Internet Editor’s Note: Dr. Matthew Skinta and colleagues recently published an article titled “Responding to gender and sexual minority stress with functional analytic psychotherapy” in Psychotherapy.
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We are currently living in a time of epidemic loneliness. For gender and sexual minority individuals – those who do not identify as heterosexual or cisgender – the deleterious effects of loneliness and exclusion are amplified by societal bias. This is expressed at the highest level with a harmful effect when government actions specifically target the disenfranchisement of citizens due to their sexual orientation or gender identity, as seen in the recent documents expressing a desire to legally erase transgender identities by the U.S. government. One result of such societal bias is the development of emotional guardedness in the face of potential prejudice or rejection. A recent article on the loneliness of gay men was incredibly popular and widely re-shared on social media, highlighting how deeply this theme resonated. In our recent article published in Psychotherapy, we explore not only some of the ways this disconnection might manifest among GSM clients in therapy but how a structured approach to creating vulnerable and authentic relationships might help clients deepen other meaningful relationships in their lives.
The Impact of Minority Stress
An important lens in GSM research today is minority stress theory. Minority stress theory postulates that the full impact of societal bias can only be measured when exploring the various, insidious ways that minority group members are affected, ranging from internalizing societal bias, hypervigilance, and the expectation that others may be rejecting when they learn of one’s sexual orientation or gender identity, and concealment of one’s identity, to overt discrimination or violence. Minority stress particularly damages a GSM person’s ability to form close and genuine relationships through mechanisms such as the internalization of stigmatizing beliefs about one’s self, the interpretation of ambivalent responses from others as signs of rejection or the development of patterns of self-censorship about one’s inner experiences in order to avoid being hurt.
While everyone needs connection and a sense of social safety in the world, GSM individuals are much more likely than heterosexual and cisgender peers to experience parental rejection or to experience the religion of their family of origin as hostile to them. One study noted that for sexual minority men of color living with human immunodeficiency virus (HIV), a therapeutic emphasis on relationships was experienced as much more helpful than a focus on cognition and more internal experiences. This could be either indicative of the greater importance of a relational approach for meeting the needs of GSM people of color, for sexual minority men living with HIV, or both.
We are not the first to note the importance of relational approaches to remedy histories of rejection, stigma, and relational ruptures for GSM clients. For example, Diamond and colleagues have recently explored using Attachment-Based Family Therapy for rebuilding ruptured relationships between GSM youth and their parents, and are expanding that work to GSM adults who experience alienation from their parents. Strengthening such fundamental relationships offers a strong, protective place from which clients can grow. Our approach, Functional Analytic Psychotherapy, uses the therapeutic relationship as the base from which a client can begin to generalize new interpersonal behaviors.
Functional Analytic Psychotherapy (FAP)
Functional Analytic Psychotherapy, or FAP, stems from a behavior analysis of the therapeutic relationship. In exploring how therapists and clients mutually reinforce or punish one another’s behaviors, the developers of FAP realized the value of a systematic, specific framework for addressing interpersonal closeness and distance in therapy. At the heart of FAP are the identification of Clinically Relevant Behaviors (CRBs), and therapeutic behaviors (Rules). In the context of intimate relationships and interpersonal connection, a CRB1 may refer to distancing or interpersonally guarded behaviors that arise during the therapy session, while a CRB2 would include a behavior, verbal or non-verbal, that promotes closeness and a sense of authenticity. Through supervision and close tracking of a client’s behaviors and outcomes, the goal is that a client will begin to generalize warmer, more authentic ways of relating into their life, resulting in the natural reinforcement of closeness and warmth by others.
Table 1. The five rules of FAP
- Watch for CRBs
- Evoke CRBs
- Reinforce CRB2s
- Observe your impact ont he client (i.e., are you accurately reinforcing?)
- Promote generalization
In considering the experiences of GSM clients, we might expect certain types of interpersonal challenges to arise from frequently shared histories of concealment or general guardedness, parental rejection, and shame.
Table 2. Common CRB1s and CRB2s among GSM clients
Therapeutic Disclosure in FAP
The primary mechanism of change in FAP is the use of operant conditioning to reinforce patterns of authenticity and vulnerability, which is meant to generalize to relationships throughout the client’s life. As such, FAP harnesses one of the most powerful reinforcers: genuine human reactions. Authentic disclosure can include statements such as “I’m feeling very close to you at this moment as I see tears in your eyes” and “I’m noticing my mind drift throughout our session and feeling like I’m being pushed out of the conversation, and I think it’s because I’m noticing how you talk over me every time I try to speak.” A critical component of therapeutic disclosure is its use within a behavioral conceptualization. After each disclosure, the FAP therapist is watching for any increase in CRB2s or decrease in CRB1s. If the client increases authentic sharing after a therapist’s disclosure of affection, then a therapist’s expression of warmth is considered to be an effective reinforcer and should be maintained as a tool for future behavioral change. However, if that specific form of therapist disclosure does not yield behavioral change, the FAP therapist will explore alternative forms of natural relational reinforcers to contingently shape the client’s intimacy-building repertoire. This functional analysis within an affirming framework is what FAP offers over a general, affirmative psychotherapy approach that may result in less targeted growth.
For clinicians first learning about FAP, one common fear is that an intimate therapeutic relationship will interfere with therapeutic boundaries, thereby blurring the lines between friendship and professional clinical work. To be clear, FAP does not shift boundaries of dual relationships, confidential communication, or session time limits. Relatedly, it is imperative to note that therapist disclosure is used only to further clinical goals of enhanced personal relationships, rather than disclosure for the sake of disclosure. Indeed, FAP therapists set the stage for therapeutic interactions by describing the honest, genuine, and ethically bounded nature of therapeutic relationships.
Creating Nurturing Interactions and Overcoming Loneliness in GSM People
We are in a historical moment in which homophobic, biphobic, and transphobic news are the headlines of the day. Therapists around the world wonder how to overcome such abrasive circumstances and becoming allies. A FAP approach will encourage therapists to notice they are part of the social context of clients, and as such are powerfully capable of creating a sacred space where their clients can feel genuine and full acceptance. Any familiarity with GSM literature, films, and songs of the past century demonstrate that GSM communities have always been aware of the costs of a life lived inauthentically or cut off from loving connection with others, and the desire for deep connections and relationships. FAP conceptualizes the challenges experienced by GSM clients as a problem of the environment, so the solution to identifying nurturing environments for vulnerable behaviors (i.e., coming out, expressing one’s authentic gender identity) as requiring consistent, affirming warmth and reinforcement in response to authenticity and genuineness. In this line of thought, FAP therapists do not only provide a fostering context in session (Rule 3 implementation) but aid clients to identify similar features outside of therapy (Rule 5 implementation).
This is an important point - dangerous contexts and harmful relationships will still exist in our client’s lives. Alongside encouraging new ways of vulnerable relating, it is important to acknowledge and explore how to find those relationships that are safe places for developing greater intimacy, and to reflect and honor our client’s experiences that this is not always the case. Supporting clients to recognize fostering environments is, in some contexts, one of the most challenging and important endeavors of FAP therapists working with GSM communities. FAP reflects one important tool in our arsenal to aid this process. We hope to publish data some of us have collected on FAP with members of GSM communities soon.
Cite This Article
Skinta, M. D., Hoeflein, B., Muñoz-Martínez, A. M., & Rincón, C. L. (2019, January). Overcoming Loneliness: Encouraging meaningful connections among gender and sexual minority people. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/overcoming-loneliness
Cacioppo, J. T., & Cacioppo, S. (2018). The growing problem of loneliness. The Lancet, 391(10119), 426.
Cohen, J. M., Feinstein, B. A., Rodriguez-Seijas, C., Taylor, C. B., & Newman, M. G. (2016). Rejection sensitivity as a transdiagnostic risk factor for internalizing psychopathology among gay and bisexual men. Psychology of sexual orientation and gender diversity, 3(3), 259.
Diamond, G. M., Diamond, G. S., Levy, S., Closs, C., Ladipo, T., & Siqueland, L. (2012). Attachment-based family therapy for suicidal lesbian, gay, and bisexual adolescents: A treatment development study and open trial with preliminary findings. Psychotherapy, 49(1), 62-71.
Holman, G., Kanter, J. W., Tsai, M., & Kohlenberg, R. (2017). Functional analytic psychotherapy made simple: A practical guide to therapeutic relationships. New Harbinger Publications.
Kohlenberg, R. J., & Tsai, M. (2007). Functional analytic psychotherapy. In Functional Analytic Psychotherapy (pp. 169-188). Springer, Boston, MA.
Mereish, E. H., & Poteat, V. P. (2015). A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of Counseling Psychology, 62(3), 425-437.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological bulletin, 129(5), 674-697.
Rood, B. A., Reisner, S. L., Surace, F. I., Puckett, J. A., Maroney, M. R., & Pantalone, D. W. (2016). Expecting rejection: Understanding the minority stress experiences of transgender and gender-nonconforming individuals. Transgender Health, 1(1), 151-164.
Skinta, M. D., Hoeflein, B., Muñoz-Martínez, A. M., & Rincón, C. L. (2018). Responding to gender and sexual minority stress with functional analytic psychotherapy. Psychotherapy, 55(1), 63-72.
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.Springer, New York, NY.