2 CEUs Setting Clear and Ethical Boundaries
Psychologist CEUs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Section 7
Selected Readings Bibliography/Authors/Instructors

Ethics CEU Test | Table of Contents

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Vandenberghe, Luc. "Keeping the focus on clinically relevant behavior: supervision for functional analytic psychotherapy." The International Journal of Behavioral Consultation and Therapy 5.2 (2009): 209+. Academic OneFile. Web. 29 Mar. 2010.

Functional Analytic Psychotherapy (FAP) is an experiential interpersonal treatment belonging to the third wave in behavior therapy. It is compatible with state-of-the-art cognitive behavioral approaches. It is different, however, in that cognition is understood in terms of verbal behavior. In addition, the influence of beliefs on other behavior is analyzed in terms of rule -following and as depending on the effect of real-life contingencies (Kohlenberg & Tsai, 1994). The translation of cognitive therapy strategies into a behavioral framework is not typical of FAP. It has, been a theme in a broader section of the third wave movement from its beginnings (e.g. Zettle & Hayes, 1982).

The hallmark of FAP, however, is its emphasis on clients' direct learning through experiencing their problems in-session, as opposed to learning about their problems. In order to appreciate this point, we may remember that cognitive behavior therapy concentrates on discussing actions, feelings and thoughts that arise in the client's daily-life settings. The main target for change is what the client believes and thinks while he or she is experiencing problems outside the therapy session. In contrast, the FAP therapist works directly on client behavior while it is affecting the therapist-client relationship. And only when therapeutic change is noticeable within the boundaries of the relationship will the therapist monitor and (when necessary) promote generalization of in-session improvement to daily-life settings.

The whole process rests upon the idea that the therapist-client relationship offers the therapist an opportunity to observe the client's clinically relevant patterns firsthand and to respond to them in ways that promote change. For instance, a client whose romantic life has been on hold for years because she only feels attracted to inaccessible men may develop a crush on her therapist. In order to be able to work on this, the therapist must quickly become aware that what is happening in the relationship is a sample of the client's daily life problem. The therapist will also need to identify exactly what the client does that contributes to the problem pattern, both in her daily life environment and in-session. In this way, those client behaviors through which the client unwittingly brings her problem directly into the relationship with the therapist are identified. It is also possible to determine what clinical improvement would look like if it were to happen in-session. The therapist needs to have a clear view on what such improvement may look like, because he or she will need to respond to that improvement when it happens. For instance, if the client were to label her positive feelings towards the therapist in a better way and relate to the therapist in ways that helped the therapist help her professionally, such in-session improvements would need to be reinforced.

Once therapist and client have agreed on what the target behaviors will be, the therapist will allow his or her reactions, which are the natural consequences of the client's actions, to affect the target behavior in-session. Sometimes the problem pattern will need to be evoked intentionally in order to give the client the opportunity to deal with it. The therapist may, for instance, appropriately express his or her positive non-romantic feelings toward the client so that she can react to them emotionally. The central process in FAP is to gradually shape improvement by patiently reinforcing progressive changes in the right direction.

Therefore, the biggest challenge for the therapist is to identify initial shifts toward improvement in client behavior. By missing slight in-vivo improvements or mislabeling them as problem behavior, the therapist may be responsible for stalling therapeutic change. In our example, a distracted therapist may react aloofly to an appropriate approach behavior by the client. The therapist may thus miss the opportunity to reinforce the client's first move toward relating in more productive ways to him or her. A complementary error may be committed. The therapist who does not identify the client's languishing approach behavior as related to her daily life problem may unwittingly reinforce it.

For thorough explanations of how to identify and classify in-session client behavior as being clinically relevant, the reader should consult Kohlenberg and Tsai (1991) and Kanter et al. (2008). For the purposes of the present article, however, it is sufficient to distinguish two kinds of Clinically Relevant Behavior (CRB): in-vivo occurrences of client behavior that is part of the client's problem and in-vivo improvements. As the examples of possible therapist errors given above make clear, it is crucial to immediately identify both types of CRB in order to make contingent responding possible. And the task of improving the therapist's focus on CRBs makes supervision of FAP therapists different in some fundamental ways. We could say that Rose's (1977) definition of supervision as assisting professionals in improving their therapeutic skills and helping them resolve problems they may be experiencing with their clients still applies. But the concepts of problems with clients and therapeutic skills take on new meanings.

In traditional cognitive behavior therapy, problems with clients are most often seen as a hindrance to treatment progress. They are to be avoided or otherwise dealt with quickly so they do not take away time from work on daily life issues. For this purpose, the therapist needs to learn to get problems out of the way as smoothly as possible. On special occasions, problems with clients are focused on differently, namely as special therapeutic opportunities. This is more likely to happen when working with personality disorders (e.g. Beck, Freeman, Davis & Associates 1990) or when a rupture of the alliance occurs (e.g. Safran & Muran, 2000). In FAP, however, work on problems between client and therapist is at all times the very fabric of the treatment process. It is therefore a fundamental rule of FAP to seek out, and when useful, intentionally evoke problems in the relationship that may be worked through for the client's benefit. In our example above, the therapist did not maintain a safe emotional distance from the client in order to keep her difficulties in dealing with romantically inaccessible persons from threatening the collaborative relationship. Instead, the therapist made the relationship closer, expressing positive feelings towards the client and thus evoking the client's difficulties.

The concept of therapeutic skill is also approached differently in FAP. Like the mainstream behavior therapist, the FAP therapist still needs conceptual skills to define classes of responses involved in the client's problems and to specify target behaviors and related contingencies. But when it comes to the treatment process, other skills are involved. As may be surmised from the example above, the therapist needs to respond continuously to the effects client problems and target behaviors have on him or her as a person. These skills include being watchful for, expressing and evoking emotions (V. Follette & Batten, 2000), dealing with emotions, interpersonal closeness and conflict, bi-directional communication (giving and receiving feedback), and discriminating and expressing what the therapist needs from the client in the relationship (Callaghan, 2006,a). Although intended for in-session CRB work, all of these skills are also related to core interpersonal abilities. Improving those skills may change the therapist's interpersonal style in fundamental ways.

All this brings out a parallel between personal growth and professional progress as a therapist. Consider a remark that may sound familiar to many supervisors: "When I compare myself today to that shallow, quiet girl I was only one year ago, I seem to be a completely different person now. And I attribute the change to this supervision experience." Another supervisee confessed: "I only understood what made me hide from my clients, or exactly why I did that, when I was able to share what I felt in this supervision group. It hurt, it hurt badly, but I became a better therapist because of it." Now compare these two statements to what clients often say at the end of therapy and you may find a clear resemblance.

School-based approaches to supervision serve as illustrations of how close supervision can come to treatment. Back when behavior therapy was still young, Rose (1977) described the use of behavioral group therapy as a supervision method. Supervision was also been described as a kind of treatment for the therapist in Rational Emotive Behavior Therapy (Woods & Ellis, 1996) and Dialectical Behavior Therapy (Fruzzetti, Waltz & Linehan, 1997). This is of course only metaphorically true, as the treatment does not concern the therapist's personal problems per se, but only his or her functioning as a professional. However, our point is that different schools of therapy use their treatment principles in supervision. This is not surprising at all, since these principles embody each school's understanding of the mechanisms of personal improvement.

When a treatment model specifies contingent reinforcement as the critical process for behavioral change, this is also reflected in the supervision strategies developed from this model. W. Follette and Callaghan (1995) described a procedure in which the behavior of the FAP therapist is shaped in-vivo during sessions with the client through direct contingent feedback provided by the observing supervisor. However, the parallel between FAP and this strategy of supervision is only partial. The FAP therapist does not shape the client's behavior in daily life settings, but rather responds to it when it occurs within the boundaries of the session. Still, a supervisor can use contingent reinforcement to influence the supervisee's behavior during supervision sessions in ways that will improve the latter's performance as a therapist. This insight has allowed a school-based conception of FAP supervision to evolve (Callaghan, 2006a; Tsai et al., 2008). The relevant literature will be discussed below under the heading Comparing the model to the state of the art.

The present article attempts to expand on existing school-based supervision practice within FAP. Criteria will be proposed for deciding when FAP-style contingent responding is a desirable supervision strategy and when other principles of change may be preferable. The proposed model distinguishes three different functions of supervision (Vandenberghe, 1997). Each of these functions should prompt a different choice of supervision strategies. The model evolved during an effort to introduce FAP in an undergraduate training program. Admittedly, it may be more advisable to teach FAP to seasoned therapists who have had extensive exposure to the therapist-client relationship and its vicissitudes. In the latter case, one can take advantage of sophisticated interpersonal repertoires and clinical wisdom shaped by years of in-session experience. These can provide skills and sensibilities that may need to be rearranged but can still serve as building blocks for learning FAP. As a result, training seasoned therapists may not give a clear picture of how much is involved in learning to identify, evoke and respond to in-session client behavior. In contrast, working with fledgling therapists made it clear how complex a task this can be. It is not the intention of the pr