Functional Analytic Psychotherapy (FAP) and ACT Jonathan Kanter, Ph.D. University of Wisconsin-Milwaukee, USA jkanter@uwm.edu Often the real work can be done by focusing on the present therapy process. There is no need to talk about experiential avoidance or cognitive fusion, for example, when it is usually quite easy to find it then and there in the room in the relationship. (Pierson and Hayes, 2007) Today s Goals Process that maximizes the impact of therapeutic work in the present moment Acceptance Defusion Contact with the Present Moment What is the best way to learn how to dance? FAP Behavior Analysis Self as Context ACT Instructions? Practice and feedback? real work in the present moment involves providing consequences What kinds of natural consequences can happen in the therapy relationship? What client problems are sensitive to these consequences? 1
CRB: Clinically Relevant Behavior CRB s occur in session and can be addressed on the spot CRB-1: Client problems occurring in session (a step backward) CRB-2: Client improvements that occur in session (a step forward) FAP s 5 Rules 1. Watch for CRBs (awareness) 2. Evoke CRBs (courage) 3. Reinforce CRBs (love) 4. Observe your effect on your client (awareness) 5. Generalize (behaviorism) 7 Daily-Life Problems Daily-Life Goals In-vivo occurrences of problems (CRB 1 s) In-vivo occurrences of improvements (CRB 2 s) Rule 1 is about awareness Your mindfulness in the session is crucial Watch for (Rule 1) and evoke (Rule 2) CRBs Identify reinforcers (Rule 4) and reinforce CRB2s (Rule 3) Add CRBs to your ACT case conceptualization Draw parallels between present moment and outside experiences Provide rules and generalization strategies (Rule 5) In-to-out parallels: I am having a reaction to what you just did. I m wondering if you are aware of other people who have reacted similarly. I m trying to determine if my reaction is unique to me or not, or if it would be helpful for us to talk about it in more detail. Out-to-in parallels: Does what happens between you and your partner ever occur between us in here? Is that the same as when you and I had that disagreement and you got really quiet? Do I make you feel that way as well? Do you see me as similar to your husband in any of these ways? 2
Contact with the Present Moment What is the goal of behavior therapy? Behavior Change Define ACT targets as CRBs Acceptance Defusion Behavior is a function of PAST and PRESENT contingencies According to ACT: The problem is verbal contingencies give rise to Self as Context 13 Fusion Avoidance which leads to dysfunctional behavior What is the goal of ACT? Acting mindfully, according to one s values ACT target Behavioral definition CRB Fusion Defusion Fusing Defusing Fusing with thoughts about therapy or the therapist Defining values, while defusing and accepting PAST Clarification PRESENT Mindfulness Paying attention while defusing and accepting Avoidance Acceptance Mindfulness Avoiding Accepting Paying attention while defusing and accepting Defining values while defusing and accepting Avoiding feelings about therapy or the therapist Mindful attention to the therapist while defusing and accepting Defining values in terms of the therapy relationship Defusion Defusing Acceptance Accepting Acting mindfully according to one s values Acting in session towards the therapist according to one s values Defining values and actions relevant to the therapy relationship and therapist: [After discussing values regarding significant relationships] I would like those values to apply to us as well. My value with respect to you is to foster a genuine, safe, loving, connected, trusting, open, sacred, accepting, unique relationship that serves as a model for what you can achieve outside of here. Rule 2 is about courage courage to have a real, genuine, live, emotional human relationship with your client Your acceptance in the session is crucial 3
Typical FAP questions: What are you thinking or feeling right now? What s going through your mind right now? What s your reaction to what I just said? What were you thinking/feeling on your way to therapy today? What were you thinking/feeling while you were waiting for me out in the waiting room? What were your reactions to our last session? Typical FAP questions: What are your feelings/reactions to our session today? What s hard for you to say to me? How are you feeling about our therapy relationship? What are you avoiding? What are you accepting? What do you wish I would have done more of? What do you think I m thinking about you/ what you said? Rule 2 ACT Dilemma ACT naturally is evocative but some ACT relationships are not natural The goal is for the therapy relationship to temporarily disrupt the context of literality that dominates outside relationships Thank your mind for that thought Don t believe a word I am saying Instead of me answering you directly, let me launch into this 20-minute metaphor about monsters or this 20-minute experiential exercise about shapes and colors When behaving abnormally in session: Ask for permission Acknowledge the weirdness Be compassionate Don t be jargony Don t be mindy Try ACT without ANY metaphors 4
Rule 3 is about love and acceptance Rule 3 is about love and acceptance Love and acceptance are extremely reinforcing the most people CRB2 General Assertiveness Disclosure, approaching intimacy Rule 3 response Amplify your natural emotional reaction, show interest Give client what s/he wants Disclosure, approaching intimacy Be careful of technique trying to be reinforcing being a therapist Let yourself be a genuine human being Work on this with yourself, your loved ones, your clients When a CRB occurs, the best responses are accepting, natural, honest, focused on value-based committed actions that can occur in the therapy relationship Typical ACT moves: Typical ACT moves: Natural consequences: Natural consequences: FAP moves: FAP moves: 5
Are the following responses to CRB1s and CRB2s punishing or reinforcing? How could they be improved? How could they be more natural, genuine, direct and focused on committed action? Treat as experiential avoidance: I m guessing you ve felt like this before with other therapies. Yes? OK, so could I you ask this: what did you do in the past when you felt like this and how did that work for you? Very indirect. Seems not completely honest. How about, I want to take that seriously but at the same time, I m thinking you are really stuck at this moment. Can I really gently shift you a little bit right now? Can you talk with me directly about these feelings rather than have them push you into this sort of judgment? Are you feeling afraid that I will disappoint you and let you down? Nice - brings up and blocks the avoidance directly. Treat as fusion: Could I ask you this: how close is that thought to you right now? Does it feel like it is right on top of you, or does it feel like it is floating out here in the space between us a bit? Like if this piece of paper is the thought I m not getting any better can you show me how far away it is from you right now? Interesting. Well if we take that thought literally I suppose we would need to deal with whether you are in fact progressing. And we can do that if your gut level sense is that it would really have value. But I wonder if another area would be to look at our relationship and what we plan to do when we have thoughts about the process itself that are scary or difficult. Second quote better because it is more direct and natural. Treat as lack of contact with present moment (mindfulness): [moving chair over next to the client so that they both look back in the same direction]. Would it be possible for us both to get into contact with what it feels like to think that therapy is going no where, right here right now? And let s put that thought out there on the floor in front of us and both of us watch in more detail what then comes up as we look at it. Good except for putting thought on floor. How about, Can you and I right now, get a little distance from that thought and really connect in this moment on that issue? Cut this b**sh**. We re going to waste our session if you keep this up. I want to connect with you. The best response to a CRB1 like this may be to ignore it and prompt a CRB2. Listen what do you really value, right now, in this relationship, with me? I really want to connect with you and these sorts of comments from you don t help with that. Let s come together on this. Treat as acceptance: Thanks for telling me that. What do you feel as you put that into this room? How about, When you say that, it hurts a bit to be called out on it, but I have to say, you are so right. I m scared you are not getting better too, and when I get scared I tend to psychobabble, but I am 100% committed to you and this process. I will try to do better and not psychobabble, but if I do, will you call me on it again? Treat as defusion: Ouch. That must be a painful thought to have. How is ouch reinforcing? 6
Treat as mindfulness: Let s both just take a second to get present with what it feels like to be here with that in the room. Treat as values: I hear you. And before we even unpack that let me just say that what I m in here for is you and what you really want in your life, not me getting applause for saying clever things. Both of these seem pretty good to me. The best response to a CRB2 may be to amplify your natural emotional reactions to the client: You know, on the one hand, that is kind of harsh, but on the other hand, it is the kind of thing I really appreciate about you. Your honesty, your ability to tell it like it is. I really take what you say seriously and when you re honest with me like this it actually makes you more human to me as a person, but like a full, real, living breathing human being. So I know that is difficult to say but, wow, fantastic. I m right here with you now on this. Let s make some changes, ok? RULE 4: Notice your effect on the client RULE 4: Notice your effect on the client Rule 4 is about awareness Micro-level: What is the client s immediate response to your intervention? Macro-level: Are CRB2s increasing in strength and frequency over time? How am I doing in response to you right now, am I making this easier or harder? What was it like to tell me that? Did I respond in a helpful way? How? Do you think you are more likely or less likely to do this again? RULE 5: Generalize Weave together in-session and daily-life material and content. Provide homework relevant to in-session interactions Now that you ve done this with me, are you willing to try it with Summary Rule 1: Watch for CRBs Define ACT CRBs and define the therapy relationship in terms of your client s stated values and committed actions Rule 2: Evoke CRBs Develop a natural relationship that is a model for other relationships Rule 3: Reinforce CRBs Rule 4: Notice your effect on client Rule 5: Generalize Be loving, emotional and accepting in session Ask for feedback Provide homework assignments based on intense live interactions 7