An example of a Hakomi technique adapted for Functional Analytic Psychotherapy.
Rather than offer an integrated model, the purpose of this paper is to provide a clear and brief example of how a technique from another form of psychotherapy--Hakomi (Kurtz, 1990), can be assimilated into FAP. It is likely that most practicing therapists have been exposed to a range of techniques through training and ongoing professional development. As FAP is a principle based therapy, techniques from other forms of psychotherapy can be used as long as they function to evoke clinically relevant behaviour and the therapist is positioned to be aware of this and reinforces client improvements in behaviour within the context of adhering to the other 'rules' of FAP, see below.
The technique that will be outlined in this paper comes from the Hakomi Method. A brief overview of Hakomi and FAP will follow. Then a Hakomi intervention will be detailed and looked at including a transcript using the technique as a part of FAP. It is hoped that this stimulates the reader into considering what techniques they have learnt from other psychotherapy models that could be utilised within FAP.
THE HAKOMI METHOD
Hakomi is a mindfulness based, body inclusive form of psychotherapy developed by Ron Kurtz in the mid 1970's (Kurtz, 1990). Hakomi utilises mindfulness to explore current experience (thoughts, feelings, memories, sensations, urges, gestures, postures etc) as indicators of painful formative experiences and subsequent beliefs (Cole & Ladas-Gaskin, 2007). The word Hakomi is a Hopi Indian word and means 'how do you stand in relation to the many realms?' or more briefly 'who are you?' (Kurtz, 1990). The aim of the therapist is to provide a safe and caring relationship, to create experiments that evoke core material and to then provide therapeutic 'missing experiences' (Fisher, 2002). This is done to help shift beliefs and enable the client more healthy and effective ways of relating to themselves and their world.
FUNCTIONAL ANALYTIC PSYCHOTHERAPY (FAP)
FAP is the application of radical behavioural principles to an interpersonal psychotherapy context. The primary mechanism that FAP claims to effect change is the therapist "providing natural reinforcement for client improvements that occur during the session" (Kohlenberg & Tsai, 1991, p.11). This is strategically done to 'shape' over time, a more effective interpersonal behavioural repertoire, that is then generalised to the clients daily life and relationships (Kohlenberg & Tsai, 1991). To assist in knowing what behaviour to reinforce in FAP, client in-session behaviour is broken down into three classes of clinically relevant behaviour (CRB). These are: in-session instances of daily life problems (CRB1); in-session instances of daily life improvements (CRB2); and client statements of functional relationships (CRB3). For a more in-depth look at CRB see Kohlenberg and Tsai (1991) or Kohlenberg, Tsai, & Kanter (2009). To assist therapists in identifying CRB, evoking CRB and in responding to CRB, FAP has five rules. These 'rules' are not to be adhered to as dogmatic musts, but serve as general guidelines for the therapist and the therapeutic intervention. These rules are as follows.
THE RULES OF FAP (TSAI, KOHLENBERG, KANTER, & WALTZ, 2009)
Rule 1: Watch for CRBs (Be Aware)
This is seen as the essential ingredient for FAP, for to be able to reinforce CRB2's, CRB needs to be defined and noticed. Basically this involves being aware of the clients daily life problems, in-session instances of the same problems, and in-session improvements on these problems. It is also hypothesised that if therapists are aware of CRB, they will automatically begin to reinforce CRB2's.
Rule 2: Evoke CRBs (Be Courageous)
In addition to CRB that is naturally evoked within the therapeutic setting, it is suggested that the FAP therapist strategically evoke in-session instances of daily life problems (CRB1), or improvements on those (CRB2). This is done through a variety of means including the use of the relationship and therapeutic techniques.
Rule 3: Reinforce CRB2s Naturally (Be Therapeutically Loving)
When CRB2's are evoked and/or noticed, central to the FAP approach is that these in-session instances of daily life problems are responded to in a way that increases their frequency over time. This involves contingently responding to CRB2's in a way that is naturally reinforcing.
Rule 4: Observe the Potentially Reinforcing Effects of Therapist Behaviour in Relation to Client CRBs (Be Aware of One's Impact)
This rule involves the awareness of the impact of therapist behaviour on the client in the short term, and longer term. Ways to implement this rule include paying attention in the moment to how the client is responding, acquiring verbal or written feedback from the client, and observing the frequency of CRB2 over time. Rule 5: Provide Functional Analytically Informed Interpretations and Implement Generalisation Strategies (Interpret and Generalise)
FAP takes the stance that certain types of therapist talk in session are useful. If clients have a functional understanding of what led to CRB in session, it increases the chances that they are able to generalise their CRB2 behaviour to daily life. A range of other generalisation strategies are used in FAP and are given as 'homework' to be undertaken by the client. In light of the above, any psychotherapeutic technique is potentially useful in FAP, provided it is in line with rule 2 above, and functions to evoke CRB from the client and the therapist is positioned to be aware of and shape improvements. The technique outlined below is likely to evoke CRB, and with a simple modification can be made more congruent with FAP.
A HAKOMI TECHNIQUE ADAPTED FOR FAP (ADAPTED FROM KURTZ, 1990 AND FISHER, 2002)
One of a broad range of techniques used in Hakomi is a form of verbal experiment generally referred to as a 'probe' or sometimes more pleasantly as an 'offering' (Cole & Ladas-Gaskin, 2007). Basically these are simple positive statements, that are used to evoke an experience connected to the clients core beliefs and history. For example for a client who is conveying that they believe they are not worthwhile a probe may be "you are perfect just as you are". As Kurtz (1990) puts it, "A probe is an experiment in mindfulness, an example of evoked experience ... We take time to prepare. We set up mindfulness, introduce a stimulus and study the reaction" (p.91). Note that it is important that the therapist only offer statements that are based in reality and congruent with their true feelings about the client and the client's issues (Kurtz, 1990).
This technique is likely to evoke CRB but a simple change can make it more conducive to FAP. Hakomi advocates for avoiding using a first person statement as they do not focus on generating transference as part of the treatment (Kurtz, 1990). The change necessary to fit this technique more 'neatly' into a FAP session would be to modify the statement so that it is in the first person, to enable the relationship to be the focus, to actually encourage responses often referred to as transference, and to explore interpersonal reactions.
The technique as a whole is an example of Rule 2--Evoke CRB's, though throughout the technique there are opportunities to use Rule 1--Watch for CRB, Rule 3--Naturally Reinforce CRB2's, and Rule 4 Observe the Potentially Reinforcing Effects of Therapist Behaviour in Relation to Client CRB's.
Further, as CRB's may be evoked that call for a shift in focus and response on the part of the therapist--the technique is not to be adhered to rigidly. The FAP therapist should maintain an awareness of CRB so that they are able to shift away from the 'probe' (or other technique) and attend to the issues, from a FAP perspective, that are most relevant for the client in the moment.
1. Introduce the technique and see if you have consent
"I have an idea about how we could find out a little more information about what's happening here. Instead of simply talking about it, how about we slow down a little and get clearer on what you are thinking, feeling and experiencing about this. I have an idea that I could say some words to you and we could notice how that lands on you.how you react"
"What I am thinking I could say, the words I could use, are (for example) 'I care about you' or 'you are important to me'".
This is a key point to pause as you may already be evoking CRB1's or CRB2's for the client and asking for consent and feedback may help to identify these.
2. Coach the client into mindfulness and wait till the client is ready
"So take a moment to close your eyes and notice what your experience is right now, just feel your breath for a moment, noticing the breath moving in ... and out ... (pause), notice what you are thinking (pause) feeling (pause) sensing (pause). Let me know, perhaps just raise a finger, when you are connected to your experience enough to hear the words".
3. Deliver the probe
"So, just notice what you experience, it could be a Thought ... a feeling ... a sensation ... an image ... a memory ... it doesn't matter what happens, just so long as you are noticing. If nothing happens at all that's okay too ... Just notice what happens when you hear the words (pause) 'John ... (using the clients name tends to make the technique more evocative and pause as it allows the client a moment to sense their experience again) you are important to me' (you can then repeat the statement as it tends to be more evocative) 'John ... you are important to me'".
In Hakomi the probe is usually delivered in a relatively neutral tone of voice, which from a FAP perspective may function to reduce the stimulus properties of the therapist, allowing for more 'genuine' expressions of the clients self, in line with Kohlenberg and Tsai's (1991) commentary on the potential use of free association within FAP.
4. Get feedback
Notice what happens for the client, whatever that is. Often this technique will evoke strong and spontaneous emotions, thought processes, behavioural urges or memories. If there are no noticeable changes externally, you could prompt the client "what are you noticing, a thought, a feeling or something else?"
Importantly, delivering a probe is unlikely to evoke a positive reaction in the client but will instead more often highlight barriers and limiting beliefs, areas of pain and suffering, and avoidance connected to the clients history and relationships (Fisher, 2001).
As an example, a client might have a history of being told positive things by others (e.g. a parent) that are manipulative. A statement by the therapist such as 'I'm here for you' may evoke issues around trust and being manipulated, with the client reacting by having a thought like "you have to say that ... I'm paying you". From a FAP perspective there are many possible therapeutic opportunities with this, including whether the client brings up this issue (potential CRB2 of being open with the therapist) or do they question how does caring actually develop in the therapeutic relationship, or clarify whether is it the kind of caring that is important to them (potential CRB2's of identification and expression of needs). Of course these are by no means all encompassing examples nor are they prescriptive as in FAP what is a CRB1 or a CRB2 is dependent on the client's outside life problems (Kanter et al. 2009).
Whilst this technique can be tailored to a wide range of issues, is worth mentioning for clients that are not assertive or fearful of revealing negative feelings, this technique can easily provide an environment in which these behaviours can be shaped, as illustrated in the transcript below.
Following is a modified transcript from a session with 'John'. His background involves a history of being punished in various ways for having had needs or feelings. This has led to use of drugs and suicidal behaviour. Due to his difficulties with feelings he also has difficulty in sustaining intimate relationships. A main CRB2 for this client is being aware of and expressing feelings, and assertive behaviour is also a CRB2. The transcript begins just as the technique is being delivered.
T: ... so John, just notice what happens, whatever that is, it could be a thought, a feeling, a sensation, a memory or something else ... Notice what happens when you hear me say the words (pause) John.... I care about your sadness (pause) John ... I care about your sadness ... (Rule 2--Evoke CRB)
C: (posturally stiffening up and slight movement backwards)
T: Moving away? (Rule 4--Observe Impact and Rule 2 Evoke CRB)
C: Yep ... kind of pushing away.
T: pushing me away? ... (Rule 4--Observe Impact and Rule 2--Evoke CRB)
T: Stay with that feeling ... what else do you notice about it? (Rule 2--Evoke CRB)
C: I don't like it ... don't want to feel sad.
T: Uh huh, this is really hard ... is it okay if we stay with it a little longer, it seems important? (Rule 2--Evoke CRB)
C: Yea ... its okay
T: So just connect into that feeling again, feel it in your body, is there anything familiar about it? (Rule 2--Evoke CRB)
C: ... yea ... actually it makes me think about Mum ... whenever I was sad she would ask so many questions ... really intense ... invasive. Everyone else in the family is the same. Mum asks how they are and they just smile, say they are good ... fine ... even when I know they've had a really shitty day.
T: Yea ... and you too huh ... is that what you do? (Rule 2 Evoke CRB, the client has begun talking about other peoples reactions instead of his own, which was seen to be a CRB1, so here the therapist is bringing the focus back to the client and his experiences)
C: Yea that's it, smile and say I'm fine, that's the only way to handle her
T: Oh gosh ... okay so when we start to focus in on sadness, when I share with you that I care about your feeling sad, you have an automatic push away feeling, connected to how your Mum was when you were sad. Like you might just say you're good even though that's not how you really feel. (Rule 3--Reinforce CRB, Rule 4--Observe Impact, and Rule 5--Functional Interpretation)
C: Yea that's it ... she would always want to fix me.
T: Uhuh and how does it feel with me right now, do you get some sense of me being too intense ... trying to fix your feelings? (Rule 2--Evoke CRB)
C: Yea kinda ... I know it's not really the same but I do feel it
T: Okay, so I want to respect that ... I feel mixed, I want to back off a little and give you some space but I also know this is the edge, that we always come back to when sadness shows up for you, when you interact with others who are important to you, you end up really struggling and shut ting down and limiting the development of your relationship with them, that's what brought you to see me in the first place. What do you think? What do you need right now, do you want to shut it away again or do you want to see if we can do something different here that you can try with others in your life? (Rule 3--Reinforce CRB2's and Rule 2--Evoke CRB)
C: Yea totally ... I know that's the problem ... I want help with this
T: So I've got an idea ... maybe there's a way that I could back off and at the same time we have your feelings be here ... it makes sense that you want to push me away given what you've just told me ... but that's also where you're getting stuck in life ... whenever feelings, especially sadness show up you tend to shut down, push others away, increase drugs, and think about dying ... so I want to find a way that sadness could be here, with me so we can find another way to handle it and at the same time without you feeling invaded by me. How does that sound? (Rule 3--Reinforce CRB2 and Rule 2--Evoke CRB)
C: Good but how ... what do you mean?
T: Well, what if we both kind of sit back in our chairs (sitting back), like what if we don't have to fix it ... it's okay. And I'm feeling sad about what you are going through, and if I just sit here with my sadness, and if you sit there with you're sadness, and we both kind of just sit here and feel our feelings ... and we don't need to fix or change them ... (Rule 2-Evoke CRB)
C: (sitting back) okay ...
T: So lets just breathe together ... (pause) ... hearing about how you had to hide your feelings makes me sad, I'm feeling a heaviness in my chest and some tears behind my eyes. (Rule 2-Evoke CRB)
C: (Tearily) I'm feeling a heavy feeling in my chest too and a sort of tight feeling in my throat.
T: Uhuh, it feels good to be here with you like this, I want to let you know I think you are so brave right now (Rule 3 Reinforce CRB2)
Whilst an optimal FAP interaction is more focused on feelings about the therapist and therapy, for this client having any emotion present with the therapist is seen as a CRB2. From here the client and therapist do go on to mindfully explore feelings, which allows more clarity about what makes it difficult to identify and express sadness to the therapist, as well as some focus on how it is to be doing that with the therapist. Importantly, this is the first time the client has for a sustained period of time remained connected to his feelings and been with the therapist/ in relationship.
It is worth mentioning that as the client is slowed down and in direct contact with their experience this technique has the potential to be highly evocative. In line with this it should be stated that the technique lends itself to modification and grading depending on where you are in the course of therapy and what level of capacity the client has for handling distress. For example you could do a 'cut down' version of this technique in a more regular conversational mode, something like,
"oh okay I think I'm picking up a theme here ... it's about needs. I want to let you know that I think it's okay to have needs. John, what you need is so important to me ... what thoughts or feelings do you have when you hear me say that?"
The aim of this paper was to provide a model for how to assimilate a technique from a different therapy model into FAP, which may involve some slight modification. As many therapists have undergone an array of training and professional development and subsequently learnt a variety of therapeutic techniques it seems fruitful for therapists to be able to consider what they have learned previously from a FAP perspective, so that they are able to carry forward these techniques, broadening the repertoire of methods they have for evoking clinical improvement for clients.
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|Publication:||The International Journal of Behavioral Consultation and Therapy|
|Date:||Jun 22, 2012|
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