Functional analytic psychotherapy

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Functional analytic psychotherapy

Functional analytic psychotherapy (FAP) is a form of psychotherapy that focuses on the therapeutic relationship as a means of promoting positive change in clients. FAP is based on the principles of radical behaviourism and functional contextualism, which emphasize the analysis of the function and context of human behaviour. FAP aims to help clients identify and reinforce the natural contingencies that support their desired behaviours, while reducing the impact of maladaptive behaviours that interfere with their goals. It also fosters the development of intimacy, trust, and emotional awareness in the therapeutic relationship, which can serve as a model for other relationships in the client’s life. In this article, we will introduce the theoretical and empirical foundations of FAP, as well as its clinical applications and challenges.

What is functional analytic psychotherapy?

Functional analytic psychotherapy (FAP) is a psychotherapeutic approach that focuses on the therapeutic relationship to maximize client change. It is based on clinical behaviour analysis (CBA), which applies behavioural principles (such as reinforcement, generalization, and contingency) to understand and modify human behaviour. FAP was developed by Kohlenberg and Tsai in the 1980s, who noticed a clinically significant association between client outcomes and the quality of the therapeutic relationship. It aims to increase the frequency of clinically relevant behaviours (CRBs), which are behaviours that occur in session and reflect the client’s interpersonal problems (CRB1) or improvements (CRB2). FAP therapists use five rules to guide their in-session responses to CRBs, which involve watching, evoking, reinforcing, providing feedback, and modelling. It also incorporates a model of social connection that emphasizes three interrelated behavioural processes: awareness, courage, and love. FAP is an ideographic and contextual approach that tailors the treatment to the individual client and their specific goals.

FAP is based on the principles of radical behaviourism and functional contextualism.

Radical behaviourism is a philosophical and scientific approach to understanding human and animal behaviour. It assumes that all behaviour is the result of interactions between the organism and the environment, and that these interactions can be analysed and modified using the principles of operant and classical conditioning. Radical behaviourism rejects the notion of mental states or internal causes of behaviour, such as thoughts, feelings, or intentions, as explanatory constructs. Instead, it focuses on observable and measurable aspects of behaviour, such as stimuli, responses, and consequences. Radical behaviourism also emphasizes the role of reinforcement and punishment in shaping and maintaining behaviour patterns, and the importance of experimental methods and empirical evidence in testing hypotheses and evaluating interventions.

Operant and classical conditioning are two types of learning processes that involve the association of stimuli and responses. In classical conditioning, a neutral stimulus is paired with an unconditioned stimulus that elicits an unconditioned response. After repeated pairings, the neutral stimulus becomes a conditioned stimulus that triggers a conditioned response. For example, Pavlov’s dogs learned to salivate at the sound of a bell that was previously paired with food. In operant conditioning, the consequences of a behaviour influence the likelihood of its repetition. A behaviour that is followed by a positive reinforcement (such as a reward) or a negative reinforcement (such as the removal of an aversive stimulus) is more likely to be repeated. A behaviour that is followed by a positive punishment (such as a shock) or a negative punishment (such as the loss of a privilege) is less likely to be repeated. For example, Skinner’s rats learned to press a lever to obtain food or avoid shock. Operant and classical conditioning are both important ways of understanding how organisms learn and adapt to their environments.

Functional contextualism is a philosophy of science that is based on the idea that any event can only be understood in relation to its context, and that the truth and meaning of an idea depend on its function or utility for achieving a specific goal. Functional contextualism is rooted in philosophical pragmatism and contextualism, which emphasize the importance of practical consequences and effective action. It is applied in behavioural science, especially in behaviour analysis and contextual behavioural science, which aim to predict and influence psychological events (such as thoughts, feelings, and behaviours) by manipulating variables in their context.

Functional contextualism also serves as the foundation of a theory of language called relational frame theory, and its most prominent application, acceptance and commitment therapy. Functional contextualism differs from other philosophical frameworks in the behavioural sciences, such as mechanism, realism, or relativism, by focusing on the whole act in context rather than on isolated parts or entities, and by using a pragmatic truth criterion rather than a correspondence or coherence criterion.

FAP aims to help clients identify and reinforce the natural contingencies that support their valued goals and actions, while reducing the influence of aversive or maladaptive behaviours that interfere with their wellbeing.

Behavioural principles

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FAP follows five core behavioural principles:

• Clinically relevant behaviours (CRBs) are the behaviours that the client wants to increase or decrease in their daily life. CRBs are observable, measurable, and related to the client’s presenting problems and goals.
• The therapeutic relationship is a natural setting for evoking, shaping, and reinforcing CRBs. The therapist pays attention to the client’s verbal and non-verbal behaviours in session, and responds contingently to promote positive change.
• Functional analysis is the process of identifying the antecedents and consequences of CRBs, as well as the function or purpose they serve for the client. Functional analysis helps the therapist understand the client’s behaviour patterns and tailor their interventions accordingly.
• Contingency management is the application of reinforcement and punishment principles to increase or decrease CRBs. The therapist provides positive reinforcement for CRBs that are adaptive, functional, or prosocial, and negative reinforcement or punishment for CRBs that are maladaptive, dysfunctional, or antisocial.
• awareness, courage, and love (ACL) are the therapist’s qualities that facilitate FAP. awareness refers to the therapist’s mindfulness and sensitivity to the client’s behaviours and their own reactions. Courage refers to the therapist’s willingness to take risks and challenge the client when appropriate. Love refers to the therapist’s genuine care and compassion for the client as a human being.

The therapeutic approach

FAP therapists apply the therapeutic approach by identifying and reinforcing clinically relevant behaviours (CRBs) that occur in session. CRBs are behaviours that either help or hinder the client’s progress toward their therapeutic goals. FAP therapists use natural and contingent reinforcement to strengthen CRBs that are beneficial, and withhold reinforcement or provide corrective feedback for CRBs that are detrimental. FAP therapists also model and evoke CRBs that are relevant to the client’s problems and values. By doing so, FAP therapists aim to create a safe and supportive environment where clients can learn new and more effective ways of relating to themselves and others.

Therapeutic example

A theoretical example of how FAP can work in practice is as follows:

• A client with social anxiety seeks therapy because he feels lonely and isolated. He avoids social situations and has difficulty making friends. He also has low self-esteem and believes that he is unlikeable and incompetent.
• The therapist conducts a functional analysis of the client’s behaviour and identifies the following patterns:
  • The client’s social anxiety is triggered by situations where he perceives a risk of rejection or criticism, such as meeting new people, speaking in public, or asking someone out.
  • The client’s avoidance behaviour is negatively reinforced by the relief of anxiety that he experiences when he avoids these situations.
  • The client’s low self-esteem is maintained by his self-critical thoughts and beliefs, which are often activated by his perceived failures or rejections in social situations.
  • The client’s loneliness and isolation are the result of his lack of social skills and positive reinforcement from others.

A functional analysis of the client’s behaviour is a systematic and collaborative process of identifying the antecedents, consequences, and functions of the client’s problematic and adaptive behaviours in the therapeutic context. This helps the therapist to understand how the client’s behaviour is shaped and maintained by the contingencies of reinforcement that occur in the therapy session, as well as in the client’s natural environment.

A functional analysis also helps the therapist to select and apply appropriate interventions that target the client’s behaviour change goals, such as providing natural and effective reinforcement for desired behaviours, withholding reinforcement for undesired behaviours, modelling and prompting alternative behaviours, and teaching skills and strategies to cope with challenging situations. A functional analysis is an ongoing and dynamic process that requires constant monitoring and feedback from both the therapist and the client.

The therapist then uses FAP principles to create a therapeutic context that will help the client change his behaviour. The therapist does this by:

• Establishing a warm, empathic, and genuine relationship with the client, which serves as a model of healthy interpersonal interaction and a source of positive reinforcement.
• Providing natural consequences for the client’s behaviour in session, such as praise, encouragement, feedback, or corrective feedback, depending on whether the behaviour is clinically relevant or irrelevant, and whether it is adaptive or maladaptive.
• Helping the client identify and discriminate between his clinically relevant behaviours (CRBs), which are the behaviours that are directly related to his presenting problem and therapeutic goals, and his clinically irrelevant behaviours (CIBs), which are the behaviours that are not related to his problem or goals.
• Reinforcing the client’s CRB1s, which are the problematic behaviours that he wants to decrease or eliminate, such as avoidance, self-criticism, or negative self-talk.
• Reinforcing the client’s CRB2s, which are the alternative behaviours that he would like to increase or develop, such as approaching, self-compassion, or positive self-talk.
• Evoking the client’s CRB2s in session by creating opportunities for him to practice them in a safe and supportive environment, such as role-playing, exposure exercises, or homework assignments.
• Generalizing the client’s CRB2s to his natural environment by helping him apply them to real-life situations, such as joining a club, giving a presentation, or dating.

By using these FAP techniques, the therapist hopes to achieve the following outcomes:

• The client will learn to cope with his anxiety in more adaptive ways, rather than avoiding it.
• The client will develop more positive and realistic views of himself and others, rather than being overly critical or pessimistic.
• The client will increase his social skills and confidence, which will enable him to form more satisfying and meaningful relationships.
• The client will experience more happiness and fulfilment in his life, rather than feeling lonely and isolated.

Which mental health problems are best suited for FAP?

FAP has been applied to a variety of mental health problems, such as depression, anxiety, personality disorders, substance use disorders, eating disorders, trauma-related disorders, and chronic pain. It is especially suited for clients who have difficulties in their interpersonal relationships, such as low self-esteem, social isolation, intimacy problems, or attachment issues. FAP can help clients strengthen their communication skills, assertiveness, self-compassion, and emotional regulation. It is a form of psychotherapy that focuses on the therapeutic relationship as a means of promoting positive change in clients.

Some examples of how FAP has been used in these domains are:

depression: FAP can help clients with depression increase their engagement in meaningful activities and social interactions, as well as reduce their avoidance and rumination. FAP therapists can provide positive reinforcement for clients’ expressions of vitality, assertiveness, and self-compassion, while also addressing the negative consequences of their depressive behaviours.

anxiety: FAP can help clients with anxiety reduce their fear and avoidance of situations that trigger their anxiety, as well as increase their coping skills and self-efficacy. FAP therapists can provide positive reinforcement for clients’ attempts to face their fears, challenge their negative beliefs, and regulate their emotions, while also addressing the negative consequences of their anxious behaviours.

Personality disorders: FAP can help clients with personality disorders improve their interpersonal functioning and emotional regulation, as well as reduce their impulsivity and self-harm. FAP therapists can provide positive reinforcement for clients’ expressions of empathy, intimacy, and authenticity, while also addressing the negative consequences of their dysfunctional patterns.

Substance use disorders: FAP can help clients with substance use disorders reduce their substance use and related problems, as well as increase their motivation and commitment to change. FAP therapists can provide positive reinforcement for clients’ expressions of values, goals, and prosocial behaviours, while also addressing the negative consequences of their substance use behaviours.

Eating disorders: FAP can help clients with eating disorders reduce their eating disorder symptoms and related distress, as well as increase their body acceptance and self-care. FAP therapists can provide positive reinforcement for clients’ expressions of self-worth, health, and diversity, while also addressing the negative consequences of their eating disorder behaviours.
trauma-related disorders: FAP can help clients with trauma-related disorders reduce their trauma symptoms and related avoidance, as well as increase their safety and trust. FAP therapists can provide positive reinforcement for clients’ expressions of courage, resilience, and recovery, while also addressing the negative consequences of their trauma behaviours.

Chronic pain: FAP can help clients with chronic pain reduce their pain intensity and interference, as well as increase their quality of life and functioning. FAP therapists can provide positive reinforcement for clients’ expressions of acceptance, coping, and adaptation, while also addressing the negative consequences of their pain behaviours.

integration with other therapies

FAP can also be integrated with other evidence-based treatments, such as cognitive-behavioural therapy (CBT), dialectical behaviour therapy (DBT), or acceptance and commitment therapy (ACT), to address specific symptoms or problems.

cognitive-behavioural therapy

FAP can be integrated with cognitive-behavioural therapy (CBT), which is a form of psychotherapy that focuses on identifying and modifying dysfunctional thoughts, beliefs, and emotions that contribute to psychological distress. CBT is based on the principles of cognitive theory and behavioural theory, which suggest that cognition influences behaviour and emotion, and vice versa. CBT therapists use various techniques, such as cognitive restructuring, exposure, or behavioural activation, to help clients challenge and change their maladaptive cognitions and behaviours. It aims to help clients develop more adaptive coping skills and enhance their psychological wellbeing.

FAP and CBT can be combined in a way that enhances the effectiveness of both approaches. FAP can provide a strong relational context for CBT interventions, by fostering a trusting and collaborative alliance between the therapist and the client, and by increasing the client’s motivation and readiness for change. It can also address some of the limitations of CBT, such as its tendency to neglect the role of emotions and interpersonal factors in psychological problems, or its reliance on structured and manualized protocols that may not suit the individual needs of each client. FAP can help clients access and express their emotions more fully, and identify and modify their interpersonal patterns that interfere with their goals and values.

CBT can also provide a strong conceptual framework for FAP interventions, by offering a clear rationale and evidence base for the use of behavioural principles and techniques in psychotherapy. CBT can also address some of the limitations of FAP, such as its lack of specificity and structure in defining and measuring target behaviours, or its reliance on the therapist’s clinical judgment and intuition that may not be reliable or valid. It can help clients define and operationalize their goals and values more clearly, and monitor and evaluate their progress and outcomes more objectively.

In summary, FAP and CBT can be integrated in a way that maximizes the strengths and minimizes the weaknesses of both approaches. FAP can enhance the relational aspects of CBT, while CBT can enhance the conceptual aspects of FAP. Together, they can offer a comprehensive and effective psychotherapy that addresses the cognitive, behavioural, emotional, and interpersonal dimensions of psychological problems.

Dialectical behaviour therapy

Dialectical behaviour therapy (DBT) is another form of therapy that combines cognitive-behavioural techniques with mindfulness and acceptance strategies. DBT is designed to help clients who struggle with emotion regulation, impulsivity, interpersonal difficulties, and suicidal or self-harm behaviours. DBT teaches clients four sets of skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

FAP and DBT can be integrated in several ways to enhance the effectiveness of both approaches. One way is to use FAP as a meta-framework for DBT, meaning that FAP principles guide the overall delivery of DBT skills and interventions. For example, FAP therapists can use natural reinforcement to encourage clients to practice DBT skills in session and in their daily lives. FAP therapists can also use FAP techniques to address any difficulties or barriers that arise in the therapeutic relationship, such as mistrust, avoidance, or resistance. FAP therapists can help clients identify and work on their clinically relevant behaviours (CRBs), which are behaviours that either interfere with or facilitate their progress in therapy.

Another way to integrate FAP and DBT is to use FAP as a supplement to DBT, meaning that FAP interventions are added to the standard DBT protocol. For example, FAP therapists can use functional analysis to identify the antecedents and consequences of clients’ problematic behaviours, such as self-harm or substance use. FAP therapists can then help clients develop alternative behaviours that are more adaptive and consistent with their values. Therapists can also use awareness exercises to help clients become more mindful of their own and others’ behaviour in the present moment.

FAP and DBT are both evidence-based therapies that share some common goals and principles, such as enhancing clients’ awareness, acceptance, and change. By integrating FAP and DBT, therapists can offer a comprehensive and flexible treatment that addresses both the intrapersonal and interpersonal aspects of clients’ difficulties.

Acceptance and commitment therapy

FAP can be integrated with ACT in several ways. One way is to use FAP as a process-oriented intervention that complements the more content-oriented interventions of ACT. For example, a therapist can use FAP to reinforce the client’s behaviours that are consistent with their values, or to evoke and shape new behaviours that are more adaptive and flexible. Another way is to use FAP as a meta-intervention that enhances the effectiveness of ACT interventions. For example, a therapist can use FAP to create a safe and trusting relationship with the client, which can facilitate the acceptance and defusion of difficult thoughts and emotions. A third way is to use FAP as a trans-diagnostic intervention that addresses common processes underlying various psychological problems. For example, a therapist can use FAP to target the client’s interpersonal difficulties, such as social anxiety, attachment issues, or intimacy problems, which can interfere with their quality of life and wellbeing.

Further Reading

If you are interested in learning more about Functional analytic psychotherapy , you may find the following weblinks useful:

Functional analytic psychotherapy – Wikipedia: This is a comprehensive overview of the history, theory, principles, and applications of FAP, with references to relevant literature and research.

Functional Analytic Psychotherapy: This is the official website of FAP, where you can find information on workshops, online trainings, tools, and resources for therapists and researchers, as well as directories of FAP trainers, consultants, supervisors, and therapists.

Functional Analytic Psychotherapy (FAP): This is an article from the Society for the Advancement of Psychotherapy that explains the core concepts and techniques of FAP, as well as its integration with other approaches such as Acceptance and Commitment Therapy (ACT) and Dialectical Behaviour Therapy (DBT).

Functional Analytic Psychotherapy (FAP) — The Seattle Clinic: This is a webpage from a clinic that offers FAP services, where you can learn more about how FAP works in practice, what to expect from therapy, and how to contact a FAP therapist.