch, Bowe, & Kanter, 2010) and Feminist therapies (Terry, Bolling, Ruiz, & Brown, 2010). Rather than offer an integrated model, the purpose of this paper is to provide a clear and brief example of how a technique from another form of psychotherapy-- Hakomi (Kurtz, 1990), can be assimilated into FAP. It is likely that most practicing therapists have been exposed to a range of techniques through training and ongoing professional development. As FAP is a principle based therapy, techniques from other forms of psychotherapy can be used as long as they function to evoke clinically relevant behaviour and the therapist is positioned to be aware of this and reinforces client improvements in behaviour within the context of adhering to the other ‘rules’ of FAP, see below. The technique that will be outlined in this paper comes from the Hakomi Method. A brief overview of Hakomi and FAP will follow. Then a Hakomi intervention will be detailed and looked at including a transcript using the technique as a part of FAP. It is hoped that this stimulates the reader into considering what techniques they have learnt from other psychotherapy models that could be utilised within FAP.
Hakomi is a mindfulness based, body inclusive form of psychotherapy developed by Ron Kurtz in the mid 1970’s (Kurtz, 1990). Hakomi utilises mindfulness to explore current experience (thoughts, feelings, memories, sensations, urges, gestures, postures etc) as indicators of painful formative experiences and subsequent beliefs (Cole & Ladas-Gaskin, 2007). The word Hakomi is a Hopi Indian word and means ‘how do you stand in relation to the many realms?’ or more briefly ‘who are you?’ (Kurtz, 1990). The aim of the therapist is to provide a safe and caring relationship, to create experiments that evoke core material and to then provide therapeutic ‘missing experiences’ (Fisher, 2002). This is done to help shift beliefs and enable the client more healthy and effective ways of relating to themselves and their world.
FUNCTIONAL ANALYTIC PSYCHOTHERAPY (FAP) FAP is the application of radical behavioural principles to an interpersonal psychotherapy context. The primary mechanism that FAP claims to effect change is the therapist “providing natural reinforcement for client improvements that occur during the session” (Kohlenberg & Tsai, 1991, p.11). This is strategically done to ‘shape’ over time, a more effective interpersonal behavioural repertoire, that is then generalised to the clients daily life and relationships (Kohlenberg & Tsai, 1991). To assist in knowing what behaviour to reinforce in FAP, client in-session behaviour is broken down into three classes of clinically relevant behaviour (CRB). These are: in-session instances of daily life problems (CRB1); in-session instances of daily life improvements (CRB2); and client statements of functional relationships (CRB3). For a more in-depth look at CRB see Kohlenberg and Tsai (1991) or Kohlenberg, Tsai, & Kanter (2009). To assist therapists in identifying CRB, evoking CRB and in responding to CRB, FAP has five rules. These ‘rules’ are not to be adhered to as dogmatic musts, but serve as general guidelines for the therapist and the therapeutic intervention. These rules are as follows. 33
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THE RULES OF FAP (TSAI, KOHLENBERG, KANTER, & WALTZ, 2009) Rule 1: Watch for CRBs (Be Aware) This is seen as the essential ingredient for FAP, for to be able to reinforce CRB2’s, CRB needs to be defined and noticed. Basically this involves being aware of the clients daily life problems, in-session instances of the same problems, and in-session improvements on these problems. It is also hypothesised that if therapists are aware of CRB, they will automatically begin to reinforce CRB2’s. Rule 2: Evoke CRBs (Be Courageous) In addition to CRB that is naturally evoked within the therapeutic setting, it is suggested that the FAP therapist strategically evoke in-session instances of daily life problems (CRB1), or improvements on those (CRB2). This is done through a variety of means including the use of the relationship and therapeutic techniques. Rule 3: Reinforce CRB2s Naturally (Be Therapeutically Loving) When CRB2’s are evoked and/or noticed, central to the FAP approach is that these in-session instances of daily life problems are responded to in a way that increases their frequency over time. This involves contingently responding to CRB2’s in a way that is naturally reinforcing. Rule 4: Observe the Potentially Reinforcing Effects of Therapist Behaviour in Relation to Client CRB’s (Be Aware of One’s Impact) This rule involves the awareness of the impact of therapist behaviour on the client in the short term, and longer term. Ways to implement this rule include paying attention in the moment to how the client is responding, acquiring verbal or written feedback from the client, and observing the frequency of CRB2 over time. Rule 5: Provide Functional Analytically Informed Interpretations and Implement Generalisation Strategies (Interpret and Generalise) FAP takes the stance that certain types of therapist talk in session are useful. If clients have a functional understanding of what led to CRB in session, it increases the chances that they are able to generalise their CRB2 behaviour to daily life. A range of other generalisation strategies are used in FAP and are given as ‘homework’ to be undertaken by the client. In light of the above, any psychotherapeutic technique is potentially useful in FAP, provided it is in line with rule 2 above, and functions to evoke CRB from the client and the therapist is positioned to be aware of and shape improvements. The technique outlined below is likely to evoke CRB, and with a simple modification can be made more congruent with FAP.
A HAKOMI TECHNIQUE ADAPTED FOR FAP (ADAPTED FROM KURTZ, 1990 AND FISHER, 2002) One of a broad range of techniques used in Hakomi is a form of verbal experiment generally referred to as a ‘probe’ or sometimes more pleasantly as an ‘offering’ (Cole & Ladas-Gaskin, 2007). Basically these are simple positive statements, that are
used to evoke an experience connected to the clients core beliefs and history. For example for a client who is conveying that they believe they are not worthwhile a probe may be ”you are perfect just as you are”. As Kurtz (1990) puts it, “A probe is an experiment in mindfulness, an example of evoked experience… We take time to prepare. We set up mindfulness, introduce a stimulus and study the reaction” (p.91). Note that it is important that the therapist only offer statements that are based in reality and congruent with their true feelings about the client and the client’s issues (Kurtz, 1990). This technique is likely to evoke CRB but a simple change can make it more conducive to FAP. Hakomi advocates for avoiding using a first person statement as they do not focus on generating transference as part of the treatment (Kurtz, 1990). The change necessary to fit this technique more ‘neatly’ into a FAP session would be to modify the statement so that it is in the first person, to enable the relationship to be the focus, to actually encourage responses often referred to as transference, and to explore interpersonal reactions. The technique as a whole is an example of Rule 2 – Evoke CRB’s, though throughout the technique there are opportunities to use Rule 1 – Watch for CRB, Rule 3 – Naturally Reinforce CRB2’s, and Rule 4 Observe the Potentially Reinforcing Effects of Therapist Behaviour in Relation to Client CRB’s. Further, as CRB’s may be evoked that call for a shift in focus and response on the part of the therapist -- the technique is not to be adhered to rigidly. The FAP therapist should maintain an awareness of CRB so that they are able to shift away from the ‘probe’ (or other technique) and attend to the issues, from a FAP perspective, that are most relevant for the client in the moment. 1. Introduce the technique and see if you have consent
“I have an idea about how we could find out a little more information about what’s happening here. Instead of simply talking about it, how about we slow down a little and get clearer on what you are thinking, feeling and experiencing about this. I have an idea that I could say some words to you and we could notice how that lands on you…how you react” “What I am thinking I could say, the words I could use, are (for example) ‘I care about you’ or ‘you are important to me’”. This is a key point to pause as you may already be evoking CRB1’s or CRB2’s for the client and asking for consent and feedback may help to identify these. 2. Coach the client into mindfulness and wait till the client
is ready “So take a moment to close your eyes and notice what your experience is right now, just feel your breath for a moment, noticing the breath moving in…and out… (pause), notice what you are thinking (pause) feeling (pause) sensing (pause). Let me know, perhaps just raise a finger, when you are connected to your experience enough to hear the words”.
3. Deliver the probe
“So, just notice what you experience, it could be a
AN EXAMPLE OF A HAKOMI TECHNIQUE ADAPTED FOR FUNCTIONAL ANALYTIC PSYCHOTHERAPY
thought…a feeling…a sensation…an image…a memory…it doesn’t matter what happens, just so long as you are noticing. If nothing happens at all that’s okay too… Just notice what happens when you hear the words (pause) ‘John …(using the clients name tends to make the technique more evocative and pause as it allows the client a moment to sense their experience again) you are important to me’ (you can then repeat the statement as it tends to be more evocative) ‘John…you are important to me’”. In Hakomi the probe is usually delivered in a relatively neutral tone of voice, which from a FAP perspective may function to reduce the stimulus properties of the therapist, allowing for more ‘genuine’ expressions of the clients self, in line with Kohlenberg and Tsai’s (1991) commentary on the potential use of free association within FAP. 4. Get feedback
Notice what happens for the client, whatever that is. Often this technique will evoke strong and spontaneous emotions, thought processes, behavioural urges or memories. If there are no noticeable changes externally, you could prompt the client “what are you noticing, a thought, a feeling or something else?” Importantly, delivering a probe is unlikely to evoke a positive reaction in the client but will instead more often highlight barriers and limiting beliefs, areas of pain and suffering, and avoidance connected to the clients history and relationships (Fisher, 2001). As an example, a client might have a history of being told positive things by others (e.g. a parent) that are manipulative. A statement by the therapist such as ‘I’m here for you’ may evoke issues around trust and being manipulated, with the client reacting by having a thought like “you have to say that…I’m paying you”. From a FAP perspective there are many possible therapeutic opportunities with this, including whether the client brings up this issue (potential CRB2 of being open with the therapist) or do they question how does caring actually develop in the therapeutic relationship, or clarify whether is it the kind of caring that is important to them (potential CRB2’s of identification and expression of needs). Of course these are by no means all encompassing examples nor are they prescriptive as in FAP what is a CRB1 or a CRB2 is dependent on the client’s outside life problems (Kanter et al. 2009). Whilst this technique can be tailored to a wide range of issues, is worth mentioning for clients that are not assertive or fearful of revealing negative feelings, this technique can easily provide an environment in which these behaviours can be shaped, as illustrated in the transcript below. Following is a modified transcript from a session with ‘John’. His background involves a history of being punished in various ways for having had needs or feelings. This has led to use of drugs and suicidal behaviour. Due to his difficulties with feelings he also has difficulty in sustaining intimate relationships. A main CRB2 for this client is being aware of and expressing feelings, and assertive behaviour is also a CRB2. The transcript begins just as the technique is being delivered.
T: …so John, just notice what happens, whatever that is, it
could be a thought, a feeling, a sensation, a memory or something else…Notice what happens when you hear me say the words (pause) John….I care about your sadness (pause) John…I care about your sadness…(Rule 2 – Evoke CRB)
C: (posturally stiffening up and slight movement backwards) T: Moving away? (Rule 4 – Observe Impact and Rule 2 –
Evoke CRB)
C: Yep…kind of pushing away. T: pushing me away?...( Rule 4 – Observe Impact and Rule
2 - Evoke CRB)
C: Yep T: Stay with that feeling…what else do you notice about it?
(Rule 2 – Evoke CRB)
C: I don’t like it…don’t want to feel sad. T: Uh huh, this is really hard…is it okay if we stay with it a
little longer, it seems important? (Rule 2 – Evoke CRB)
C: Yea…its okay T: So just connect into that feeling again, feel it in your body,
is there anything familiar about it? (Rule 2 – Evoke CRB)
C: …yea…actually it makes me think about Mum…when-
ever I was sad she would ask so many questions…really intense…invasive. Everyone else in the family is the same. Mum asks how they are and they just smile, say they are good…fine…even when I know they’ve had a really shitty day.
T: Yea…and you too huh…is that what you do? (Rule 2 -
Evoke CRB, the client has begun talking about other peoples reactions instead of his own, which was seen to be a CRB1, so here the therapist is bringing the focus back to the client and his experiences)
C: Yea that’s it, smile and say I’m fine, that’s the only way to
handle her
T: Oh gosh…okay so when we start to focus in on sadness,
when I share with you that I care about your feeling sad, you have an automatic push away feeling, connected to how your Mum was when you were sad. Like you might just say you’re good even though that’s not how you really feel. (Rule 3 – Reinforce CRB, Rule 4 – Observe Impact, and Rule 5 – Functional Interpretation)
C: Yea that’s it...she would always want to fix me. T: Uhuh and how does it feel with me right now, do you get
some sense of me being too intense…trying to fix your feelings? (Rule 2 – Evoke CRB)
C: Yea kinda…I know it’s not really the same but I do feel it T: Okay, so I want to respect that…I feel mixed, I want to
back off a little and give you some space but I also know this is the edge, that we always come back to when sadness shows up for you, when you interact with others who are important to you, you end up really struggling and shut-
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ting down and limiting the development of your relationship with them, that’s what brought you to see me in the first place. What do you think? What do you need right now, do you want to shut it away again or do you want to see if we can do something different here that you can try with others in your life? (Rule 3 - Reinforce CRB2’s and Rule 2 - Evoke CRB) C: Yea totally…I know that’s the problem…I want help with
this
T: So I’ve got an idea…maybe there’s a way that I could back
off and at the same time we have your feelings be here...it makes sense that you want to push me away given what you’ve just told me…but that’s also where you’re getting stuck in life…whenever feelings, especially sadness show up you tend to shut down, push others away, increase drugs, and think about dying…so I want to find a way that sadness could be here, with me so we can find another way to handle it and at the same time without you feeling invaded by me. How does that sound? (Rule 3 - Reinforce CRB2 and Rule 2 - Evoke CRB)
C: Good but how…what do you mean? T: Well, what if we both kind of sit back in our chairs (sitting
back), like what if we don’t have to fix it…it’s okay. And I’m feeling sad about what you are going through, and if I just sit here with my sadness, and if you sit there with you’re sadness, and we both kind of just sit here and feel our feelings…and we don’t need to fix or change them… (Rule 2-Evoke CRB)
C: (sitting back) okay… T: So lets just breathe together…(pause)…hearing about how
you had to hide your feelings makes me sad, I’m feeling a heaviness in my chest and some tears behind my eyes… (Rule 2-Evoke CRB)
C: (Tearily) I’m feeling a heavy feeling in my chest too and a
sort of tight feeling in my throat…
T: Uhuh, it feels good to be here with you like this, I want to
let you know I think you are so brave right now (Rule 3 Reinforce CRB2) Whilst an optimal FAP interaction is more focused on feelings about the therapist and therapy, for this client having any emotion present with the therapist is seen as a CRB2. From here the client and therapist do go on to mindfully explore feelings, which allows more clarity about what makes it difficult to identify and express sadness to the therapist, as well as some focus on how it is to be doing that with the therapist. Importantly, this is the first time the client has for a sustained period of time remained connected to his feelings and been with the therapist/ in relationship.
DISCUSSION It is worth mentioning that as the client is slowed down and in direct contact with their experience this technique has the potential to be highly evocative. In line with this it should be stated that the technique lends itself to modification and grad-
ing depending on where you are in the course of therapy and what level of capacity the client has for handling distress. For example you could do a ‘cut down’ version of this technique in a more regular conversational mode, something like, “oh okay I think I’m picking up a theme here…it’s about needs. I want to let you know that I think it’s okay to have needs. John, what you need is so important to me…what thoughts or feelings do you have when you hear me say that?” The aim of this paper was to provide a model for how to assimilate a technique from a different therapy model into FAP, which may involve some slight modification. As many therapists have undergone an array of training and professional development and subsequently learnt a variety of therapeutic techniques it seems fruitful for therapists to be able to consider what they have learned previously from a FAP perspective, so that they are able to carry forward these techniques, broadening the repertoire of methods they have for evoking clinical improvement for clients.
REFERENCES Baruch, D. E., Kanter, J. W., Busch, A. B., & Juskiewicz, K. (2009). Enhancing the therapy relationship in Acceptance and Commitment Therapy for psychotic symptoms. Clinical Case Studies,8, 241-257. Busch, A.M., Manos, R.C., Rusch, L.C., Bowe, W.M., & Kanter, J.W. (2010). FAP and Behavioral Activation. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 65-81). New York: Springer Callaghan, G. M., Gregg, J. A., Marx, B., Kohlenberg, B. S., & Gifford, E. (2004). FACT: The utility of an integration of Functional Analytic Psychotherapy and Acceptance and Commitment Therapy to alleviate human suffering. Psychotherapy: Theory, Research, Practice, Training, 41, 195-207. Cole, J.D., & Ladas-Gaskin, C. (2007). Mindfulness centered therapies: An integrative approach. Seattle: Silver Birch Press. Fisher, R. (2002). Experiential psychotherapy with couples: A guide for the creative pragmatist. Phoenix: Zeig, Tucker & Theisen, Inc. Kanter, J.W., Weeks., C.E., Bonow, J.T., Landes, S.J., Callaghan, G.M., & Follette, W.C. (2009). Assessment and Case Conceptualisation. In Tsai, M., Kohlenberg, R.J., Kanter, J., Kohlenberg, B., Follette, W.C., Callaghan, G.M. (Eds.). A guide to Functional Analytic Psychotherapy: Awareness, Courage, Love and Behaviorism (pp.1-19). New York: Springer. Kohlenberg, B. & Callaghan, G. M. (2010). FAP and Acceptance Commitment Therapy: Similarities, divergence, and integration. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 31-46). New York: Springer. Kohlenberg, R.J., Tsai, M., & Kanter, J.W. (2009). What is Functional Analytic Psychotherapy? In Tsai, M., Kohlenberg, R.J., Kanter, J., Kohlenberg, B., Follette, W.C., Callaghan, G.M. (Eds.). A guide to Functional Analytic Psychotherapy: Awareness, Courage, Love and Behaviorism (pp.1-19). New York: Springer. Kohlenberg, R.J., Kanter, J.W., Tsai, M., & Weeks, C.E. (2010). FAP and Cognitive Behavior Therapy. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 11-30). New York: Springer. Kohlenberg, R.J., & Tsai, M. (1991). Functional Analytic Psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press. Kohlenberg, R. J., & Tsai, M. (1994). Functional Analytic Psychotherapy: A behavioral approach to treatment and integration. Journal of Psychotherapy Integration, 4, 175-201. Kurtz, R. (1990). Body centred psychotherapy: The Hakomi method. California: Liferythm.
AN EXAMPLE OF A HAKOMI TECHNIQUE ADAPTED FOR FUNCTIONAL ANALYTIC PSYCHOTHERAPY Rosenfarb, I. (2010). FAP and Psychodynamic therapies. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 83-95). New York: Springer. Terry, C., Bolling, M.Y., Ruiz, M.R, & Brown, K. (2010). FAP and Feminist therapies: Confronting power and privilege in therapy. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 97-122). New York: Springer. Tsai, M., Kohlenberg, R.J., Kanter, J.W., & Waltz, J. (2009). Therapeutic technique: The five rules. In Tsai, M., Kohlenberg, R.J., Kanter, J., Kohlenberg, B., Follette, W.C., Callaghan, G.M. (Eds.). A guide to Functional Analytic Psychotherapy: Awareness, Courage, Love and Behaviorism (pp. 61-102). New York: Springer. Waltz, J., Landes, S.J., & Holman, G.I. (2010). FAP and Dialectical Behavior Therapy. In Kanter, J.W., Tsai, M., & Kohlenberg R.J. (Eds.). The practice of Functional Analytic Psychotherapy (pp. 47-64). New York: Springer.
AUTHOR CONTACT INFORMATION PETER COLLIS
Health and Counselling Service University of Canberra Kirinari Street, Bruce ACT 2617 Australia Phone: +61 (0)2 6201 2351 Email:
[email protected]
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©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Equifinality in Functional Analytic Psychotherapy: Different Strokes for Different Folks Sabrina M. Darrow1, Georgia Dalto2, & William C. Follette2 1 University of California, San Francisco & 2University of Nevada, Reno Abstract Functional Analytic Psychotherapy (FAP) is an interpersonal behavior therapy that relies on a therapist’s ability to contingently respond to in-session client behavior. Valued behavior change in clients results from the therapist shaping more effective client interpersonal behaviors by providing effective social reinforcement when these behaviors occur in or between sessions. One crucial discrimination for therapists to make is the distinction between the topography or physical form of their behavior versus how well or poorly it actually functions to shape client behavior. We notice that there are times when some therapists may focus too sharply on how similar their behavior is to that of a supervisor or prototypical therapist rather than focusing on how effectively their behavior functions as reinforcement. A review of some traditional psychotherapy adherence and competence literature suggests that therapists and supervisors may overly attend to the topography of behavior in assessing treatment fidelity. This paper will suggest strategies to minimize an over-reliance on topography, including shifting the focus from technique to principle.
Keywords Functional Analytic Psychotherapy, adherence, competence
“Use what talents you possess; the woods would be very silent if no birds sang except those that sang best.”
Imagine that a 35 year-old female depressed client is tearful while discussing an upsetting intimate encounter with her boyfriend. The case conceptualization hypothesizes that she has assertion difficulties and an ineffective repertoire for discussing sexual intimacy. Imagine further two scenarios. In one this female client’s FAP therapist is a mid-fifty year old male therapist, while in the other the therapist is a mid-twenty year old attractive female. Would one expect that each therapist would say the same things (e.g., “I know how you feel.”), use the same body language, utilize self-disclosure, or ask for more specific details? It is readily apparent that a supervisor would be hard pressed to give the same guidance to each of these therapists to make the same topographical response and predict that it would have the same effect. However, a common goal that the therapists could both accomplish could be identified – create an interaction where the client is reinforced for efforts to describe the situation, however ineffectively, while making it safe for the client to explore other ways of describing the situation that may be more useful with the therapist and with her partner. Readers familiar with the behavior analytic framework in which FAP is grounded will recognize the emphasis on function rather than topography in the preceding example (see Follette & Darrow, 2010). Although this issue may be familiar, the goal of this paper is to discuss just how challenging it is to focus on function within interpersonal relationships. Specifically, we will focus on the equifinality of therapist behavior, that is, how various topographies of therapist behavior work to accomplish the same goal. To start this discussion, the goals towards which FAP therapists are working must be defined. There are two main goals: establishing a meaningful relationship and shaping effective interpersonal client behavior while maintaining this relationship.
–Henry van Dyke An important component of evaluating treatment efficacy is developing a way to address therapist adherence and competence (Waltz, Addis, Koerner, & Jacobson, 1993). Adherence refers to how closely a therapist follows the intervention outlined in a manual and is typically evaluated using a checklist of important therapist behaviors. Competence refers to how skillfully the interventions are performed and often includes skills thought to be universal across therapeutic approaches (e.g., forming therapuetic relationship; Norcross & Goldfried, 2005). Within functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, et al., 2009), the therapeutic relationship, adherence, and competence are intrinsically linked. FAP is based on the premise that client behavior change is best effected through socially mediated contingencies. Therefore, establishing relationships with various clients is a necessary, though not sufficient, skill to competently implement this treatment. Furthermore, many adherence models in use cannot easily be adapted for use in FAP. As a principle based intervention, a checklist of particular behaviors important to FAP does not suffice. The focus on principles rather than specified techniques proves a challenge when training therapists and judging their behavior. *This author was supported in part by NIH T32 MH018261 at the University of California, San Francisco. Correspondence concerning this article should be addressed to William C. Follette, Department of Psychology/298, University of Nevada, Reno; Reno, NV 89557. Correspondence via electronic mail may be sent to sabrina.darrow@gmail. com
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In FAP, a meaningful relationship is one in which the therapist’s responses matter to the client; in other words, the therapist’s responses function as consequences in shaping client behavior. Follette, Naugle, and Callaghan (1996) offer a detailed analysis of how a therapist establishes this relationship. A FAP therapist needs to be a salient source of reinforcement in order to compete with outside contingencies and support difficult client behavior change. To become a strong source of reinforcement, therapists will likely need to provide meaningful statements of affection or concern. The therapist must support change, appreciate the difficulty in changing, and help the client discriminate when it has or has not occurred. However, a functionally important relationship may look very different across therapist-client dyads. For example, a person could present to therapy depressed as a result of proximal environmental changes (e.g., recent end of a romantic relationship). From a FAP perspective, both building rapport and expression of affect will be important. However, unlike a client who has difficulties with intimacy, this person will only need to describe her emotional reactions to the extent that it orients the therapist and the client to important variables related to her feelings of depression (e.g., loss of social support). The relationship with a client working on intimacy issues will appear more intimate (i.e., discussions will include topics that are generally shared with fewer people).Thus, the outcome by which we judge how well a relationship is established is by how well the therapist can impact important client behaviors rather than the extent to which the client makes affective disclosures of particular topographies. Understanding this functional view of the therapeutic relationship clarifies the relationship to the second goal: shaping clinically relevant behaviors (CRBs). CRBs are the target behaviors identified in the case conceptualization; CRB1s are ineffective behaviors and CRB2s are effective behaviors (see Kanter, et al., 2009 for more about assessment in FAP). The working hypothesis is that decreasing CRB1s and increasing CRB2s will make possible more clinically significant change in clients’ lives. Thus, the goal of FAP is to create a sufficiently significant therapeutic relationship in order to shape clinically relevant behavior in such a way as to improve client functioning. When applying the concept of equifinality to therapist behavior, one level of analysis to examine is the ultimate outcome of therapy (i.e., whether different therapists through different paths are able to shape a client repertoire that will function in the client’s social community). While this is an important consideration, a more fine-grained analysis is also important. Shaping behavior implies intermediate goals. Thus, how a particular therapist behavior functions in any moment in therapy is the crucial point to consider. With this in mind, the following sections relate examples to illustrate the variety of topographies within different functional classes of therapist behavior that can accomplish the goal of FAP. Additionally, we will offer some strategies that may help prevent an emphasis on topography rather than function in implementing FAP.
FUNCTIONAL CLASSES OF THERAPIST BEHAVIOR STIMULUS CLASSES: ANTECEDENTS In delineating FAP therapist behaviors, one important question to ask is, “How does a therapist create stimulus conditions necessary to evoke the repertoires he or she is trying to shape?” Of course this will depend on the individual client and the particular iteration of the case conceptualization. However, there are some important characteristics worth discussing. Events are established as discriminative stimuli based on their participation in a contingent relationship. Thus, there are two main pathways for therapist’s responses to function as antecedents for clinically relevant behavior. One way is through stimulus generalization processes: therapist’s responses may function as discriminative stimuli based on their similarity to events in the client’s history.1 A therapist may ask, “What do you need from me right now?”, when trying to help a client better express her needs to others. If this is a question often posed by her partner in an exasperated tone when he wants to be left alone, its use is unlikely to evoke the assertive behavior in-session. Rather, the question may serve to evoke behaviors similar to those engaged in by the client with her partner (e.g., apologizing). The second way events become discriminative stimuli is through therapists and clients creating their own learning history together, such that therapist stimuli come to evoke client behavior in reliable and predictable ways. A seemingly casual therapist inquiry, such as “how’s it going”, may evoke a meaningful response given a history where the therapist has reinforced this intimacy-building behavior. Therapists should attend to both pathways when attempting to evoke certain behaviors and assessing their effectiveness in doing so. When new FAP therapists are confronted with the task of shaping in-the-room behavior, they typically want directives regarding how they get clinically important behaviors to occur (i.e., how to evoke CRBs). Since FAP therapists are targeting interpersonal repertoires and often dealing with issues related to intimacy, it is tempting to make prescriptions about how therapists will need to take risks and push their intimacy boundaries in order to evoke relevant client behaviors. Although this may be true with certain clients and within particular interactions, there are many ways that therapists can functionally evoke CRBs that may not involve therapists taking risks. That said, FAP asks therapists to bring their best, natural repertoires into the therapy room and this can feel risky. The following section describes some examples of topographically diverse responses that may function as discriminative stimuli for CRBs. Beginning FAP therapists may initiate therapy in a way that is comfortable for them given their training histories. Some therapists will provide psychoeducation while others will take time for an in-depth discussion of the client’s family history. It is likely that these efforts to be helpful will be noticed by the client. This could lead to a meaningful interaction that could include CRBs (e.g., expression of appreciation or discomfort regarding 1 A discussion of the how the distinction between formally similar events and arbitrary relationships relates to shaping client behavior in FAP is beyond the scope of this paper. See Skinner (1957) and Hayes, Barnes-Holmes & Roche (2001) for more information on this distinction.
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demonstrations of caring). The critical issue here is whether the client responds to the therapist’s behavior as genuine caring and trying to understand the client’s concerns. Any therapist behaviors that achieve those functions are consistent with FAP. Any behavior that makes the client feel objectified or like a witness on the stand, regardless of the topography, fails. An obvious part of the setting conditions in FAP will be a therapist’s stimulus properties that may be formally similar to others in the client’s history (e.g., age, gender, ethnicity, and race). Consider a situation where a client is working on expressing her needs (i.e., increased manding in interpersonal relationships). When the client relates an interaction between herself and her partner, both a female and a male therapist may attempt to evoke this repertoire by pointing out opportunities for the client to tact an emotion and then prompt for a corresponding mand.2 However, the client may withdraw from the conversation with the male therapist. Reflecting on this interaction, the client and therapist may discover that some way the therapist behaved evoked this withdrawal due to the similarities between the therapist and the client’s partner. They could then identify a change in the therapist’s (and ultimately the partner’s) behavior that may help the client stay engaged in future conversations. This sequence may never occur with the female therapist. Yet it is likely that the female therapist may be able to strengthen a manding repertoire in such a way that it will function in the client’s outside relationship as well. One therapist stimulus property that may evoke different client behaviors is therapist attractiveness. Consider a client whose goal is to improve his emotional tacting repertoire. An attractive therapist of the client’s preferred gender will likely evoke topographically different client behaviors compared to interactions with a therapist to whom the client is not attracted. Interacting with the attractive therapist may evoke more feelings of vulnerability. The client may also express desires to present himself favorably. Alternatively, the client could work on expression of other emotions with the therapist to whom he is not attracted. He could tact appreciation of the therapist’s support, increased closeness upon sharing feelings about a partner, annoyance with the therapist’s agenda setting, good wishes for the therapist’s vacation, and so on. Functionally, all of these types of interactions could lead to the same end: the client improving his expression of emotions to important individuals in his life. Another consideration is a therapist’s natural response style. A soft-spoken therapist might evoke emotional disclosure of a much different nature than a more direct, louder therapist. A client may become agitated or not feel heard when a soft-spoken therapist does not react strongly to his expressions of frustration with a coworker. Alternatively, a client may feel belittled by a therapist who actively encourages him to express his emotions in a different way. Evoking either of these responses may be important in shaping effective interpersonal client behavior. 2 Tacting and manding are two important classes of verbal behavior (Skinner, 1957). A tact is a verbal operant that specifies the antecedent conditions and is reinforced by understanding (general conditioned reinforcement). A mand is a verbal operant that specifies the reinforcer. Both are important for interpersonal relationships and are closely related (e.g., tacting feelings is important to access supportive behaviors; manding for a certain type of supportive behavior may enhance intimacy.)
Especially towards the beginning of therapy, therapists may make direct attempts to evoke CRBs. Therapists may express caring or other affect in order to evoke behaviors relevant to intimate relationships. However, the way in which the therapist expresses herself may vary greatly from how the client’s verbal community expresses affect. Attributing the client’s failure to respond appropriately to a client deficit could be a mistake. Rather, the topography of the therapist’s expression is not one the client has learned to discriminate as an occasion to build intimacy (i.e., therapist response is an SΔ). Alternatively, therapists may engage clients in some type of experiential exercise as a way to evoke CRBs. How well these attempts function towards this end will depend on many factors. Similar to the above example, the stimulus situation created may be one that varies greatly from the client’s outside environment and the client’s deficits may need to be interpreted with this difference in mind. STIMULUS CLASSES: CONSEQUENCES In thinking about the topographically diverse ways to reinforce behavior, it is useful to reflect on the different ways people have given influential responses in our various relationships. Parents, coaches, teachers, friends, and colleagues are likely to differ in the way they pay attention to the things which we hold important. There is even more variability on an individual level. As with antecedents, certain stimulus properties or response styles may have natural reinforcing effects with particular clients. Similarly, there is no reason to make prescriptions about the tone of a response, whether it is meant to reinforce or punish. Of course, aversive consequences should be used with care since part of the goal is always to maintain the relationship. However, punishment just means doing something that decreases the probability of a behavior and many diverse response topographies can have this function. Simply stating, “that was unclear”, may function to punish behavior. An expression of caring, if not viewed as genuine may also function to punish a response. Furthermore, the timing of a response may change its function. A therapist might say, “I feel like I understand you so much better knowing your frustrations with your boss.” This might function as a punisher if the client was manding for help with how to confront his boss. Likewise, we know that what we would describe topographically as negative attention can function to reinforce rather than punish behavior. There has been debate in the broader field of behavior analysis as to the usefulness in distinguishing between positive and negative reinforcement (Baron & Galizio, 2005). It is beyond the scope of this paper to comment on this issue, but what appears clear regardless of whether this distinction is made is that reinforcement occurs with a noticeable change in the environment. Thinking of therapist behavior from this perspective helps highlight how different topographies may function for different therapists. If therapist A is typically soft-spoken and generally warm, a slight variation in her tone may work to decrease a client response. This type of presentation can be thought of as providing a lot of reinforcement (i.e., warm smiles, expressions of caring and encouragement, etc.) that can help a client feel safe and emit much behavior in the room. However, it may be harder for this therapist to provide a “stronger” reinforcer when the cli-
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ent engages in some new behavior. To do this, therapist A may need to provide a stronger expression of affection or excitement for a client than what therapist B might. Furthermore, a certain topographical response may function as a reinforce or a punisher depending on the situation, or the therapist. A therapist’s response may not function as intended if it is modeled based on a supervisor that has a very different set of stimulus properties or response style. For example, it might be awkward for a typically lighthearted therapist to model her expressions of caring on a supervisor whose response style is more serious. The client might interpret this awkwardness as the therapist not being genuine and this could result in this response functioning as a punisher. Additionally, it is important to adapt ways of expressing oneself to what is familiar to the client. It might not function to reinforce a client’s improvement if the therapist chooses language that is more sophisticated than the client’s. For example, “I feel connected to you in a deep way” may not function as a reinforcer for a lower functioning client who has never thought of “being connected” as an important interpersonal state. Additionally, how certain therapist responses function may vary as a result of past interactions with the client. When initially building a relationship with a client, a therapist may provide more obvious signs of caring (e.g., “I feel special that you shared such a meaningful part of your experience with me”). After the therapist and client have established a working relationship, more subtle responses (e.g., changes in tone, body language, nods of understanding) may have the same function. The initial responses may appear “over the top” and no longer have the same function at a later time point. Finally, it may be tempting to make statements regarding how a client should feel if a therapist is successful at reinforcing the client’s effective behavior. However, behavior analysts have avoided equating pleasure with reinforcement (or aversive contingencies with pain) as this attributes causal status to mental events. Additionally, when viewing expressions of pleasure as a learned behavior, there will likely be variability in whether certain interactions are similar to ones in which clients have learned to express pleasure. Many interactions in FAP are likely to involve clients trying some new behavior, and they may be awkward at first. Although a therapist may functionally respond in a way that increases the frequency of the client trying out this new behavior, it may be that neither the client nor the therapist describes this as a pleasurable experience. Therefore, therapists need not limit their responses to ones that reliably lead to expressions of positive emotions. NOTICING REPERTOIRES In order to shape CRBs, FAP therapists must notice their occurrence. Some clients may naturally exhibit these behaviors in-session. Other clients may describe engaging in problematic or effective behavior in their natural environment but not emit these behaviors in the room with the therapist. Thus, the therapist’s noticing repertoire is crucial to create opportunities to respond contingently to the client’s behavior such that desired behavior increases and undesired behavior decreases. At one level, noticing entails observing topography. More importantly, therapists must notice their personal reactions to
client behavior as a measure of how effective that behavior is in the client’s natural environment. If the therapist finds she is becoming unfocused or is losing interest in the conversation, she might hypothesize that this experience is common to other people who engage in conversation with the client. It is important to accurately assess how representative the therapist’s response is of the reactions of other people in the client’s life. A lack of correspondence can lead the therapist to focus on changing behavior that is functional for the client while not attending to behavior that is not functional. Noticing repertoires may differ in terms of to what parts of a client’s narrative different therapists attend, or how they orient to things the client identifies as important. For example, imagine that a client mentions wanting to increase his repertoire for expressing love to his children. A therapist whose father was hard-working and independent may not readily recognize the importance of shaping client behaviors such as being physically affectionate with one’s children or directly telling one’s children they are loved. Whereas a therapist with a loving, expressive father might be naturally inclined to look for sophisticated, emotionally expressive behaviors in her client. Different therapists will identify different client behaviors as important means or obstacles to a given end. In therapy there are many paths from point A to point B. What is crucial is that the therapist can notice when a given goal is achieved and when it is not. If a therapist can accurately identify behaviors that indicate the goal has been reached and those that indicate the goal has not been reached, it may not matter precisely which forms of the behaviors are noticed. Thus two therapists may notice and respond to different subsets of ineffective behavior and still conduct effective therapy that achieves a desired end-state. Consider a case where the client’s goal is to develop an effective manding repertoire. It is crucial that there is agreement about what it would look like for the client to achieve this end (e.g., consistently stating his needs clearly to the therapist, reporting instances of this behavior in his interactions with his wife, boss, and others using language that would be effective in that social community). Therapist A might notice behaviors such as the client getting angry or accusatory when the therapist does not do what the client wants, while therapist B may attend more to instances when the client appears sullen or depressed. Both of these sub-sets of behaviors present opportunities for the client to learn to describe his needs (i.e., mand), and it may not be crucial to which members of this response class different therapists attend. Throughout the course of therapy, interim goals are often identified and therapists may differ in how high they set the bar during the various stages of therapy. When working on developing tacting repertoires, one therapist might reinforce a subtle change in the client’s description of a situation (e.g., use of the word “I”, which indicates inclusion of the client’s perspective) while another therapist may identify the client’s use of short, concise descriptions as the next successive approximation to reinforce. As long as the selection of these different criteria results in successful progression through therapy and the achievement of the desired end-state, such differences in noticing repertoires may not be important.
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The field of psychology as a verbal community may also encourage an emphasis on form over function by valuing some therapist topographies more than others. For example, active listening skills are taught in clinical training programs, and these behaviors are sometimes thought to be central to conducting effective therapy. In FAP, noticing involves more than just listening and making note of what the client finds important. Instead, noticing is key to providing opportunities for the contingent responding that is the backbone of this therapy.
CAVEATS: NOT ALL BEHAVIORS ARE CREATED EQUAL While it is important to recognize the wide variety of behavioral topographies that can have the same function, some aspects of therapists’ behaviors are not equivalent with regard to achieving the goal of FAP: to create a sufficiently significant therapeutic relationship in order to shape CRBs in such a way as to improve client functioning. TIMING AND LENGTH OF RESPONSES A lot of basic research in the experimental analysis of behavior examines the timing of reinforcement relative to the occurrence of the behavior of interest (Pierce & Cheney, 2008). One general conclusion is that consequences that occur close in time to the response of interest will have a greater impact than more distal consequences. This is something to consider in evaluating therapists’ responses that are meant to affect CRBs. Some FAP therapists may recognize important behavior occurring in the midst of a longer client response (e.g., improved affective expression while the client relates a story about work). Figuring out how to interrupt this stream of behavior to reinforce an improvement is a tricky but important skill. If the therapist waits until the end of the story, it may take her a lot of effort to describe the behavior she thought was an improvement and this may dilute the reinforcing function of her response. Alternatively, she may respond in a way that reinforces the storytelling behavior, rather than the specific instance of improvement. Additionally, it is not uncommon for therapists to realize that important behavior occurred once the moment has passed (i.e., at the end of session or in between sessions). Attempts to recreate a particular interaction (i.e., “when you told me about that interaction with your wife last week…”) are not optimal for shaping behavior (although this type of interaction may have other important functions as a demonstration of caring). This is why therapists are encouraged to notice and respond to CRBs in the moment. A related issue is whether therapists should attempt to reinforce every instance of clinically relevant behavior (i.e., FR1 schedule). Approximating a schedule of continuous reinforcement may be ideal when a client is acquiring a brand new skill. However, this skill will be strengthened if the schedule is changed to a variable ratio schedule; this schedule is also more likely to be similar to the contingencies in the outside social environment, increasing the likelihood the behavior will generalize to this environment.
VARIABILITY Although natural response styles can have certain stimulus functions, it is important to encourage therapists to have a variety of ways to respond to clients for many reasons. Considering the discriminative functions that therapists want to have, variability and changes in their behavior are more likely to evoke CRBs than perpetually responding in a similar way. This might be counter to a rule that some therapists may follow in attempting to build a therapeutic relationship: “important people listen to me”. While this may be true, a steady stream of listening behavior is not likely to evoke the same types of behaviors evoked within a client’s outside relationships. Additionally, it will be difficult to figure out contingent relationships; functional analysis requires varying the stimulus conditions, both antecedents and consequences. Similarly, a therapist’s repertoire should include ways to respond to both ineffective behavior and client improvements. Some therapists may naturally pay more attention to improvements whereas others consistently apply consequences to ineffective behavior. As of now, there are not any data to suggest that a certain proportion of therapist’s responses should be reinforcing improvements versus applying consequences to ineffective behavior. Of course, the schedule of reinforcement has to be one that will function to maintain the relationship. However, this schedule will affect the speed at which client behavior changes and time constraints may result from client impatience or costs. A therapist who only responds to improvements will likely take longer to reach the same outcome as a therapist who actively responds to ineffective behavior. Imagine, for example, a client’s CRB1s include excessive, tangential speech and dominating the conversations, while CRB2s include building pauses into the conversation and allowing the therapist to participate. In this scenario, the therapist has very few natural opportunities to reinforce CRB2s. If the excessive talking is providing automatic reinforcement for the client, the effect of reinforcing any CRB2s that do show up is likely to be diluted. Unless the therapist also blocks or punishes the excessive talking, the competing contingencies are likely to impede progress. NATURAL VERSUS ARBITRARY A very important distinction first emphasized by Ferster (1967) is that of arbitrary versus natural reinforcement. Providing natural reinforcement in FAP requires the therapist to create situations and provide reinforcing responses that are similar to those that occur in the client’s outside social environment. Thus, some knowledge of the environment to which we want client’s behavior to generalize is a necessity. There are not many environments outside of clinical psychology where “how did you feel about that” is provided as an occasion to tact emotion. Similarly, “thank you for sharing your anger with me” is not a likely consequence for an individual expressing anger. Rather, it is necessary to create opportunities where tacting an emotion will have a meaningful impact on an interaction (e.g., increase understanding of how a dyad can interact that leads to a better outcome). Importantly, therapists may respond in an arbitrary way toward the beginning of therapy. This may be necessary to strengthen a new client repertoire for which there is minimal or no support in his social environment. As the client becomes
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more proficient, it is crucial for the therapist to provide consequences that are similar to the client’s social environment in order for generalization to occur.
STRATEGIES FOR IMPROVING FAP ADHERENCE AND COMPETENCE Expanding the therapist’s knowledge of basic behavioral principles is crucial to keeping the focus on the function rather than the form of behavior. A working understanding of stimulus and response classes can help prevent an overemphasis on topography. Suppose a therapist notices that several of her behaviors (e.g., sharing the story of a personal failure with the client, telling the client she appreciates his being open with her) serve to increase the client’s tendency to be more honest and vulnerable in therapy. This observation that several of her behaviors have a similar impact on the client (i.e., participate in same functional class) can serve to broaden her response repertoire. This can be invaluable in increasing the client’s sensitivity to the behavioral variability that characterizes the natural environment. In addition to noticing the variety of behaviors making up a functional class, therapists should be encouraged to actively try out different responses to accomplish the same goal. A more thorough understanding of equifinality can be fostered through this experiential exercise. An invaluable function of group supervision in FAP is that of the Greek Chorus (Tsai, Callaghan, et al., 2009). Peer supervisors from diverse backgrounds can offer feedback as to how the therapist’s behavior functions both with the group and with different clients. This is important in preventing the therapist’s repertoire from being constrained to those behaviors that may have worked for her in past relationships but might not be functional with a particular client. For example, joking or teasing may have increased closeness felt by the therapist in her relationship with her father. However, if these same behaviors function to distance others on the supervision team, this may be an indication that the therapist’s joking may not lead to a desired goal in relationships outside of her family of origin. The Greek Chorus can also provide a broader range of reactions to client behavior than just that of the therapist. Thus the group’s reaction may be more representative of the reactions of people in the client’s natural environment. This will help the therapist notice and attend to those client behaviors that will most efficiently lead to a successful therapeutic outcome as well as notice instances of ineffective behavior the therapist might have missed. Another function of the Greek Chorus can be to highlight the importance of and increase topographical variability on the part of the therapist. Different people will have different reactions to the therapist’s behavior and this can prevent the therapist from becoming locked in a pattern of responding that functions well only with a narrow range of people. Topographical variability is crucial not only in preparing the therapist to work with a diverse client population, but also in expanding the repertoire of effective responses which can be used with a single client. A broad range of responses can allow the therapist to better represent the variety of reactions the client is likely to encounter in his natural environment.
Supervision can also be a place where the therapist publicly identifies his own strengths and weaknesses (T1s and T2s) in relation to a given case. Therapists should be encouraged to become aware of these (e.g., a tendency to respond in a favorite but inflexible way, a propensity for noticing only those client problems he is competent in addressing) and share them with the group. Then, the other members of the team can watch for these behaviors, remind the therapist of things to work on, and hold the therapist accountable for the impact of the behavior he brings into the therapy room. In addition, this process may help expand each therapist’s appreciation of how a wide range of topographical responses may have the same function. A given member of the team may identify his ability to use humor to make the client feel connected as a T2. Another therapist may not have been aware that this behavior could have the same function as her own preferred method of increasing closeness (i.e., direct expressions of caring).
CONCLUSION The purpose of this article is to promote appreciation for the various ways that therapists may accomplish the goal of FAP: to create a sufficiently significant therapeutic relationship in order to shape clinically relevant behavior in such a way as to improve client functioning. This variability may occur across therapists as well as across clients seen by the same therapist. There is one final caveat: there may be some outcomes that not everyone can produce. A male therapist may help the majority of his client’s improve their interpersonal repertoires but may not be able to help a female client express her existential angst to the same extent that a very patient, caring female therapist could achieve. In other words, there may be some differences in the ultimate outcome reached by different approaches. If a therapist often finds himself curtailed in reaching important outcomes, we would recommend he seek more training. However, it is not likely or necessarily problematic that all therapists will be exceptional with all clients. The important message is that we adhere to the principles of behavior analysis by continually assessing how we are functioning, noticing if our behaviors functioned in a way not intended, and being willing to adjust our future behavior based on this assessment.
REFERENCES Baron, A., & Galizio, M. (2005). Positive and negative reinforcement: Should the distinction be preserved? The Behavior Analyst, 28(2), 85-98. Ferster, C. B. (1967). Arbitrary and Natural Reinforcement. The Psychological Record, 17(3), 341-347. Follette, W. C., & Darrow, S. M. (2010). The function and topography of behavior: Things aren’t always as they seem. European Psychotherapy, 9(1), 81-92. Follette, W. C., Naugle, A. E., & Callaghan, G. M. (1996). A radical behavioral understanding of the therapeutic relationship in effecting change. Behavior Therapy, 27(4), 623-641. doi: 10.1016/s0005-7894(96)80047-5 Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A postSkinnerian account of human language and cognition. New York, NY, US: Kluwer Academic/Plenum Publishers, 285. Kanter, J. W., Weeks, C. E., Bonow, J. T., Landes, S. J., Callaghan, G. M., Follette, W. C., et al. (2009). Assessment and case conceptualization. Tsai, Mavis.
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DARROW, DALTO, & FOLLETTE Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York, NY US: Plenum Press. Norcross, J. C., & Goldfried, M. R. (2005). Handbook of psychotherapy integration (2nd ed.). New York, NY, US: Oxford University Press, 548. Pierce, W. D., & Cheney, C. D. (2008). Behavior analysis and learning (4th ed.). New York, NY, US: Psychology Press, 431. Skinner, B. F. (1957). Verbal behavior. East Norwalk, CT, US: Appleton Century Crofts, 478. doi: 10.1037/11256-000 Tsai, M., Callaghan, G. M., Kohlenberg, R. J., Follette, W. C., Darrow, S. M., Kanter, J. W., et al. (2009). Supervision and therapist self-development. Tsai, Mavis. Tsai, M., Kohlenberg, R. J., Kanter, J. W., Follette, W. C., Callaghan, G. M., & Kohlenberg, B. (2009). A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism. New York, NY US: Springer Science + Business Media. Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61(4), 620-630. doi: 10.1037/0022006x.61.4.620 Author Contact Information
SABRINA M. DARROW, PHD
UCSF/SFGH Psychiatry Department 2727 Mariposa St. Suite 100 San Francisco, CA 94110 Phone: (415) 437-3075 Fax: (415) 437-3020
[email protected] GEORGIA DALTO
Psychology Department/MS298 University of Nevada, Reno Reno, NV 89557 Phone: (207) 323-5138 Fax: (775) 327-5043
[email protected] WILLIAM C. FOLLETTE, PHD
Psychology Department/MS298 University of Nevada, Reno Reno, NV 89557 Phone: (775) 682-8699 Fax: (775) 327-5043
[email protected]
INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Treatment of a Disorder of Self through Functional Analytic Psychotherapy Rafael Ferro-Garcia1, Miguel Angel Lopez-Bermudez2, & Luis Valero-Aguayo3 1 Centro de Psicología Clínica C.E.D.I. Granada (Spain), 2Centro de Psicología CEPSI, Bailen, Jaén (Spain) & 3Universidad de Malaga (Spain) Abstract This paper presents a clinical case study of a depressed female, treated by means of Functional Analytic Psychotherapy (FAP) based on the theory and techniques for treating an “unstable self” (Kohlenberg & Tsai, 1991), instead of the classic treatment for depression. The client was a 20-year-old college student. The trigger for her problems was a sentimental break-up in addition to a degree of academic failure. She reported difficulty knowing how she felt, what she wanted, what she thought. At pretreatment, her scores on self-report questionnaires (the BDI, AAQ, and EOSS) were high, indicating moderate depression, no acceptance of feelings, and a high level of public control of self. The treatment lasted 23 sessions, with a follow-up 13 months later. Results showed the elimination of diagnostic criteria based on her behaviors in and out of sessions, and a considerable decrease in her scores in questionnaires, suggesting that FAP techniques targeting problems with the self may be clinically useful.
Keywords Functional Analytic Psychotherapy, Depression, Personality Disorder
F
unctional Analytic Psychotherapy (FAP, Kohlenberg & Tsai, 1991; Kanter, Kohlenberg & Tsai, 2010; Tsai, Kohlenberg, Kanter, Kohlenberg, Follette & Callaghan, 2009) is a form of psychotherapy in its own right and can be combined with other therapies producing synergistic results (Kohlenberg, Tsai, Ferro, Valero, Fernandez Parra, & Virues, 2005). Its integration with other therapies is yielding good results (Busch, Manos, Rusch, Bowe & Kanter, 2010; Callaghan, Gregg Marx, Kohlenberg, & Gifford, 2004; Gaynor & Scott, 2002; Gifford, Kohlenberg, Hayes, Pierson, Piasecki, Antonuccio & Palm, 2011; Kohlenberg & Callaghan, 2010; Kohlenberg, Kanter, Tsai & Weeks, 2010; Waltz, Landes & Holamn, 2010). Philosophically, FAP is based on the principles of radical behaviorism and contextualism. It emphasizes contingencies that occur during a session of therapy, in a therapeutic context and also emphasizes the functional equivalence between the two environments as well as natural reinforcement and shaping (Kohlenberg & Tsai, 1991, 1995a). FAP proposed therapeutic targets called Clinically Relevant Behavior (CRB) (Kohlenberg & Tsai, 1991). There are three types of CRB. CRB1 are the client´s problems that occur during the session. CRB2s are the client’s improvements occurring during the session. CRB3s are the clients’ interpretations about their own behavior that also include the causes. Also five Therapeutic Rules for therapists are proposed. They involve identifying, evoking, reinforcing, noticing the impact of reinforcement, and interpreting the client’s behavior. Many case studies have supported FAP (see Baruch, Kanter, Busch, Plummer, Tsai, Rusch, Landes & Holman, 2009; Ferro, 2008) and more specifically, it has been successful in cases of emotional problems (Ferro, Valero & Vives, 2006, López-Ber-
múdez, Ferro & Calvillo, 2010, López-Bermúdez, Ferro & Valero, 2010). The explanatory model of self-development proposed by FAP (Kohlenberg & Tsai, 1991, 1995b), can explain problems of self and Personality Disorders. The process of acquiring the verbal report of “self ” and the experience referred by the report is equivalent to the learning of concepts. The “self ” or “I” as an independent unit emerges from previously learned longer sentences which contain “I” such as “I want…,” “I see…,” and “I am…” or in abstract form, “I x”. The key to the development of “self ” can be found in transferring the control of these self-referential responses from public stimuli to private stimuli, and the degree of difficulties with the self experienced by an individual can vary depending on the degree of private control that they have over their responses, “I x”. In general, the fewer responses of this type that a person has under private control, the greater the confusion or difficulty in answering questions that have to do with personal preferences, desires, values, etc.. People with moderate disorders of self may have a significant number of responses of the type “I x” (I want, I feel, I can see, etc.) that are under public control, in part or totally. Their sense of self and their opinions, their moods or their desires may be quite affected by the presence of other people (Kohlenberg & Tsai, 1991). The application of FAP in these disorders is still scarce. Callaghan, Summers y Weidman (2003) presents the treatment of a case of Histrionic and Narcissistic Personality Disorder, through the data collected with the FAPRS coding system, showing statistically significant positive changes on the client throughout therapy. On the other hand, Kanter et al., (2006) providen single subject data on two subjects with Major Depressive Disorder and Personality Disorders. The results indicate that one of the 45
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subjects showed a clear improvement after introducing strategies FAP, while in the other subject there is no such obvious changes. In the following article, a case study of a client is described. She showed symptoms of depression and anxiety, and also had a moderate disorder of self (Kohlenberg & Tsai, 1991, 1995b; Kohlenberg, Tsai, Kanter & Parker, 2009). The case study shows how therapy was carried out using FAP, the results obtained and the maintenance of these results during a follow-up of more than one year. In addition, this case represents the first application of Kohlenberg and Tsai´s model of disorders of the self to a clinical FAP case, using the EOSS and other measures to demonstrate outcomes. The protocol of therapy center included provide information about the therapeutic process, confidentiality, professional secrecy, and informed consent about records and scientifc use of data, that the clients sign at the beginning of sessions. The client’s personal informations not relevants for therapy have been changed to protect confidentiality.
METHOD SUBJECT Gloria was a 24-year-old college student when she came to the clinic. She was an only child and her family lived in a town. She met the criteria for Major Depressive Disorder of DSM-IVTR (APA, 2001), including a depressed mood most of the day, markedly diminished interest in things, insomnia, tiredness and fatigue, excessive feelings of worthlessness and guilt, and decreased ability to concentrate. The trigger for her depression was a sentimental break-up with a boy with whom she was in love. She described herself as very sensitive and as having difficulty in expressing how she was feeling. She found it difficult to be spontaneous and comments from other people affected her greatly. She hardly ever went out with other people and only focused on her studies. Although she was generally a good student, at that time she had started to fail several subjects and had decided not to sit two exams. This poor academic performance had affected her greatly. She stated that “I only see my studies as a refuge from my problems.” She described herself as being very shy and had difficulty talking about her feelings. She spent the day crying but did not know why. She described that her problems had been coming for a long time, her grandparents (with whom he grew up) always compared her to others in a negative way, and one of her uncles had always put her down and told her that she would never amount to anything. During the first clinical sessions she made statements such as the following, “I am the fool of the family”, “I have always kept everything in”, “I have never really lived”, and “I have never played, nor have I ever enjoyed anything”. In view of these data it was put forward that Gloria’s problem was not only her current emotional state, but that she had an unstable self, classified as a less severe disturbance (Kohlenberg & Tsai, 1991, 1995b). That is, she had difficulty knowing how she felt, what she wanted, what she thought, and so on, depending on who was present. She was also very sensitive to criticism and lacked spontaneity. We conducted a conceptualization of the case (Ferro, Valero
& López-Bermúdez, 2009; Kanter, Weeks, Bonow, Andes, Callaghan & Follette, 2009) from which the following Clinically Relevant Behavior (CRB) emerged: CRB1, avoidance behavior: avoidance of other people (not going out with class mates or friends, not going to the doctor, etc.), and avoidance of making requests (becoming blocked when talking about her feelings, needs, opinions, etc). CRB2: All “I x” responses that were emitted (both requested and spontaneous). That is, expressing her views, needs, desires. Facing criticism. Going out with friends and classmates. CRB3: Functional explanations about what was happening to her. MEASUREMENT We used the following measures. The Experience of Self Scale (EOSS, Kanter, Kohlenberg & Parker, 2001) is a tool which aims to analyze and measure the degree of public and private control over the experience of self. The EOSS has been administered to a sample of students and patients with Borderline Personality Disorder (BPD) and results indicated that the BPD patients have a strong degree of public control over their experience of self. In addition, EOSS scores presented high correlations with measures of self-esteem and dissociation (Kanter, Kohlenberg & Parker, 2001; Kohlenberg, Tsai, Kanter & Parker, 2009). The EOSS has 4 subscales that examine 5 experiences of the self (feelings, needs, attitudes, opinions and actions) depending on the type of public control (intimate and casual relations) and depending on the proximity (alone and accompanied). EOSS 1 generally the experience of self. EOSS 2 values the expression of the 5 experiences with a less familiar person (neighbor, acquaintance, etc.) EOSS 3 measures these experiences in relation to a more intimate personal relationship (family, friends, etc.). And EOSS 4 assesses the self as regards spontaneity, creativity, giving opinions, criticism both from people and self criticism. Also, we used the Acceptance and Action Questionnaire (AAQ; Barraca, 2004) developed to assess experiential avoidance and psychological acceptance, and the Beck Depression Inventory (BDI-II, Beck, Steery & Brown, 1996) evaluates the presence of symptoms and severity of depression THERAPY Treatment lasted a year over 23 sessions and a further follow up for a period of 13 months. It was decided to work directly with her control over her sense of self, since it was believed that this was the problem that had caused the emotional situation. Similarly, it was decided not to work on behavioral activation directly. In general, the therapeutic rules proposed by FAP were followed (Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, Kanter & Waltz, 2009), and more specifically, the recommendations for working with these types of problems of the self were followed (Kohlenberg & Tsai, 1991; Kohlenberg, Tsai, Kanter & Parker, 2009), including reinforcing her talking in the absence of specific external cues, matching therapeutic tasks to the level of private control in the client’s repertoire, reinforcing as many of
TREATMENT OF A DISORDER OF SELF THROUGH FUNCTIONAL ANALYTIC PSYCHOTHERAPY
the client’s “I x” statements as possible, and the use of self-observation and being aware of what she was seeing. The initial phase lasted approximately until the 7th session. In the first two sessions a functional analysis of Gloria’s problems was carried out, from which the conceptualization of her CRBs arose. In the first session, the following questionnaires were administered: AAQ (Barraca, 2004), EOSS (Kanter, Kohlenberg &Parker, 2001), and BDI-II (Beck, Steery & Brown, 1996). In the 2nd session the nature of her depression was explained through the model proposed by Behavioral Activation (Martell, Addis & Jacobson, 2001). That is, negative life circumstances together with inadequate repertoires may be seen as an establishing operation (Michael, 1993) for loss of interest, other depressive symptoms (sadness, worthlessness, fatigue, etc.), and avoidance behaviors (passivity, ruminating thoughts, not taking the exams, etc.). This creates a vicious circle that is the depressive state. A description was also given of a slight disorder of self and its relationship with depression. Information continued to be gathered in order for a more complete functional analysis of the problem to be made. In Session 3 she admitted that she was surprised to hear herself speak with such naturalness of her problems (CRB2, recognizing an improvement). The therapist (T) described that she appeared to be more expressive when talking about her problems than in the other sessions (Rule 3, trying to reinforce this CRB2). The fourth session evoked her insecurity around the issue of asking favors of others. After a long silence and appearing to be nervous (CRB1) she told T that she needed a letter to request a new sitting of an examination that she had missed. Asking for a favor in this case was interpreted as a CRB2. T said that in such situations (missing an examination) reports are not usually made but as he thought it was an improvement he would happily comply (naturally trying to reinforce CRB2). This caused a CRB1as Gloria felt guilty and said “sorry,” “forget it,” and “please do not do it.” T repeated the reasons why he would do so and said there was no need to apologize. Afterwards they analyzed the type of functional response “asking for favors” and how she had acted. In the period from then until the 5th session, Gloria passed two exams. She acknowledged that since attending the sessions she had started to pass exams because she managed her time and was generally better organized. At no time was any intervention made directly, nor was she instructed to study. At this point, she acknowledged with a bit of distress that she had left two subjects for September (a mysterious response that had not appeared before) because she had not felt like studying and was not feeling well emotionally. In this session, she spontaneously admitted that she was in a better mood. Also in this session she was asked to do the exercise to Dream With Eyes Open, in this exercise asks the client to describe what are their dreams, their desires to achieve in your life. Which she found very difficult (such as is stated in Kohlenberg and Tsai, 1991, that people with moderate disorders of the self have difficulty doing these introspective exercises) and came up with some obvious nervous answers: “being with my family, traveling ...” In Session 6, T reinforced the changes because he saw her to be more talkative and animated, She expressed for the first time the cause of her discomfort: “I’ve been in love with a guy
who abused me. He has humiliated me many times. He always used me and we have never been an even couple. I commit to a relationship without thinking of myself. I realized he was not interested in me as a partner “ (CRB2 and 3). T saw how she was avoiding calling him by his name (CRB1) and first mentioned his name after questions from the T (CRB2). T analyzed what she expected from a relationship within a couple, something that was difficult for her. In the 7th session a Non-dominant Hand Writing Exercise was performed (Tsai, Kohlenberg, Kanter & Waltz, 2009) which consisted of asking her to write about how she felt, what she feared, desired, and so on with her non-dominant hand. The goal was to evoke CRB related to emotional expression with fewer opportunities to avoid. Answers included: “I am afraid of being lonely,” “It is very hard to talk about my personal stuff,” “I’m fighting against my problems,” “I want others to accept me as I am,” “I am trying to overcome what I have not been able to overcome”, “I am afraid to meet up with my friends,” “I have not been able to face this” (referring to the problem with the guy, CRB1 and 2). A second phase was made up from the 8th to the 20th sessions. In the 8th session, she brought a gift from her home town to express her gratitude to T for the favor that he did with the report. Analysis was made as to whether she is generous to others as she had been to the T. Analysis was also made as to whether, when she was upset about something that she might have done to someone, she ever tried to do anything like she had just done with the gift. She said that she did not want to owe anything to anyone. She described how, in her home town, she had dedicated her time to her family and had been offended by a comment that her grandmother had made to her. As she described it, she appeared moved and she wept. She described in detail that she had been assertive and had faced up to the criticism. The T asked if she had ever done this before and if she had noticed a change. She said that her father realized that she was changing. She said that she had always avoided confrontations with her friends and especially with the boy in question (“I didn’t ever have the courage”). At this point, the T explained what avoidance was and how it works by dencreasing fears. He did not insist on discussing the problem of the boy (trying to adapt to the client’s level). The 9th session was a month after the previous session and she had been back to her home town. She said that things had been better with her family and that she had only been out a little with her friends but that she had tried (the shaping of T seemed to be taking effect, Rule 4). With her friends in this city and with her fellow students things were going very well. She spontaneously said, “Coming here has given me a lot of security.” She sat for exams in two subjects and passed. She described her feelings in a spontaneous way “I am very happy”. The T asked her what conclusions she could draw now from what had happened in the summer. (Rule 2, evoking CRB). She spontaneously began to talk about her feelings about the boy: “I was in love and he used me” and described the hard time she had been through, how she had felt his contempt for her and when he had laughed at her. Through the T’s shaping, she gave examples and described situations in which she had had a very bad time and from which she had run away. Then and now were compared and the differences were highlighted. She was asked in what
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ways she was changing. She was also asked what she feared at the time, to which she replied “I am afraid of falling back” (into a depression). In the 10th session she continued saying that she was better and that her mother had said that she looked better. The T was aware and sensitive to the fact that she was dressed in bright colors and commented on the fact that she had always dressed in black before and that in this session she had come with more colorful clothes. The T asked what she thought had been the problem. To which she replied: “I didn’t have any personality before. Now I am being me”. For the first time she had taken a weekend off from studying to have fun with her friends. In the 11th session she stated that she was concerned about her grandparents because they had an argument and Gloria had tried to mediate. When asked if she would have done this before, she said ‘no’. She spontaneously explained that she was often obsessed with family problems and at one point said, “That is just what I am like” (CRB2). The T asked her what things she was worried about and she said that she was worried about falling in love again, about going back to where she had been and about failing at school. In the 12th session she explained that the problems between her grandparents were not down to her and that if they did not want to sort it out, it would never be sorted out. She stated that she was coming to therapy feeling more relaxed and without feeling overwhelmed. When she was asked to set new goals and challenges, she concluded: “It is hard for me to give my opinion. I am afraid of being wrong. I do not know what I want”. The Free Association Exercise was carried out (Kohlenberg & Tsai, 1991), trying to adapt it to her repertoire by using as common words (white, black, water, sun, etc.), making more structured task. During the exercise she appeared to be resistant and anxious. In the 13th session she revealed, with difficulty, that she liked a boy. She found it difficult to talk about this, trying to get out of it and becoming blocked. What she was looking for in a partner was analyzed. As the T gave her some help by saying what he would look for in a partner, she became more spontaneous and described the values that she looked for “Someone with whom to share, start a project together, love, understanding, respect, trust and sincerity”. The same exercise of free association was performed again with roughly the same words and she appeared to be calmer and more relaxed. The 14th session took place six months after therapy started and the EOSS was administered again. She was still dressing in a different way compared to before. She explained that she was feeling good and had noticed a change of attitude in herself. Her father thought that she had changed a lot. The T also commented that he had noticed the change. She was more spontaneous when speaking (CRB2). They performed the exercise of free association and she was asked for the first time to close her eyes and speak of her desires, her needs and her feelings, increasing degree of private control. She spoke of her desires and needs without difficulty but apparently had trouble when talking about her feelings. In the 15th session she said that she avoided going to the doctor and that she was not registered with any family doctor. She had failed an exam but that she had taken it well. She described her mood as good and said that she was calmer. The T stated
that she looked surer of herself, more spontaneous and more cheerful. She recognized this but maintained that she could not face people. The free association exercise was repeated with her eyes closed and she focused on what she felt, with the therapist helping with a series of descriptions of what she might be feeling at that time (quiet, calm, joy) and exposing her to mental images (a beach, etc.) and by encouraging her to describe what she was feeling, this time without help. The 16th session was a month after the previous one. Gloria looked better and her dress sensibility had changed even more. After it was commented on, she replied that “I feel that I have a strength now that I didn’t have this last summer”. Her family were still seeing changes in her. She had been more spontaneous with almost everybody and went on to describe: “I have been singing, I have been laughing, I have been dancing...” She had had an oral presentation on a subject and although she had been very nervous, she had done it well. When asked about the boy who had hurt her, she said: “These days I feel indifferent towards him”. The 17th session was brought forward a week. She described how she had been stressed out with her studies (CRB2, talking about how she felt). She spontaneously said that she had had a fear for some time: “I’ve been running away from a problem for years because I was too afraid to confront it, afraid of going to my house”. She did not know why (CRB1). The T shaped what could be the cause (Rule 5). She concluded that she avoided meeting the guy who hurt her and also avoided seeing her uncle and aunt who were critical of her. The 18th session was a month after the previous one. She said she had returned home and had had a confrontation with her grandfather and that she had handled it well (CRB2). She spontaneously gave an opinion: “I do not like the people in my home town. I do not feel comfortable with them.” “I saw a friend and it is not like it used to be.” She spontaneously said that she had strong feelings for a boy (CRB2, talking about her feelings). She spontaneously said, “I’ll pass on him, on Sunday I decided it was finished”, and the T commented that she was avoiding. She acknowledged that it was to avoid getting hurt. She brought the 19th session forward because she was feeling bad. She maintained that she thought that she was where she was a year before. The problem was that the guy who she had met said he was not sure of the relationship and did not know what to do and she proposed leaving things for the time being. She realized she was in love and that he had hurt her. The T tried to encourage her to express what she felt and what she had learned from this experience (Rule 5). The 20th session was 3 weeks later. She had been to her home town and had devoted her time to her family. She maintained that when she was with her group of friends in her home town she felt weak and put this down to the failure in her latest relationship. The free association exercise was carried out again, this time without any type of help and she had no trouble expressing her feelings (sadness, melancholy, insecurity). She explained that she left the session feeling stronger (CRB2). The final phase was from the 21th session a month later. She spontaneously acknowledged that she had seen many improvements and differences from before. She had been awarded a scholarship and was going to spend the follow-
TREATMENT OF A DISORDER OF SELF THROUGH FUNCTIONAL ANALYTIC PSYCHOTHERAPY
Figure 1. Data pre, during and post treatment from questionnaires applied to Gloria.
ing year abroad. She said that she was really excited about this (CRB2). She had faced some completely new situations (she had spoken to the university staff and that had gone well). The T asked her what he knew about the first guy (evoking CRB) and she said that she had not seen him for a year and then, for the first time, she described how she had had sexual relations with him and that it had not gone well. She also said that she had been speaking with the second guy who seemed to be running away from her (CRB2). On talking to him, he said that he was seeing another girl and that, on hearing this, she had not felt bad. Also, in her home town, she had had a confrontation with a girl in her group of friends who had criticized her (CRB2). The 22th session was a month and a half after the previous. She noted many improvements and discussed her problems in the past tense. She acknowledged that her social relationships were going well and that those with her family too. As regards the home town friends with whom she had had difficulty, she said that she had been out with them and she had been fine (CRB2). As far as her studies were concerned, they were going well. She was studying and was not under too much pressure. She had had some exams and she had been calm. When asked by the T what she had learned from the treatment, she replied: “To be myself, to be more independent, to not care so much what others thought. Not to be afraid of getting to know people. Not to feel anxiety and not to feel affected by my family problems.” The 23th session was a month after the previous one. She described how her exams were over and that she had failed one and that she had taken it very well and had slept for 8 hours (CRB2). She also indicated that she had had problems with her flat. Her landlady had not wanted to return her deposit and that she had faced this problem and had achieved what she wanted. She also said she was looking for a house or apartment abroad. The end of therapy was proposed. The AAQ, EOSS and BDI questionnaires were completed.
A telephone follow-up 6 months after the last visit was conducted. There was also a follow up via email 13 months after the last session, in which she said that she was abroad on a scholarship and that, thanks to the therapy, the experience was completely different and that the therapy had been an enriching experience.
RESULTS Data from the various assessments during the therapy can be seen in Figure 1. At pretreatment, the total of the EOSS scores was 113, indicating a high public control of her self. The BDI score was 19, indicating moderate depression. On the AAQ she had a score of 36, indicating a clinical level of avoidance. After therapy and during follow-up, scores dropped significantly, with the total of the EOSS dropping to 52, the BDI dropping to 3, and the AAQ dropping to 24, which is in the normal range. The scores of various subscales of EOSS can also be seen at three stages of the therapy. Previous data suggest that she had a high public control of self in general (EOSS-1: 32). It also showed public control of self when dealing with people with a degree of intimacy such as family and friends (EOSS-3: 31). It also showed a high degree of control in terms of spontaneity and creativity, both alone and with others (EOSS-4: 32). In contrast, the results were lower for her control of self when dealing with strangers (EOSS-2: 18). Six months later, during treatment, there is a clear lowering of the scores (EOSS-1: 24, EOSS-2: 12, EOSS-3: 14 and EOSS4: 21). This coincides with the improvement that had been detected in the clinic; her appearance had improved, she was more spontaneous, others described her as changed and she maintained that she felt different and now felt she was being herself. Although she could express her needs and desires well she still had problems in expressing feelings. Six months later, when treatment had finished she felt much
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better and the following evaluation scores were made: EOSS-1: 12, EOSS-2: 10, EOSS-3: 14 and EOSS-4: 16. In the last sessions she described how she had had a misunderstanding with another guy which, although she had been affected by it, she had been able to take it in another way. She knew how to express her feelings to both the therapist and the boy.
DISCUSSION This case was treated as a moderate problem an unstable self (Kohlenberg & Tsai, 1991, 1995b) following the proposed recommendations of FAP. At no point were her depressive symptoms directly addressed by trying to improve her activities, but the treatment focused on putting her experience of self under private control. It seems that this therapy was effective, because the symptoms of depression were eliminated, she became more open to acceptance and her sense of self improved after the treatment, with the results being maintained after a follow-up of more than a year. The specific recommendations for treating problems of self seem to have been effective in this case.The FAP techniques proposed (free association, exercise of writing with the non-dominant hand, or dream with eyes open) may be clinically useful and are worthy of further study, but this case does not provide conclusive evidence that they are effective. According to these results, the EOSS is a measure which may be dynamic and responsive to client changes over the course of treatment. In addition, EOSS results seem to coincide with the results compared with other measures such as BDI and AAQ. Moreover, it appears to be useful to evaluate the experience of self, indicating the level of control over this experience in social relations of differing degrees of intimacy and also indicating the level of spontaneity. Therefore we know that it is very limited and that there are many alternative explanations for the case successful (e.g., the passage of time, the strong relationship with the therapist) and does not provide conclusive evidence that they are effective. Overall, the amount of research on the EOSS has been modest, with only a single study by Kanter, Parker & Kohlenberg (2001). Further research is needed on this measure. Finally, although there are several examples of work where FAP has been applied with personality disorders, including Callaghan, Summers & Weidman (2003), Kanter, Landes, Busch, Rusch, Brown, Baruch & Holman (2006), and Koerner, Kohlenberg & Parker (1996), it is clear that more research needs to be conducted in this area.
REFERENCES American Psychiatric Association (2001). DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders (Text Revised). [Spanish version. Barcelona: Masson]. Barraca, J. (2004). Spanish Adaptation of the Acceptance and Action Questionnaire (AAQ). International Journal of Psychology and Psychological Therapy, 4, 3, 505515. Baruch, D. E., Kanter, J.W., Busch, A. M., Plummer, M. D., Tsai, M., Landes, S.J. & Holman, G.I. (2009). Lines Of Evidence in Support of FAP. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W.C. Follette, & G. M. Callaghan, (Eds). A Guide to Functional Analytic Psychotherapy. Awareness, Courage, Love and Behaviorism. (pp.: 21-36). New York: Springer. Beck, A.T., Steery, R.A., & Brown, G.K. (1996) Manual for the Beck Depression
Inventory-II. San Antonio, TX: Psychological Corporation.[Spanish version TEA Editores] Busch, A. M., Manos, R.C., Rusch, L. C., Bowe, W.M. & Kanter, J. W. (2010). FAP and Behavioral Activation. In J. W. Kanter, M. Tsai & R.J. Kohlenberg (Eds) The Practice of Functional Analytic Psychotherapy. (pp.: 65-81) New York: Springer Callaghan, G.M., Gregg, J.A., Marx, B.P., Kohlenberg, B.S. & Gifford, E. (2004). FACT: The utility of an integration of Functional Analytic Psychotherapy and Acceptance and Commitment Therapy to alleviate human suffering. Psychotherapy: Theory, Research, Practice, Training, 41, 195-207. Callaghan, G., Summers, C. J. & Weidman, M. (2003). The treatment of Histrionic and Narcissistic Personality Disorder Behaviors: A Single-Subject Demonstration of Clinical Improvement Using Functional Analytic Psychotherapy. Journal of Contemporary Psychotherapy, 33, 4, 321-339. Ferro, R. (2008). Recent Studies in Functional Analytic Psychotherapy. International Journal of Behavioral Consultation and Therapy, 4, 2, 239-249. Ferro, R., Valero, L. & Lopez Bermudez, M.A. (2009). The Conceptualization of Clinical Cases from Functional Analytic Psychotherapy. Papeles del Psicólogo, 30, 3, 255-264. Ferro, R., Valero, L. & Vives, M.C. (2006). Application of Functional Analytic Psychotherapy: clinical analysis of a patient with depressive disorder. The Behavior Analyst Today, 7, 1-18. Gaynor, S.T. & Scott, P. (2002). Complementing CBT for depressed adolescents with learning through in vivo experience (LIVE): Conceptual Analysis, Treatment description, and feasibility study. Behavioral and Cognitive Psychotherapy, 30, 79-101. Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Pierson, H. M., Piasecki, M. P., Antonuccio, D. O., & Palm, K. M. (2011). Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation. Behavior Therapy, 42(4), 700-715. Kanter, J. W., Landes, S. J., Busch, A. M., Rusch, L. C., Brown, K. R., Baruch, D. E. & Holman, G. (2006). The Effect of Contingent Reinforcement on Target Variables in Outpatient Psychotherapy for Depression: A Successful and Unsuccessful Case Using Functional Analytic Psychotherapy. Journal of Applied Behavior Analysis, 39, 463-467. Kanter, J. W., Parker, C. & Kohlenberg, R. J. (2001). Finding the self: A behavioral measure and its clinical implications. Psychotherapy: Theory, Research and Practice, 38, 198-211. Kanter, J. W., Tsai, M. & Kohlenberg, R. J. (2010). The Practice of Functional Analytic Psychotherapy. New York: Springer Kanter, J. W., Weeks, C. E., Bonow, J. T., Landes, S. J., Callaghan, G. M. & Follette, W. C. (2009). Assessment and Case Conceptualization. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W.C. Follette, & G. M. Callaghan, (Eds). A Guide to Functional Analytic Psychotherapy. Awareness, Courage, Love and Behaviorism. (pp.: 37-59). New York: Springer. Koerner, K.; Kohlenberg, R.J. & Parker, R. (1996). Diagnosis of Personality Disorder: A Radical Behavioral alternative. Journal of Consulting and Clinical Psychology, 64, 1169-1176. Kohlenberg, B. S. & Callaghan, G. M. (2010). FAP and Acceptance Commitment Therapy (ACT): Similarities, Divergence, and Integration. In J. W. Kanter, M. Tsai & R.J. Kohlenberg (Eds) The Practice of Functional Analytic Psychotherapy. (pp.: 31-46) New York: Springer Kohlenberg, R. J. , Kanter, J.W., Tsai, M. & Weeks, C. W. (2010). FAP and Cognitive Behavior Therapy. In J. W. Kanter, M. Tsai & R.J. Kohlenberg (Eds) The Practice of Functional Analytic Psychotherapy. (pp.: 11-30) New York: Springer Kohlenberg, R. J. & Tsai, M. (1991). Functional Analytic Psychotherapy. Creating intense and curative therapeutic relationship. New York: Plenum Press. Kohlenberg, R.J. & Tsai, M. (1995a). Functional Analytic Psychotherapy: a behavioral approach to intensive treatment. In W. O’Donohue & L. Krasner (Eds.), Theories of behavior therapy. Exploring behavior change, (pp.: 637-658).Washington: APA. Kohlenberg, R. J., & Tsai, M. (1995b). I speak, therefore I am: A behavioral approach to understanding the self. The Behavior Therapist, 18, 113-116.
TREATMENT OF A DISORDER OF SELF THROUGH FUNCTIONAL ANALYTIC PSYCHOTHERAPY Kohlenberg, R.J., Tsai, M., Ferro-Garcia, R., Valero, L., Fernandez-Parra, A., & ViruesOrtega, J. (2005). Functional Analytic Psychotherapy and Acceptance and Commitment Therapy: Theory, aplications and continuity with the behavior analysis. International Journal of Clinical and Health Psychology, 5 (2), 37-67. Kohlenberg, R.J., Tsai, M., Kanter, J. W. & Parker, C.R. (2009). Self and Mindfulness. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. Follette & G.M. Callaghan (Eds.). A Guide to Functional Analytic Psychotherapy. Awareness, Courage, Love, and Behaviorism. (pp.: 103-130). New York: Springer. Lopez-Bermudez, M.A., Ferro, R. & Calvillo, M. (2010). An Application of Functional Analytic Psychotherapy In a case of Anxiety Panic Disorder Without Agoraphobia. International Journal of Behavioral Consultation and Therapy, 6, 4, 356-372. Lopez-Bermudez, M.A., Ferro, R. & Valero, L. (2010). Intervencion en un Trastorno depresivo mediante la Psicoterapia Analitica Funcional. Psicothema, 22, 1, 9298. [Intervention with a depressive disorders through Functional Analytic Psychotherapy] Martell, C.R., Addis, M. E. & Jacobson, N. S. (2001). Depression in Context. Strategies for Guided Action. New York: Norton. Michael, J. (1993). Establishing operations. The Behavior Analyst, 16, 191-206. Tsai, M., Kohlenberg, R.J., Kanter, J.W., Kohlenberg, B., Follette, W. & Callaghan, G.M (2009). A Guide to Functional Analytic Psychotherapy. Awareness, Courage, Love, and Behaviorism. New York: Springer. Tsai, M., Kohlenberg, R.J., Kanter, J.W. & Waltz, J. (2009). Therapeutic Technique: The Five Rules. In M.Tsai, R.J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. Follette, & G.M. Callaghan (Eds.). A Guide to Functional Analytic Psychotherapy. Awareness, Courage, Love, and Behaviorism. (pp.: 61-102). New York: Springer.
Waltz, J., Landes, S.J. & Holman, G. I. (2010). FAP and Dialectical Behavior Therapy (DBT). In J. W. Kanter, M. Tsai & R.J. Kohlenberg (Eds). The Practice of Functional Analytic Psychotherapy. (pp.: 47-64) New York: Springer
AUTHORS’ CONTACT INFORMATION RAFAEL FERRO-GARCIA
Centro de Psicología Clínica CEDI Avda. Constitución 25, 7 Izda. 18014 Granada (Spain) E-mail:
[email protected]. MIGUEL ANGEL LOPEZ-BERMUDEZ
Centro de Psicología CEPSI, Plaza General Castaños, Bailén 23710 Jaen (Spain) Email:
[email protected] LUIS VALERO-AGUAYO
Facultad de Psicologia Campus Teatinos, Universidad de Málaga 29071 Malaga (Spain) Email:
[email protected]
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©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Development and Preliminary Evaluation of a FAP Protocol: Brief Relationship Enhancement Gareth Holman, Robert J. Kohlenberg, & Mavis Tsai University of Washington Abstract The purpose of this study was to develop a brief Functional Analytic Psychotherapy (FAP) protocol that will facilitate reliable implementation of FAP interventions, thus supporting research on FAP process and outcome. The treatment was a four-session individual therapy for clients who were interested in improving their relationship with their romantic partner. Data were collected from both the client and their partners. The treatment development process was conducted across two clinical case series. The first case series (n = 7) provided preliminary evidence of the feasibility and acceptability of the treatment, but rates of FAP interventions were low. Subsequently the treatment protocol and training and supervision procedures were revised. The second clinical case series (n = 6), based on the revised protocol, produced significantly higher rates of FAP interventions and further evidence of the acceptability and feasibility of the treatment. The study provides preliminary evidence that FAP interventions may be reliably implemented in the context of a brief, structured treatment.
Keywords Functional Analytic Psychotherapy, brief therapy, relationship enhancement, therapy relationship
T
his paper reports an effort to create a brief Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et al., 2008) intervention protocol. The goal of the protocol is to facilitate therapist implementation of FAP principles with fidelity and competence. Just as important, we sought to make this implementation as efficient, as consistent, and therefore as replicable as possible. In taking on this task, we were responding to a judgment like that offered by Weeks, Kanter, Bonow, Landes, & Busch (2011) in their excellent discussion of a logical framework for FAP interactions: that FAP procedures have perhaps not been specified with enough ‘specific instructions’ to therapists (Weeks et al., 2011; p. 89), and that as a result there may be considerable inefficiency and difficulty in efforts to study FAP. However, while Weeks et al. (2011) focused on clearly articulating a general framework for how the core mechanism of change in FAP (the 5 rules) might play out in a therapy interaction, in this study explored the complementary approach of developing a very minimal and therefore (hopefully) efficient treatment protocol. The protocol is minimal in three primary ways. First, we sought to reduce variability and complexity in the treatment process by focusing on a single outcome: improvement of the client’s romantic relationship. Further, in this pilot treatment development work, we focused on the treatment of non-distressed clients in non-distressed relationships. Because of this significant difference from a typical clinical situation, the treatment as presented in this paper might be considered an analogue treatment protocol. However, we hope that in future work the protocol might be applied and evaluated in clinical situations. Second, we sought to create a brief protocol (4-sessions) to increase its repeatability and thus feasibility for research. In ad-
dition, we have noted concern that relationship-focused treatments such as FAP may be less compatible with brief treatment formats than more conventional behavior therapy interventions. The study reported here therefore also represents a preliminary test of the hypothesis that FAP may be implemented in a brief treatment. Third, the protocol provides significant structure for each treatment session, seeking to reduce variability of in-session activities between therapists and clients that might complicate study of treatment process or outcome. In sum, in contrast to the flexible yet highly specific framework offered by Weeks et al. (2011), the ‘specific instructions’ our protocol offers concern the conduct of FAP with a specific type of client problem and provide detailed guidelines about how to structure each treatment session. The goal however is the same: the consistent and repeatable implementation of FAP principles. The protocol was developed by an iterative process over the course of two clinical case series. These series, reported briefly here, offer preliminary evidence of the feasibility, acceptability, and utility of the protocol, as well as some evidence that the protocol successfully supported implementation of FAP principles.
METHODS FOR THE FIRST CLINICAL SERIES CREATION OF THE TREATMENT PROTOCOL VERSION 1.0 An initial version of the treatment manual was created by the first and third authors. This first manual was based on the agreement that the protocol would be four-sessions long, would treat an individual client, and would target the goal of improving the client’s romantic relationship satisfaction. We intended to recruit couples however, so that we could assess both members of the 52
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couple at pre- and post-treatment. A FAP rationale was delivered in the first session. The initial session was to focus on rapid functional assessment of the client’s romantic relationship problems, based on client’s report of their relationship patterns and observation of client in-session behavior. This functional assessment lead to selection of goals expected to improve relationship satisfaction, which were refined and revised over the course of treatment. Clinically Relevant Behavior (CRB; in FAP terminology, examples of client problems or improvements occurring in the therapy interaction) were subsequently identified on the basis of this ongoing functional assessment and goal definition. To target anticipated ‘commonly-occurring-problems/goals,’ to evoke CRB, and to provide structure for sessions, we created a procedure for opening sessions (the Greeting and Opening), a procedure for closing sessions (Sharing of Appreciations), and a menu of procedures that might be used in-session or assigned as homework, based on functional assessment of the client’s problem. The Greeting and Opening involved client and therapist mindful and open sharing of feelings and experiences and mindful and open listening to the other’s feelings and experiences. Sharing of Appreciations involved client and therapist exchanging several rounds of appreciations regarding the session and course of treatment, providing among other functions an opportunity for the therapist to reinforce any CRB-2 (CRB that represent improvements). The remainder of session-time was focused on implementation of FAP principles. The overarching theory of therapeutic mechanism was that decreased frequency of CRB1 (CRB that represent problems) and increasing frequency/strength of CRB2 would lead, via generalization (e.g., by means of homework assignments), to decreased frequency of problems occurring in the client’s romantic relationship and increased frequency of positive (defined functionally as increasing relationship satisfaction) interactions, and this would in turn lead to increased global relationship satisfaction. This preliminary manual was then evaluated in a clinical series involving 8 couples. Participants were recruited via print and online ads placed locally. All study procedures were approved by the UW IRB committee. THERAPISTS The first author and three other graduate students with 1+ years of FAP training served as therapists in this first series. Initial cases were conducted one after another; the final three cases were conducted simultaneously. Therapists and the authors of this paper met regularly to discuss cases and the protocol. CLIENT AND PARTNER DEMOGRAPHIC AND RELATIONSHIP DATA Clients were 7 females and 1 male. All couples were heterosexual, male-female couples. Average age was 29.6 years (range: 18-57 years; SD = 10.7), and participants had completed an average of 4.5 years of post-HS education (range: 2-8 years; SD = 1.8 years). Mean relationship duration was 49 months (4.1 years; SD = 51.5 months) and ranged between 8 months and 168 months (14 years). Three of the 8 couples were married. No participant had ever been in couples therapy prior to this study. ASSESSMENTS Participants completed a battery of assessments at pre- and post-treatment, including several relationship satisfaction ques-
tionnaires, including the Dyadic Adjustment Scale (Spanier, 1976) and the Quality of Relationship Inventory (Pierce, Sarason, Sarason, Solky-Butzel, & Nagle, 1997). Participants also completed a daily diary card throughout the study period, on which they rated levels of connection (‘how close you feel to your partner’) and respect (‘how much mutual respect you feel in the relationship’) occurring in their relationship and indicated whether conflict had occurred (yes or no). Following definition of treatment goals after the first session, clients also provided a goal-attainment rating (Kiresuk, Smith, & Cardillo, 1994) for each goal daily. Finally, immediately before each session, clients reported progress on their goals for the previous week overall and over the whole course of treatment, and after each session clients completed a questionnaire on which they provided several ratings (e.g., their degree of connection with the therapist and the helpfulness of the session) and answered questions about events relevant to FAP process (e.g., What issues came up for you in the session/with your coach that are similar to your daily life interactions with your partner? What risks did you take in the session/with your coach or what progress did you make that can translate into your interactions with your partner?) Following each session, therapists reported whether CRB1 and/or CRB2 had occurred and whether they had responded effectively or ineffectively to these CRB. To further assess implementation of FAP interventions, each session was coded using the Cumulative Record of In-Vivo Interventions (CRIVI; Kanter, Schildcrout, & Kohlenberg, 2005), a count of the frequency of therapist speech focused on the invivo (IV) (i.e., immediate or ongoing) therapy interaction. The assumption is that greater frequency of IV focused interventions indicates greater implementation of FAP interventions. In previous research, greater frequency of such focus was related to greater likelihood of the client reporting improved relationships in the subsequent week (Kanter et al., 2005). Ratings were performed by a group of research assistants who were trained to adequate reliability with a criterion rater on a previous project. Finally, for each session in which the therapist reported that CRB occurred, two FAP experts (the first and second authors) viewed the session and either confirmed or disconfirmed that sufficient evidence that a CRB had occurred was present in the session. This judgment was based on a protocol that specified types of evidence for the occurrence of CRB and criteria for confirmation/disconfirmation This method is obviously potentially quite biased; results of this coding are offered here as exploratory with this significant caveat.
RESULTS FOR THE FIRST CLINICAL SERIES BASELINE ASSESSMENT DATA All clients (n = 7) and partners (n = 7) completed baseline assessments. Clients and partners had on average comparable satisfaction scores at baseline, and their DAS scores were representative of non-distressed couples (Spanier, 1976). RETENTION One couple dropped out of the study before the post-treatment assessment. The client reported that she had started a new job
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that prevented her from continuing participation in the study. This client is therefore excluded from the following presentation of results. PRE TO POST-TREATMENT CHANGES There was no consistent pattern of improvement on the standard relationship satisfaction measures at post-treatment for clients or partners. DIARY CARD RATINGS OF CONNECTION AND RESPECT AND GOAL ATTAINMENT Weekly mean ratings of connection and respect increased in 4 of the 6 cases presented here. The average ratings increased approximately 1 standard deviation across the treatment period, from 5.5 (SD = .9) to 6.8 (SD = 1.2) for connection and from 5.4 (SD = 1.1) to 6.6 (SD = 1.1) for respect. Ratings of connection and respect tended to correlate across the entire treatment period (r = .87, p < .01). CLIENT PRE-SESSION RATINGS OF GOAL ATTAINMENT Before each session, clients rated their past week and overall (i.e. throughout the entire study period) progress on between 1 and 3 specific goals. Goal attainment was rated on a scale from 1 to 10, where 10 indicates perfect or complete goal attainment, 5 indicates no progress, and scores below 5 indicate regression or worsening of the goal behavior. The average overall goal attainment reported at Session 2 (the first rating point) was 6.2 (corresponding to the ‘neutral’). The average overall goal attainment was 6.7 at Session 3 and 7.6 at Session 4 (indicating ‘some progress’). THERAPIST RATINGS OF IN-SESSION GOAL RELATED BEHAVIOR OCCURRENCE Following each session, the therapist provided ratings of whether he/she believed that CRB had occurred in session. The response scale included the rating ‘Unsure.’ With the exception of one session, the first therapist rated ‘Unsure’ for all sessions. For the remaining two therapists, who treated the remaining two clients, therapists reported that CRB occurred in three out of eight sessions. CRIVI RATINGS For each session, the average percentage of IV hits ranged from .7 to 3.6. Across all four sessions, the mean percentage of IV hits was 2.5. EXPERT RATING OF OCCURRENCE OF CRB For the Phase 1 sessions in which therapists reported that CRB occurred (n = 4), expert raters failed to confirm the occurrence of CRB in all cases except for one.
DISCUSSION OF THE FIRST CLINICAL SERIES Based on the first clinical series results, it is warranted to conclude that the protocol was feasible and acceptable. Recruitment goals were met and there was satisfactory adherence to the assessment protocol. Six out of seven clients completed all four sessions and provided generally high ratings on post-session rating forms. Daily diary card ratings of relationship quality (connection and respect) as well as ratings of goal attainment increased modestly across the treatment period, however no
improvements were reported on the standard measures of relationship satisfaction. It was evident, however, that the treatment protocol as implemented in the first series did not adequately support implementation of FAP interventions, indicated by absence of therapist report that CRB occurred in many sessions, by the failure of FAP experts to confirm the occurrence of CRB in sessions in which therapists reported that CRB did occur, and by the low rates of IV interventions recorded in the CRIVI ratings. Consequently, the most important result of the first clinical series was the identification of obstacles to FAP implementation, informing subsequent improvement of the treatment protocol. Specifically, to explain the low level of IV interventions and to guide subsequent treatment development, based on review of sessions from the first clinical series, the following hypotheses were generated: (1) The goal identification process was too open ended and required too much session time; (2) behavior analysis of goal-related behavior was not adequately implemented, leading to vagueness or narrowness in goal definition and lack of functional understanding of goal-related behavior, which in turn undermined conceptualization of CRB; (3) in-vivo behaviors were not adequately assessed throughout each session, and even when significant in-vivo process was clearly present, it was often ignored if it did not relate closely to the identified (narrow) treatment goals. Accordingly, we updated the treatment manual in the following ways: (1) We streamlined the goal setting procedure, requiring clients to select from a list of standard goals; (2) we expanded procedures for functional definition of problematic and goal-related behavior and created several worksheets to facilitate identification of context, behaviors, and consequences associated with problems and improvements; (3) we greatly expanded and elaborated procedures for noticing/evoking CRB across all treatment elements (e.g., listing commonly occurring CRB in relation to the goal setting process, the Greeting and Opening, etc.), and (4) we emphasized identification of CRB on the basis of much more broad, flexible assessment of functional similarity with romantic relationship behaviors. The result of these modifications was a 46-page treatment manual, accompanied by two 60-minute training sessions, and a protocol for weekly group supervision focused on the above features of the protocol. It should be noted that these hypotheses for treatment development were generated in a context in which multiple confounding variables were present: there are numerous explanations for the observed phenomena in the first case series. These include the inexperience of the therapists in conducting brief FAP, as well as, more generally, the unsuitability of FAP for a brief therapy context in general. However, if the second clinical series (presented below) resulted in improved outcomes on the key criteria for treatment development success, this was to be taken as limited evidence of the validity of these treatment development hypotheses for reaching the desired goals.
METHODS FOR THE SECOND CLINICAL SERIES Methods were as in the first case series, with these exceptions: (1) the use of the revised treatment manual; (2) addition of
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an organized weekly group supervision session, (3) additional items were added to the client post-session questionnaire assessing whether problems/improvements similar to those occurring in the client’s romantic relationship (i.e., CRB) had occurred in session; and (4) the addition of a variable length baseline assessment period, using the daily diary card, prior to the first session.
RESULTS OF THE SECOND CLINICAL SERIES CLIENT AND PARTNER DEMOGRAPHIC AND RELATIONSHIP DATA Clients were 3 females and 3 males. Partners were 3 females, 2 males, and one transgendered individual. Two couples were same-sex couples: one male-male couple, one female-female couple. One couple was female and transgender. Average age was 30 years (range:21-41 years; SD = 7.3), and participants had completed an average of 5.6 years of post-HS education (range: 2-12 years; SD = 3.2 years). Mean relationship duration was 21.2 months (SD = 8.4 months) and ranged between 8 months and 11 years. Two of the 8 couples were married; one couple was in domestic partnership. One of the couples has previously participated in couples therapy together prior to this study. BASELINE ASSESSMENTS DATA At pre-treatment, client and partner DAS scores were 111.8 (SD = 6.0) and 116 (SD = 9.0) respectively. As in Phase 1, these baseline DAS scores are closely representative of non-distressed couples. COMPLETION All six couples/clients who entered the clinical series completed all study procedures. PRE- TO POST-TREATMENT CHANGES At post treatment, there was no clear pattern of improvement on any of the standard relationship satisfaction scales for clients or partners. DIARY CARD RATINGS OF CONNECTION AND RESPECT Clients completed the daily diary card for a variable baseline period of 1 to three weeks. One client completed the card for one week; three clients completed the card for two weeks; two clients completed the card for three weeks. As in first clinical series, weekly mean ratings of connection and respect increased in all cases over the treatment period. Weekly mean ratings of connection increased from 6.3 (SD = .7) to 7.1 (SD = 1.0) and ratings of respect increased from 6.6 (SD = .8) to 7.1 (SD = 1.3). Again, ratings of connection and respect tended to correlate across the entire treatment period (r = .89, p < .01). CLIENT PRE-SESSION RATINGS OF GOAL ATTAINMENT As in Phase 1, before each session, clients rated their past week and overall (i.e. throughout the entire study period) progress on between 1 and 3 specific goals. All clients rated two goals. The average overall goal attainment reported at Session 2 (the first rating point) was 6.8 (corresponding to ‘neutral’; SD = 1.0). The average overall goal attainment was 7.0 (SD = .9) at Session 3 and 7.4 (SD = .6) at Session 4 (indicating ‘some progress’).
CLIENT RATINGS OF IN-SESSION GOAL RELATED BEHAVIOR OCCURRENCE Following each session, clients provided ratings of the occurrence of behaviors related to their relationships goals in the interaction with their therapist (i.e., CRB). Examples of problem behaviors and relative improvement were rated separately. In addition, for occurrence of problem behaviors, clients rated how similar the behaviors were to behaviors that occur with their partner, how aware the therapist seemed of the occurrence of these behaviors, and whether the therapist prompted the client to respond differently (in line with the identified treatment goals). For occurrence of relative improvements, clients rated how aware the therapist was of these behaviors, whether the therapist made the client feel appreciated or acknowledged for the improvement, whether the improvement was discussed in relationship to the client’s behavior in their romantic relationship, and whether the therapist discussed how to generalize improvements to the romantic relationship. All of these ratings were made on a Likert-type scale ranging from 1 to 5, where 1 indicates ‘not at all’ and 5 indicates ‘extremely.’ In all sessions, clients reported that issues similar to their issues with their partner had occurred in session with either high (more than three times) or low (3 or less times) frequency. Ratings of the similarity of issues occurring in session to the issues occurring in the client’s romantic relationship ranged from 3 (indicating ‘somewhat similar’) to 5 (indicating ‘extremely similar’). The mean ratings for Sessions 1 through 4 were 3.3 (SD = .7), 3.6 (SD = .5), 4.6 (SD = .5), and 4.3 (SD = .5) respectively. Client ratings of therapist’s awareness of the occurrence of issues ranged from 3 (indicating ‘somewhat aware’) to 5 (indicating ‘extremely aware’). The mean ratings for Sessions 1 through 4 were 4.3 (SD = .5), 5 (SD = 0), 4.8 (SD = .4), and 4.8 (SD = .4) respectively. Client ratings of whether the therapist prompted them to respond different given the occurrence of issues ranged from 2 (indicating ‘a little’) to 5 (indicating ‘extremely’). The mean ratings for Sessions 1 through 4 were 2.8 (SD = 1.1), 4.3 (SD = .7), 4.2 (SD = .7), and 4 (SD = 1) respectively. Clients reported that improvements with respect to the target issues (i.e., improvements rather than issues) occurred in all sessions with either ‘high’ (indicating more than three times) or ‘low’ (indicating three or less times) frequency. Client ratings of the therapist’s awareness of improvements ranged from 3 (indicating ‘somewhat’ aware) to 5 (indicating ‘extremely’ aware). The mean ratings for Sessions 1 through 4 were 4 (SD = .8), 4.3 (SD = .7), 4.6 (SD = .5), and 4.7 (SD = .7) respectively. Client ratings of whether the therapist responded to improvements in a way that helped the client feel appreciated or acknowledged ranged from 3 (indicating ‘somewhat’ aware) to 5 (indicating ‘extremely’ aware). The mean ratings for Sessions 1 through 4 were 4.3 (SD = .5), 4.5 (SD = .5), 4.8 (SD = .4), and 4.2 (SD = .9) respectively. Client ratings of whether the therapist discussed the relationship of in-session improvements to patterns in the romantic relationship ranged from 2 (indicating ‘slightly’ discussed) to 5 (indicating ‘extremely’ discussed). The mean ratings for Ses-
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sions 1 through 4 were 4.3 (SD = 1.1), 4 (SD = 1), 4 (SD = 1), and 4.2 (SD = 1.1) respectively. Client ratings of whether the therapist discussed translation of in-session improvements to the client’s romantic relationship ranged from 2 (indicating ‘slightly’ discussed) to 5 (indicating ‘extremely’ discussed). The mean ratings for Sessions 1 through 4 were 3.7 (SD = .9), 3.7 (SD = 1.1), 3.7 (SD = 1.1), and 4.2 (SD = 1.1) respectively. THERAPIST RATINGS OF CRB OCCURRENCE In all sessions except for two (the first sessions for the first two clients), therapists reported that client behavior similar to the client’s clinically significant behavior with their partner had occurred with either ‘low’ (indicating three or less occurrences) or ‘high’ (indicating more than three occurrences) frequency. Following session 1, all therapists indicated that issues occurred with high frequency in all sessions, with only two exceptions – Sessions 2 and 4 for the second client. Therapist ratings of the similarity of issues occurring in session to issues occurring in the client’s romantic relationship increased from a mean of 3.25 (indicating ‘somewhat similar’; SD = .43) in Session 1 to a mean of 4.8 (indicating ‘moderately’ to ‘extremely similar’; SD = .4) in Session 4. Therapist report that they effectively extinguished or punished behaviors representative of issues (CRB1) increased from a mean of 2.3 (indicating ‘slightly’ punishing/extinguishing; SD = 1.3) to a mean of 4.4 (indicating ‘moderately’ to ‘extremely’ punishing/extinguishing; SD = .5) in Session 4. Therapist report that they (ineffectively) reinforced the occurrence of issues decreased slightly from a mean of 1.75 (indicating ‘slightly’ reinforced; SD = 1.1) in Session 1 to a mean of 1.4 (SD = .5) in Session 4. In all sessions, therapists reported that client improvements in goal-related behavior had occurred with either ‘low’ (indicating three or less occurrences) or ‘high’ (indicating more than three occurrences) frequency. Therapist report that they effectively reinforced such improvements increased from a mean of 4.2 (indicating ‘moderately reinforced; SD = .6) in Session 1 to a mean of 5 (indicating ‘extremely reinforced’; SD = 0) in Session 2, where it remained for the subsequent two sessions. Therapist reported that they (ineffectively) punished in-session improvements at a mean level of 1 (indicating ‘not at all’; SD = .6) in Session 1, followed by a mean 1.6 (SD = .8), a mean of 1 (SD = 0), and a mean of 1.2 (SD = .4) in Sessions 2 through 4 respectively. Therapists rated their discussion of the functional similarity between in-session and romantic relationship behavior at a mean of 3.2 (indicating ‘somewhat’ effectively discussed; SD = .7) in Session 1, increasing to a mean of 4.2 (indicating ‘moderately’ effectively discussed; SD = .7) in Session 4. Therapists rated their discussion of generalization of in-session improvements to the romantic relationship at a mean of 2.4 (indicating ‘slightly’ effectively discussed; SD = 1.0) in Session, increasing to a mean of 4.6 (indicating ‘moderately’ to ‘extremely’ effectively discussed; SD = .5) in Session 4. CRIVI RATING The percentage of IV hits for each session ranged from 0 to 46.7. Across all four sessions, the mean percentage of IV hits was 17.2.
EXPERT CONFIRMATION OF OCCURRENCE OF CRB In 20 out of 22 sessions in which therapists reported that CRB had occurred, the expert raters confirmed the occurrence of CRB using the method presented above.
DISCUSSION OF THE SECOND CLINICAL SERIES As in the first clinical series, standard measures of relationship satisfaction did not demonstrate improvement, though again clients reported modest progress on idiographic measures. More importantly, however, the second clinical series provided much greater evidence of implementation of FAP interventions, as evidenced by client, therapist, and observer ratings. In particular, the frequency of in-vivo hits rated by the CRIVI increased from 2.5% in the first clinical series to 17.2% in the second clinical series. This data lends support to the hypothesis that the improved protocol and/or training/supervision procedures used in the second clinical series more effectively supported implementation of FAP.
GENERAL DISCUSSION This study aimed to develop and test a brief FAP treatment protocol. The protocol was developed across two clinical series. Following the first clinical series, given data that the protocol did not adequately support implementation of FAP interventions, the protocol was refined. Subsequently, the second clinical series provided much stronger evidence of successful implementation of FAP interventions. In particular, rates of in-vivo interventions in the second clinical series exceeded rates found in the largest study of a FAP intervention to date (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002): 17.2% for our second clinical series vs. 9.2% in the previous FAP study. Client and therapist self-reports immediately after each session provided further evidence that FAP principles were implemented effectively, with expert raters confirming the occurrence of 20 out of 22 therapist reported CRB in the second clinical series. Notably, client and therapist ratings generally changed across sessions in ways predicted by FAP theory (Weeks et al., 2011): e.g., CRB2 increased in frequency and CRB1 decreased in frequency. Taken together, this data provides preliminary evidence that FAP may in fact be implemented in a brief treatment setting. Despite these promising findings, neither clinical series produced improvements on standard measures of relationship satisfaction. There are a variety of factors that might explain this lack of change (e.g., clients were already highly satisfied and measures are not sensitive to change in the high satisfaction range; the treatment period was not of sufficient duration to produce global change in satisfaction; specific treatment goals were not adequately linked to global satisfaction; the samples treated in these clinical series were small and somehow not representative), however it may also be that 4 individual sessions of FAP are not an effective way to improve overall relationship satisfaction. In addition, several significant limitations of the study reported here should be noted. First, the self-report of clients and therapists and the ratings of our experts (authors of the current paper) are susceptible to bias, following the expectations of the researchers. Second, the changes to the protocol between the
DEVELOPMENT AND PRELIMINARY EVALUATION OF A FAP PROTOCOL
first and second clinical series co-occurred with the addition of group supervision sessions for therapists, and in general it is not clear which factors, if any, of those discussed in this paper may have produced the observed effects. This work represents a preliminary study of the utility of a brief, focused FAP protocol for relationship improvement with a single client. Despite the limitations of this work, we hope that it provides some inspiration for the study of similar brief, structured FAP protocols and that this study in turn advances the scientific study of FAP.
REFERENCES Kanter, J. W., Schildcrout, J. S., & Kohlenberg, R. J. (2005). In vivo processes in cognitive therapy for depression: Frequency and benefits. Psychotherapy Research, 15(4), 366-373. Kiresuk, T.J., Smith, A., & Cardillo, J.E. (1994). Goal attainment scaling: applications, theory, and measurement. New Jersey: Lawrence Erlbaum Associates, Inc. Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C., & Tsai, M. (2002). Enhancing cognitive therapy for depression with functional analytic psychotherapy: Treatment guidelines and empirical findings. Cognitive and Behavioral Practice, 9(3), 213-229. Kohlenberg, R. J., & Tsai, M. (1991). Functional Analytic Psychotherapy: A guide for creating intense and curative therapeutic relationships. New York: Plenum. Pierce, G.R., Sarason, I.G., Sarason, B.R., Solky-Butzel, J.A., & Nagle, L.C. (1997). Assessing the quality of personal relationships. Journal of Social and Personal Relationships, 14, 339-356. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15-28.
Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B. S., Follette, W. C., & Callaghan, G. M. (2008). A guide to functional analytic psychotherapy: Awareness, courage, love and behaviorism. New York: Plenum. Weeks, C.E., Kanter, J.W., Bonow, J.T., Landes, S.J., & Busch, A.M. (2011). Translating the theoretical into practical: A logical framework for Functional Analytic Psychotherapy interactions for research, training, and clinical purposes. Behavioral Modification, 36, 87-119.
AUTHOR CONTACT INFORMATION GARETH HOLMAN, PHD
Evidence-Based Practice Institute, Seattle WA Department of Psychology University of Washington, Seattle WA Mailing Address: 1111 Alberni St #3603 Vancouver, BC, Canada V6E 4V2 Email:
[email protected] Phone: 206-334-2755 MAVIS TSAI, PH.D.
Independent Practice and University of Washington 3245 Fairview Ave. East, Suite 301, Seattle WA 98102. Email:
[email protected] Phone: 206-322-1067 ROBERT J. KOHLENBERG, PH.D., ABPP
Department of Psychology Box 351629 University of Washington Seattle, WA 98195 Email:
[email protected] Phone: 206-543-9898
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INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Functional Analytic Psychotherapy is a Framework for Implementing Evidence-Based Practices: The Example of Integrated Smoking Cessation and Depression Treatment Gareth Holman, Robert J. Kohlenberg, Mavis Tsai, Kevin Haworth, Emily Jacobson, & Sarah Liu University of Washington Abstract Depression and cigarette smoking are recurrent, interacting problems that co-occur at high rates and – especially when depression is chronic – are difficult to treat and associated with costly health consequences. In this paper we present an integrative therapeutic framework for concurrent treatment of these problems based on evidence-based practices and Functional Analytic Psychotherapy (FAP). We report the results of a pilot study in which clients (n = 5) received the integrated treatment. Case material is presented to illustrate the integration of interventions within a FAP framework.
Keywords Functional Analytic Psychotherapy, integration, smoking cessation, behavioral activation, treatment development
F
unctional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et al., 2008) provides a framework for the implementation of evidence-based practices (EBPs) by helping therapists conceptualize and manage moment-by-moment therapy process. This process may be managed such that it conforms with the evidence-based practice when such is appropriate. This process also may help fill in the gaps – areas where therapists are asked to use clinical judgment – that are present in EBP protocols. If an EBP provides a map to a given destination (e.g., improved depression outcomes), then FAP acts like a GPS, locating the client and therapist in the here and now and guiding the therapy process, especially in areas where the map is fuzzy. The FAP therapist manages process on the basis of an ongoing, idiographic functional analysis of therapist-client interactions with the aim of understanding and solving client’s problems. This functional analysis serves a variety of functions relevant to implementation of EBP: (1) It may facilitate conceptualization of behaviorally specific treatment targets. For example, a FAP therapist might, through functional analysis, clarify their understanding of behaviors associated with ‘mistrust’ while treating a patient diagnosed with PTSD using the Cognitive-Processing Therapy protocol (Resick & Schnicke, 1993). (2) It may provide an understanding of how the motivational context of the therapy relationship impacts treatment adherence. For example, a FAP therapist may discriminate that a depressed patient does not initiate conversation about the impact of the therapy relationship, but that homework completion and mood reliably improves in weeks following sessions where the therapist initiates such conversations (cp., Kanter, Schildcrout, & Kohlenberg, 2005). (3) It provides a theoretical basis for addressing ‘alliance ruptures’ (e.g., Safran & Muran, 1996; Tsai, Kohlenberg, & Kanter, 2010), such as breaches of trust or positive regard or disagree-
ments about treatment goals and methods. Disagreements are interpreted in the context of the client’s problems and goals, such that a disagreement that would otherwise be labeled as resistance or non-compliance may be seen as a sign progress for a client whose problems involve excessive acquiescence. Indeed, FAP views conflict as an essential area of relationship functioning, one in which many of our clients have deficits. Conflicts in FAP may be considered opportunities for therapeutic shaping of effective behavior, rather than as non-compliance or resistance to a treatment protocol. (4) Finally, FAP directs attention to examples of the client’s problems occurring here and now in the therapy interaction; these here and now instances are shaped directly as they occur. It is a central hypothesis of FAP that such direct intervention on here and now examples of problems and improvements provides important therapeutic benefits. In summary, then, FAP provides a means of understanding how specific behaviors occurring in the therapy interaction may contribute to or detract from clinical outcomes during the course of conducting an EBP. In this way, FAP may be compared to other general therapeutic frameworks that aim to guide therapists in the implementation of interventions to best suit a specific client (e.g., Persons, 2008; Nezu, Nezu, & Lombardo, 2004). In common with these other approaches and with behavior therapy in general, FAP advocates an individualized assessment of the impact of an intervention of the individual client, and a systematic variation of intervention in case of non-response. The unique aspects of FAP are its focus on the use of functional analysis and its attention to the therapy relationship. To illustrate the above ideas, this paper presents the example of an integrated, FAP-based smoking cessation and depression treatment. We present a description of the treatment, some brief case material to illustrate key aspects of the treatment, and them
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summarize the results of a small pilot treatment development study. We selected smoking and depression because they are commonly co-occurring, often inter-related problems (Shiffman & Waters, 2004; Breslau & Johnson, 2000; Covey, Glassman, & Stetner, 1990) with significant public health consequences for which behaviorally based evidence-based treatments exist (Lejuez, Hopko, & Hopko, 2001; Perkins, Conklin, & Levine, 2007; Brown et al., 2001), offering an opportunity for parsimonious integration on the foundation of FAP. Further justifying the interpersonal focus of FAP, interpersonal problems contribute broadly to the onset, relapse, and/or maintenance of both smoking and depression (e.g., Mickens et al., 2011). We suspect that some clinicians may consider smoking cessation to be a rather simple clinical task, less interesting than meaty clinical issues related to intimacy and problems of self. We hope in this paper to show that this prejudice is misguided and that the task of smoking cessation provides in many ways a crucible in which the problems at the heart of depression may unfold. If additional motivation is needed, consider that smoking tobacco remains the leading cause of preventable death in the United States each year (Centers for Disease Control, 2005).
METHODS The treatment, named Integrated Treatment of Smoking and Depression (ITSD), integrated elements of behavioral activation for depression and standard behavior therapy for smoking cessation within the framework of Functional Analytic Psychotherapy. It involved 24 sessions over a 20-week period: twiceweekly sessions for the first four weeks and weekly sessions thereafter. Additionally, therapists and clients communicated via telephone or email, to reinforce homework compliance and especially to provide coaching around the smoking quit date. Finally, clients were encouraged to purchase and use nicotine replacement therapy (e.g. patch or gum) during their quit attempt. The primary elements of behavioral activation (Lejuez, Hopko, & Hopko, 2001; Martell, Addis, & Jacobson, 2001) as implemented in the treatment included provision of a behavioral conceptualization of depression; functional analysis of avoidance patterns based in part on activity monitoring; and planned behavioral activation activities designed to increase contact with positive reinforcement. The primary elements of behavior therapy for smoking cessation (Perkins, Conklin, & Levine, 2007) included discussion of past quit attempts to identify individual supports and risk factors; preparation for smoking cessation by means of self monitoring of urges and related triggers; gradual implementation of delayed smoking; setting a quit date; recruitment of social support and other coping skills to support cessation; and finally developing a relapse prevention plan. Further, our approach to the acceptance of depressogenic thoughts and smoking urges was informed by Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999), which has recently been investigated in the form of a group treatment for smoking cessation, that also integrates FAP, with promising positive outcomes (Gifford, Kohlenberg, Hayes, Pierson, Piasecki, Antonuccio, & Palm, 2011).
In the context of the integrated treatment, the client was provided a rationale for treating depression and smoking cessation at the same time. The rationale focused specifically on the inter-dependence of depressed mood and smoking behavior and how interpersonal stressors might impact both mood and urges to smoke. The rationale also included a standard rationale for FAP, emphasizing that behaviors occurring in the interaction between therapist and client might be significant and provide useful therapeutic opportunities, especially for addressing problematic interpersonal patterns that impact mood and smoking urges. The clinical procedures for each problem listed above were implemented in an integrated way. Early treatment focused on development of rapport and understanding with the purpose of establishing the therapist as a salient reinforcer for behavior change (i.e., increasing client motivation). Behavioral analysis of current client maladaptive patterns focused on the interaction of smoking and depression. Development of client skills to evoke and accept support from the therapist were implemented as a means of increasing general social support outside of session. Specific activation goals were selected to be incompatible with both smoking and depressed mood, e.g., daily exercise or spending time with children (around whom it is a strong value to abstain from smoking). Long-term values and goals served by smoking cessation and overcoming depression were highlighted. Further, engagement in smoking cessation activities were themselves considered to be behavioral activation targets. Throughout this process of implementation and integration therapists applied FAP principles to manage therapy process. To support this task, the treatment manual highlighted ways in which FAP principles might be applied for each smoking cessation or behavioral activation intervention, and clients completed standard FAP session bridging sheets between sessions (see Tsai et al., 2008), on which clients provided feedback about in-session process and the therapeutic relationship directly to the therapist. Two examples of this application of FAP principles within ITSD are presented below, in connection with interventions targeting acceptance of social support and establishing commitment to a quit date. ACCEPTANCE OF SOCIAL SUPPORT A client expressed that she often feels a compulsion to ‘not do the task’ when she perceives that someone else wants her to do it. This might be theorized to be counter-control, the result of a long history of aversive control, and/or as avoidance of feelings of relatedness or dependence which in the past have predicted interpersonal pain (e.g., vulnerability followed by betrayal). Such aversion to others’ expectations is of obvious significance in a relationship focused on the therapist assisting the client to activate and quit smoking cigarettes. And in general this client did not receive support from others because she believed that no one was trustworthy: ‘Everyone will let you down sooner or later.’ The therapist conceptualized this resistance as part of a general avoidance of experiences of connection or dependence on others. The therapist and client discussed the notion that the client did indeed want to feel connected to others, but that fear prevented her from building such connection. Subsequently, behaviors that functioned as avoidance of fear or connection
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were considered to be targets for reduction (CRB1 in FAP terminology), while behaviors entailing acceptance of support and caring were considered targets for increase (CRB2 in FAP terminology). Therapist and client then engaged in shaping of the client’s acceptance of support from the therapist, through such activities as the therapist helping the client in session to package cigarettes into daily rations to support gradual daily smoking reduction, explicit requests by the therapist that the client complete homework assignments for the therapist rather than for herself or for other reasons, as well as overt discussions of how the client was blocking acceptance of support or connection. Following weeks of this approach, the client completed many aspects of the smoking cessation protocol and reported towards the end of treatment that, while she did not feel ‘attached’ to the therapist, she did feel that the therapist was ‘on her team’ and that this was a new kind of connection with the therapist and a rare event in her relationships with others. SETTING A QUIT DATE Committing to a quit date involved making a commitment to the therapist and was discussed as such. This raised a number of challenges for our patients. Particularly salient was the struggle patients experienced in identifying what support they needed and in asking for adequate support. Several patients had daily life problems related to excessive passivity and avoidance of expressing their needs for fear of causing conflict or disappointing others. Expressions of needs and requests to the therapist were therefore, in this context, considered CRB2. However, reinforcement of these CRB2 had to be balanced against the importance of blocking avoidance of the aversive consequences associated with smoking cessation. For instance, is a request to postpone the quit date by one week in order to get past a stressful work deadline an example of self-awareness and skillful assertion or part of a problematic pattern of procrastination and avoidance? In one instance, the client’s postponement of his quit date in this way was treated by his therapist as an example of expressing needs, self-awareness and effective self-management, so the therapist supported the client’s request. This was discussed in session as the patient taking the risk of directly expressing his needs and the therapist trusting that the patient knew what he needed to quit smoking. In subsequent weeks, not only did the client quit smoking, he also took needed action in other areas of his life, asserting himself more effectively with his parents and with his son. In the following section, we describe a small (n = 5) pilot treatment development study in which we preliminarily evaluated the ITSD treatment.
PILOT STUDY METHODS All study procedures were approved by the University of Washington IRB committee. Participants were recruited from the local community via print and online advertisements. Eligible participants were adults aged 18 years or older, currently smoking at least 10 cigarettes per day, received a current diagnosis of major depression, and agreed to attempt smoking cessation. We excluded potential participants diagnosed with other major mental illness, current suicidality, other primary substance abuse, current panic disorder, or engaged in current ongoing
treatment besides medication. Participants underwent screening that included a structured diagnostic interview and provided baseline data related to mood, overall functioning, demographics, and smoking behavior. PARTICIPANTS Clients were four white females and one white male, ranging in age from 28 to 44 (M = 33). They smoked an average of 13.2 cigarettes per day (range: 10 – 20) and all had at least two previous quit attempts. Their mean Beck Depression Inventory-II score at screening was 32.2 (range: 22 – 46), falling in the ‘severe’ range. All clients met DSM-IV criteria for current Major Depressive Disorder and for nicotine dependence. Two clients met criteria for ‘double depression’ (dysthymia and a current major depressive episode). All clients had at least one episode of major depression prior to the current episode. This sample therefore represents a group with relatively severe and chronic depression. THERAPISTS Therapists were one professor, two Ph.D. clinical instructors, and two graduate students in the doctoral training program in adult clinical psychology at the University of Washington. All therapists met weekly as a group to discuss development of the treatment, interventions, and ongoing cases. In addition, the graduate student therapists received weekly 1-hour supervision sessions with a senior clinician. ASSESSMENT Clients completed outcome and process measures weekly throughout the study period, as well as larger batteries of measures at pre-, mid-, and post-treatment. Weekly measures included a Beck Depression Inventory-II (BDI-II; Beck, Streer, Ball, & Ranieri, 1996), report of smoking status, and a session bridging form. The Longitudinal Interval Follow-up Evaluation (LIFE; Keller, Lavori, Friedman, Nielson, Endicott, McDonald-Scott, & Andreason, 1987), a semi-structured interview that assesses the longitudinal course of psychiatric disorders, yielding a retrospective assessment of relapse/recurrence, was administered at mid- and post-treatment as a follow-up to the initial diagnostic assessment. For smoking, the primary outcome measure was the pointprevalence of smoking for the 7 days and, at follow-up, 30 days prior to assessments (measured by the question, “Have smoked a cigarette, even a puff, in the past 7/30 days?”). Verification of smoking abstinence was obtained by measurement of carbon monoxide (CO) content in the breath, an indicator of recent smoking.
RESULTS RECRUITMENT Over the three months that we advertised for the study, 26 people contacted us to inquire about participation in the study. Of those, 8 met preliminary screening criteria and agreed to undergo a screening interview at the clinic. Five of those who underwent the screening interview were eligible for and accepted entry into the study.
FUNCTIONAL ANALYTIC PSYCHOTHERAPY IS A FRAMEWORK FOR IMPLEMENTING EVIDENCE-BASED PRACTICES
TREATMENT RETENTION Four of the clients who entered the study completed treatment (i.e., completed the agreed upon number of sessions). One client, whose depression remitted and who successfully quit smoking within 12 sessions of treatment, completed a total of 16 sessions, at which point she changed from weekly to monthly sessions for the remainder of the treatment period. At the posttreatment assessment, she had not completed all 24 sessions, yet she remained remitted from depression and abstinent from cigarettes. She is therefore not considered a treatment failure. DEPRESSION OUTCOMES At mid-treatment, the mean BDI-II score was 19.25 (range: 1129), down from 33.8 (range: 22-46) at pre-treatment. At posttreatment, the mean BDI-II score was 13.5 (range: 4-19.5). According to LIFE interviews conducted at post-treatment, four of five clients experienced remission of their major depressive episode, though two of these four continued to experience clinically significant symptoms of depression. Both of these clients were also experiencing concurrent and long-standing chronic pain related to other medical conditions that impaired their sleep and energy levels. The client whose depression did not remit by post-treatment (one of the two who met criteria for ‘double depression’) opted to continue in treatment with her study therapist. A global assessment of outcome, the OQ-45.2 (Lambert et al., 2004), also displayed clinically significant improvements across multiple domains of functioning at mid-treatment and posttreatment. Total score on the OQ-45.2 represents a composite of symptomatic distress (SD), interpersonal relationships (IR), and social role functioning (SR), with higher scores indicating greater dysfunction. The norm-based clinically significant cutoff for the total score is 63. At pre-treatment, the mean for all five clients was 94.8 (range 75-115). Subscales scores were 55.2 (range: 44-72), 24.4 (range: 17-29), and 16.4 (range: 12-22) for SD, IR, and SR respectively. At mid-treatment, the mean was 67.74 (range: 56-76), with subscale mean scores of 35.25 (range: 26-42), 18.75 (range: 12-29), and 11.25 (range: 8-13), for SD, IR, and SR respectively. At post-treatment, the mean total score was 55.8 (range: 34-84), with subscale mean scores of 28.8 (range: 17-38), 16 (range: 9-30), and 11 (range: 6-16) for SD, IR, and SR respectively. Thus, at post-treatment, four of five clients had OQ-45.2 total scores below the clinically significant cut-off. Notably, the two clients who continued to exhibit clinically significant though sub-threshold (for Major Depression) depression symptoms were both below the clinically significant cut-off for the OQ-45.2, and showed improvements in interpersonal relationships and social role functioning comparable to the other clients who remitted. Their symptomatic distress scores, however, remained relatively elevated. The one client whose depressive episode did not remit did show a clinically significant (i.e. >13 points) reduction in her total OQ-45.2 score over the course of treatment (from 98-104 during the initial weeks of treatment to 78-84 during the final weeks of the allotted treatment period), though she remained in the clinically significant range at the end of treatment. Though these comparisons should be interpreted with caution due to the small sample size in the current study, these out-
comes for depression (i.e., 80% remission) are comparable to those achieved in randomized controlled trials of standardized cognitive-behavioral therapies for major depression . SMOKING OUTCOMES Three out of five clients were completely abstinent by posttreatment. One client (a depression remitter) was abstinent for six weeks, starting at week 14 of treatment, but was smoking an average of .05). Therapist training may affect preferences to use RFIs.
Keywords Functional Analytic Psychotherapy, Therapeutic Relationship, Measures to Assess Therapeutic Relationship, Implicit Measurement of Therapy Processes
T
he role of the therapeutic relationship is emphasized as an important factor across several therapies, including newer contextual behavioral therapies such as Functional Analytic Psychotherapy (FAP). FAP exclusively focuses on the use of the therapeutic relationship as a primary mechanism of therapeutic change. FAP requires that therapists assess for and consequate in-session behaviors that are characteristic of the client’s presenting problems and approximations of behaviors related to their treatment goals. The focus on in-session behavior and the use of behavioral techniques to consequate in-session behaviors is termed in-vivo (Kohlenberg & Tsai, 1991). In-vivo interventions, briefly defined as the use of moment-to-moment therapy interactions (Kanter et al., 2009), are believed to be potent therapeutic interventions because they enable therapeutic change to occur more rapidly or enhance the effectiveness of non-FAP related techniques (e.g., cognitive disputation) (Baruch et al., 2009; Robert J. Kohlenberg, personal communication, March 27, 2007). Currently, there are no published measures of the factors (e.g., beliefs about in-vivo interventions, attitudes about in-vivo interventions) that may promote or inhibit therapists’ use of this important class of interventions. The current study was a first step toward improving our understanding of the factors related to therapists’ use of in-vivo interventions.
For the purposes of the paper, the term Relationship Focused Interventions (RFIs) will be used in place of in-vivo interventions. The term relationship-focused intervention better captures the role of the therapeutic relationship in FAP. Also, invivo interventions are not unique to FAP and practitioners from other therapies may be more amenable to the term Relationship Focused Interventions. Thus, it may help facilitate research on RFIs by practitioners from other theoretical orientations or therapy approaches. Relationship Focused Interventions use the “live” momentto-moment interactions between the client and the therapist (Kanter et al., 2009). Maximal behavior change occurs when a reinforcer is delivered close in time and location to the behavior’s occurrence; thus, maximal therapeutic change is thought to occur when behaviors are consequated close in time and location to the behavior’s occurrence (i.e., in-session behaviors; R. J. Kohlenberg, personal communication, March 27, 2007; cf. Baruch et al., 2009 for a detailed examination of the empirical literature on basic behavioral principles underlying FAP). Basic behavioral research supports the idea that relationship focused processes are powerful behavior change strategies and many therapies promote the use of these processes (e.g., Beck, Rush, Shaw, & Emery, 1979). Several empirical studies suggest that RFIs are unique to interpersonally-focused therapies and that their addition may improve outcomes. A study of cognitive therapy for depression showed that the occurrence of RFIs was rare (Bolling, Parker, & Kohlenberg, 2000). This result was replicated in a second study that found that the use of RFIs in both behavioral activation and cognitive therapy was rare (Kanter et al., 2009). A third study (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002) suggested
Christeine Terry is now at Portland Psychotherapy Clinic, Research, and Training Center in Portland, OR. The authors would like to offer their gratitude to Anthony Greenwald, Ph.D. who generously provided his time and assistance in developing and piloting the RFIs IAT and the study procedures. They also wish to extend their gratitude to Jason Luoma, Ph.D., Jenna LeJeune, Ph.D., and Madelon Bolling, Ph.D. who provided feedback on earlier drafts of the paper. In particular, the first author wishes to extend her gratitude to Jason Luoma whose guidance, as well as his feedback, was immensely helpful in revising this article.
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THERAPISTS’ ATTITUDES ABOUT AND PREFERENCES TO USE RELATIONSHIP FOCUSED INTERVENTIONS
that the addition of RFIs to therapies that do not typically incorporate them might increase their efficacy. In this study, incorporating RFIs into typical cognitive therapy was related to increased satisfaction with social support and increased improvements in outside relationships. Research from Goldfried and colleagues (Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997; Goldfried, Raue, & Castonguay, 1998; Wiser & Goldfried, 1998) also supports the idea that RFIs can improve therapy outcomes. In a study of expert psychodynamic therapists and cognitive-behavioral therapists, sessions that were identified as having an in-session impact on the client and that resulted in client change were found to have more in-session focus than lower clinically significant sessions (Goldfried, Raue, & Castonguay, 1998). Currently, there are no published measures of the factors (e.g., beliefs about RFIs, attitudes about RFIs) that may promote or inhibit therapists’ use of this important class of interventions. However, in order to study this area, reliable and valid measures of therapist preferences are needed. The current study represents a first step towards understanding the factors related to therapists’ use of Relationship Focused Interventions. The main focus of this study is the use of both explicit and implicit measurement strategies to examine attitudes about and preferences toward Relationship Focused Interventions. The primary difference between explicit and implicit measures is that explicit measures rely on experiences available to introspection, while implicit experiences, generally, do not. As implicit measurement appears to be less vulnerable to self-presentation biases, we elected to create and use an implicit measure of RFIs because we believed that practitioners may be prone to present more favorable attitudes about RFIs or that it may be difficult for practitioners to reflect on their own preferences for these interventions. We elected to use the Implicit Association Test (IAT), a method that has substantial support for its use as a reliable and valid method of assessing implicit experiences (Greenwald, Poehlman, Uhlmann, & Banaji, 2009; Lane, Banaji, Nosek, & Greenwald, 2007). The IAT assesses implicit attitudes via asking participants to sort stimuli representative of a concept or attribute and is based on the idea that the sorting task should be easier when the two concepts that are sorted similarly are strongly associated than when they are weakly associated (Nosek et al.). The IAT generally has moderate to high split-half internal consistency, high test-retest reliability, and good convergent, discriminant, and predictive validity (Nosek et al., 2007). Furthermore, the reliability of the IAT appears to higher than other implicit measures designed to assess the same construct (Nosek et al., 2007). Research also suggests that it is quite difficult to fake (Kim, 2003; Steffens, 2004) and that the IAT may be a better predictor of behavior related to socially sensitive attitudes than of behaviors related to attitudes that are not as socially sensitive. THE CURRENT STUDY The study had three aims. The first aim was to create measures of therapist’s RFIs preferences (defined as approaching or avoiding RFIs opportunities). The second aim was to explore how FAP training affects participants’ responses on RFIs measures. The final aim of the study was to examine whether therapists’
preferences about RFIs were affected by the diagnostic label of the client (Major Depression vs. Cocaine Dependence). In designing the study, we predicted that mental health care trainees would self-report positive attitudes about RFIs, but would display an implicit bias against RFIs. We also predicted that FAP practitioners would report both explicit and implicit preferences for RFIs. We also examined the effect of client diagnosis on preference for RFIs. Research has shown that practitioners tend to hold more negative attitudes about substance use than depression (Angermeyer & Dietrich, 2006; Corrigan et al., 2000). Therapists’ negative attitudes about substance use may impact the therapist’s preferences about RFIs in that therapists may be less willing to invest their emotional resources for clients they view negatively. Therefore, we predicted that practitioners who received a client description with the diagnosis of Cocaine Dependence would display a stronger bias against RFIs than practitioners who received a client description that involved a diagnosis of Major Depression.
METHODS PARTICIPANTS National Sample of Mental Health Care Trainees (MHTs; n = 144). This
national sample of mental health care trainees (MHTs) were individuals enrolled in advanced training programs (Masters, Ph.D., and Psy.D. programs) in clinical psychology, counseling psychology, and social work, as well as interns at sites in clinical psychology, social work, and psychiatry. Mental Health Practitioners with specialized training in RFIs (termed FAP community members, n = 49). FAP community members were re-
searchers, therapists, and graduate students who either identified their primary focus of research/therapy as FAP, or who had received training in FAP. MEASURES Demographics. The demographics questionnaire included questions focused on participants’ therapy practice (e.g., caseload, theoretical orientation) and basic identifying information. Preference for using Relationship Focused Interventions (RFIs) IAT. This measure was created for the study to measure a therapist’s preference to use RFIs. The RFIs IAT is very similar to the IAT in its structure, but differs in that the participants are sorting stimuli about therapeutic situations rather than race, gender, or political affiliation. A second difference between the RFIs IAT and IATs that assess socially constructed attitudes (e.g., race) is that the RFIs IAT includes the use of a storyboard (the storyboard is described below) in which the stimuli used in the IAT were introduced prior to the IAT measure. RFIs Storyboard. The first screen of the storyboard task included: 1.) a brief description of the task; 2.) a request that the participants imagine themselves as the therapists of the fictional clients they were about to read about; 3.) a statement that the pictures in the storyboard would be used in later tasks and were designed to help them remember the client statement associated with the picture; 4.) the diagnosis of the clients. Based on the participant’s randomization, he/she read a description of the client that varied only in the diagnosis of the client: Major De-
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pression, Cocaine Dependence, or no Axis I diagnosis (control condition). The participants were then presented a picture of Caucasian female client (gender and race were held constant to reduce their effects as confounds) with a statement made by the client directly under the picture (see Figure 1in appendix). The client’s name (the names of the clients were “Client X” or “Client Y”) was displayed above the picture. Eight pictures (4 pictures per client) with their associated client statements were shown to the participants. The eight client pictures were taken from Ekman’s Japanese and Caucasian Facial Expression of Emotions (JACFEE; Matsumoto & Ekman, 1988). All pictures in the JACFEE set have undergone empirical testing to ensure the validity and reliability of the emotions being displayed in each picture (Matsumoto & Ekman, 1988). Based on the content of the four statements pictures displaying sadness, anger, and happiness were selected. To minimize the influence of factors such as the women’s attractiveness we pre-tested the pictures of the Caucasian women in the JACFEE set. Pictures without any identified concerns about their use were used in the RFIs storyboard and subsequently, as the stimuli in the RFIs IAT. Eight statements were created for the study (1 statement per picture) and were pre-tested for their clarity and face validity. Four of the statements discussed an important person in the client’s life who was not the therapist (termed daily life statements). Client Y always offered daily life statements. The other four statements were identical to the statements about the important person, but were about the therapist (termed relationship-focused statements). Client X always offered relationship-focused statements (see Figure 1in the appendix for a storyboard that was used in the study)1. The pictures, through their associations with the statements, were believed to be representative of daily life or relationship-focused opportunities. Relationship-Focused Interventions (RFIs) IAT. After viewing the storyboard, participants completed the RFIs IAT. The RFIs IAT was designed to assess implicit preferences to approach RFIs relative to avoiding RFIs. The pictures from the RFIs storyboard were used as the target stimuli and synonyms for approach or avoid were used as the attribute stimuli (see Ostafin, Marlatt, & Greenwald, 2008 for another study with the same approach/avoid stimuli; see Figures 2 and 3 in the appendix for the stimuli used in the RFIs IAT and for a schematic of the RFIs IAT procedure). The target categories of ”Client X” (the name of the client representing RFIs opportunities) and “Client Y” (the name of the client representing daily life opportunities), as well as the terms “approach” and “avoid,” were displayed in the appropriate upper corners of the screen throughout all of the tasks. Participants were required to correct errors to continue with the task (the response latency was recorded throughout the error correction process). The structure and procedure of the RFIs IAT is similar to other seven block IATs (e.g., Teachman, Wilson, & Komarovskaya, 2006). The IAT is a response time task that requires participants to categorize stimuli that belong to the category (i.e., Client X, 1 The assignment of the woman to Client X and the woman to Client Y was counterbalanced. The presentation order of Client X (RFI opportunities) of Client Y (daily life opportunities) was also counterbalanced.
Client Y) or attribute (i.e., approach, avoid). In the RFIs IAT, participants were required to sort pictures of the clients from the RFIs storyboard. Additionally, participants sorted terms belonging to each of the attribute categories (i.e., approach or avoid; see Figure 3 in the appendix for a schematic of the RFIs IAT). The critical portions of the IAT are the trials where the attributes and concepts are assigned to the same key (i.e., combined trials). The differences between the response latencies of the combined trials comprise the IAT effect, a measure of relative strength of associations of categories with attributes. Positive scores on the RFIs IAT indicated preferences to use RFIs relative to avoid RFIs. Negative scores on the RFIs IAT indicated preferences to avoid RFIs relative to approach RFIs. Analyses indicated the RFIs IAT had acceptable internal consistency (α = .71 for the practice block and α = .77 for the test blocks) and were within the range of reliability estimates found in IATs of other implicit experiences (Nosek et al., 2007). Therapeutic Relationship Measure (TRM). The TRM was created specifically for the study to assess explicit attitudes and beliefs about RFIs. Participants were asked to rate their level of agreement with using the therapy relationship as a therapeutic technique on a Likert scale from -7 (very negative feelings/strongly disagree) to +7 (very positive feelings about/strongly agree) (0 represented a neutral attitude or neither agree/disagree). Based on the analyses of the reliability of the TRM one item (a question about the ethics of RFIs) was removed because it did not correlate with the other items on the measure and the removal of the item substantially improved the reliability of the measure. The internal consistency of the measure was good (α = 0.90). The final version of the TRM consisted of 6 items (scored -7 to +7), resulting in a range of total possible scores of -42 to +42 with negative scores indicating increasingly negative attitudes and beliefs about RFIs and positive scores indicating increasingly positive attitudes and beliefs about RFIs. Explicit RFIs Thermometers. Thermometer measures are typically used in IAT research to assess explicit attitudes. Thermometers were created for the study to assess explicit attitudes and preferences about RFIs interventions. The scales on both thermometers range from -3 (very coldly/not at all likely to use the therapeutic relationship) to +3 (very warmly/very likely to use the therapeutic relationship) with 0 as the mid-point (neither cold nor warm/neither unlikely nor likely to use the therapeutic relationship). Two RFIs Thermometers were created: 1.) the RFIs Warm/Cold Intervention Thermometer, designed to measure explicit ratings of warmness or coolness toward RFIs; 2.) the RFIs Approach/Avoid Thermometer designed to measure how likely an individual is to use the therapeutic relationship (RFIs) as a therapy technique. Positive scores on the thermometers indicate positive feelings or preferences to approach RFIs. Negative scores on these measures were representative of negative feelings or preferences to avoid RFIs. PROCEDURE Participants for the Mental Health Trainees sample (MHT) were recruited via postings on student listservs of professional organizations. Directors of Clinical Training and Graduate Program Coordinators from training programs and internships in psychology, psychiatry, and social work and colleagues of the
THERAPISTS’ ATTITUDES ABOUT AND PREFERENCES TO USE RELATIONSHIP FOCUSED INTERVENTIONS
researchers were also emailed to solicit participation of eligible participants. FAP community members were recruited through the FAP listserv and through contacts with professional colleagues. All individuals who participated in the study were eligible to enter a drawing to win one of four $50.00 gift certificates. All study assessments and documents were located on a website programmed using Web Inquisit (Inquisit 3.0.3.1.0). After reviewing the description of the study and the procedure for entering the drawing for the gift certificate, participants completed the measures described above and other measures from a study on stigmatizing attitudes about mental illness. The presentation order of the study measures and tasks were counterbalanced. IAT Effect (the D Measure). The D measure is the preferred algorithm to calculate the IAT effect, a measure of the relative strength of associations of the concepts with attributes (Greenwald et al., 2003). In this study a positive D score on the RFIs IAT indicated a greater preference to approach RFIs opportunities relative to avoiding RFIs opportunities. DATA ANALYSIS Hypothesis Testing. Hierarchical (sequential) regressions and Pear-
son product-moment correlations were conducted to examine the hypotheses of the study. For all hierarchical regressions, group membership (MHTs vs. FAP community members) was entered first. The order of entry for the remaining predictor variables was determined by theoretical considerations. The regression model that produced the best fit of the data is reported.
RESULTS EXCLUSION OF SUBJECTS A total of 164 MHTs and 56 FAP community members completed the study. Based on recommendations from previous IAT researchers (Greenwald et al., 2003; Nosek et al., 2007), individuals with IAT data that contained an error rate of greater than 35%, those whose data included extremely long latencies (greater than 3,000 ms), and those with 10% or more of their latencies faster than 300 ms were omitted from the study. Twentyseven participants were excluded (20 were MHTs, 7 were FAP community members) due to incomplete data (defined as 20% or more of data missing across study measures), or because their data were duplicated and recorded multiple times, or because IAT performance did not meet the criteria outlined above. DEMOGRAPHICS Demographics: National Sample of Mental Health Care Trainees (MHTs) (n = 144). The mean age in the MHT sample was 29.6 years (SD =
6.0, range 19 - 57). Approximately 80% (81.3%) of the sample identified as female and 18.7% as male. The sample was predominately Caucasian (87.5%) with other races and ethnicities identified by less than 5% of the sample. Most (52.8%) reported a highest level of education as a Master’s Degree, with 45.1% reporting a Bachelor’s Degree, and 2.1% reporting a Doctorate Degree. Over half of the participants in this sample identified their theoretical orientation as Cognitive-Behavioral followed by eclectic/integrative. The average caseload of the participants was 12 (SD = 18.7, range 1 - 200. Approximately half of MHTs
endorsed knowing a friend or family member suffering from depression (43.8%) or a substance use disorder (41.0%). Demographics: FAP Community Members (n = 49). Due to concerns about the possibility of identifying a FAP community member based on their age, categorical response options for age were used (e.g., age 20 – 25). The most frequently occurring age group in the sample was 26 – 30 years old (32.7%) followed by 50 years or older (22.4%). Approximately 65% of FAP members identified as female and 35% identified as male. Caucasian was the most frequently identified race/ethnicity by FAP participants (84.0%) with other race/ethnicities identified by less than 6% of the sample. FAP community members tended to be welleducated with 49.0% having a Doctorate’s degree, 42.9% with a Master’s Degree, and 2.0% with a Medical Degree. Of the FAP participants who were currently in graduate school, the majority were in their 4th year of graduate school or beyond (34.7%). The theoretical orientation identified by a majority of the sample was behavioral (57.1%) with cognitive-behavioral the second most frequently endorsed theoretical orientation (20.4%). The mean caseload for FAP participants was 18.2 (SD = 30.6, range 1 - 200). A substantial portion of participants reported having a friend or family member suffering from depression (57.1%) or substance use (34.7%). In regards to training in FAP, unfortunately 43.1% of the sample did not provide a response to this specific question. Of the participants who responded 17.5% stated that they had received training in FAP for less than 1 year, 14.0% stated that they had been practicing/learning FAP for 5 – 10 years, and 9.2% stated that they had between 3-5 years of training. Less than 10% of the sample responded that they had received 2-3 years or had over 10 years of training. The sample varied widely in number of years practicing FAP with 38.6% stating they have been practicing for over 3 years and 12.3% stating they have been practicing for less than 1 year. EXPLICIT ATTITUDES ABOUT AND PREFERENCES TO USE RFIS On average, mental health care trainees endorsed very positive attitudes and beliefs about RFIs. The mean score on the TRM for the mental health care trainee sample was 28.55 (SD = 9.95) with a range of 2.00 to 42.00. Overall, FAP community members endorsed extremely positive attitudes and beliefs about RFIs. The mean score on the TRM for the FAP community member sample was 37.28 (SD = 5.32) and mean scores ranged from 21.00 to 42.00. RFIs Thermometers. On average, FAP community members had higher scores on RFIs Warm Cold thermometer (M = 2.84, SD = 0.37) than MHTs (M = 1.67, SD = 1.16). Similar to the means on the RFIs Warm Cold Thermometer, the mean of the FAP sample on the RFIs Approach Avoid Thermometer (M = 2.52, SD = 0.51) was higher than the mean of the MHT sample (M = 1.61, SD = 0.99). IDENTIFICATION OF POTENTIAL PREDICTOR VARIABLES No demographic variables (e.g., race, gender) had a significant impact on the study measures (all p’s > .05). Variables related to participants’ training, theoretical orientation, caseload, and current treatment of a client with depression or substance use disorder had significant effects on study measures, although the
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Table 1. Correlations Between Variables Relating to Explicit Attitudes about Relationship Focused Interventions (n=193). Measure 1. Therapeutic Relationship Measure
1
2
3
4
5
6
–
-.377**
-.330**
.642**
.728**
-.163
–
.196
-.444**
-.397**
.008
–
-.128
-.179
.002
–
.710**
-.177
–
-.142
2. Group membership (MHT vs. FAP) 3. Theoretical orientation (CBT vs. Other) 4. Warm Cold Thermometer 5. Approach –Avoid Thermometer 6. RFIs IAT D Score n’s for many of these demographic questions were not sufficient to conduct the appropriate inferential statistical tests (i.e., n’s < 30; the exception was the theoretical orientation variable in which there was sufficient n to conduct the analyses). Mental Health Trainees. Results with MHTs were contrary to our expectation. The mean score on the TRM (the explicit measure of attitudes about RFIs) for MHTs was M = 28.58, (SD = 9.75) with a range of 2.00 to 42.00 indicating positive attitudes about RFIs. The mean D score on the RFIs IAT (the implicit measure of preferences to use RFIs) for MHTs was also positive, M = 0.10 (SD = 0.38), indicating a preference to approach RFIs opportunities relative to avoid RFIs opportunities. The relationship between implicit and explicit attitudes about RFIs interventions in mental health care trainees was positive, but not significant, r = .18, p = .08. To facilitate comparison between the implicit and explicit measure, Cohen’s d effect sizes were calculated using the difference between the mean on each measure and the score indicating “no preference” on each measure (a score of 0 on each measure). The effect size of the RFIs IAT was 0.28, a small effect (Cohen, 1988). The effect size of the explicit preference to use RFIs was 1.62, a large effect (Cohen). Between group comparisons. Average scores on the TRM were significantly higher for FAP participants (M=37.43, SD = 5.42) compared to MHTs (M = 28.58, SD = 9.75), t(155) = 5.69, p < .001, d = 1.12. In addition to group membership, the influence of other potential predictor variables (identified by theory and review of the empirical literature on RFIs) on TRM scores was examined by conducting a hierarchical regression. After entering the group membership, potential predictor variables were entered in the following order: theoretical orientation2, RFIs thermometer measures, and RFIs IAT D scores (see Table 1). Group membership was a significant predictor of explicit attitudes about RFIs, F(1, 73) = 12.07, p = .001, R2 = .14. The second step of the model (entry of the theoretical orientation variable into the regression model) resulted in a significant change in R2, F(2, 72) = 9.58, p = .02. Entry of the explicit RFIs thermometer measures (the third step of the regression model) resulted in a significant change in R2, F(4, 70) = 26.62, p < .001. The final step of the model (entry of the RFIs IAT D scores) did not result in a significant change in R2, F(5, 69) = 21.19, p = 0.53. Based on the results of the hierarchical regression, the third model that 2 We selected theoretical orientation as a potential predictor variable because we believed that there may be differential emphasis on the use of the RFI dependent on an individual’s theoretical orientation. Additionally, published research has revealed that practitioners trained in Cognitive Therapy for Depression or Behavioral Activation do not tend to use RFIs (Bolling et al., 2002; Kohlenberg et al., 2002; Kanter et al., 2009).
– included group membership, theoretical orientation, and the explicit RFIs thermometer measures was the best predictor of explicit attitudes about RFIs, F(4, 70) = 26.62, p < 0.001, R2 = 0.60. These results suggest that explicit attitudes about RFIs interventions are likely to be influenced by group membership, an individual’s theoretical orientation, and an individuals’ reported level of warmth towards RFIs (Warm Cold RFIs Thermometer) and their explicit preference to use RFIs (Approach Avoid RFIs Thermometer). The difference between FAP (D = 0.16, SD = 0.46) and MHT (D = 0.11, SD = 0.39) groups on the implicit RFIs preference measure approached significance, t(102) = -1.79, p = .08. A hierarchical regression was conducted to examine if group membership (MHT vs. FAP) and other study variables (selected for theoretical reasons or based on the empirical literature on RFIs) significantly predicted RFIs IAT D scores (implicit RFIs preference). The potential predictors selected and the order they were entered into the model were: theoretical orientation, the explicit RFIs thermometer measures (entered simultaneously), and explicit attitudes about RFIs (TRM). The regression model predicted approximately 4% of the variance in RFIs IAT D scores and was not significant (p = .53). Effect of patient diagnosis. An ANCOVA was conducted to examine the influence of client description (cocaine vs. other diagnoses) on RFIs IAT D scores while controlling for the effect of group membership (MHT vs. FAP). The covariate, group membership, did not significantly affect RFIs IAT D scores, F(1, 104) = 0.16, p = .686. Because group membership did not influence RFI IAT D scores, the groups were combined and an ANOVA was conducted to examine the influence of client description on RFIs IAT D scores. The ANOVA was not significant, F(2, 104) = 1.78, p = .173. A hierarchical regression was done to examine if other study variables (selected for theoretical reasons) predicted implicit preference to use RFIs. With the exception of the correlation between the explicit attitudes about RFIs (TRM) and RFIs IAT, correlations between the predictor variables and RFIs IAT D scores were not significant (p > .05). The regression models predicted less than 3% of the variance in RFIs IAT D scores and were not significant (p = .20). Based on these results, a client’s diagnosis or a practitioner’s theoretical orientation does not appear to influence a therapist’s implicit preferences toward RFIs.
DISCUSSION The study was a preliminary attempt to examine attitudes about and preferences to use an important technique in FAP, the Relationship Focused Intervention (RFIs). Additionally, we sought
THERAPISTS’ ATTITUDES ABOUT AND PREFERENCES TO USE RELATIONSHIP FOCUSED INTERVENTIONS
to examine how therapist and client factors might influence explicit and implicit attitudes and preferences to use RFIs. No published measures on RFIs attitudes or preferences could be located therefore one of the critical tasks of the study was to create reliable and viable measures of therapists’ attitudes about and preferences to use RFIs. The measures created for the study, including the implicit measure (the RFIs IAT) appear to be reliable and viable, although further research on their reliability and validity are needed. We believed that MHTs would display an implicit preference to avoid RFIs; however, both MHTs and FAP community members displayed implicit preferences to approach RFIs. Discrepancies between explicit and implicit preferences to approach RFIs were discovered, suggesting that implicit preferences may be less subject to self-presentation biases or an individual’s awareness of his/her preferences. Specialized training in RFIs influenced individuals’ explicit and implicit preferences to use RFIs, as well as their attitudes about RFIs. Individuals with specialized training in RFIs (i.e., FAP community members) had higher scores (indicating greater likelihood to use RFIs or more positive attitudes about RFIs) on implicit and explicit measures about RFIs. For practitioners interested in using RFIs and for practitioners interested in training other mental health professionals to use RFIs, results from this research indicate that training may influence practitioners’ attitudes and preferences to use RFIs. Future studies should examine how the amount of training and types of trainings in RFIs affect explicit and implicit preferences and attitudes about RFIs. Additionally, within subject studies of how these preferences and attitudes change across time with training would be helpful in describing and understanding how training affects RFIs preferences and attitudes, and subsequently may lead to improvements in training practitioners to use RFIs. In addition to specialized training in RFIs, theoretical orientation appeared to affect preference for RFIs. Practitioners identifying with a CBT orientation had significantly lower scores on the explicit measure of attitudes about RFIs than MHTs who endorsed a non-CBT orientation. This finding is consistent with results in published empirical studies about the low occurrence of RFIs in therapists trained in Cognitive Therapy and Behavioral Activation for Depression (Bolling et al., 2000; Kohlenberg et al., 2002; Kanter et al., 2009).The reason for this difference in preferences is uncertain. While training in CBT does not prohibit the use of RFIs, it may be that the lack of specialized training in RFIs prevents the development of positive attitudes and preferences to use of RFIs. RELATIONSHIP OF CLIENT DIAGNOSIS AND PREFERENCES TO USE RFIS To our surprise, a client’s diagnosis of Cocaine Dependence did not influence practitioners’ implicit or explicit preferences to use RFIs. We believed that practitioners’ beliefs or attitudes about substance use would have influenced practitioners to avoid using therapeutic interventions that require interpersonal closeness on the part of the therapist. However, the results from the study suggest that a client diagnosis of a substance use disorder does not significantly impact practitioners’ preferences to use RFIs. The results should be interpreted with caution because
of the small n of practitioners assigned to each of the conditions (Cocaine Condition n = 29; Major Depression n = 37; No Diagnosis n = 38). 3Because of the small n’s in each condition there may been insufficient power to detect small, but potentially important differences between the groups. Future research should further examine if client diagnosis or other client characteristics impact preferences toward and actual use of RFIs. The discrepancy between self-reported preferences and implicit preferences to use RFIs is consistent with other studies of constructs that are subject to self-presentation biases or that may be difficult to introspect about (Greenwald, Poehlman, Uhlmann, & Banaji, 2009; Nosek et al., 2007). It is important to note that the discrepancy between explicit attitudes about/ preferences for RFIs and implicit preferences to use RFIs was not just found in therapists without specialized training in RFIs. Results from this study suggest that therapists with specialized training in RFIs also display these discrepancies. One interpretation of these findings is that social desirability influences explicit attitudes/preferences for RFIs (i.e., practitioners report increased positive feelings about and likelihood to use RFIs), but is less likely to influence implicit preferences for RFIs. Another interpretation is that practitioners may have more difficulty accessing and reflecting upon their preferences to use RFIs. Because research on the IAT has shown that implicit and explicit measures of the same attitude differentially impact behavioral outcomes, future studies should examine which therapeutic outcomes are best predicted by explicit measures of RFIs and which outcomes are best predicted by implicit measures of RFIs. LIMITATIONS AND FUTURE DIRECTIONS An important limitation of the research was the small sample size of FAP practitioners and the MHTs assigned to the Cocaine Diagnosis condition of the RFIs IAT task. Future studies should attempt to replicate the findings of the current study by using a larger sample of practitioners. Some potential predictor variables (e.g., training in FAP, identification of a psychodynamic theoretical orientation) were not entered into the regression models because of insufficient sample size to warrant their inclusion in the models. It is also relevant to note that this study examined preferences to use RFIs rather than actual reported use of RFIs. It awaits further research to determine the extent to which preferences predict actual use of RFIs.
CONCLUSION The study was an attempt to create reliable and viable measures of practitioners’ attitudes about and preferences to use an important FAP technique, Relationship Focused Interventions (RFIs). Additionally, we attempted to examine the influence of therapist and client variables on practitioners’ attitudes and preferences to use RFIs. Results from the study indicate that we were successful in creating reliable and usable measures. Furthermore, results suggest the importance of assessing both implicit and explicit attitudes and preferences. Finally, we showed that therapist training in RFIs may influence attitudes and preferences for RFIs. We hope that researchers interested in RFIs 3 We conducted several analyses to determine if there were any significant differences among the participants in the conditions and no significant differences on any of the study measures were discovered.
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will continue to investigate the use of RFIs and the factors that influence therapists’ use of RFIs.
REFERENCES Angermeyer M. C., & Dietrich, S. (2006). Public beliefs about and attitudes towards people with mental illness: A review of population studies. Acta Psychiatrica Scandinavica, 113, 163 – 179. Baruch, D. E., Kanter, J. W., Busch, A. M., Plummer, M. D., Tsai, M., Rusch, L. C. et al. (2009). Lines of evidence in support of FAP. In M. Tsai, R. Kohlenberg, J. Kanter, B. Kohlenberg, W. Follette, & G. Callaghan (Eds.), A guide to Functional Analytic Psychotherapy. New York: Springer. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy for Depression. New York: Guilford Press. Bolling, M. Y., Parker, C. R., & Kohlenberg, R. J. (2000). In-Vivo focus in cognitive therapy: Does it occur? Does it help? Unpublished manuscript, University of Washington, Seattle. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates. Corrigan, P. W., River, L. P., Lundin, R. K., Wasowski, K. U., Campion, J., Mathisen, J., et al. (2000). Stigmatizing attributions about mental illness. Journal of Community Psychology, 28(1), 91 – 102. Goldfried, M. R., Castonguay, L. G., Hayes, A. M., Drozd, J. F., & Shapiro, D. A. (1997). A comparative analysis of the therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions. Journal of Consulting and Clinical Psychology, 65(5), 740 – 748. Goldfried, M. R., Raue, P. J., & Castonguay, L.G. (1998). The therapeutic focus in significant sessions of master therapists: A comparison of cognitive-behavioral and psychodynamic-interpersonal interventions. Journal of Consulting and Clinical Psychology, 66(5), 803 – 810. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual differences in implicit cognition: The Implicit Association Test. Journal of Personality and Social Psychology, 74(6), 1464 – 1480. Greenwald, A. G., Nosek, B. A., & Banaji, M. R. (2003). Understanding and using the Implicit Association Test: I. An improved scoring algorithm. Journal of Personality and Social Psychology, 85(2), 197 – 216. Greenwald, A. G., Poehlman, T. A., Uhlmann, E. L., & Banaji, M. R. (2009). Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology, 97(1), 17 – 41. Inquisit 3.0.3.1 [Computer software]. (2008). Seattle, WA: Millisecond Software LLC. Kanter, J. W., Landes, S. J., Holman, G. I., Rusch, L. C., Whiteside, U., & Sedivy, S. K. (2009). The use and nature of present-focused interventions in cognitive and behavioral therapies for depression. Psychotherapy Theory, Research, Practice, and Training, 46(2), 220 – 232.
Kim, D. (2003). Voluntary controllability of the Implicit Association Test (IAT). Social Psychology Quarterly, 66(1), 83 – 96. Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C. R., & Tsai, M. (2002). Enhancing cognitive therapy for depression with Functional Analytic Psychotherapy: Treatment guidelines and empirical findings. Cognitive and Behavioral Practice, 9(3), 213 – 229. Kohlenberg, R. J. & Tsai, M. (1991). Functional Analytic Psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press. Lane, K. A., Banaji, M., Nosek, B. A., & Greenwald, A. G. (2007). Understanding and using the Implicit Association Test: IV: What we know (so far) about the method. In B. Wittenbrink & Schwarz (Eds.), Implicit measures of attitudes (pp. 59 – 102). New York: The Guilford Press. Matsumoto & Ekman (1988). The Japanese and Caucasian Facial Expressions of Emotion (JACFEE). Nosek, B. A., Greenwald, A. G., & Banaji, M. R. (2007). The Implicit Association Test at age 7: A methodological and conceptual review (pp. 265 – 292). In J. A. Bargh (Ed.), Automatic Processes in Social Thinking and Behavior. New York: Psychology Press. Ostafin, B. D., Marlatt, G. A., & Greenwald, A. G. (2008). Drinking without thinking: An implicit measure of alcohol motivation predicts failure to control alcohol use. Behaviour Research and Therapy, 46, 1210-1219. Steffens, M. C. (2004). Is the Implicit Association Test immune to faking? Experimental Psychology, 51(3), 165 – 179. Teachman, B. A., Gregg, A. P., & Woody, S. R. (2001). Implicit associations for fearrelevant stimuli among individuals with snake and spider fears. Journal of Abnormal Psychology, 110(2), 226 – 235. Wiser, S. & Goldfried, M. R. (1998). Therapist interventions and client emotional experiencing in expert psychodynamic-interpersonal and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 66(4), 634 – 640.
AUTHOR CONTACT INFORMATION CHRISTEINE M. TERRY, PH.D.
Portland Psychotherapy Clinic, Research, and Training 1830 NE Grand Ave. Portland, OR. 97212 Email:
[email protected] ROBERT J. KOHLENBERG, PH.D.
University of Washington, Department of Psychology Box 351525 Seattle, WA. 98195 Email:
[email protected]
THERAPISTS’ ATTITUDES ABOUT AND PREFERENCES TO USE RELATIONSHIP FOCUSED INTERVENTIONS
APPENDIX
Note: Pictures taken from Ekman’s Japanese and Caucasian Facial Expression of Emotions (JACFEE; Matsumoto & Ekman, 1988). Pictures published with permission. Figure 1. Example of Client-Therapist and Client-Important Other Storyboards.
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CONCEPT CONTRASTS FOR IVI IAT
Note: Pictures were taken from Ekman’s Japanese and Caucasian Facial Expression of Emotions (JACFEE; Matsumoto & Ekman, 1988). Pictures are published with permission. Figure 2. Relationship-Focused Interventions (RFIs) Implicit Association Test (IAT) Concept Categories and Attributes.
SEQUENCE OF TASKS FOR RFIS IAT
Note: The table is based on the IAT figure published in Greenwald, McGhee, & Schwartz (1998). Categories for target-concept discriminations are assigned a right or left response, indicated by the black circles in the third row. These are combined in the third step and then recombined in the fifth step, after reversing response assignments (in the fourth step) for the target-concept discrimination. Correct responses are indicated as open circles. Figure 3. Example of Client-Therapist and Client-Important Other Storyboards.
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Working In-Vivo with Client Sense of Unlovability Mavis Tsai & 3Richard Reed Independent Practice, 2University of Washington, & 3VA Puget Sound Health Care System
1,2 1
Abstract Clients sometimes react negatively when their in-session problem behavior is simply blocked. This article illustrates how a FAP (Functional Analytic Psychotherapy) therapist can work effectively in session with a client’s problem feeling of unlovability by: 1) understanding its antecedents and functions, 2) using therapeutic love to reinforce in-session improvement, and 3) discussing how to generalize improved ways of acting and associated positive feelings resulting from the therapeutic interaction to daily life. A verbatim transcript of an interaction between a therapist and client is provided, along with annotations of the client’s clinically relevant behaviors (CRBs) and the therapist’s use of FAP’s five rules of therapeutic technique. When the client experienced the ways he really mattered to his therapist, he was freer to allow this sense of being cared about, rather than his feeling of unlovability, reinforce loving and caring by others.
Keywords Functional Analytic Psychotherapy, therapeutic love, in-vivo work, client unlovability
I
t is important that sessions end on a positive note with clients emitting target behaviors or CRB2s (Clinically Relevant Behavior, type 2, in-session improvements). In fact, when sessions predominantly end with CRB1s (Clinically Relevant Behavior, type 1, in-session problems), clients may drop out of treatment prematurely (Kanter, 2011). In this article, the issue of how to work skillfully with a client’s CRB1s of feeling unlovable and also discouraging the expression of caring by the therapist in order to pave the way for the evoking of CRB2s of both reinforcing therapists caring and associated feelings of being lovable is addressed. Although the definition of a CRB1 is “client problems that occur in session” (Kohlenberg & Tsai, 1991), in the authors’ experience, sometimes clients have reported feeling “invalidated” or “broken” when therapeutic interactions have focused solely on the problematic aspects or CRB1s. Although CRB1s may currently be problematic, it is helpful for clients to be validated (Linehan, 1997; Koerner, 2012) for the initially adaptive functions of their CRB1s before attempting to evoke their CRB2s. For example, the CRB1 of acting like one is not important (avoidance of emotion, non-assertion of needs, and reluctance to selfdisclose) and its associated feeling of unlovability, may stem from families of origin in which emoting, asserting needs, and self-disclosing were behaviors that were extinguished or punished and thus became unsafe to engage in. We will explore how to use the five rules of FAP in working with the common issue of a client feeling unlovable. The client, “Gary,” is a 50 year old divorced man who has been in weekly therapy with the first author for two and a half years. He has struggled with depression since he was 17. Initially, he presented with the goals of wanting to deal more effectively with his depression and deciding whether to seek a life partner. Since the beginning of therapy, he has been working on connecting better with people, and has made considerable progress. Nearly two years ago, he made the decision to begin online dating, and has
met over 50 women, including one with whom he had an intense relationship of three months duration. Although he has become more effective in dealing with his down periods, and they are shorter and farther in between, he still experiences bouts of depression, many of which are triggered by what he experiences as the vicissitudes of dating and his experiences of not being lovable. In this verbatim transcript excerpt (edited for clarity), we will describe how the FAP rules (in bold print) were used in working with Gary’s sense of unlovability. T: I feel like what you keep coming back to is the sense of “I’m unlovable.” C: That’s where I’m stuck right now. T: I would really like for us to find an effective way for us to
work with that in session, so that in the moment, you really feel heard, understood, cared about, that you are not feeling invalidated. So that it sinks in that I care about you, and that you are able to make some kind of shift, or get unstuck, or open up a little bit, feel a little more compassion for yourself. That’s where I’d like to go because right now you are stuck feeling unlovable. [Rule 2, therapist is expressing caring feelings that are potentially evocative of CRB.]
C: I read in Paul Gilbert’s book that when people feel unlovable,
they’ve had the experience of being unable to elicit positive emotion from the people they are close to. My feeling unlovable, it sounds like he’s saying, is a legitimate feeling. I’ve had many, many experiences of being unable to elicit positive feelings from people around me. So it makes me feel less broken, to say “I have this long history that way, and that’s why I feel unlovable from time to time.” It seems to produce some relief in me, that it’s not that I’m broken, it’s that I have this history, and I can see as a child it wasn’t my fault. It seems it’s my fault as an adult, but as a child, it wasn’t my fault that I
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couldn’t elicit positive feelings from my mother. [CRB3, client
functional analytic interpretation of behavior which is also a CRB2 for this client.] T: That makes a lot of sense. I hear you saying that this in-
terpretation makes you feel less broken, that it certainly not your fault you couldn’t elicit positive feelings from your mother, and therefore you labeled that as “I’m unlovable.” It also makes sense that’s the feeling you’d go back to and that’s the belief or self-statement you’d make. Cause I notice when you go back to this in your log, when you are feeling unlovable, it’s because somebody wasn’t reacting to you positively. [Rule 3, naturally reinforce CRB2.] So we’re talking about it sort of intellectually, and I’d like us to move to feeling with our hearts around this. [Rule 2, evoke feelings occurring in the moment in relation to therapist.]
C: I’m sure it will pass, but at this moment I am, I can’t really
see beyond my being unlovable in this moment. I’ve known in the pattern of the past couple years when I have some experiences I’ve had in the last couple weeks, I’ll feel this way, and then they’ll pass, I’ll have some positive experiences, and I don’t think I’ll be stuck here for a long time, but at this particular moment, I feel like I could argue I’m unlovable. I know I won’t feel this way for long, but I feel this way now. [CRB2, stating that his feelings of unlovability are temporary.]
T: I’m just going to be here with you, with your feelings of being
unlovable. I feel sad you’ve had this long history of feeling like you can’t get positive feelings, the regard you want. Cause I know you tried so hard, especially in the dating world. Sometimes you have good weeks, and this has been a disappointing week in terms of dating. I can see how it can trigger these feelings of this isn’t working, I’m not able to get where I want, I’m unlovable. [Rule 3, naturally reinforcing his more reasonable statements about knowing he won’t stay stuck for long; Rule 2, therapist’s natural reinforcement can also be evocative.]
C: [is quiet.] [CRB1, not acknowledging and reinforcing caring by therapist.] T: You know what I feel saddest about? It’s that I imagine you
felt this way so much as a little boy, and you had no one to comfort you around it. [blocking CRB1, Rule 2 expressing and re-presenting caring.]
C: My thought is that as a little boy I didn’t know there was
anything different.
T: You didn’t know there was any other way to be or to feel. Is
that what you’re saying?
C: Yeah. T: I want to check in to see what’s happening between us as we
talk about this. Cause last time we talked about it, you felt like I wasn’t paying attention to this feeling, and I thought I was. I’m really being with you around it. What is that like for you? [Rule 4. Observe the Potentially Reinforcing Effects of Therapist Behavior in Relation to Client CRBs. One way of assessing therapist impact is to ask the client directly about it. This question can also be evocative, Rule 2.]
C: I don’t feel very much. [CRB1] T: What do you notice about not feeling very much? You know
how we started the session talking about how you wanted to make the most of every moment? So in this moment, I’m telling you that I feel really sad that you have this long history of feeling unlovable, of often feeling you like you were unable to evoke caring and positive regard from others. I’m just being with you around it. Is there a way you are shutting me out? [Rule 2, blocking avoidance of therapist caring, and re-presenting it] C: Well my thought, partly I’m shutting you out with the
thought “I AM unlovable” to a degree. I don’t know why it’ so important to me to be liked or loved by other people. Seems like it’d be simpler if it wasn’t so important to me. It’s something I’m not very good at. [CRB1, not accepting (reinforcing) therapist care and concern.]
T: So what you’re thinking is I don’t get it, that you are unlov-
able?
C: Yeah. [CRB1] T: What if that doesn’t match my experience? That I like you
and I love you. Do you want me to define what I mean when I say I love you? Have I done that before? I think I have. What have I said about what it means? [Rule 2, re-presenting caring and love]
C: You care about me, you always have my best interests at
heart, you think about me in between sessions and wonder how this and that is going in my life. [CRB2, acknowledges (reinforces) therapist caring.]
T: There’s also a very visceral feeling in my heart, really tender,
and there’s a place in my heart that’s just for you, and if anything happened to you, I’d feel really, really sad. Can you see that in my eyes? That time you were late on your bike and I was really worried? [Rule 3, a strong natural reinforcement for his acknowledgement; Rule 2, saliently re-presenting therapist caring, ]
C: [quiet, then nods] [CRB2] T: What do you notice now, are you making the most of this moment right now? [Rule 4, Rule 2] C: I was trying to take in what you said, and how you said
it, the expression on your face, and your eyes. I felt like you really meant it. I was trying to take that in. [CRB2] And the same time I try to reconcile that with my other experiences in the world. Maybe it’s more painful now because in the last couple years I have been in my view more of a likable/lovable person but I keep getting the same result. It can be one thing to say you’re not likable and lovable and to recognize you are isolating, cold to people, you’re behaving in a way you can imagine others wouldn’t like or feel close to, that’s one thing. But in the last couple years, to see myself change, and be getting similar results, that’s harder to understand. [CRB1]
T: I have two responses to that, one is really wanting you to stay
with what’s happening between us. I think you left it pretty quickly, it seems hard for you to stay with what our connection feels like. [Rule 4, Rule 2] And then the other response matches you in wanting to discuss what’s not happened, but I can easily focus on what has happened, all the progress you’ve made, and all the people who do like you and care about you. The most important thing that happened is you felt belief in what I said and reinforced me, and then you moved away
WORKING IN-VIVO WITH CLIENT SENSE OF UNLOVABILITY
from it [Rule 4, Rule 2]. That’s one thing we’ve been working on lately, your staying with your feelings. You’re feeling kind of tender and connected, and you left. You went off into your head “how do I compare this with what’s happening in my outside life?” [Rule 5, Provide Functional Analytically Informed Interpretations and Implement Generalization Strategies. Therapist is providing an interpretation that is an “out-to-in parallel” (see p. 93 in Tsai et al. 2009) where daily life events correspond to in-session situations, suggesting that Gary leaves moments of connection by going into his head instead. This is also evocative for Gary, Rule 2.] C: [quiet] T: Remember that day you came in 15 minutes late, and I was really worried. What do you remember about that? [Rule 2] C: I remember you looked really worried that something bad
had happened to me. That you went and looked out and you didn’t see my bicycle. And it was raining and stormy. [CRB2, acting in a way consistent with being lovable]
T: [quiet]. So how do you respond to yourself evoking such in-
tense caring from me? That’s an example of me loving you cause I was worried. There are lots of examples of me loving you and just being so happy and proud of what you’re doing, how you’re being. I wonder if you can hold your positive experiences starting with me, along with your “I’m unlovable”, to find room for both. [Rule 2, Rule 3. This is also an example of Rule 5, suggesting an in-to-out parallel, to deliberately practice a CRB2 with the therapist and then implement it in daily life.]
C: [nods and smiles] [CRB2] T: I like seeing you nod like that. [Rule 3] C: I think I can. [CRB2] T: I feel really proud of you for being open to that. [Rule 3] So
what’s a good homework assignment for you given that we talked about these feelings of being unlovable and you were open to feeling loved by me, actually connecting with that feeling, and then reinforced me for loving you. What’s a good homework assignment? [Rule 5]
C: well, one might be that when I’m feeling particularly unlov-
able that I think about how you care about me and love me and try to make room for both. [CRB2]
T: Does that feel validating, caring and compassionate for yourself? [Rule 2] C: I think I can feel even compassionate for myself even feeling unlovable. [CRB2] T: To me that’s a really big shift, cause when you start feeling
compassion for yourself, that’s starting to love yourself, and the more you love yourself, the more others will be drawn to you, and the more you focus on and acknowledge how others do love you, the more you love yourself. It’s this cycle that feeds on itself. [Rule 3, Rule 5]
C: I think the unlovable feelings are not as predominant or
overwhelming, as convincing as they were at the beginning of the session. [CRB2] In conclusion, this brief report describes how a client’s sense of unlovability and punishing expressions of love and caring from others was shifted in a FAP session. The transcript provides an
example of a logical framework for turn-by-turn interactions (Weeks, Kanter, Bonow, Landes, & Busch, 2011) that can inform the practice of FAP. Through a weaving of the FAP rules, there were three major emphases. First, rather than just blocking or extinguishing Gary’s CRB1 of expressing unlovability, he needed to have a sense of understanding or validation of this feeling. A functional analysis of the antecedents and reinforcers maintaining the behavior is important. In this case, Gary had repeated experiences of not being able to elicit/evoke positive feelings from close others, starting with his mother. He understood that this was not his fault as a child. Although not discussed in the excerpt, this feeling of unlovability is probably maintained by a protective function. That is, it protects him by providing a cocoon so that he does not have to interact more with others and risk rejection or punishment when he is feeling down. Second, the positive reinforcement within the therapeutic relationship--the genuine caring, deep connection and therapeutic love that the therapist feels for Gary is expressed in a way that he can truly let it in and experience in the moment and enabled him to reinforce the therapist for her caring. Third, there is discussion on what Gary can do in the future when the feeling of unlovability comes up outside of session-to be compassionate towards himself the way his therapist was compassionate with him, to recall the genuinely loving interaction in session, to practice his new repertoire of evoking positive behaviors (not in transcript, but includes being open-hearted and showing interest in others) and to focus on how others do care about him and increase (reinforce) their caring. This is the sacred work of therapeutic love, where a client’s healing begins in the session by experiencing the ways he really matters to his therapist, and to let this, rather than his sense of unlovability, guide his behavior towards his therapist and others.
REFERENCES Gilbert, P. (2009). Compassionate Mind. Oakland, CA: New Harbinger. Kanter, J.W. (2011, July). Research for clinicians: Evaluating the client-therapist interaction in successful and unsuccessful cases of Functional Analytic Psychotherapy (FAP). Presented at the annual international meeting of the Association for Contextual Behavioral Science, Parma, Italy. Koerner, K. (2012). Doing Dialectical Behavior Therapy: A practical guide. New York: The Guilford Press. Kohlenberg, R. J. & Tsai, M. (1991). Functional Analytic Psychotherapy: A guide for creating intense and curative therapeutic relationships. New York: Plenum. Linehan, M. (1997). Validation and Psychotherapy. In A.C. Bohart & L.S. Greenberg (Eds.), Empathy Reconsidered (pp. 353-392). Washington, D.C.: American Psychological Association. Tsai, M., Kohlenberg, R.J., Kanter, J.W., Kohlenberg, B., Follette, W., & Callaghan, G. (2009). A guide to functional analytic psychotherapy: Awareness, courage, love and behaviorism. New York: Springer. Weeks, C., Kanter, J.W., Bonow, J.T., Landes, S.J., & Busch, A. (2011). Translating the theoretical into practical: A logical framework of Functional Analytic Psychotherapy interactions for research, training and clinical purposes. Behavior Modification published online http://bmo.sagepub.com/
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AUTHOR CONTACT INFORMATION MAVIS TSAI, PH.D.
Independent Practice and University of Washington 3245 Fairview Ave. East, Suite 301 Seattle WA 98102.
[email protected] 206-322-1067
RICHARD REED, PH.D.
VA Puget Sound Health Care System, S-116MHC 1660 South Columbian Way Seattle, WA 98108
[email protected] 206-277-3287
INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2012, VOL. 7, NO. 2–3
©2012, ALL RIGHTS RESERVED ISSN: 1555–7855
Reliability and Validity of the Spanish Adaptation of EOSS, Comparing Normal and Clinical Samples Luis Valero-Aguayo1, Rafael Ferro-Garcia2, Miguel Angel Lopez-Bermudez3, and Mª Angeles Selva-Lopez de Huralde1 1 University of Malaga (Spain), 2CEDI Clinical Psychology Center of Granada (Spain), and 3CEPSI Psychology Center of Bailen, Jaen (Spain) Abstract The Experiencing of Self Scale (EOSS) was created for the evaluation of Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991, 2001, 2008) in relation to the concept of the experience of personal self as socially and verbally constructed. This paper presents a reliability and validity study of the EOSS with a Spanish sample (582 participants, 18 to 70 years old; 198 men and 384 women), gathered from different cities, universities and clinical centers. The clinical sample consisted of 162 people undergoing psychological or psychiatric treatment and 420 people without problems. Standard questionnaires (Eysenk Personality Questionnaire-Revised, Rosenberg Self-Esteem and Dissociative Experiences Scale) which measure similar self-concepts were used to explore the validity of the EOSS. The results show high internal reliability (Cronbach’s α =.935) and both high and significant correlations with the “neuroticism” scale of the EPQ-R (.212, p
