First steps in FAP: experiences of beginning Functional Analytic Psychotherapy therapist with an obsessive-compulsive personality disorder client.
Luciana (1) is a 36 years old twice-married woman with three children, a 13 years-old daughter from a first marriage and two young children (3 years and 18 months old) from her second marriage. She herself was adopted at 8 months. Her first marriage to a successful lawyer lasted three years. She met her second husband four years ago and, after her third pregnancy, stopped working to look after her children. Luciana sought therapy because she was not sure whether she should leave her husband toward whom she felt persistent anger and distrust. She reported having suffered all her life and wanting to feel better. She hoped therapy could help free her from the distrust and anger she felt in all her close relationships.
Having made an appointment with the first author, Luciana had come with her husband. They wanted helped with marital difficulties so the therapist referred them to a couple therapist. In the course of this initial consultation, Luciana had stormed out of the room before coming back a few minutes later declaring that she did not love her husband anymore. A few weeks later, Luciana telephoned the first author saying that, in addition to the couple therapy she'd started with her husband, she wanted individual therapy. She had the impression the therapist could help her in some way: maybe to love her husband again, maybe to separate from him and, in any case, to feel less distressed.
In the first therapy session, Luciana talked of life-long suffering, which she saw as being rooted in being abandoned by her natural parents. She particularly resented not knowing who they really were and having to rely on stories from her adoptive parents. Through them she heard that her natural mother had probably been a prostitute whose 'crazy' behavior had been deeply troubling to them in the first years after her adoption. As to her natural father, she heard he was a violent man who'd started a new family and did not want to have anything to do with her. She alluded in very vague terms to her first marriage being a difficult time and said that her suffering had now transferred to not loving her second husband anymore. She felt particularly guilty and uneasy toward her 'perfect' adoptive family and herself felt she had to be 'perfect' in every way. She feared that her persistent anger would make her become 'crazy' like her natural mother had been.
Luciana's main difficulties in daily life were problems with anger, thoughts of being neglected, distrust of close others, difficulties in making decisions for herself, and an inability to communicate her feelings in a workable manner. She reported that she had never been able to fully open up and deeply connect with anyone. Witty and highly intelligent, she often used her sharp intellect and humor to keep others at a distance.
In terms of DSM categories, Luciana met criteria for Obsessive-compulsive Personality Disorder, with four criteria: preoccupation with details, inflexibility about matters of ethics, reluctance to delegate (e.g. difficulty in letting her children be babysat) and significant rigidity. She also presented three clear Borderline Personality Disorder traits : persistently unstable self-image, chronic feelings of emptiness (she described feeling as a 'bottomless shopping bag') and difficulties controlling anger.
Apart from relational difficulties, Luciana reported no significant difficulties in life. For her part, the therapist felt an uncomfortable sense that Luciana would prove a very difficult client to work with. Her FAP training came to mind and she wondered if what she felt might reflect what others felt with Luciana and account for her difficulties. Openly focusing therapy on the therapeutic relationship could help Luciana develop an interpersonal repertoire that might best help her reach her relational goals. With some trepidation, the therapist thus offered FAP to Luciana, and contacted the second author for supervision and to discuss client suitability for a first FAP therapy.
FUNCTIONAL APPROACH TO PERSONALITY DISORDER AND CLINICALLY RELEVANT BEHAVIOR
From a behavioral standpoint, personality disorders are not seen as resulting from deep-set 'structures' but rather as clusters of behaviors that have been adaptive at an earlier time but are now problematic. Consistent with this view, description and classification of symptoms is not typically useful for identifying the functional relations maintaining problematic client behavior (Koerner, Kohlenberg, & Parker, 1996). For such clients, Horowitz (1997) as well as Kraus & Reynolds (2001) suggest identifying particular difficulties in relationships and devising treatment strategies specific to the client's particular difficulties. Kohlenberg & Tsai (1991) suggest that the best arena for observing such difficulties is the therapeutic relationship.
A key element in identifying the functional relations maintaining problematic client behavior is creating a therapeutic relationship that allows observation of the relevant behavior to take place. Although many therapeutic approaches emphasize a strong therapeutic relationship as way to deliver their therapeutic technology, FAP considers the behaviors that are evoked by the therapeutic relationship, as well as the strong emotions it evokes, as central to behavior change (Kohlenberg, 2000). A key first step in creating such a relationship is to present the client with a rationale for FAP, the so-called 'FAP-rap' (Tsai et al., 2008). This consists in informing the client that therapy will focus on the way her daily-life difficulties present themselves in the therapeutic relationship and inviting her to consider these difficulties not as a problem but as opportunities to practice in-the-moment how to address them in a way that can help her reach her therapeutic goals. The therapist shared the FAP-rap to Luciana in the second session, emphasizing how the therapeutic relationship could be a 'sacred space' for trying out new behavior. At first Luciana responded guardedly, asking : "How could you always be on my side?" When asked to quantify her doubt that the therapist was really committed to make the therapeutic relationship a 'sacred space', she rated her belief at 75%. The therapist praised such high level of trust and invited her, over the coming sessions, to track whether therapy provided what she needed.
Once the client has given informed consent to doing FAP, the therapist applies the first rule of FAP: identifying clinically relevant behavior (CRBs). There are two types of CRBS: CRB1s which are directly observable in-session behaviors linked to client reports of outside-of-session problems (which FAP names Outside behaviors or Os for short), and CRB2s which are in-session behaviors that represent improvements over CRB1s. A third type of CRBs are CRB3s. These represent the client's producing functional explanations of her behavior, i.e. specifying the antecedents and consequences of her behavior.
Identification of CRB1s and CRB2s is an ongoing collaborative process between therapist and client and forms the basis of FAP case conceptualization and treatment (Kanter, Weeks, Bonow, Landes, Callaghan et al., 2008). Identifying CRBs can be challenging to beginner FAP therapists. The therapist is invited to keep an eye out for those behaviors that could be functionally similar to outside problem behaviors without knowing in advance what form these difficulties might take in the therapeutic relationship. To identify CRB, therapists are invited to use their own feelings as a barometer of possible client CRB1s and CRB2s (Tsai, Kohlenberg, Kanter & Walz, 2008). Another method, drawing in-to-out parallels (Kohlenberg & Tsai, 1191), consists in the therapist asking the client if difficulties arising in the moment between them also arise in her outside life.
This phase of FAP is both delicate and important and can seem daunting to beginning therapists. In identifying CRB1s, the therapist runs the risk of appearing to be criticizing and becoming aversive to the client. This could threaten the therapeutic relationship. Creating from the beginning a warm and supportive relationship and a 'sacred space' is thus crucial.
Luciana described how, in close and intimate relationships, she alternated between periods of giving an appearance of 'perfection' and 'being just fine', and periods of intense anger, dysregulation, distrust, and rejection of others. During sessions she also alternated between periods of presenting herself as doing fine and moments expressing intense anger toward others and sometimes also toward the therapist which she expressed by stating she knew therapy could never help (both CRB1s). In her adoptive family, the emphasis was on 'being normal' and never expressing negative emotions, but she had also received a lot of attention for dysregulated behavior, which often led to the family intervening on her behalf and taking charge. Thus both dysregulated behavior and 'acting perfect' were reinforced. Outside of moments of crisis, her opinions and feelings were rarely probed and validated, leading her to feel neglected and abandoned. In these 'normal times' her adoptive family reinforced only displays of 'perfection' and 'selflessness.
Early on in therapy, Luciana talked about suicide, which both therapist and supervisor saw as a CRB1 the function of which was to prompt the therapist to give her maximum attention and take charge. This behavior was problematic in her outside life too, prompting close ones to lavish attention on her while at the same time invalidating her sense of being an independent and worthy person. For Luciana, suicidal talk functioned as a disguised mand (Kohlenberg & Tsai, 1991). Luciana was expressing her negative feelings (an apparent tact) as a way of asking for intervention from her entourage (a mand). Another example of in-session disguised mand came in the first session when Luciana looked straight into her therapist's eyes and declared: "You understand me". The therapist felt the meaning was that she had an obligation always to 'understand', which made her apprehend what would happen if she ever failed to provide such understanding. In her outside relationships, giving others such trust and responsibility at the outset of a relationship served to prevent her relationships from maturing and developing and led her to regularly feel betrayed (a daily life problem, O1 corresponding to CRB1). Further, Luciana was unable to express her needs other than through angry outbursts, which were reinforced by significant others giving her attention and seeking solutions for her. Here again she was not able to produce functional mands but used tacts as disguised mands. The therapist gently invited Luciana to notice how she used a lot of implied demands (CRB1) by expressing how helpful it would be for Luciana to make more direct demands (CRB2) so she could better give her the support she needed. Asked if such a skill could help in her outside relationships, Luciana agreed enthusiastically. A key strategy used by the therapist in the previous example was to present a corresponding CRB2 concurrently to identifying the CRB1 and to genuinely reflect the positive impact such CRB2 would have on her, thereby indicating it would be reinforced. In this gentle fashion, Luciana and her therapist were able to gradually develop a joint case conceptualization.
In FAP, case conceptualization is an iterative process that evolves throughout therapy and centers on identifying CRBs (Kanter et al., 2008). Consequently, the identification of CRBs evolves as therapy progresses. Over the course of the first 6 sessions the following CRB1s were jointly identified by Luciana and her therapist :
* Joking and intellectualizing during sessions.
* Acting and speaking so as to appear as the "perfect" client.
* Making unclear demands of the therapist (disguised mands).
* Inability to express negative emotions in session and toward the therapist in a workable way.
* Responding with anger and making imperious demands when feeling neglected by the therapist.
* Not taking the therapist's perspective into account.
* Complaining about the therapist and attributing her feelings and beliefs to her.
* Demanding excessive between-session communication (through text and phone messages).
* Blaming her past history for in-the-moment unworkable behaviors.
* Not trusting that any relationship can give her what she needs by demeaning her relationship with the therapist and not initiating intimate sharing.
* Jointly identified CRB2s :
* Speaking her truth, regardless of what she thinks the 'perfect' client should say.
* Making clear requests for emotional support from the therapist (clean manding).
* Describing her feelings of the moment (clean tacting).
* Being direct in expressing doubts and confusion, expressing her negative feelings in session and about the therapist with authenticity.
* Listening carefully and empathically to the therapist's opinion
* Inquiring about the therapist's feeling and thoughts
* Giving reasons for her behavior based in what is going on in the moment (producing CRB3s).
* Trusting relationships by sharing her feelings with her therapist and expressing her need for closeness from her therapist in a considerate way.
In the first phase of therapy, work focused on establishing the relationship as a sacred space that Luciana could fully trust. At first, even after the presentation of the FAP rap, Luciana remained deeply ambivalent about the relationship. She alternated between joking and intellectualizing, and expressions of deep skepticism regarding the therapist's trustworthiness and the genuineness of her concern for her (CRB1s). For her part, the therapist experienced strong feelings of incompetence and a pull to move away from Luciana when she engaged in these behaviors (therapist problematic behavior, T1). The rate of CRB1s was high and the therapists' affective reactions were an indication of that.
Other problematic CRB1s in this phase of the treatment were changing appointments at the last minute, changing subjects, interrupting or criticizing the therapist, asking the therapist to tell her if should stay with her husband or leave, and excessive text and telephone communications in between sessions. Conceptualizing these behaviors as CRB1s helped to validate the therapist's experience and draw parallels between these behaviors and Luciana's problems in her outside relationships. Together, the therapist and Luciana noted these behaviors were more frequent when Luciana felt neglected, a first step in identifying the antecedents to her CRB1s and thus helping Luciana give functional explanations of her behavior (CRB3).
At first, Luciana would not consider observing her feelings and emotions, even for an instant. The therapist systematically validated how Luciana felt, so aiming to reinforce the part of Luciana's complaints that constituted rough approximations of sharing (tacting) her difficult feelings. She gently and persistently asked Luciana to notice her sensations and thoughts in the moment. When Luciana expressed that she felt a failure and a 'bad' client for not being able to do this 'right', the therapist further treated this as a CRB2 (an approximation of expressing her difficult feelings in the moment while disregarding her need to look 'perfect') and chose to reinforce by validating her difficulties and praising her for sharing them. In supervision, the therapist also noted her need to appear competent and impose an agenda and move quickly from one subject to the next with the supervisor, a T1 which also occurred with her client. On the invitation of the supervisor, she gradually became able to contact and express more of her difficulties and insecurities with Luciana and let go of wanting to overly structure the supervision and therapy sessions (which she identified as an improved therapist behavior during treatment sessions, T2).
In this phase of the therapy, Luciana would often use her personal history to justify her emotional dysregulation and angry behaviors, including toward the therapist (a CRB1 that prevented her from producing CRB3, that is identifying the immediate antecedents to her behavior). In the third session Luciana angrily told her therapist she could never understand the depth of her suffering because no one could understand how it felt to be abandoned and rejected and to be the daughter of 'the whore and the phantom'. As she said this, her therapist experienced a strong sense of failure and rejection. However, being vigilant for CRB, she identified that sharing this had been a CRB2 for Luciana for whom not letting others know how she truly felt was a CRB1. Behind her first sense of failure and rejection, the therapist also felt kindness and tenderness toward Luciana and felt truly moved to see her express her deep feeling of the moment. She shared this, which naturally reinforced Luciana's expressions of her difficult emotions. Luciana reported in later sessions that from this point onward she felt understood and had started to feel she could be 'free to be herself'.
ROLE OF SUPERVISION
A parallel issue arose in supervision as the therapist at first hesitated to express her distress and sometimes her anger at feeling she could never establish a strong enough relationship to truly help Luciana (T1). She experienced significant emotional difficulties in staying present and connected with her supervisor and, in parallel, with her client (T1). By gently reinforcing and normalizing expressions of anger, distress and of not being 'the perfect therapist', the supervisor helped the therapist feel cared for and able to express her sense of growing closeness. In parallel with her experience with the supervisor, she was then able to generalize and better access and express her deep empathy to her client while inviting her to express more directly and therapeutically her distress and anger (T2).
Keeping others at a distance, not revealing what she felt and not inquiring about the feelings of the people closest to her were O1s for Luciana. Invited to identify the qualities she would like to embody in her relations, she chose sharing, being authentic and considerate of others' feelings. So the therapist encouraged Luciana to ask her how she felt (CRB2), while committing to genuinely sharing her feelings, including negative ones (T2). This T2 had been shaped by the supervisor inviting the therapist to share her difficult feelings and doubts regarding the su pervision relationship. Following a mix-up in the consultation time which had led him to cancel the supervision session at the last minute (a supervisor problematic behavior, S1), the supervisor encouraged the therapist to genuinely express her sadness and anger at his not being present for her that paralleled the therapist's improved ability to therapeutically express negative feelings toward the client (T2). Subsequently, the therapist told Luciana how upset she felt that she had cancelled an appointment at the last minute (T2), and Luciana was able to validate her therapist's feelings (CRB2). At another point, the therapist openly expressed her disappointment after Luciana recounted reacting in an impulsive and angry way with her stepdaughter (T2), and Luciana was able to validate her therapist's point of view without feeling rejected or betrayed (CRB2). The therapist in turn sought to reinforce these CRB2s by genuinely sharing how important it was to her to feel Luciana could express all she felt, including negative emotions.
GENERALIZING PROGRESS TO OUTSIDE LIFE
In that phase, the therapist prepared Luciana to start generalizing her progress to her outside relationships by encouraging her to identify the antecedents and consequences of her behaviors, i.e. producing CRB3s. For example: when feeling neglected (antecedent), Luciana would criticize her therapist (behavior) making them both feel more distant from one another (consequence). However if, when feeling neglected (antecedent), she expressed how sad she felt and her need for support in a considerate way (behavior) her therapist responded warmly and shared her own feelings, bringing them closer together (consequence).
After having practiced reporting her in-the-moment emotions with her therapist (CRB2), Luciana started generalizing this behavior to her interactions with her husband (O2). At times, she noticed feeling emotionally closer, understood and validated by him. She also reported becoming better able to reinforce her husband's own sharing of his feelings (O2) in a way similar to how she had reinforced her therapist's expressions of feelings (CRB2), leading to a decrease in marital conflict (O2). With her adoptive family, she became able to better ask for support when needed, for example by asking for help with the children or housekeeping, without striving to appear the 'perfect daughter' (O2). As to the therapeutic relationship, Luciana reported caring deeply for the therapist and valuing their relationship (CRB2). An important CRB3 was recognizing how her love and care had often been overshadowed by feeling neglected (antecedent) and how, by expressing in a considerate manner her attachment to others (behavior), she was able to move closer to her therapist and significant others (consequence). In the second part of the therapy, Luciana became more open to describing her relational difficulties in functional terms as largely sharing similar antecedents and consequences.
In terms of DSM categories, Luciana does not at present meet criteria for obsessive-compulsive personality disorder, not displaying any of the four traits she did before start of therapy. She does not meet criteria for borderline traits anymore : where she reported feeling like a bottomless shopping bag, she now says she feels like a well-filled bag able to carry what life will bring.
In terms of self-report measures, her score on the Beck Depression Index 2 (Beck & Steer, 1984) went from 25 (moderate depression) to 14 (lowest score for mild depression). Her score on the Melanie Fennell self-esteem index (Fennell, 1997) went from severe to low problem. On the Worry domains questionnaire (McCarthy-Larzelere, Diefenbach, Williamson, Netemeyer, Bentz et al., 2001) her score decreased from 49 (dysfunctional) to 28 (normal levels of worry). Finally, experiential avoidance, as measured by the Acceptance and Action Questionnaire II (Bond, Hayes, Baer, Carpenter, Guenole et al., 2011) went from 25 (highly avoidant of inner experience) to 40 (just short of normal).
In the course of 52 sessions of therapy, Luciana's in session problem behaviors (CRB1s) significantly decreased and her target behaviors (CRB2s) increased. Gradually, theses in-session improvements generalized to her outside life and she reported a decrease in relational difficulties, a deepening in her relations and an increased satisfaction with her life.
The therapist who had hitherto used CBT and ACT selected this client for her first FAP therapy because it appeared at the onset that issues around trust and relationships were uppermost for Luciana. However choosing FAP presented significant challenges as, from the outset, the therapist felt a strong sense of not being good enough and a fear of not being able to help. Prior to FAP training, she might, with a strong sense of guilt, have turned the client down or, despite a strong suspicion it wouldn't help, offered the client to work on whether or not to leave her husband. FAP helped her recognize her uneasy feelings as potentially a function of client problematic behavior and see it as a function of pervasive relational difficulties. This helped her find the courage to offer FAP.
After presenting the FAP rationale, the next significant challenge was to establish the therapeutic relationship as a sacred space in which to practice improved relational behavior, as doubting the possibility of genuine intimate and trusting relationships was the central issue in the client's life. FAP supervision is seen as an important way to hone FAP skills (Vandenberghe, 2009; Follette & Callaghan, 1995) and FAP supervisors regularly draw their consultees' attention to the possible parallels between their behavior in the supervision relationship and their behavior in their therapeutic relationships. A parallel challenge arose between creating and testing a trusting relationship 100% devoted to Luciana's interests and the growth of an intense and trusting supervision relationship. As she became gradually more open and direct in expressing her needs and emotions in supervision, including difficult thoughts and feelings, the therapist became more able to genuinely respond to Luciana in therapy, thus strengthening the therapeutic relationship and shaping Luciana's increased sharing. The therapist experienced a parallel between the growth in Luciana's trust in confidence in the thera peutic relationship and the growth of her own confidence in the supervision relationship.
Another significant challenge was jointly conceptualizing problem and target behaviors as they arose in session. Here again, the supervision relationship helped, as it served both as a model and a practice ground in which to explore how clinically relevant behavior could be evoked and reinforced using moment-to-moment experience of the consultee-supervisor interactions.
Finally, by creating a relationship in which considerate expression of difficult feelings and thoughts was systematically reinforced, the supervision relationship helped the therapist hone her skills of genuinely reinforcing improved behavior in her client. It also helped the therapist ask and obtain support in those moments when client problem behaviors made her feel as though she could not help.
We offer this case as an illustration of how using FAP can help therapists work with clients they feel from the outset might prove difficult to work with and how supervision can help meet some of the challenges of beginning FAP. Our hope is that it might inspire therapists to begin FAP, perhaps with a client with whom they feel that their usual approach might prove insufficient. We welcome correspondence about beginning FAP experiences.
The authors wish to thank Robert Kohlenberg for useful comments on an earlier draft of this article
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(1) Not the client's real name
Katia Manduchi , & Benjamin Schoendorff [1,2,3]
 Private Practice,  Fernand-Seguin research center, Louis H. Lafontaine Hospital, Montreal, &  Universite du Quebec a Montreal
AUTHORS CONTACT INFORMATION
Via Pananti 10, 47923 Rimini (Italy)
Centre de recherche
Fernand-Seguin de l'Hopital Louis-H. Lafontaine
7331, rue Hochelaga, Montreal (Quebec) H1N 3V2
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|Author:||Manduchi, Katia; Schoendorff, Benjamin|
|Publication:||The International Journal of Behavioral Consultation and Therapy|
|Date:||Jun 22, 2012|
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