Functional Analytic Psychotherapy Basic Principles. Clinically Relevant Behavior (CRB)

Transcription

1 Functional Analytic Psychotherapy Basic Principles Clinically Relevant Behavior (CRB) CRB1: In-session instances of daily-life problems CRB2: In-session instances of daily-life improvements CRB3: Client statements of functional relationships Mechanism of Change Therapist contingent responding to decrease CRB1s and increase CRB2s Rules Rule 1: Watch for CRBs Rule 2: Evoke CRBs Rule 3: Naturally Reinforce CRB2s Rule 4: Notice Your Effect on Your Client Rule 5: Provide Statements of Functional Relationships Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, 1

2 PROVIDING A FAP RATIONALE Focusing on the Here and Now: The most powerful kind of interaction is based on the present, when something you say affects me, or something I say affects you. Therapy has more impact when you talk about your experience in the present moment, like feelings of being depressed and anxious, or thoughts of being unsure of yourself that are happening in the session rather than just reporting about those feelings during the week. When we look at something that is happening right now, we can experience and understand it more fully and therapeutic change is stronger and more immediate. Focusing on the Therapeutic Relationship as a Way to Learn New Patterns: The therapy relationship provides opportunities to learn how to express yourself fully and create better relationships. It will be helpful for us to focus on our interaction if you have issues or difficulties that come up with me which also come up with other people in your life (such as co-workers, acquaintances, supervisors, friends, partner or spouse). When one expresses one s thoughts, feelings, and desires in an authentic, caring and assertive way, one is less likely to be depressed. Specific Example: Sometimes the things you are depressed about, and your depression itself, will show up in our sessions. For example, I know you feel hopeless about your relationship with your wife, and in turn there may be times when you feel hopeless in here, with me, about our work. That is o.k. if that happens. In fact, when things like that happen, when your depression shows up in here, it will be very important for us to take notice. That is because when things happen live between us, they are special opportunities for us to do real work and to really help you understand and change what is happening to you, as it is happening. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 2

3 LEARNING TO FAP QUESTIONS FOR THERAPISTS Some of the questions below are of a personal nature. You will be asked to share your answers in this group only to the degree you feel comfortable. 1. Please make an outline or a time chart for a few main events, enduring circumstances, highlights, turning points, and relationships that have shaped who you are as a person, from your birth to the present time. 2. In what ways has your behavior been shaped by the events, etc. above that you have outlined? Consider only large operants such as optimism and pessimism, self confidence, self-esteem, tolerance and patience, ability to tolerate someone else s pain, ability to be intimate, and the types of people you can be intimate with? 3. How do you think the ways you ve been punished has shaped who you are (your behavior) as a therapist, both positively and negatively? 4. In general, what do you think your strengths and weaknesses are as a therapist? 5. What concerns and apprehensions do you have about using FAP? Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 3

4 TYPICAL FAP QUESTIONS TO EVOKE AND UNDERSTAND CRBS FAP questions bring the client s attention to what s/he is thinking, feeling and doing (1) at the moment and (2) about the therapy, therapist, or therapeutic relationship. 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? To the rationale I just gave? To me as your therapist? To the fact that I m still in training? To agenda setting? To structured therapy? To the homework assignment? What were you thinking or feeling on your way to therapy today? What were you thinking or feeling while you were waiting for me out in the waiting room? What are your hopes, concerns, and fears as you start this therapy relationship with me? What are your behaviors that tend to bring closeness in your relationships? What do you tend to do that decreases closeness in your relationships? How would you feel about us watching for your behaviors in here which increase or decrease closeness? What were your reactions to our last session? What stood out to you regarding our last session? What stands out to you about today s session? What are your feelings or reactions to our session today? What s hard for you to say to me? How are you feeling about our therapy relationship? What s good about it? What needs to be improved? What do you wish I would have done or done differently? What do you think I m thinking about you/what you did/what you just said? How do you feel about your progress? What do you think I m feeling about your progress? Are your reactions to me similar to your reactions to? Is that how you feel about me, too? Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 4

5 BEGINNING THERAPY QUESTIONS 1 1. In general, when I begin a new relationship or activity, I jump in quickly, ignoring any reservations I have. move cautiously, taking time before I expose myself. trust slowly before I make any commitment. try hard to make a good impression. feel shy and keep to myself until I feel comfortable. am very quick to be critical of what s going on. become very involved and stay that way. am concerned that I might get trapped. start out with high hopes and then get disappointed. am different depending on the situation. other, describe: 2. I note these similarities and differences between my usual style of beginning and how I am beginning this relationship: 3. I will increase the likelihood of having a good experience and getting what I want from therapy if: 4. What I like about therapy so far is: 5. Therapy would work better for me if: 6. Other information that will be helpful in working with me that is important for my therapist to know is: 7. Any other feedback thoughts, feelings, or requests? 1 Beginning and mid-therapy questions adapted from Making Therapy Work by Bruckner-Gordon et al. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 5

6 MID-THERAPY QUESTIONS 1. I am pleased about my progress in: 2. I wish I had made more progress in: 3. I m having a hard time expressing myself about: 4. I want you to know: 5. It would be difficult for me to face: 6. I am interested in changing my therapy to include: 7. I could improve our relationship by: 8. You could improve our relationship by: 9. It is hard for me to tell you about: 10. What bothers me about you is: 11. You are a lot like: 12. My reactions to you remind me of: 13. As I think about my sessions, I would like: 14. I wish my therapy would be: 15. We need to continue talking about: 16. I am finding it hard to accept: 17. I recognize that I am changing because: 18. It is getting easier for me to: 19. I no longer feel: 20. I saw things in a new way when: 21. It was a powerful experience when: 22. For the first time I: 23. It seemed you were insensitive to me when: 24. I felt hurt or angry when you: 25. It is difficult for me to manage my feelings during therapy sessions when: 26. It has been hard to cope with my feelings in between sessions when: 27. It has been painful for me to discover: 28. I had a dramatic, intense, or seemingly inappropriate reaction to you when: 29. I feel closest to you when: 30. I m most likely to push you away when: 31. Now that I m in the middle of therapy, I: 32. This is different from/similar to what usually happens when I am involved in the middle of an activity or relationship because: 33. Your policies are hard for me when: 34. When the therapy session ends, I often: 35. The beginning of a session is hard for me when: 36. I wish you would: 37. I am glad that you: Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 6

7 END OF THERAPY FAP QUESTIONS FOR CLIENTS TO CONSIDER 1. For many clients, the end of therapy brings up feelings and memories of previous transitions and losses. What thoughts and feelings do endings in general bring up for you? What thoughts and feelings are you having about the ending of this therapy relationship? 2. What have you learned? What has been helpful for you in this therapy? 3. What are you aware of about yourself that you weren t aware of before? 4. What are the skills you ve learned that you want to keep implementing in your life? 5. What stands out to you most about your interactions with your therapist? 6. What do you like and appreciate about your therapist? 7. What regrets do you have about the therapy or what would you like to have gone differently? 8. What situations, thoughts or behaviors make you vulnerable to (insert disorder/ presenting problem here), and how can you deal with them to decrease the likelihood or the severity of what you were experiencing when you first came in? 9. What are the things you can do to maintain your gains in therapy and to continue to improve your life? Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 7

8 THE THERAPEUTIC OPPORTUNITY SCALE: Promoting sensitivity to CRB 2 Therapeutic opportunities may be pure or contextual: Pure: Client spontaneously makes a statement or expresses affect related to the therapist, therapeutic relationship, therapy, or the immediate relational experience. Contextual: Events in the context of therapy may evoke CRB. These require therapist probing. Contextual opportunities: 1. Time structure 2. Therapist vacation 3. Termination 4. Fees 5. Therapist mistakes 6. Silences 7. Client affect 8. Doing well 9. Positive feedback 10. Therapist qualities 11. Context shifts 12. Therapist feelings 13. Direct requests 14. Generalizations 2 Conceived by Madelon Bolling, Ph.D. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 8

9 Describe the following: END OF THERAPY LETTER TO CLIENT 1. The client s goals and progress in therapy. 2. Your client s unique and special qualities, and what you appreciate about him/her. 3. Interactions you had with your client that stand out, what impacted you personally, what you enjoyed and what touched or moved you. 4. What you take away from your work with your client, what you will remember about him/her, and how you are different as a result of having worked with him/her. 5. What you want your client to take away from his/her work with you, and what s important for your client to remember. 6. Any regrets? 7. Your hopes and wishes for your client. 8. What you will miss about your client. 9. Parting advice, what to watch out for in the future, and relapse prevention ideas. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 9

10 Functional Analytic Psychotherapy Levels of Integration Level 1 Rule 1: Unobtrusively watch for CRBs. CRBs will be evoked naturally by the treatment s content. You will naturally reinforce CRB2s, if o the behaviors are naturally in your repertoire o you have your clients best interests at heart Level 2 Rule 2: Evoke CRB2s by prompting behavior. Rule 3: Naturally Reinforce CRB2s by being flexible, creative, genuine, and caring. Rule 4: Notice your effect on your clients and adjust your reinforcement repertoire as needed. Facilitate generalization of in-vivo gains by weaving invivo and daily-life material together in the session and homework assignments. Level 3 Rule 5: Provide functional interpretations of client behavior. Functional analysis to determine treatment targets and interventions. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 10

11 Relevant History DL Problems IV Problems (CRB1s) IV Improvements (CRB2s) DL Goals 25-year-old, single, lesbian female Moved to Seattle two years earlier Lots of friends but reports no support, no connection, isolated, alone Father ( High regard, awe ): o Japanese o Expectations, perfectionism o Distant, cold, no emotional expression Mother: o English o Contradictory, invalidating o Denial of problems: She doesn t care how I am, she just wants me to look good. Must avoid talking about anything real. Primary access to reinforcers through nonemotional expression No private control of experience Several recent deaths Several failed relationships Very social; predominant verbal behavior about need for intimacy, connection o But no overt behavior Presented as overwhelmed by feelings (grief, sadness, anger, love) Private affect experienced as aversive and confusing ( Cloud/rush ) Unable to tolerate discomfort of negative affect (suicidal) Hx = Do not publicize affect, do not contact potential private stimuli Cognitive Concepts: Having this many negative feelings means I m a loser. I am a sell-out if I am depressed. Who I am depends on my relationships with others and how they see me. I am betraying my family to the oppressor by showing my feelings. If I feel or show my negative emotions I will get rejected. Report of cloud/rush in therapy Avoidance of negative affect in therapy Control by Jonathan of public emotional responding in the presence of aversive private events Jonathan thinks I m crazy because I have so many negative feelings. Jonathan will reject me if I am real. Engage in connectionenhancing behaviors Acceptance of negative affect in therapy Accurate public expression of aversive private experience in therapy (private stimulus control) Jonathan accepts me with all these negative feelings. Being real will enhance intimacy and connection with Jonathan. Establish supportive relationships Seek real, genuine, intimate relationships Acceptance of aversive affect Effective, appropriate public expression of affect It is o.k. that I have all these feelings. Feeling/showing negative emotions is necessary for genuine intimacy. Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, jkanter@uwm.edu 11

12 Relevant History DL Problems IV Problems (CRB1s) IV Improvements (CRB2s) DL Goals Jonathan Kanter, Ph.D., University of Wisconsin-Milwaukee, 12