Functional Analytic Psychotherapy Is a Framework for Implementing Evidence-Based Practices: The Example of Integrated Smoking Cessation and Depression Treatment
Holman, Gareth, Kohlenberg, Robert J., Tsai, Mavis, Haworth, Kevin, Jacobson, Emily, Liu, Sarah, The International Journal of Behavioral Consultation and Therapy
Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et al., 2008) provides a framework for the implementation of evidence-based practices (EBPs) by helping therapists conceptualize and manage moment-by-moment therapy process. This process may be managed such that it conforms with the evidence-based practice when such is appropriate. This process also may help fill in the gaps--areas where therapists are asked to use clinical judgment--that are present in EBP protocols. If an EBP provides a map to a given destination (e.g., improved depression outcomes), then FAP acts like a GPS, locating the client and therapist in the here and now and guiding the therapy process, especially in areas where the map is fuzzy.
The FAP therapist manages process on the basis of an ongoing, idiographic functional analysis of therapist-client interactions with the aim of understanding and solving client's problems. This functional analysis serves a variety of functions relevant to implementation of EBP:
(1) It may facilitate conceptualization of behaviorally specific treatment targets. For example, a FAP therapist might, through functional analysis, clarify their understanding of behaviors associated with 'mistrust' while treating a patient diagnosed with PTSD using the Cognitive-Processing Therapy protocol (Resick & Schnicke, 1993).
(2) It may provide an understanding of how the motivational context of the therapy relationship impacts treatment adherence. For example, a FAP therapist may discriminate that a depressed patient does not initiate conversation about the impact of the therapy relationship, but that homework completion and mood reliably improves in weeks following sessions where the therapist initiates such conversations (cp., Kanter, Schildcrout, & Kohlenberg, 2005).
(3) It provides a theoretical basis for addressing 'alliance ruptures' (e.g., Safran & Muran, 1996; Tsai, Kohlenberg, & Kanter, 2010), such as breaches of trust or positive regard or disagree ments about treatment goals and methods. Disagreements are interpreted in the context of the client's problems and goals, such that a disagreement that would otherwise be labeled as resistance or non-compliance may be seen as a sign progress for a client whose problems involve excessive acquiescence. Indeed, FAP views conflict as an essential area of relationship functioning, one in which many of our clients have deficits. Conflicts in FAP may be considered opportunities for therapeutic shaping of effective behavior, rather than as non-compliance or resistance to a treatment protocol.
(4) Finally, FAP directs attention to examples of the client's problems occurring here and now in the therapy interaction; these here and now instances are shaped directly as they occur. It is a central hypothesis of FAP that such direct intervention on here and now examples of problems and improvements provides important therapeutic benefits.
In summary, then, FAP provides a means of understanding how specific behaviors occurring in the therapy interaction may contribute to or detract from clinical outcomes during the course of conducting an EBP. In this way, FAP may be compared to other general therapeutic frameworks that aim to guide therapists in the implementation of interventions to best suit a specific client (e.g., Persons, 2008; Nezu, Nezu, & Lombardo, 2004). In common with these other approaches and with behavior therapy in general, FAP advocates an individualized assessment of the impact of an intervention of the individual client, and a systematic variation of intervention in case of non-response. The unique aspects of FAP are its focus on the use of functional analysis and its attention to the therapy relationship.
To illustrate the above ideas, this paper presents the example of an integrated, FAP-based smoking cessation and depression treatment. We present a description of the treatment, some brief case material to illustrate key aspects of the treatment, and them summarize the results of a small pilot treatment development study. …