Close relationships are central to mental health (Wetterneck & Hart, 2012). Loneliness and poor social connection represent a significant public health concern, increasing risk of death as much as excessive cigarette smoking, more than excessive drinking and obesity (Holt-Lunstad et. al., 2010).
Functional Analytic Psychotherapy (FAP) is a contextual, behavioral, relational approach to psychotherapy in which therapists focus on what happens in session between the client and therapist to shape the interpersonal behaviors, emotional awareness, and self-expression necessary for clients to create and maintain close relationships and to live meaningful lives (Kohlenberg & Tsai, 1991; Tsai et al., 2009; Tsai, Callaghan & Kohlenberg, 2013).
While earlier forms of FAP did not specify specific targets of treatment, current forms of FAP are incorporating a model of social connection derived from multiple sources, including social-cognitive research, neuroscience, and behavior analysis, that emphasizes three inter-related behavioral processes labelled awareness, courage (related often to vulnerable self-expression) and love (related to loving responsiveness to one’s self and others).
Similar to other relational approaches, a fundamental assertion of FAP is that the therapeutic relationship is the primary curative aspect of treatment. FAP’s unique contributions may stem from the application of behavioral concepts that suggest novel and more precise interventions therapists can employ in-session to create powerful and intense relationships that have measureable positive effects on client interpersonal problems, defined individually for each client (Tsai, Yard & Kohlenberg, 2014).
FAP Has a Concise Conceptual Framework Rooted in Contextual Behavioral Theory
Contrary to widespread notions that behaviorism is a relatively impersonal approach to treating simple problems, FAP’s contextual behavioral conceptual framework facilitates an intensive, emotional, and in-depth therapy experience.
Viewing clients in context
The contextual framework facilitates a compassionate view of a client’s daily life problems and actions. These behaviors are seen as the natural result of one’s history and were once adaptive and necessary, but are no longer working. This stance creates space for acceptance and the emergence of more adaptive behavior.
Natural reinforcement is authentically responding to client problems and improvements in session in order to strengthen adaptive behavior. Given the well-established importance of immediacy in the effectiveness of reinforcement, a fundamental goal of FAP is to shape and respond to adaptive interpersonal behaviors as they occur in session (Ferster & Skinner, 1957) rather than commenting on client reports of what they did in between sessions.
Generalization is when a client learns a more skillful behavior and is then able to successfully implement this behavior in other areas (e.g., with significant others) because of functional similarities between the environments. For example, if the same behavior is evoked in both therapy and the client’s daily life environments (e.g., hostility, not following through, avoidance of emotion), then they are functionally similar.
Functional analysis answers the question “what is a behavior’s function?” or “what makes a client persist in engaging in a particular behavior?” by identifying the contextual antecedents and consequences that make the behavior more or less likely. Understanding the function of a behavior (e.g., drinking when with friends to relieve social anxiety), rather than just its form (e.g., drinking 5 drinks per night), leads to different and more individualized therapeutic interventions (Tsai, Kohlenberg, Kanter, Holman & Plummer Loudon, 2012).
Clinically Relevant Behavior (CRB)
FAP therapists use direct observation, client reports, and their own reactions to formulate a case conceptualization that will enable them to anticipate and watch for clinically relevant behaviors (CRBs) as they occur in session.
The client’s daily life problems that show up in session are referred to as CRB1s, and in session improvements are termed CRB2s. CRB1s are expected to decrease as CRB2s are more frequently naturally reinforced by the therapist.
Clinical Application of FAP
In accordance with thorough and ongoing assessment and case conceptualization, doing FAP entails implementing five therapeutic 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 highlighting therapeutic opportunities that may otherwise go unnoticed.
Rule 1. Watch for CRBs (be aware)
FAP focuses on how outside life problems show up in the therapy relationship, rather than just talking about a client’s daily life problems. Watching for CRBs leads to more accurate detection of and effective responses to clients’ problems and improvements as they occur with the therapist.
By cultivating awareness, a therapist can be better attuned to:
- a) the antecedents, consequences, and historical contexts of client behavior;
- b) CRB2s that initially present as clumsy and off-putting that might not be recognized as improvements (e.g., when a client who has never expressed feelings before yells at the therapist);
- c) when the same behavior can be a CRB2 in one client but a CRB1 in another client (e.g., being late to session may be a CRB2 in a client who is compulsively on time at cost to oneself and a CRB1 in another client who is chronically late to everything); and
- d) when the same behavior may be a CRB2 in the earlier stages of therapy but can become a CRB1 in later stages (e.g., willingness to ask for the therapist’s opinion on important issues initially may be a CRB2 for someone who is unwilling to be open to others, but can become a CRB1 in the later stages of therapy if this client becomes so attached he struggles with independent decisions).
Rule 2. Evoke CRBs (be courageous and emotionally present in the relationship)
FAP calls for therapists to be genuine, emotionally present, and courageous in being vulnerable and pushing beyond their own comfort levels in the service of bringing forth their clients’ best selves. Evoking CRBs typically involves bringing challenging client behaviors (CRB1s) into the session and helping clients develop more adaptive responses (CRB2s).
For example, if a client is afraid of emotional intimacy, therapists may actively show genuine caring (e.g., saying what they like and appreciate about the client), self-disclose what they have in common (e.g., similar struggles in adolescence), focus on ways the client avoids connection in session, and collaboratively build a space for the client to explore a sense of safety in mattering to each other.
Rule 3. Naturally reinforce CRBs (be therapeutically loving)
Natural reinforcement in the service of client goals is therapeutic love that is ethical and genuine, and is functionally similar to caring relationships in the client’s community. FAP therapists try to immediately and authentically respond to client problems and improvements as they occur in session to strengthen (reinforce) more effective ways of acting. A FAP therapist is sensitive to the client’s current skill level, not requiring more than they are currently capable of doing, while still encouraging improvements.
Rule 4. Notice your impact (be interpersonally aware)
FAP therapists consistently respond to CRBs while paying attention to client reactions and considering the question: “am I having the desired effect on my client?”
Thus, the most accurate measure of whether therapeutic reinforcement is effective is if the target behavior (e.g., a client directly asking for what they need) is strengthened. In addition to noticing the impact of their interactions, this rule encourages therapists to be aware of: a) their emotional reactions to the client and whether these reactions accurately represent those of people in the client’s daily life; and b) their own T1s (therapist problem behaviors) and T2s (therapist target behaviors).
Rule 5. Provide functional interpretations of behavior and implement generalization strategies (interpret and generalize)
Providing a clinical interpretation informed by functional analysis includes accounting for how clients’ behavior made sense given their history (e.g., how their attempts at intimacy were punished by important others), and how to generalize progress in therapy to daily life. Homework assignments are also important to Rule 5; the best homework assignments are when a client has engaged in a CRB2 (e.g., being emotionally vulnerable) and is asked to try out the improved behavior with significant others.
Empirical Support for FAP
Reviews of FAP publications point to a growing number of empirical investigations (Garcia, 2008; Mangabeira, Kanter & Prette, 2012). Empirical support for FAP to date includes:
- a randomized clinical trial showing significant reductions in diagnostic symptoms across depression and anxiety disorders and significant increases in social connectedness in FAP compared to watchful waiting (Maitland, 2014);
- studies suggesting the incremental effectiveness of adding FAP to other therapies and methods (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002; Gaynor & Lawrence, 2002; Kanter, Schildcrout and Kohlenberg; 2005; Gifford et al., 2011; Holman et al., 2012; Bowen, Haworth, Grow, Tsai & Kohlenberg, 2012; Kohlenberg et al. 2014);
- studies suggesting that immediate, in-session responding to CRB2s with natural reinforcement (FAP’s hypothesized mechanism of change) produces increases in target behaviors in and out of session (Callaghan, Follette, Ruckstuhl & Linnerooth, 2008; Kanter et. al, 2006; Busch, Callaghan, Kanter, Baruch & Weeks, 2010; Landes, Kanter, Weeks, & Busch, 2013);
- developments in methods for evaluation and data recording (Callaghan, Summers & Weidman, 2003; Callaghan, 2006; Leonard et al., 2014);
- a laboratory analog supporting FAP’s model of social connection and mechanism of change (Haworth et al, 2014); and
- a small, randomized cross-over trial of FAP online training found significant improvements in observer-rated and self-reported therapist skill at FAP and therapist reports of closer, more impacted relationships with their clients (Kanter, Tsai, Holman, Koerner, 2012).
FAP training and Therapist Self Development
FAP concurs with other approaches and empirical findings that the therapeutic relationship is the most important tool in therapy (Lambert & Barley, 2002).
Training in FAP involves cultivating not only intellectual understanding of the five rules and underlying behavioral principles, but also the behavioral skills of awareness, courage, and love (ACL) that are often targets for clients, in the service of implementing FAP’s rules and principles in the most powerful way possible. 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.
FAP training that focuses on therapist self-reflection increases therapists reported clinical skill as well as powerful and memorable impact on their professional and personal lives (Kanter et al., 2012; Tsai, Yard & Kohlenberg, 2014; Tsai et al., 2009).
Summary and Benefits
FAP, a contemporary contextual behavioral therapy grounded in empirically supported principles, is intense, caring, relational and evocative. It is often used to enhance the impact of other therapeutic approaches by increasing emotional intensity, interpersonal focus, and the quality of the therapeutic alliance. It is also used as a stand-alone approach targeting ideographically defined variables, often within the context of client goals related to improving social connection, a cross-diagnostic functional dimension.
FAP’s five rules focus on how therapists can:
- be aware of clients’ clinically relevant behaviors (CRBs)–problem behaviors and target behaviors occurring within the client-therapist relationship that correspond to those happening in their outside relationships;
- evoke CRBs;
- naturally reinforce CRBs;
- notice their own impact;
- make interpretations and help clients generalize target behaviors.
When implemented well, these rules can call for therapeutic stances and techniques that no single therapeutic orientation would predict and help answer the key question: “What is the theoretically sound basis for selecting the technique that is most appropriate for a particular client at a certain time?”
The rules can be translated into a model of therapist awareness, courage and love (ACL) which then promote ACL in clients so they can create and maintain close relationships and live meaningful lives. Therapist cultivation of ACL involves in-depth training in which clinicians are required to develop self-knowledge and the ability to take strategic risks and be vulnerable with clients, and the ability to be emotionally close and to express genuine emotions with care. ACL represent middle level terms, behaviorally defined, that are important in creating a science more adequate to the challenges of the human condition (Kanter, Holman & Wilson, 2014).
Recommended Websites for Further Reading