Psychology assignment

Functional Analytic Psychotherapy: A Behavioral Relational Approach to Treatment

Mavis Tsai Independent Practice, Seattle, Washington and

University of Washington

Samantha Yard and Robert J. Kohlenberg University of Washington

Functional analytic psychotherapy (FAP) is a relational approach to psychotherapy that is behavioral, yet involves an intensive, emotional, and in-depth therapy experience. FAP is approachable by therapists of diverse theoretical backgrounds owing to the minimal use of behavioral jargon, and can be used as an addition or complement to other interventions. The methods described in this article—being aware of clients’ clinically relevant behaviors, being courageous in evoking clinically relevant behaviors, rein- forcing improvements with therapeutic love, using behavioral interpretations to help clients generalize changes to daily life, and providing intensive and personal experiential training of FAP practitioners— maximize the impact of the therapeutic relationship to promote change and personal growth for both clients and therapists.

Keywords: functional analytic psychotherapy, relational, awareness, therapeutic relationship, functional analysis

Functional analytic psychotherapy (FAP) is a behavioral ap- proach based on empirically supported principles that harnesses the power of the therapeutic relationship and maximizes the gen- uineness, intensity, compassion, and effectiveness of the therapist (Kohlenberg & Tsai, 1991; Tsai, Callaghan, & Kohlenberg, 2013; Tsai, Kohlenberg, & Kanter, 2010; Tsai et al., 2009). FAP thera- pists view each client (like themselves) as having complex life stories of joy and anguish, dreams and hopes, passions and vul- nerabilities, unique gifts and abilities, all resulting from reinforce- ment histories that are deeply rooted in their cultural, social, and generational experiences. Thus, like other relational psychothera- pies, a fundamental assertion in FAP is that the therapeutic rela- tionship is at the heart of the change process, and that our ability to form close, rewarding relationships is at the core of our mental health (Sisti, Stewart, Tsai, Kohlenberg, & Kohlenberg, 2014; Wetterneck & Hart, 2012). Similarly, FAP theorists recognize that advocacy of particular treatments for specific disorders may inad- vertently underemphasize the curative aspects of the therapeutic relationship itself (Lambert & Barley, 2002), despite widespread acceptance of this factor’s impact on psychotherapy outcomes (Martin, Garske, & Davis, 2000). Perhaps articulation of a cross- theoretical relational orientation will help to refocus the field on this fundamental change mechanism. This article will explore the contributions of FAP to a trans-theoretical relational orientation, while remaining grounded in behavioral principles.

Concise Conceptual Framework Derived From Behavioral Theory

Contrary to widespread notions that behaviorism lacks depth and is a mechanistic approach to treating simple and behaviorally observable client problems, FAP is concordant with an intensive, emotional, and in-depth therapy experience (Nelson, Yang, Maliken, Tsai, & Kohlenberg, in press; Tsai, Fleming, Cruz, Hitch, & Kohlenberg, in press). Counterintuitively, its major theoretical underpinnings, based on applied behavior analysis, are reinforce- ment, specification of behaviors of interest, and generalization.

Reinforcement

Central to behavior analytic treatment is the direct shaping and strengthening of more adaptive behavior through reinforcement— all consequences or contingencies that increase or decrease the strength of behavior. A long standing, well established, and fun- damental empirical finding about reinforcement is that the closer in time and place the behavior is to its consequences, the greater will be the effect (e.g., Ferster & Skinner, 1957). This is why FAP focuses on the here-and-now therapist–client interaction that, in turn, allows immediate reinforcement of adaptive interpersonal behaviors, as opposed to simply giving compliments or comment- ing on client reports about what they might have done in between sessions.

Specification of Behaviors of Interest

To ensure reinforcement of behaviors that are most likely to lead to improvements in mental health and social relationships, FAP therapists specify behaviors of interest, including successive ap- proximations that are relevant to clients’ presenting problems. As opposed to relying solely on client verbal descriptions of their

This article was published Online First April 28, 2014. Mavis Tsai, Independent Practice, Seattle, Washington and Department

of Psychology, University of Washington; Samantha Yard and Robert J. Kohlenberg, Department of Psychology, University of Washington.

Correspondence concerning this article should be addressed to Mavis Tsai, 3245 Fairview Avenue East, Suite 301, Seattle, WA 98102. E-mail: mavis@u.washington.edu

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Psychotherapy © 2014 American Psychological Association 2014, Vol. 51, No. 3, 364–371 0033-3204/14/$12.00 DOI: 10.1037/a0036506

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daily life problems, direct observation and behavioral definition are essential to this process. Furthermore, for the subtle types of issues that psychotherapy clients can present, observation and behavioral definition of what the client actually does in terms of problem and goal behaviors can best be accomplished if—(a) the client’s problems occur during the session so they can be directly experienced by the therapist, and (b) therapists have in their own repertoire the client’s goal behaviors (e.g., interpersonal relating skills). For example, it would be difficult for a therapist to rein- force being open and vulnerable (if this is the interpersonal goal for a particular client) if the therapist is personally closed and guarded.

Generalization

If therapy evokes the same behavior in clients as their daily life environments (e.g., hostility, not following through, avoidance of emotion), then they are functionally similar (somewhat akin to the notion of transference). This functional similarity increases the likelihood of generalization of client gains to daily life. To en- courage this process, FAP therapists also discuss generalization explicitly and assign homework to clients based on their in-session improvements. In common with other relational therapies, FAP uses the therapy relationship as an opportunity to encourage im- provement during client–therapist interactions as a basis for pro- ducing daily life gains. FAP may differ in that it uses concepts based on learning research and eschews models of psychopathol- ogy.

Major Concepts

Based on behavioral theory, FAP embraces the following con- cepts: a contextual view of reality, behavior as action, functional analysis, natural reinforcement, and clinically relevant behavior. Each is central to understanding how FAP therapists build curative therapeutic relationships.

Contextual View of Reality

Behaviorism is a contextual theory in which individuals’ per- ception of reality is a function of their unique experiential rein- forcement histories. Thus, clients’ actions are seen as the natural result of their histories, and their present actions and view of reality were adaptive and necessary in their earlier development. These same patterns, however, are no longer adaptive in their current life. This assumption provides FAP therapists with a pow- erful way to acknowledge and understand a person’s individuality and the ways that both past and present events, including feelings and thoughts, interact to account for the course of their life. Given such a view, therapeutic compassion and acceptance are logical next steps—creating space for forgiveness and the emergence of new, more adaptive behavior.

Behavior as Action

Behavior refers to anything a person does—observable events (e.g., walking, crying), private acts (e.g., thinking, feeling), and bodily functions (e.g., heart rate, hormonal secretions). Thus, every aspect of being human is encompassed by this definition of behavior, as long as the act is expressed as a verb—instead of

having a memory, people remember; instead of having courage, people act despite experiencing fear. With this definition of be- havior, clients become agents in change in that they are encour- aged and prompted to act in new ways (at first during therapy, and then during daily life), thus providing them with the opportunity to experience reinforcement first in session, and then as a result of their daily life gains.

Functional Analysis

Functional analysis answers the question “What is a behavior’s function?” by identifying the contexts that evoke the behavior, and the consequences that make it more or less likely. For example, to say that a man has a drinking problem because he consumes a certain amount of alcohol (i.e., a description of what a behavior looks like) is not sufficient for understanding how to enact change for that individual. Instead, a functional analysis also would in- clude its possible functions such as the drinking alleviates social anxiety, lowers social inhibition, or numbs negative feelings. Un- derstanding the functions of a behavior leads to different thera- peutic interventions (Tsai, Kohlenberg, Kanter, Holman, & Plum- mer Loudon, 2012). One way this can be instantiated during therapy is to help a client with drinking issues notice if he has urges to drink during the session, and if so, what correlates with that urge. He may notice that he wants to withdraw and numb his feelings when his therapist offers kind words, and thus could be offered a functional analytic interpretation that connects how in his history, praise from a parent was often followed by aversive consequences from either a jealous sibling or the parent’s partner.

Natural Reinforcement

Natural reinforcers are related to those that occur in one’s daily life environment. To be naturally reinforcing during the therapy session, therapists need to connect authentically with their clients just as people connect in the outside world, including sharing, expressing, disclosing, or amplifying reactions to client behavior. It is, however, crucial for therapists to recognize and shape suc- cessive approximations of goal behaviors even if they are not yet at the level that would be positively reinforced in daily life. Thus, FAP therapists are expected to be more sensitive to client improve- ments than others—especially early in treatment. For example, a crude display of negative emotion toward the therapist may dem- onstrate improvement for a client who does not ever express any emotions publicly; in that case, the therapist may naturally rein- force this behavior while shaping more skillful expressions in the future. Therapist sensitivity and authenticity is crucial to the suc- cess of natural reinforcement. For example, an authentic response such as, “Wow, you just exploded at me rather than shut down and withdraw like you normally do when you get pissed. The intensity of your anger is a little scary for me, but it helps me understand you a lot better than you pulling away without telling me why, like you usually do. Would you be willing to work with me on continuing to express your anger in a way that feels less scary to me?” will likely be more naturally reinforcing than a contrived and generic response such as “Thank you for sharing your feelings with me.” Sensitivity and authenticity increases the therapist’s reinforcement value for the client; that is, the therapist matters more to the client, setting the stage for the therapeutic relationship becoming an even more powerful vehicle of change.

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365FUNCTIONAL ANALYTIC PSYCHOTHERAPY

Clinically Relevant Behavior

Three types of client daily life behaviors that also occur during therapy sessions are of particular relevance and are referred to as clinically relevant behaviors (CRBs). CRB1s strictly refer to client daily life problems when they occur in session. CRB2s are client improvements that also occur in session. CRB1s are expected to decrease during the course of therapy as CRB2s are more fre- quently naturally reinforced. CRB3s are client interpretations (based on functional analysis) of their own behavior. Based on behavioral principles, known as “rule following” and “relational frame theory” (Törneke, 2010), such client interpretations often lead to more CRB2s and facilitate generalization, and therefore can be valuable.

Thus, FAP is a highly individualized intervention that requires a thorough assessment and case conceptualization of each client using the major concepts defined above. Client problems or goals are grouped together based on their function or the purpose they serve, with specific form or appearance varying from client to client. These functional groups of behaviors may, for example, include specific responses that serve to distance others, affect how clearly feelings are expressed, or impact reactions to conflict. The most researched approach to FAP case conceptualization is the Functional Idiographic Assessment Template (Callaghan, 2006), whereas a less formal method is illustrated by the “Case Concep- tualization Form” (Tsai et al., 2009, p. 213).

Clinical Application of FAP

In accordance with thorough and ongoing assessment and case conceptualization, doing FAP entails implementing five therapeu- tic rules that emphasize clients’ CRBs. These rules are suggestions for therapist behavior that typically lead to clinical improvement, and can enhance methods from other theoretical orientations (e.g., Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002) by highlight- ing therapeutic opportunities that may otherwise go unnoticed.

Rule 1. Watch for CRBs (Be Aware)

This rule forms the core of FAP. In using Rule 1, therapists continually attend to the question: “How do the client’s daily life problems (CRB1s) and target behaviors (CRB2s) show up in this therapeutic relationship?” It is important to note that the same topographically identical behavior by different clients, such as coming late to an appointment, can be a CRB1 or a CRB2 depending on the nature and history of their daily life problems. For example, a client who has obsessive–compulsive disorder and comes late or misses a session might be engaging in a CRB2 and thus should be reinforced by the therapist.

A therapist’s personal reactions to the client can be a valuable guide for identifying CRBs, but it is imperative that therapists continually engage in self-awareness practice to notice when their own responses are idiosyncratic and related to their own learning histories versus broadly representative of how others might gen- erally react to the client. These decisions are based on training, supervision, and ongoing consultation, which target therapist- specific CRBs (T1s and T2s) that may be influential in conducting FAP with clients. An intense focus on therapists being aware of their own deficits and problems is, of course, dealt with more or less explicitly in other relational therapies as well.

Rule 2. Evoke CRBs (Be Courageous and Emotionally Present in the Therapeutic Relationship)

From an FAP standpoint, the ideal client–therapist relationship evokes CRB1s, which are the precursors for developing CRB2s. For example, many clients struggle with intimacy behaviors, such as trusting, taking interpersonal risks, acting authentically, and giving and receiving appreciation. To foster therapeutic relation- ships that encourage, demonstrate, and shape these behaviors, FAP calls upon therapists to be emotionally present, to structure the therapy in an emotionally evocative manner, and to be courageous in evoking CRBs. FAP therapists act courageously through being authentically themselves with the client, staying the course (not avoiding or escaping) when a client’s behavior is aversive to the therapist, and engaging in behaviors that may not be immediately reinforced but are aimed toward shaping more effective responses and repertoires over time.

To structure a therapeutic environment that evokes CRBs, FAP therapists provide a rationale to gain informed consent and to prepare clients for an intense and evocative therapy that focuses on in vivo interactions. Providing this rationale itself often evokes CRB. For example, an FAP therapist might say to a depressed client:

“I understand that you are seeking treatment for depression. One reason why people may get depressed is that they find it hard to express how they feel and what they need in their relationships, and find it difficult to assert those needs to important people in their life. If this is true for you, and if you think it will be helpful, then one focus of our therapy will be on how you can become a more powerful person, by developing ways for you to express your true feelings with conviction and compassion, and go after what you want in your relationships and in life. The most effective and efficient way for you to develop the skills to become a more expressive person is to start right here, right now, with me, and to discuss with me what you are thinking, feeling, and needing, even if it feels scary or risky. If you can bring forth your best self with me, then you can transfer these behaviors to other people in your life. How does that sound?”

To the extent that therapists can allow themselves to be who they really are in the service of client growth, a more powerful and transformative therapeutic relationship can be created. This is because the therapist serves as a model of healthy self- expression and effective interpersonal behaviors; the therapist– client interactions serve as a context for validation, normaliza- tion, and natural reinforcement; and the emotional experience of relating to the therapist more closely mirrors the client’s experiences in their outside relationships. Considering the fol- lowing questions may help therapists increase their potency as change agents:

(1) What unique qualities make you distinctive as a person and as a therapist? How can you use your distinctiveness to your clients’ advantage? (2) Do you have similar interests or comparable life experiences to your client? Consider disclosing these commonalities if it will facilitate a particular client having greater contact with his or her issues and/or increase a sense of connection. (3) What do you experience as special about your client, how are you positively impacted? (4) What are the ways you care about your client? (5) How can you take risks to deepen your therapeutic relationship in ways that serve the

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366 TSAI, YARD, AND KOHLENBERG

client’s best interests (e.g., share a poem that reminds you of the client)? Such disclosures can enhance the therapeutic relation- ship, normalize clients’ experiences, model adaptive and inti- macy building behavior, demonstrate genuineness and positive regard for clients, and equalize power in the therapeutic rela- tionship. Of course disclosure should be undertaken strategi- cally, with awareness for how the disclosure may evoke, rein- force, or punish CRBs for a particular client (Tsai, Plummer, Kanter, Newring, & Kohlenberg, 2010).

In addition to the courage it takes to be authentically oneself in the therapy room, FAP therapists must act courageously in evoking CRBs because these actions will not always evoke CRB2s; indeed, sometimes the reaction from clients will be unpleasant or off- putting for the therapist. To use a hypothetical example, if a therapist were to share a poem that they wrote about the client, and the client were to react with ruminations about not being worthy of the therapist’s time, this might be aversive. The natural inclination in an aversive state is to withdraw and escape, so it takes courage to remain present, maintain authenticity, and continue to evoke CRBs. Perhaps in the situation with the poem, the therapist would highlight what type of response he/she had been looking for (e.g., appreciation for the therapist’s efforts in writing the poem) and ask the client to try a response in the direction of a CRB2 (for some clients, an improvement would be a statement like “I don’t know how to say something appreciative.”). Thus, the writing and read- ing of a poem, the staying present with the client’s aversive response, and the suggestion to attempt a CRB2 all require some level of courage from the therapist.

As both an evocative and a feedback tool, a session-bridging form is given to clients after every session (see Appendix D, Tsai et al., 2009) where they are asked to share their candid responses to maximize the effectiveness of the therapy. Questions include— What stands out to you about our last session? Thoughts, feelings, insights? What would have made the session a more helpful experience? Anything you are reluctant to say or ask for? What issues came up for you in the session/with your therapist that are similar to your daily life problems? What risks did you take in session/with your therapist or what progress did you make that can translate into your outside life?

Rule 3. Naturally Reinforce CRBs (Be Therapeutically Loving)

The hypothesized mechanism of clinical change in FAP is contingent responding by the therapist that is compassionate and respectful to client behaviors as they occur in session in an effort to strengthen (reinforce) more effective ways of acting. It is important to be sensitive to the skills clients have, not require more than they are currently capable, and yet still encourage improve- ments. In FAP terms, this regard for clients is called “therapeutic love,” a profound, ethical caring with which therapists encourage clients to grow in the direction of their values. Although this has parallels to unconditional positive regard, FAP therapists do not see that concept by itself as sufficient to bring about change. Instead, this caring environment is the context in which therapists respond to client behaviors in an effort to decrease CRB1s and increase CRB2s.

Rule 4. Notice Your Impact

When therapists respond to CRBs, they must pay attention to client reactions and consider the question: “Am I having the desired effect on my client?” By definition, clients have experi- enced therapeutic reinforcement only if their target behavior is strengthened. Therefore, therapists must assess the degree to which their behaviors that were intended to reinforce actually functioned as reinforcers and adjust accordingly. In addition, it is important for therapists to focus on the role of therapist in-session problem behaviors (T1s) and therapist in-session target behaviors (T2s) by exploring the following questions: “(1) What do you tend to avoid addressing with your clients? (2) How does this avoidance impact the work that you do with these clients? (3) What do you tend to avoid dealing with in your life (e.g., tasks, people, memories, needs, feelings)? (4) How do your daily life avoidances impact the work that you do with your clients? (5) What are the specific T2s you want to develop with each client based on the case conceptu- alization?”

Rule 5. Provide Functional Interpretations of Behavior and Implement Generalization Strategies (Interpret and Generalize)

Providing a clinical interpretation informed by functional anal- ysis includes accounting for how client behavior was historically adaptive, and how to generalize progress in therapy to daily life. Implementing Rule 5 emphasizes “out-to-in parallels” when daily life maladaptive behaviors manifest in-session and “in-to-out par- allels” when newly learned in-session adaptive behaviors are gen- eralized to daily life (Tsai et al., 2009). For example, a client withdrawing from her therapist expressing caring is an out-to-in parallel, and her relaxing into this caring and allowing it to happen in her daily life with others is an in-to-out parallel.

Provision of homework is also important to Rule 5; the best homework assignments are when a client has engaged in a CRB2 and is asked to test the improved behavior with significant others (e.g., “You took the risk of sharing some deep feelings with me, and we felt more connected as a result. Would you be willing to practice stepping out of your comfort zone this next week, in the same way you did in our relationship—and keep a log of your interpersonal risks?”).

Case Example

To illustrate an FAP interaction entailing the use of all five rules, below is a verbatim transcript, edited for clarity. This session took place about four months into a therapy with the first author. The client is a 35-year-old man seeking therapy for unsuccessful relationships with women. To comply with APA ethics code in reporting case material, de-identification was used, and informed consent was obtained.

Therapist: Can you feel the difference when you are feeling your “mojo” (client’s term for when he is feeling “on”), here with me and with others? [Rule 2, evoke CRBs]

Client: Yeah, okay, good. I practiced what we talked about with my date. I can kind of feel that physically. So I really paid attention to my body. I tried not to speak too quickly, get kind of tumbling up here in my head. Staying centered here in my solar plexis, and

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367FUNCTIONAL ANALYTIC PSYCHOTHERAPY

yeah I could feel it. I know that centered feeling. I feel it right now. [CRB3]

T: You’re really different from before. I can feel how you exude your energy differently when you are centered. [Rule 1, awareness; Rule 3, natural reinforcement of what’s happening in the moment]

C: Mm hmm. You can feel that confidence coming from me. [CRB2, acknowledging what therapist said and staying connected]

T: Yes, I can feel that confident energy coming from you. [Rule 3; may also be a Rule 2, evoke by helping the client stay present in his confident energy] What’s it like to hear me tell you that? [Rule 4, therapist can ask regarding impact or just silently notice]

C: Yeah, it’s interesting, your feedback helps me really come to that place where I can tell the differences in those two states of being. [CRB2 & 3]

T: And I think all these women are responding. [Rule 3] C: Yes, I’m getting positive responses from several women who

have responded to me as a person. I was feeling that centeredness, and it helped me keep there, rather than getting too caught up in the anxious machinations of my brain. [CRB3]

T: You’re such a quick study. We focus on something in here, you just get it right way. I ask you to try it with others in your life [Rule 5], and you immediately do it. It’s very exciting. [Rule 3]

C: Well, you and I have really achieved something here that I’ve been looking for in therapy for a long time. The last couple times in therapy I’ve been looking for somebody to help me find out what I might be bringing to the table. This is a testament to our work together, a testament to FAP. ‘Cause what we did is you helped me pay attention to my behavior in the room, I paid attention to what was going on with me. In other therapies I could talk a good game about what’s going on in my relationships, but we were talking about it rather than focusing on something I could take out of the room. In this case, it was a feeling, a centered, locked in feeling I got in touch with that I was then able to take out of here, so thank you. [CRB2, CRB3]

T: Well it’s thrilling to me. [Rule 3] In sum, this client presented as very intellectual and somewhat

disconnected from himself. This behavior was gently blocked by the therapist who then evoked, shaped, and naturally reinforced a focus on feeling present and grounded in the moment. The client was then asked to practice the specific behaviors associated with those feelings in his outside relationships. This example shows how the application of FAP’s five rules can lead to an increased and meaningful focus on the therapeutic relationship, which entails awareness, appropriate risk-taking by both client and therapist, natural reinforcement of positive change by the therapist, and the generalization of in-session progress to daily life, thus maximizing therapeutic outcome. Specifically, the therapist implemented Rule 1 by being aware of the client’s CRBs in session, both his CRB1s (e.g., being too intellectual, being disconnected from his feelings) and his CRB2s (being centered in his body, feeling his “mojo,” expressing connection toward the therapist); Rule 2 by evoking and shaping his CRB2s of being more present with her; Rule 3 by naturally reinforcing his more connected behaviors in the moment, both within himself and with her; Rule 4 by noticing and/or asking about the effect of her natural reinforcement; and Rule 5 by asking him to try his CRB2s of being present and connected in the session with others in his life. Thus, FAP therapists bring their authentic selves into the therapeutic relationship in terms of how they use the five rules to create a sacred space of awareness, courage, and

therapeutic love where their clients can blossom and are asked to generalize these changes to their daily lives.

Evidence for Outcome and Mechanism of Change

In essence, FAP’s focus on the therapeutic relationship involves watching for, noticing, and responding to CRBs in the here and now. By definition, CRBs refer to daily life problems that appear in the context of the therapist–client interaction that reflect the clients’ daily life issues. We contend that adding such a focus increases the intensity and power of psychotherapy, broadly de- fined. While converging lines of evidence exist from a variety of literature in support of some of FAP’s basic principles (Baruch et al., 2009), FAP researchers have attempted to gather data to address the effects of therapist focus on CRBs by measuring therapist behavior (and sometimes client behavior) in session and exploring relations between in-session therapist behavior and in- dicators of client outcomes.

Our first study assessed the impact of adding in FAP’s focus on CRBs with cognitive therapists (Kohlenberg et al., 2002). In this study, four experienced cognitive therapists first did cognitive therapy (CT) with 15 depressed patients. Then, while receiving training and supervision in FAP, they saw an additional 23 pa- tients, continuing to do CT but with an added emphasis on noticing CRBs and shaping CRB2s. This latter treatment was termed FAP- Enhanced Cognitive Therapy (FECT). Results indicated that cli- ents receiving FECT showed a more favorable reaction to the FAP rationale, and significantly improved on the GAF (Global Assess- ment of Functioning), and interpersonal functioning as measured by the SSQ (Social Support Questionnaire). The incremental ef- fectiveness of adding FAP to cognitive behavioral therapy (CBT) also has been demonstrated via single-subject design studies (Gaynor & Lawrence, 2002; Kanter et al., 2006).

To further investigate the impact of the therapist attending to the therapy relationship as called for by FAP rules, Kanter, Schild- crout, and Kohlenberg (2005) looked at each therapist–client in- teraction in the aforementioned FECT versus CBT study (Kohlen- berg et al., 2002) for the therapist’s explicit discussion of the therapist–client relationship and reactions to the client. These therapist–client interactions were referred to as in vivo (IV) hits. The rate of IV turns was 2.8 times higher in FECT compared with CBT (95% CI � 2.2–3.6, p � .001). There was a statistically significant relationship between IV hit rates per session and whether or not clients reported that the session was helpful in making progress with their problems, and a trend for improved interpersonal relationships. This turn-at-speech analysis found that for every five IV hits that were added by therapists in a session, there was an incremental improvement in outcome. Our explana- tion for this finding is that an increased number of IV hits are an indication of the therapist following the FAP rules, again support- ing the hypothesis that the mechanism of change in FAP is con- tingent therapist responding with natural reinforcement to CRBs.

To more clearly isolate and identify FAP’s purported mecha- nism of action and to demonstrate the effects of this mechanism on the behavior of individual clients, the Functional Analytic Psycho- therapy Rating Scale (FAPRS) was developed to measure turn-by- turn client and therapist behavior and to allow for reliable identi- fication of in-session occurrences of daily life problems (CRB1s), improvements (CRB2s), and contingent therapist responses (Cal-

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laghan, Summers, & Weidman (2003). Focusing on four sessions of a client with Personality Disorder Not Otherwise Specified successfully treated with FAP, coders reliably demonstrated they could identify client CRBs and therapist contingent responses to CRBs with the FAPRS, and that client CRB1s decreased and CRB2s increased over the course of therapy in response to thera- pist contingent responses. Overall, research using the FAPRS has provided support for contingent responding to CRBs as the mech- anism of change in FAP (Busch, Callaghan, Kanter, Baruch, & Weeks, 2010; Callaghan, Follette, Ruckstuhl, & Linnerooth, 2008; Kanter et al., 2006).

These results using intensive turn-by-turn coding were limited, however, because the clients coded were case studies that did not systematically control exactly what the therapist did in session to rule out alternative hypotheses. This was remedied by Busch et al., (2009) on a client with comorbid depression and Histrionic Per- sonality Disorder. This client demonstrated large and sudden im- provements when the therapist began focusing on CRBs, and turn-by-turn coding of every session of this case demonstrated a clear link between focusing on (observing, evoking, and respond- ing to) CRBs and client improvements both in and out of session.

In the only randomized-controlled study incorporating FAP, Gifford and colleagues (2011) randomly assigned 303 smokers from a community sample to bupropion, a widely used smoking cessation medication, or bupropion plus a combination of FAP and ACT (Acceptance and Commitment Therapy) in a smoking ces- sation trial. There were no differences between conditions at posttreatment; however, participants in the FAP and ACT condi- tion experienced significantly better outcomes at 1-year follow-up, suggesting that FAP may support relapse prevention following health behavior changes.

The research focusing on CRBs is still in its infancy. Neverthe- less, taken together, there is accumulating support for the specific mechanism of action in the therapy relationship according to FAP. This research does not indicate that FAP’s proposed mechanism is the only active way the therapeutic relationship may positively impact clients, but it does appear to be one such way. Essentially, FAP’s behavioral approach to the psychotherapy relationship, by focusing on specific client and therapist behaviors and their impact on each other, has facilitated a process research agenda that pro- vides a window into exactly what a therapist can do in session to create a powerful, intense relationship that has measurable positive effects on client relational problems, defined individually for each client.

FAP Training and Therapist Self-Development

Training in FAP has evolved to encompass the need for thera- pists to have not only intellectual understanding of the five rules and underlying behavioral principles, but also the skills of coura- geous, compassionate, and strategic risk-taking in the service of client growth. Thus, FAP therapist training protocols, both in- person and online, are based on the same fundamental principles as the therapy itself—a conceptualization of targeted therapist-trainee behavior as CRB2s that are evoked and naturally reinforced during the training sessions by trainers and other trainees.

The stated vision for FAP training is to create: (1) an intellec- tually stimulating atmosphere where creativity, diversity, collabo- rating, and questioning are valued; (2) an environment where all

are reinforced as powerful thinkers and agents of change in the therapy room and in their daily lives; (3) an intentional community where everyone feel the support, acceptance, and compassion of mighty companions in their outward journeys as clinicians and in their private journeys of personal growth; (4) a place with no pretenses, where participants can be seen and heard as who they are, where they express their true voices, where their wounds are validated and their gifts are nurtured.

The training environment is highly structured to maximize the evocation and natural reinforcement of trainee CRBs. This occurs through numerous exercises in which trainees take meaningful interpersonal risks and respond to one another’s risks with genuine feedback. For example, in the “Life History” exercise, trainees are encouraged to take risks related to emotional expression (Rule 2, engage in CRB2s). As trainees present their life histories, the trainer and other participants listen with awareness and observe CRBs in the presenter (Rule 1). After the autobiography, each listener provides genuine feedback or reflections, intended to func- tion as deliberate practice of natural reinforcement of CRB2s (Rule 3). After receiving reflections, the presenter is asked to provide brief feedback to the other trainees about their feedback (Rule 4). Finally, trainees are encouraged to try these interpersonal risk- taking behaviors and the giving of reflections with others, includ- ing their clients, and to report on these behaviors in the form of “risk logs” (Rule 5) emailed to all group members prior to weekly meetings.

FAP’s use of behavioral principles in training is consistent with an accumulating body of recommendations from training and dissemination researchers suggesting that using more active learn- ing strategies, such as deliberate practice and feedback, may im- prove outcomes in therapeutic skill (Beidas, Koerner, Weingardt, & Kendall, 2011). FAP training also has capitalized on technology by conducting therapist training using web-based video conferenc- ing. Both anecdotal evidence from over 25 FAP training groups and an initial pilot randomized trial investigating the impact of this training indicate powerful and memorable impact on trainees’ professional and personal lives (Kanter, Tsai, Holman, Koerner, 2013; Tsai et al., 2009). These outcomes make sense considering the relational nature of the training involved. In the context of FAP training, both trainees and trainers develop intimate connections with one other, sharing their deepest fears, losses, hopes, dreams, and passions. The training is a testing ground for therapists’ capacities to demonstrate courage, to build intimacy, and to evoke interpersonal growth in one another. By explicitly and directly evoking intimate interactions and authentic therapist self- expression, the trainings set the stage for what is needed in the therapy room. In addition, this experience increases the therapists’ self-awareness, teaches the importance of authentic therapeutic relationships, and provides the skills practice necessary for sup- porting clients through the process of deepening their connection skills.

Conclusion

By creating emotionally evocative and genuine relationships, FAP therapists powerfully shape the interpersonal behaviors, emotional awareness, and self-expression necessary for clients to create and maintain close and lasting relationships in their own lives. FAP interactions are similar to other relational

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therapies in terms of: (1) awareness of clinically important in-session behaviors; (2) interventions aimed at evoking such behaviors; (3) natural responding with an undercurrent of re- spect; (4) awareness of how clients react to therapist responses; and (5) discussion of how the nature of therapeutic interactions might relate to outside relationships. To create the most potent context for client progress, FAP has these critical dimensions: ideographically focused ongoing assessments and hypothesis- testing for each client; therapists who are trained to be authentic in session and to stay aware of their own emotions in the service of the client’s goals; regular discussion of how the therapeutic relationship can be used as a means for improving relationships with others; and emotionally evocative risk-taking by both therapist and client in the service of client growth.

Although all relational approaches conceptualize the thera- peutic relationship to be the primary curative aspect of treat- ment, FAP’s contributions may stem from behavioral concepts that help to give new and more precise insights into clinical phenomena. Such concepts include—(1) awareness of clients’ CRBs, (2) acting courageously and authentically to evoke CRBs, (3) immediately responding to client problems and im- provements as they occur in session, and (4) using behavioral interpretations to help clients generalize in-session improve- ments to daily life. Furthermore, clinical application of these concepts extends into the training of FAP therapists who must not only be knowledgeable about the treatment but also have experience in exploring their own interpersonal repertoire and demonstrate courageous application of FAP strategies to en- courage therapeutic intimacy and, ultimately, clinical progress. These guidelines hopefully can complement and enhance ther- apies from other theoretical orientations and point to compel- ling directions in change and personal growth for both clients and therapists.

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Received February 17, 2014 Revision received February 19, 2014

Accepted February 19, 2014 �

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