3 以功能分析为本

CHAPTER 3 Stay Grounded in Functional Analysis A little reflection will show that there is beyond question a body of very important but unorganized knowledge which cannot possibly be called scientific in the sense of knowledge of general rules: the knowledge of the particular circumstances of time and place. —­F. A. Hayek Toward the end of the session, Tom seems to freeze. He had been engaging well, talking about his progress with writing this week. You ask him what obstacles might come up inside of him as he continues his writing and job search next week. “I still struggle with…am I likable?” He pauses. “Sometimes I wonder… It’s silly, but—­what do you really think about me?” You stumble for a moment, remembering a supervisor’s old rule: don’t answer the question directly. But that doesn’t seem quite right in the moment, so instead you decide to offer honesty. “I want you to know, first of all, that I’m honest with you about how I feel about you. I have so much respect for the work you’re doing here. I look forward to our sessions every week.” “I appreciate you saying that,” Tom says. “I guess there’s part of me that thinks you’re just being nice.” You see him freezing up for the next few minutes. He averts his eyes, and his breathing is high in his chest. You’re not sure what else to say, so you wrap up the session. A few hours later you receive an email: “I’m so sorry I screwed up. I froze. I could see the look on your face when I said you were just being nice. I always mess up like that. I hope you will forgive me.” What was happening for Tom in that moment in session? And for you? Functional analysis (FA) is the assessment framework that guides the process in FAP. It stands on top of the basic contextual behavioral foundation described in chapter 2. Moving beyond the general stance of CBS involves building a highly individualized and specific grasp of a particu- lar client’s behaviors and their functions—­including the “particular circumstances of time and place” that have shaped and continue to shape this client’s actions. FA can be a daunting, technical process. Like building skill at chess, or painting, or business negotiation, it can take years to master. This is because using FA to understand a unique situation requires not just understanding FA principles but also developing the capacity for pattern recogni- tion when applying those principles (How does this particular situation make sense? Have I seen this pattern before?). Pattern recognition facilitates making sense of complex information, and it is born from years of experience. We cannot promise to make you an expert at FA in one chapter. Instead, as in the previous chapter, we aim to present the key principles that represent the core clinical value of FA, and in this way we aim to get you started on the road to mastery. It will be up to you to practice. Doing a functional analysis suggests a discrete procedure, with distinct rules and a beginning, middle, and end. In clinical practice, FA might take this form at times, but more often—­as with many forms of assessment—­the process is more diffuse, iterative, and flexible. In fact, flexibility is a strength of FA. You can use it as much or as little as is effective. To start, we suggest the following reframing: rather than thinking of FA as a procedure, we invite you to practice “thinking function- ally.” Just as a chess player thinks about positions, a painter about light, or a negotiator about opening statements, a successful practitioner of FAP thinks about function. Thinking functionally is a process of building your understanding of how a behavior functions in the contexts that have shaped it. It revolves around three key questions: What is the behavior? In what contexts does it or did it occur? What is or was its function in those contexts? FAP especially focuses on functional thinking to work with a client’s problem behaviors that show up in the therapy process. The aim in FAP is to create a highly individualized, assessment-­ based approach to each therapy relationship. As you participate in the therapy process, functional thinking is a touchstone to return to again and again—­a reminder to notice function, to not let avoidance of important issues take root in the process, and to work the process in a way that’s effec- tive for the client. The process is what matters. FA is a tool for being focused and strategic in the process, not a replacement for the process. In this chapter, we’ll start with a broad application of thinking functionally and gradually narrow the focus to thinking about the therapy process. In the sections that follow, we lay out some basic steps involved in thinking functionally in FAP, starting with the questions above. STEP 1: ORIENT TO BEHAVIORS AND CONTEXTS In the case of Tom, whom we’ve been following from chapter 1, Tom came to therapy stating that his problem is “feeling so unworthy all the time. I need to feel more confident.” This is a typical presenting problem that we encounter in therapy. It is focused on a pervasive negative feeling and an inability to shake that feeling. To boot, it comes with an idea about what is needed instead: to feel confident. As you have no doubt experienced as a clinician, however, while the original pre- senting problem often describes exactly what the client most longs to fix, only sometimes does the presenting problem describe in a useful way what needs to change in order to produce that shift. We have to look deeper to find that useful understanding. The situation is similar any time we’re working with a complex system, and behavior is certainly a complex system. If you go to a physical therapist because your lower back hurts, it might turn out that the source of the problem lies in the placement of your computer monitor or a problem in your feet. Similarly, when a person feels depressed, the proximal source of the low mood might lie in a frustrating work environment, a divorce, a medical condition, and so on. Chronic irritability might originate in a sense of shame. Anxiety and a feeling of being out of control might arise out of rigid efforts to control. And so on. Clients may or may not be aware of the links between their problems and the sources of these problems. (And of course there may be multiple “sources” interacting in complex ways.) In turn, the pathway that leads from source to problem might involve a number of steps. The placement of the computer monitor causes lower back pain because neck position causes discom- fort, which causes postural changes that cause tension in other areas and, down the line, the result is back pain. The work situation punishes assertiveness, which gives rise to resentment and a sense of shame at home, and because the client lacks the skill for seeking support, hopelessness sets in. From a CBS perspective, then—­mirroring the task of “seeing behavior” described in the previ- ous chapter—­our initial task is to see and understand the behaviors involved in the client’s issues. To see that ongoing stream of behavior clearly, we ask questions—­lots of questions—­that build empathy and understanding and allow us to describe the client’s experience like a screenwriter or novelist. We might ask the following questions: What was happening when you started to feel that way? What were you doing? What were you thinking? What were you feeling? Where were you when that happened? What happened before that? What factors do you think contributed to that? When you felt that way, what did you do? What happened next? What did you do next? Then how did you feel? How did others respond? How did you respond? What happened after that? What else happened? These questions are all about understanding the sequence of events: everything that falls under the umbrella term “behavior”—­thoughts, feelings, urges, and actions—­as well as the responses of other people and the events in the world to which the client was responding. Notice that none of these questions include the word “why.” As a rule, we avoid why questions at this stage because why questions lead to reasons that may not be connected to the actual flow of events; for example, “I don’t know why—­I guess I’m just weak.” Or, “I don’t know, you tell me.” At the same time, bear in mind that you aren’t interested in the flow of events for its own sake. You are tracking the flow of behaviors and contexts relevant to a given client’s presenting problem. You are aiming to eventually zero in on what seem to be the key behaviors that lead to the present- ing problem, as identified by either you or the client. Imagine you have a client, Susan, who says she feels burned-­out at work. Here is some sample dialogue; it illustrates this process of tracking behaviors that lead to the presenting problem and zeroing in on the key behaviors that seem relevant. Therapist: So you feel burned-­out. Client: Yeah, I just really don’t want to be there. It’s agony to get out of bed on Monday morning. Therapist: Sounds really challenging. Tell me more about what it’s like to be at work. Actually, let’s review last week. When you arrived at work on Monday, what were you looking at? Client: Well, it starts even before that. I was already late on a project. I volunteered for it, stupidly, two weeks ago, even though I knew I wouldn’t have time for it. Then I pro- crastinated all day Saturday and most of Sunday, and then finally had to put in about six hours on Sunday evening. I was miserable. Therapist: Ugh. What was going on that you accepted a project even though you didn’t have time? Client: Oh, man. I do that a lot. Therapist: Do you say yes first and then think through the costs later? Client: Exactly. I’m a yes person. Therapist: Are you aware that saying yes might be a bad idea when you say it? Client: Well…yes, recently I have been having a little sense of dread when I sign up for new work. But the thought of saying no…that’s just not what you do. Therapist: That’s not what you do. I say no all the time. Client: Ha! At my work, not many people say no. I don’t say no. You get judged if you say no. Immediately with the inquiry—­“When you arrived at work on Monday, what were you looking at?”—­the client described a series of events that, based on the therapist’s understanding of burnout, seem likely to have contributed to the client’s presenting problem. Further questioning seemed to confirm this hunch. Imagine that more similar questions reveal a few key patterns that recur again and again: • She’s severely overcommitted, often sacrificing her evenings and weekends to work on projects that she doesn’t enjoy but has promised to complete. • She tends to quickly agree to doing more work and feels regret afterward. • She tends to avoid saying no or otherwise expressing her reservations about a task when speaking with supervisors. • She tends to get into arguments with coworkers about what she perceives as their inef- ficiencies that negatively impact her own work; she enters these conflicts in a confron- tational, judgmental way. In this relatively simple demonstration, Susan discovered that she already knew what many of the relevant patterns were but had not yet put together the whole picture in such a way that she could understand her experience. Toward the end of the discussion, then, you might step back and summarize what you have learned: I think you’re feeling burned-out for good reasons. You’re in a situation where your needs are constantly sacrificed in favor of work. You’re carrying a near-­constant state of stress about deadlines. You don’t feel able or hopeful about changing this situation. And you don’t have much support at work. In fact, your relationships with coworkers are often another source of stress. When there are multiple possible factors bearing upon a presenting problem, it can also be useful to ask a clarifying question to get at which factor is most important. You might ask Susan, “Which of these issues, if we fixed it, would have the biggest effect on your burnout?” Susan, for instance, might discover that even if she had less conflict with coworkers, she would still be stressed-­ out. After some discussion, you might discover that limiting her acceptance of new work will have the biggest impact; not only will it free up her weekends so she can take care of her relationships and do other rewarding things, but if she is less stressed overall she will be less likely to become upset with her coworkers’ foibles. STEP 2: CLARIFY FUNCTIONS As you zero in on the behaviors that seem to create the problem, you may begin to get a sense of how the behaviors function. Recall from chapter 2 that there are two very general classes of function: • Some behaviors function to move us toward something appetitive. • Some behaviors function to move us away from something aversive. Grasping the function more specifically usually involves digging into—­with more psychologi- cal depth—­the situations in which the problem behavior happens. This often means looking at the client’s experience—­emotions, thoughts, images, sensations, and so forth—­more closely. Consider the following exchange with Susan. Therapist: I’d like us to understand better what was going on for you in that moment when your supervisor asked for volunteers for a project, and out of everyone in the room, you were the one who immediately stepped forward. What was going on inside of you in that moment? Client: What do you mean? I think I just ha ve to say yes. Therapist: I get it. Let’s see if we can put that moment in slow motion. Let me ask a few ques- tions to help focus the lens. First, in the meeting last week, before there was a request for volunteers for the project, what were you feeling as you sat in the meeting? Client: Pretty good. I had just finished a report. Was kind of riding the high from that. Therapist: And what else? Client: Slightly annoyed, because I knew the POS group was going to sit on the report for a week and then make some annoying objections. Therapist: Okay. Hmm. Let me think. If you hadn’t been riding high, would you have been more or less likely to volunteer for the work? Client: Less likely. I would hesitate. That time I just dove right in. Therapist: Right, without connecting that the timelines were really not workable. Okay. So moving forward, one thing we might work on is ensuring there is a “waiting period” before any yes; that way you can check out the plan more carefully. [Here the thera- pist hypothesizes that the appetitive thing Susan moves toward, especially when feeling confident, is contribution. This is only a problem because she does it without regard of the workability of the commitment. In other words, Susan’s initiative does not work well in this context. She might need to learn the skill of the soft commit- ment: “I would be willing to do it, but can I have an hour to just confirm that this will be workable?”] Therapist: Okay, now let’s go back to the POS group. When you say yes, what does it get you with respect to them? Client: Oh, simple. It shows them that I am going to keep moving no matter what. I’m the achiever. I look good. Therapist: Does it say the same thing to your supervisor? Client: Yes. Though…good lord! Who knows if that’s really true. She knows I’m burned-­out as well. Therapist: And…imagine this. If you had slowed down and considered that this timeline was actually not a good fit for you, what would have happened if you didn’t raise your hand to volunteer? Client: Oh. Well, it would have felt uncomfortable. I’d sit there awkwardly waiting… I’d think, “Is anyone else going to step up? What a bunch of slackers.” Therapist: Would you think about what they’re thinking of you? Client: Of course. I always step up, so they’d be thinking, “Where’s Susan?” Therapist: So is it fair to say your impulsive volunteering is partially about an unwillingness to sit in that discomfort and risk your coworkers thinking you’re not showing up? And you are also wanting to show the POS group and the supervisors that you are on the ball, even though you don’t know if that’s really the effect you are having on them? And those little nudges are enough to propel you to unwise yes after unwise yes? Client: Yes, that’s fair. For Susan, in the situation where she impulsively says yes, the therapist has identified a couple of functions of that behavior: She is moving toward the appetitive stimuli of being accomplished at work and looking good to her colleagues and supervisor. She is also moving away from the aversive stimulus of their questioning her willingness. At this point, the three main questions of functional analysis have been addressed: What is the behavior? In what contexts does it or did it occur? What is or was its function in those contexts? And look how far the therapist has come from Susan’s presenting problem of “I feel burned-­out at work.” Again, in terms of general heuristics, you are looking for only a few basic functional patterns: • The client’s behavior functions to avoid something unpleasant (real or imagined). • The client’s behavior functions to approach something appetitive (real or imagined). Your search for function has gone far enough when there is a sense of coherence—­as in yes, that makes sense—­and a sense that there is an adequate explanation of the presenting problem. Let’s look at a couple of more subtle points related to this process of clarifying function. Zeroing In on the Functional Consequence A common pitfall in functional thinking is making the assumption that a seemingly aversive response has the function of punishing a problem behavior, and then being puzzled at why the behavior persists. For example, let’s say a woman gives her husband the cold shoulder and he gets angry and yells at her. Why would she persist then in stonewalling him? Or consider Susan: If saying yes consistently lands her in hot water, why does she persist? The reality is, if the behavior is happening, there is some form of payoff—­either now, in the past, or intermittently. For example, for the woman who is stonewalling, it’s possible that shutting down—­even though her husband yells at her—­feels safer and more powerful than trying to speak when she is upset and hurt. In other words, the consequence of getting yelled at is not the functional consequence—­the consequence that actually influences her. The consequence that influences her is the relative sense of control she gets. For Susan, the situation is similar. The functional consequence is the immediate sense of looking good and not looking bad. The negative consequence of burnout doesn’t actually have enough influence over her in that moment to lead to a different choice. This counterintuitive assessment also applies to seemingly appetitive consequences. “I know I should just fill out my time card, but I just don’t want to do it…so I procrastinate all day.” Some people might think of turning in their work hours as moving toward something appetitive because it leads to being paid; however, let’s look more closely at the actual function of the behavior in this example. It’s possible that avoiding the time card all day allows a continuous escape from the aver- sive experience of facing the fact that hours are short this week, so it will be difficult to pay the bills. Inquiring About Avoidance One important thing to note about avoidance is that sometimes we’ve avoided some situation—­ perhaps a painful experience from the past—­so thoroughly and for so long that it is no longer clear what we are avoiding or whether the thing we fear would actually occur in the present. Susan’s volunteering, for example, helps her avoid the (imaginary) situation in which others think poorly of her. However, by facing that fear, she might discover that in fact nobody judges her when she hangs back. For this reason, it can be useful to put the client in touch with what he or she might contact by no longer avoiding a situation. Try starting the exploration with this question: What would you have to face (or do or feel or respond to) if you didn’t do this behavior? Going into History As suggested in the passage above, to understand why a behavior happens in the present, it’s often useful to get into the history of the behavior. In relation to avoidance, the thing that a behav- ior functions to avoid (for Susan, being judged) might not actually be present in the present. But if we look into the history, we will find it. Therapist: Do you remember experiencing the fear that others would judge you—­that they’ll think you’re not going to show up—­earlier in your life? Client: [pauses] Well… Oh, yeah. I was going to say no, but…that’s the whole story of me and my mom. Especially after her divorce, it felt like she was constantly hounding me to be there. I hated that. What emerges in this conversation is that Susan has a long history of people reacting negatively to her “not showing up”—­that is, their perception of her not being there. She learned that “not showing up” incurs judgment, which is painful to her, and so she works to avoid that aversive situ- ation. However, working to avoid that aversive outcome by constantly showing up is now having a nega- tive effect on her life. What she doesn’t realize is that, in general, others are much less likely to judge her than she fears. Getting clarity about how the past is different from the present can help people become more flexible. Going into the Future Finally, when clarifying the function of a behavior, it can be useful to go into the future. For example, we might balance out the “consequences now matter more than consequences later” problem by getting in closer contact with the future consequences of a problem behavior. With Susan, we might spend some time discussing the likely consequences if she continues to work at her current level of burnout. Therapist: What will happen if you keep living this way—­say, for another twenty years? Client: 48 That’s hard to think about. Who knows what would happen to my health. Could I physically keep going that long? My son…he wouldn’t know me. That’s horrible to think about. Even though examining consequences is often painful, it can help increase the motivation to change the behavior because doing so makes the aversive consequences of maintaining the problem pattern more salient and more painful. The flip side of this pain is to get in contact with what might be gained—­what purpose, what meaning, what goals, what freedom—­if one were to let go of the constricted problem behavior. STEP 3: LOOK FOR FUNCTIONAL CLASSES Once you have collected a set of problem behaviors and identified their functions, you will start to notice basic patterns in the function of the problematic behaviors that are somewhat unique to the individual. For instance, Susan is very sensitive to looking bad to others, and she will work hard to look good even when the costs are high (burnout, conflict, and so on). We can then start looking for other situations in which Susan similarly avoids (something like) “looking bad.” In other words, we now have a hypothesis about how Susan might struggle in other parts of her life. Therapist: Are there other places in your life where you try to avoid looking bad? Does it ever happen with your husband? Client: Yeah. I hate it when he is critical of me. Or sometimes even an innocent question— for some reason I take it as an attack. Then I can be really bitchy with him. We might then ask if she has experienced a related dynamic with friends. Susan discloses that she lost one of her best friends due to complex circumstances: Susan had to cancel attending her wedding, letting her friend down, and since then Susan has been unable to feel connected to her friend due to feelings of deep shame. As different as these behaviors may appear on the surface—­volunteering for more work, speak- ing crossly to her husband, and withdrawing from her friend—­they all have a common function: helping Susan avoid feeling ashamed or deficient or “not looking good.” Behaviors are functionally similar when they serve similar core functions: for instance, avoiding some specific feared outcome or seeking some desired appetitive outcome. In turn, once you can see the common function, there is an opportunity to focus more flexibly on the root problem—­facing shame, in Susan’s case. Sets of behaviors defined by a core common function in this way are known as functional classes. You can look clearly at the cost of the whole class. You can muster reasons to overcome this struggle. And you can look for instances of the functional class occurring in the therapy process. More on this key element of FAP in step 5 below. STEP 4: DEFINE IMPROVEMENTS Up to this point, we’ve focused on problem behaviors. The next step in functional analysis—­and an extremely important one—­is identifying and testing behaviors that will help alleviate a client’s problems. With Susan’s problem of overcommitting by saying yes impulsively, we might improve her skill at saying no, which could help her say no in ways that are more likely to garner people’s understanding and support rather than their judgment. Once you have a hypothesis about which behavior would be more effective at a crucial moment for the client, you can help the client put that behavior in place. Then you can evaluate whether or not the behavior helps. With enough practice, does the behavior help change the whole stream of behavior such that the presenting problem is somewhat ameliorated? STEP 5: NOTICING CLINICALLY RELEVANT BEHAVIOR Now we’ll look at a very important focus of functional thinking in FAP: seeing the client’s problem behaviors (and improvements) when they occur in the session and in the therapy relationship. Noticing clinically relevant behavior in the moment is key in FAP because of the opportunity and the liability described in chapter 1: if we don’t see these behaviors clearly, we risk reinforcing problem behaviors or punishing the tentative steps toward improvement or change. If we see the behaviors clearly and understand what they mean—­that is, how they function for this person—­ then we can make sure we respond therapeutically. What do we mean? Instead of reinforcing problem behavior, we evoke and reinforce needed improvements in a way that is authentic and compassionate. This process is the focus of the remainder of the book. Why is functional thinking useful for this process? For starters, function is not typically visible, so delving deeper into the function of a behavior in order to understand it is very useful. Also, once you can see a client’s behavior in functional terms (as functional classes, for instance), it becomes easier to notice moments in which the behavior arises, even if what happens in session is, on the surface, quite different from what happens outside—­in the client’s life. Here’s an example of functional thinking: Imagine a client tells you—­as one of her presenting problems—­that she’s having trouble initiating sex with her partner. FAP would not call for you to look for situations in which the client might want to initiate sex with you so she can improve her skills in this area. Instead, your functional analysis might lead to the discovery that the behavior of initiating sex is part of a broader functional class of behaviors: this client generally finds it difficult to reach out sensitively but directly to someone else to get her needs met, and one place this deficit shows up is with her partner in the bedroom. If the client buys that this is a valuable area to work on, you can attend to situations in the therapy relationship that invoke this behavior, from mundane situations, such as needing to reschedule a session, to those that make the client feel more vulnerable. For example, perhaps she finds herself wondering one day if you really care about her, and she wishes to appropriately seek reassurance about that. Here’s another example: Susan is critical and defensive with her husband, overly compliant with her supervisors at work, and overly polite and nondemanding in session with you—­even though she occasionally appears irritated by something you’ve done. All of these behavioral exam- ples are instances of a general functional class of behaviors that function to avoid the vulnerability she feels when she is assertive about her needs. The common structure in all of these examples is that the problem behaviors both inside and outside of the therapy relationship are part of the same functional class. Being able to see the func- tion parallels between in-­session and out-­of-­session events helps build a momentum and coherence in the effort to change behavior—­“In here we’re going to work on the same things you’re working on in your life.” CRBS: CLINICALLY RELEVANT BEHAVIORS In FAP, we refer to behaviors that show up in the therapy room that are related to the client’s clini- cal problems as clinically relevant behaviors (CRBs). CRBs are divided into two categories: an example of problematic behavior is referred to as CRB1, and an example of improvement relative to this behavior is referred to as CRB2. With clients, we commonly drop the CRB prefix and just use the generic abbreviations “1” and “2” to refer to problems and improvements. These abbreviations become useful shorthand language, as in, “Did you just do a 1?” “Was that a 1 or a 2?” And so forth. A major strength of this terminology is its simplicity. Asking “Is this a 1 or a 2?” focuses the conversation on functional analysis. The question is easy to remember in the moment during therapy, yet it encapsulates a great deal. It represents the ongoing focus on the process of assess- ment and brings that focus to bear on the present moment. This CRB terminology allows us to state the aims of FAP quite simply. Clinically, we seek to reduce the frequency of CRB1 and increase the frequency of CRB2. Using functional analysis to define CRB1 and CRB2 is, therefore, the key aim of the functional analytic process in FAP. The terminology is also the foundation for case conceptualization in FAP. Key Features of CRB1 and CRB2

1. CRB1 and CRB2 are only CRBs because they are functionally related to the client’s presenting problems.
2. CRB1s and CRB2s should always be behaviors that clients have some control over and therefore can work on changing with deliberate effort. For instance, fear may be a prob- lematic response to showing vulnerability, but it’s hard to choose to change fear. A better focus—­one in which the client would have more choice—­might be the behav- iors the client engages in when afraid. For example, the CRB1 might be to hold back and avoid disclosing something to someone who is in fact trustworthy, and the CRB2 might be to disclose despite the fear.
3. Label CRB1 and CRB2 in ways that are empathic, validating, and motivating. Use the client’s own language when possible. Steer away from terminology that’s overly clinical or judgmental. It’s fine to use metaphors to describe functional classes of CRB. For instance, the behavior of avoiding self-­disclosure could quite reasonably be called “keeping your guard up” or “having your wall up,” and the behavior of disclosing too much too soon might be called “spilling.” Ensure sufficient precision by checking that you and your client are on the same page regarding how you use these terms.
4. Remember that CRB1 isn’t inherently bad, and CRB2 isn’t inherently good. In fact, it’s often important to relate to CRB1 with as much acceptance and compassion as you would to CRB2. Discriminating CRB1 and CRB2 In this section we offer some practice in thinking functionally—­specifically in discriminating 1s and 2s. Here’s a warm-­up. Imagine a client asks you to call her physician to request a prescription refill. What’s the function of this behavior for the client? If you’re like about 50 percent of people we’ve asked during trainings over the past couple of decades, you have an immediate sense that the behavior is problematic. Perhaps you think the client seems overly demanding or dependent, which is definitely a possible assessment. The client may have a habit of making excessive, unreasonable demands. In contrast, the client may also have a very good reason for asking you. Perhaps she is working hard to be more assertive because failing to do so in the past has caused her a lot of problems. Notice that the implications of these different functional interpretations of the request would steer your response in different directions. If the request is an example of CRB1, you might decline the request and ask the client to make the phone call herself. If it’s an example of CRB2, you might agree to make the call, perhaps also expressing that it’s not typical for you to agree to such requests, but in this situation you see how it could really help. EXERCISE: EXPLORING POTENTIAL FUNCTIONS OF CRB Read each scenario below, and then, on a separate piece of paper, write your ideas about what the functions of the behavior might be and whether the behavior is likely to be CRB1 or CRB2. Given the scant context we’re providing, there will be several functional possibilities in each case. The challenge is to write a few different interpretations for each scenario, including at least one in which the behavior is CRB1 and another in which it’s CRB2. Go through all four scenarios in this way before reading our sample interpretations. •Scenario 1: A client arrives for his session. When you ask him what he’d like to focus on in this session, he says, “I don’t know.” •Scenario 2: You greet a client in the waiting room and mistakenly call her by the wrong name. She appears irritated for a brief moment and is silent as you enter your office. •Scenario 3: At the end of a session, a client says, “I’ve been meaning to ask you something. I think you’re a pretty cool person. I wonder, when therapy is over, is there any chance you’d like to get a beer sometime?” •Scenario 4: You’re helping a client cope better with memories of trauma. One day in session she says, “Is it okay if we talk about something else today? There’s something I’d kind of like to talk about.” Here are our sample functional interpretations for these scenarios. As always, such interpretations are only hypotheses to be evaluated through assessment with a given client. • Scenario 1: A client arrives for his session. When you ask him what he’d like to focus on in this session, he says, “I don’t know.” Possible interpretation 1: This is CRB1 for the client. His avoidance of identifying and express- ing his needs leads to problems in many areas of his life. Possible interpretation 2: This is CRB2 for the client. He tends to excessively control himself, is perfectionistic, and avoids asking for help when he doesn’t know what to do. Saying “I don’t know” represents a step toward identifying a situation in which he needs help and engaging in a meaningful dialogue about that situation with the therapist. • Scenario 2: You greet a client in the waiting room and mistakenly call her by the wrong name. She appears irritated for a brief moment and is silent as you enter your office. Possible interpretation 1: This is CRB1. The client avoids expressing her irritation or disap- pointment with others and tends to gradually disconnect from them as her resentment grows. Possible interpretation 2: This is CRB2. The client usually overreacts to minor slights, which causes difficulties in her relationships. In this instance she’s been successful in not overreacting. • Scenario 3: At the end of a session, a client says, “I’ve been meaning to ask you something. I think you’re a pretty cool person. I wonder, when therapy is over, is there any chance you’d like to get a beer sometime?” Possible interpretation 1: This is CRB1. The client tends to be oblivious to social limits (such as the difference between a therapeutic relationship and a friendship), and this insensitivity creates conflict and suffering for him. Possible interpretation 2: This is CRB2. The client pervasively avoids asking for what he wants, and he’s working on being more assertive, regardless of the possibility of being declined or rejected. • Scenario 4: You’re helping a client cope better with memories of trauma. One day in session, she says, “Is it okay if we talk about something else today? There’s something I’d kind of like to talk about.” Possible interpretation 1: This is CRB1. The client consistently tries to avoid her trauma memories and primarily uses distraction to cope with those memories and the emotions they bring up. Possible interpretation 2: This is CRB2. The client tends to be so preoccupied with her trauma that she neglects other important aspects of her life. The Functional Idiographic Assessment Template When starting functional analysis with a client, you can begin with a blank slate, creating a way of talking about the client’s problems that is completely tailored to her. That said, sometimes it’s helpful to review existing lists of common CRBs or, more broadly, functional classes of interper- sonal behavior relevant to FAP with your client. Rather than making a description from scratch, these lists provide language you and the client can choose from to describe what might be happening. Glenn Callaghan (2006) developed the functional idiographic assessment template (FIAT), a tool for identifying functional classes of behavior when performing FAP. Callaghan analyzed the typical FAP treatment targets among his own clients and his students’ clients and came up with a set of five key functional classes of interpersonal behavior. He organized these functional classes into a questionnaire with numerous specific behaviors set forth for each class. You may find the full FIAT useful in identifying CRB1s and CRB2s, especially as you’re getting familiar with the FAP approach. It can be found at http://www.functionalanalyticpsychotherapy.com/fiat.pdf. For the purposes of this chapter, we’ve streamlined the items on the FIAT, presenting them as descriptions rather than questions. Keeping in mind the five classes of behavior can help you be alert to specific in-­session behaviors that may indicate a possible CRB1. The worksheet only lists CRB1s, but deriving corresponding CRB2s is straightforward. And doing so can stimulate your thinking when you work on case conceptualization. You may also find it useful to show the form to clients and to work together collaboratively to identify the behaviors that are relevant for the client. Read through the following descriptions of various types of CRB1 and check off any that arise frequently, either in session or outside of session. Take special note of any categories for which many items are checked. They could represent classes of behavior that are particularly problematic or where improvements would be most useful. CLASS A—­ASSERTION OF NEEDS (IDENTIFICATION AND EXPRESSION) Class A behaviors include anything people want or value or “need,” including the need to state opinions, ideas, convictions, passions, longings, desires, dreams, and—­basically—­who they are. “Assertion of needs” also includes making requests for social support or other needs that are more practical. Possible Class A CRB1s    Difficulty identifying needs or the type of help or support wished for from the therapist or others    Difficulty expressing needs    Difficulty getting needs met by the therapist or others    Expressing needs too subtly or indirectly    Pushing the therapist or others away with neediness    Giving much more than is received in return    Being extremely independent and feeling too vulnerable when receiving help    Being too demanding when asking for needs to be met    Being unable to tolerate the therapist or others saying no to requests    Other: CLASS B—­BIDIRECTIONAL COMMUNICATION (IMPACTS AND FEEDBACK) Class B behaviors involve how people affect others and how they give and respond to feedback. The term “feedback” refers to how others respond and react to the person’s behavior. Feedback can be verbal or nonverbal and in the form of facial expressions, body language, and so on. Possible Class B CRB1s    Difficulty receiving positive feedback, such as appreciation or compliments    Difficulty receiving negative feedback, such as criticism    Difficulty giving positive feedback    Difficulty giving negative feedback, including constructive criticism    Having unreasonable self-­expectations, which may show up as perfectionism or a pervasive sense of failure    Having unreasonable expectations of the therapist or others    Being hypersensitive to or overly aware of his or her impact on the therapist or others    Not having much awareness of his or her impact on the therapist or others    Inaccurately assessing his or her impact on the therapist or others    Being hard to track or follow in conversation    Talking too much or for too long without checking impact    Making too much eye contact    Making too little eye contact    Other: CLASS C—­CONFLICT Aggressive or hostile class C behavior is just one of many potentially problematic behaviors that can come up with conflict. Unworkable responses to disagreement or uncomfortable interac- tions can also include many behaviors that are more passive or avoidant. Possible Class C CRB1s    Difficulty tolerating conflict or disagreement    Difficulty expressing negative feelings    Avoiding conflict    Expressing anger indirectly, such as by being passive-­aggressive    Expressing too much anger    Not being willing to compromise    Being ineffective at resolving conflict    Apologizing too much    Assuming everything is his or her fault    Blaming the therapist or others for problems    Creating unnecessary conflict    Using conflict as way to avoid closeness    Being unwilling to forgive the therapist or others    Other: CLASS D—­DISCLOSURE AND INTERPERSONAL CLOSENESS Class D behaviors relate to “interpersonal closeness,” which refers to behaviors that lead to feeling connected to or close with another person. Possible Class D CRB1s    Difficulty conversing    Difficulty expressing closeness and caring    Difficulty receiving closeness and caring    Being fearful of closeness or attachment    Being reluctant to take emotional risks    Being reluctant to self-­disclose    Being reluctant to let his or her true self be seen or heard    Downplaying the importance of what he or she shares    Talking about himself or herself too much    Not listening well    Being self-­absorbed or asking for too much support    Being secretive    Being too intrusive when asking about the personal experiences of the therapist or others    Not being aware of the needs of the therapist or others (for example, going overtime in session or not giving the therapist openings to talk)    Talking too much and too tangentially    Not trusting others    Trusting others too easily or too soon    Other: CLASS E—­EMOTIONAL EXPERIENCE AND EXPRESSION Class E behaviors, related to emotional experience and expression, refer to all types of emo- tions, from sadness and anxiety to love and pride. Possible Class E CRB1s    Difficulty identifying emotions    Being unaware of emotions as they’re happening    Intentionally hiding emotions    Being flat or distant in emotional expression    Difficulty with crying    Difficulty feeling or expressing sorrow, sadness, or grief    Difficulty feeling or expressing anxiety or fear    Difficulty feeling or expressing joy    Difficulty feeling or expressing pride    Difficulty feeling or expressing humor    Engaging in negative self-­talk when feeling emotions    Expressing emotions in an overly intense manner    Unable to control his or her expression of emotions    Talking about emotions too much    Having overly labile or intense emotions    Unable to have perspective on his or her emotions; feeling overwhelmed by emotions and unable to detach from them    Expressing emotions in a way that annoys or alienates the therapist or others    Avoiding or suppressing certain emotions    Other: Flexibility: A 1 or a 2? As you think about the preceding examples or reflect on your own clients or yourself, you might notice something important: sometimes it isn’t at all clear whether a particular behavior is CRB1 or CRB2. In fact, a particular behavior may seem to include both problematic aspects and improvement. Let’s return to the example of the client who asks you to call her physician for a prescription refill. The request itself might in some ways be CRB2: it represents assertiveness, and the client’s life will be better if she’s more assertive. At the same time, the particular way in which she’s assertive (perhaps she doesn’t validate enough or her tone of voice is too harsh) causes her some trouble, so there’s an element of CRB1, as well. How does FAP deal with such situations? Although it can be useful to cleanly discriminate between CRB1 and CRB2, doing so shouldn’t be forced. Multiple functions, including problematic behavior and improvement, can and often do mingle in the same behavior. Recognizing that multiple functions are present allows us to move beyond the simpler question of whether a given behavior is CRB1 or CRB2 and instead ask, “How is this behavior an improvement, and how is it a problem?” From there we can nurture the threads of CRB2 and weed out the threads of CRB1, or we can shape CRB1 into more effective behavior. The ACT Matrix: A Very Useful Tool Another invaluable tool for functional thinking and discriminating 1s and 2s is the ACT matrix (Polk & Schoendorff, 2014; Polk, Schoendorff, Webster, & Olaz, 2016). We highly recommend The Essential Guide to the ACT Matrix, which discusses the use of the matrix tool in the context of ACT and FAP-­based treatment. Seriously, it is hard to overstate how useful the matrix is as a clinical tool! Clinically Relevant Therapist Behavior So far we’ve focused on client behaviors. But, as we stated in the introduction of this book, your behaviors as the therapist are an equally important part of the process of therapy. Anything and everything you do in therapy has a function for you and will have a function for your clients: your behavior will affect the clients in some way, and the effects can either support the therapeutic process or interfere with it. As part of your functional analysis of the in-­session process and the therapy relationship, therefore, FAP asks you to pay attention to your own behaviors as well as those of clients. More broadly, we invite you to develop a broader awareness of your patterns of behavior across cases: How do you tend to get into trouble or undermine progress as a therapist? When are you at your best? A therapist’s personal history and personal relationships are often involved in these patterns. We’ll address this topic of “personal” more directly in chapter 6. For example, with Susan you might grow impatient with her confusion about identifying her own needs more clearly or her anxiety about reducing behaviors that are clearly (to you) self-­ defeating, and your impatience might lead you to focus excessively on behavior change rather than building motivation, clarifying purpose, or finding emotional acceptance. You might see this pattern of impatience about behavior change show up commonly with anxious, highly controlled clients. Paralleling the terminology for client behaviors, therapist behaviors that interfere with the therapy process are known as T1s, and those that support therapy process are T2s. Like CRBs, T1s and T2s are defined based on how they function for you and your clients in therapy: Do they serve to facilitate or detract from therapy progress? You may, of course, have different T1s and T2s with different clients. Here are some examples: Examples of T1 • Being too controlling or directive • Avoiding clients’ expressions of emotion • Focusing excessively on problem solving (as opposed to validation, acceptance, and present-­moment experience) • Allowing clients to direct the focus of sessions in ineffective ways • Failing to define case conceptualizations or homework activities precisely enough Examples of T2 • Allowing clients to collaborate in planning sessions • Allowing or inviting clients’ expressions of emotion • Providing validation, expressing acceptance, and attending to present-­ moment experience • Directing the focus of the session effectively • Focusing attention on the problem solving needed to define precise treatment plans or homework assignments STEP 6: THE PROCESS OF FUNCTIONAL ANALYSIS—­ HYPOTHESIS TESTING Finally, let’s return to the notion of functional thinking—­or functional analysis—­as a process. We labeled this section “step 6,” but it’s not really a discrete step. If it were a step, it would be looping back through all the previous steps as you learn more about the client and what works in therapy to help him move forward. In other words: functional thinking is an iterative, hypothesis-­testing process. It is a process of questioning, investigating, testing, revising, and clarifying. The most important—­possibly the only—­criterion by which a functional analysis is judged is this: Has this analysis helped us achieve the desired therapy outcomes? If not, no matter how coherent or elegant or right the analysis feels to you, it must be revised or discarded. A spirit of hypothesis testing and iteration is important, as well, because the phenomenon we are seeking to understand is inherently complex. We have to puzzle our way through it. To illus- trate, we’ll explore the example of the client who asks you to call her physician for a prescription refill. If you follow our guidelines in this chapter, your first step would probably be to consider the client’s stated clinical goals. Let’s say she has ongoing difficulty expressing her needs. Perhaps she has an overbearing husband and an extremely demanding boss, and she’s mostly focused on being obedient and staying quiet, at the cost of feeling disconnected and miserable. In this context, you might notice that asserting her needs in this way is something new, even if it seems clumsy. Therefore, it would be extremely important to recognize this in your response. If you continue to explore, however, you might discover other aspects of the behavior or context that might temper your response. For example, perhaps when she does, on rare occasion, assert her needs, she tends to make rather rigid and inconvenient requests, alienating others or leaving them unhappy with her. As a result, they typically refuse her requests or comply only begrudgingly. Ultimately, she walks away from these interactions thinking that requesting things of people doesn’t work very well. And because she’s blind to the way her requests come across as rigid and inconsiderate, she’s decided that it’s only worthwhile to inconvenience others if a request is extremely important. How might these considerations shape how you respond to her? Now we’ll make this situation even more realistic—­and realistically complex. Imagine that the client makes her request at a time when you’re feeling especially harried in life. Perhaps the session is already running overtime. Maybe you’re thinking about your next client, who’s one of the most challenging clients you’ve ever had. Perhaps you’re experiencing health problems or feel you don’t have enough time for yourself. For whatever reason, when you hear this request to do yet another thing, you immediately feel tension in your body. How would all of this impact how you respond to her? Now imagine that this client is very attuned to your emotional response. She accurately per- ceives your response as stress or irritation, and she interprets your response to mean “My therapist is angry at me and I made a mistake.” If you’re attuned to her as well and sense this reaction—­and how it fits in with her presenting problem—­how would those aspects of context shape your response? In contrast, if she doesn’t tune in to your emotional response to her request, how would this shape your response? Ideally, your functional thinking becomes responsive to all aspects of context. After all, these kinds of complex, evolving contexts are the arena in which clients’ behaviors are functioning and in which they must find their way. Finally, thinking functionally is a process because behavior is a complex system. As we help clients change one aspect of their behavior, often new challenges emerge, and thus new assessment—­ new analysis—­is needed. The client who stops drinking alcohol, for instance, now has to deal with lots of difficult emotions. Once Susan has learned to be more assertive, she now has to contend with her dissatisfaction with her job and her husband. Functional thinking is an adaptive process that serves the process of therapy. A Basic Functional Analysis “Script” Functional analysis can take a variety of forms. It can happen in a more structured assessment, or it can happen more casually, spread out over many sessions. It can be incredibly technical and detailed, or it can be quite loose and seemingly conversational. Over the years we have found that a few core common questions define many functional analy- sis conversations, and these questions can often be organized into a kind of natural flow. Here is a version of that flow. To build your skill with functional thinking, you might practice this flow with a partner. Ask your partner to pick a real-­life problem situation, and then ask the following questions. Listen sup- portively to the answers. Don’t attempt to problem solve. Follow the flow of questions. Feel free to modify the questions slightly to fit the conversation you are having, but don’t deviate too much. Trust the questions. Observe the results. What is the problem situation that you want to talk about? What happens in that situation? What do you do? What does the other person do? Describe the interaction. What is the key thing you do in that situation that contributes to the problem? Be specific. Does that behavior ever show up in other situations in your life? Does that behavior ever show up between you and me? What is the immediate payoff for you doing that behavior? What do you “get”? What is the cost of that behavior in the short term? What will happen if this behavior continues long term? If you didn’t do that behavior, what would happen? What would be difficult? What would you have to face or feel or accept? For what purpose would you be willing to feel or face or accept that? Considering all of this, what is the key thing for you to work on? Once you have completed the flow, see if you can step back and summarize what you learned about the situation, the behavior, how the other person is stuck, and what that person needs to do to move forward. Ask for feedback about whether your summary is on track and whether the other person feels understood by you. Finally, exchange feedback about the process. For example: Which questions were especially useful? Which questions were less useful? Which questions were you uncomfortable asking but actually proved insightful? What insights were discovered? SUMMARY • Functional analysis is the central assessment method of FAP, standing upon the founda- tion of the CBS perspective. • Functional analysis is a complex method. Expertise is built, in part, on pattern recogni- tion and lots of experience. Start to master functional analysis by practicing functional thinking, which is centered on this question: “What is the function of this behavior?” • Functional analysis involves a few basic steps: • Orient to the behaviors involved in the presenting problems. • Assess function. • Notice functional classes (sets of behavior defined by a common core function). • Define improvements. • FAP adds a unique step to functional analysis: to notice how the problem behavior may show up in the therapy relationship. A CRB1 is an example of a client behavior related to problems occurring in the therapy session. A CRB2 is an example of an improvement occurring here and now. One aim of FAP therapy is to increase the frequency of CRB2 and decrease the frequency of CRB1. • Iterate the above process as needed until positive therapy results are achieved.