Creating Safety in the Beginning of Treatment
Guidelines from Functional Analytic Psychotherapy (FAP)
Internet Editor’s Note: Dr. Tsai and colleagues recently published an article titled “Creating Safe, Evocative, Attuned, and Mutually Vulnerable Therapeutic Beginnings: Strategies from Functional Analytic Psychotherapy,” in Psychotherapy.
If you’re a member of the Society for the Advancement of Psychotherapy you can access the Psychotherapy article via your APA member page.
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Do you trust us right now?
This question matters, because by opening this article, you have begun a kind of relationship with us. It’s a strange and asynchronous relationship, to be sure; while the first author is writing from her laptop on a gloriously sunny day in Lake Macquarie, Australia, the other authors are contributing from cloudy Seattle, Washington. While we rethink and revise our message to you, one of us is eating tater tots, another is walking on her treadmill.
We don’t know where you are, or what you’re experiencing. Perhaps you’re thinking of taking a cursory glance at the next paragraph or two and then moving on. But for however long you stay with us, reading and thinking about these words, we are in a relationship.
And your decision to be in this relationship with us right now is an honor. We are all constantly bombarded by information these days, so the fact that you are taking a moment of your highly sought-after time to read this? Honestly? It feels sacred. It feels momentous. It makes all five of us feel appreciative of you and connected to you.
Maybe that sentiment is easy to breeze past. If so, can you try to slow down and genuinely let yourself feel what we are saying to you? Can you briefly look away from the screen and breathe deeply into this moment? It means a lot to us that you are here. What is it like to slow down together to open our often-armored hearts, allowing them to meet?
What we are doing together in this exercise is an example of a typical interaction in Functional Analytic Psychotherapy (FAP), a relational approach based on contextual behavioral science that emphasizes the creation of a safe, attuned, evocative and mutually authentic relationship (Holman, Kanter, Tsai, & Kohlenberg, 2017; Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, Tsai et al., 2009; Tsai, Callaghan & Kohlenberg, 2013; Tsai, Gustafsson, Kanter, Plummer Loudon & Kohlenberg, 2016). FAP principles are especially relevant for therapeutic beginnings that yield an engaging and potent treatment (Tsai, Yoo, Hardebeck, Plummer Loudon, & Kohlenberg 2019). In this article, we will focus on factors that create trust and safety, without which a client is unlikely to stay in therapy.
Trust may be seen as a predisposition to approach another person in a situation in which one could potentially get hurt. Instilling trust and safety are crucial in FAP because clients are shaped and reinforced to take risks, to be vulnerable, to push beyond their boundaries of comfort, and to take more steps to trust the therapist. That said, the behavior of trusting may very well be a goal of therapy and it is the rare client who will trust fully from the first session. Indeed, such blind trust may be as problematic as an inability to trust. Here are four factors we consider important in foster trust and safety as a client begins their therapeutic journey:
Increasing Your Authenticity
Consider being more forthcoming with your thoughts, reactions, and observations (not hiding behind a therapist persona). Encourage your clients: 1) to ask questions (e.g., What are your questions about me, my training, my background? or What qualities do you most seek in a therapist?); 2) to voice their reactions to the therapist (e.g., What reactions do you have to my gender, age, ethnicity?); and 3) to voice their feelings related to the appointment (e.g., What are your thoughts and feelings about having this appointment today? or What would make this a really good first session for you?). Remain open to the possibility, however, that these therapist behaviors may be aversive to clients depending on their histories (e.g., they may have been hurt by someone who was open and warm and may feel safer with a therapist who is distant).
Creating a Healing Attachment Experience
Many clients come to therapy with a history of traumatic or neglectful ties with early caregivers. It’s important to provide them with a secure base, to recreate a healthy attachment experience that makes up to some degree for what they missed. According to Siegel (2014, p. 107), a child’s developing mind and sense of self benefit from secure attachments in which the child experiences “consistent, emotionally attuned, contingent communication” tailored to their emotional needs. This results in the internalized experience of feeling “seen, safe, soothed and secure” (Siegel, 2014, p. 108). By asking our clients, “What would help you feel safe with me?” and by tuning into them deeply—their body language, voice tone, emotional cues—we create an attunement that reassures them they are seen. In addition, we can generate security by maintaining boundaries through consistent presence, modelling emotion regulation and providing a safe container for their affect.
Being Aware of Your Own Learning History
Each time we meet a client, we have reactions to them. When we take the time to understand how our own learning and attachment history has evoked those responses, we can discern if: 1) our reactions are idiosyncratic to our own histories, and unlikely to be of therapeutic value, or 2) our reactions tell us something clinically useful about this person. For instance, is this client overly demanding, such that many people would judge them negatively? We can hold our reactions with curiosity and gently bring them into the space between us, sharing what we are noticing and asking our client if this reflects their experience in the moment. When we are willing to share vulnerably, we open the invitation to the client to follow suit and to connect in our shared space.
Increasing Connection with Your Best Self Prior to the Session
Before seeing a client, spend a few moments contemplating these questions to connect with your deepest values and skills as a therapist: “How can you best open your heart to this person today? What might get in the way of you connecting fully? What are your most useful therapeutic qualities related to what you know about this client? How can you best focus on your client’s strengths rather than just their presenting problems? How can you move beyond your comfort zone as a therapist in the service of your client’s growth?
Summary and Conclusion
FAP encourages therapists to enhance safety and trust by being open and vulnerable in ways that serve their clients’ best interests. We conclude by inviting you to address our guidelines, posed in a question format, so you can further explore your unique history, qualities and skills that are relevant to creating safety and trust for your clients:
- How can you increase your authenticity, and bring your true self to your work in order to best serve your clients?
- How can you bring your humanity to your clients, to strengthen a healing attachment experience for them?
- What about your own attachment and learning history contribute to your strengths and weaknesses as a therapist?
- How can you increase connection to your best self immediately prior to a session?
We hope that by delving into your personal responses, you will set the stage for deeply meaningful and unforgettable therapeutic experiences.
Recommended Websites For Further Reading
Cite This Article
Muldoon, B., Hardebeck, E., Pedersen, K., Kohlenberg, R. J., & Tsai, M. (2020, July). Creating safety in the beginning of treatment: Guidelines from functional analytic psychotherapy (FAP). [Web article]. Retrieved from https://societyforpsychotherapy.org/creating-safety-in-the-beginning-of-treatment
Holman, G., Kanter, J., Tsai, M., & Kohlenberg, R.J. (2017). Functional Analytic Psychotherapy Made Simple: A Practical Guide to Therapeutic Relationships. Oakland, CA: New Harbinger Publications.
Kohlenberg, R. & Tsai, M. (1991). Functional Analytic Psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press.
Siegel, D. J., & Hartzell, M. (2014). Parenting from the inside out: how a deeper self-understanding can help you raise children who thrive. New York: Jeremy P. Tarcher/Penguin.
Tsai, M., Callaghan, G., & Kohlenberg, R.J. (2013). The use of awareness, courage, therapeutic love, and behavioral interpretation in Functional Analytic Psychotherapy. Psychotherapy, 50(3), 366-370. doi: 10.1037/a0031942
Tsai, M., Gustafsson, T., Kanter, J., Plummer Loudon, M., & Kohlenberg, R. J. (2016). Saying Good Goodbyes to Your Clients: A Functional Analytic Psychotherapy (FAP) Perspective. Psychotherapy. doi:10.1037/pst0000091
Tsai, M., Kohlenberg, R., Kanter, J., Kohlenberg, B., Follette, W., & Callaghan, G. (Eds.), (2009). A Guide to Functional Analytic Psychotherapy: Awareness, courage, love and behaviorism in the therapeutic relationship. New York: Springer.
Tsai, M., Yoo, D., Hardebeck, E., Plummer Loudon, M., & Kohlenberg, R.J. (2019). Creating Safe, Evocative, Attuned, and Mutually Vulnerable Therapeutic Beginnings: Strategies From Functional Analytic Psychotherapy. Psychotherapy.56(1):55-61. doi: 10.1037/pst0000203.