Expanding the cognitive behavioural therapy traditions: An application of Functional Analytic Psychotherapy treatment in a case study of depression.

Abstract

According to the DSM-IV (APA, 1994) Depression is characterized when five or above of the following symptoms have been present for 2 weeks or more including feelings of sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration. It is predicted that within twenty years more people will be affected by depression that any other mental health problem (WHO, 2009). The rationale for a behavioural analytic approach called Behavioural Activation (BA) in this case was based upon multiple factors including: 1) clinical considerations of the growing body of evidence questioning the efficacy in challenging cognitions in moderate to severe depression (Jacobson et al,.1996; Dimidjian et al., 2006), 2) the level of distress presented on assessment and the clients lack of ability to separate from their aversive experiences and in particular their thoughts; 3) client choice of approach; and 4) therapist experience. In the process of treatment it became apparent that the client was experiencing difficulties in connecting to himself and others which pre-disposed the current onset of Depression and identified by the client as maintaining the problem. As a result, the treatment was collaboratively expanded to include Functional Analytic Psychotherapy (FAP). BA is a contemporary contextual psychological treatment for depression based on a behavioural analytic view of depression as an understandable response to difficult life circumstances (Mar tell, Addis and Jacobson, 2001). In BA the aim is not to replace the individuals' aversive experiences, but to help the client develop a new understanding of their own patterns of responding to depressed mood, problem solving and other methods to decrease unhelpful patterns of negative reinforcement. Therefore, BA seeks to change the function of the private experiences that the client tries to avoid, rather than to change the context or the form. Expanding beyond BA, FAP also has its roots within contextual functionalism and radical behaviourism, however; it involves a focus on therapeutic intimacy as part of the treatment (Kohlenberg & Tsai, 1991). FAP highlights the therapeutic relationship as a valuable and unique opportunity for natural reinforcement to occur in session. A collaborative case formulation drives understanding of how the client's avoidances show up in session, how the therapist naturally reinforces client improvements and facilitate generalization into daily life. Within the FAP case conceptualization, clinically relevant behaviours (CRBs) are identified; problematic behaviors in session such as avoidances are typically categorized as CRB1s, and in-session improvements are identified as CRB2s. These CRBs are addressed with the guidance of the five FAP Rules (Kohlenberg & Tsai, 1991; Tsai et al., 2009) 1) Watch for CRBs; 2)Evoke CRBs; 3) Reinforce CRBs Naturally; 4) Observe the Potentially Reinforcing Effects of Therapist Behaviour in Relation to Client CRBs; and 5) Provide Functionally Informed Interpretations and Implement Generalization Strategies. Within Rule 4, FAP pays attention to T1s (therapist related deficits) and T2s (therapist target behaviors that are likely to evoke and reinforce client improvements or CRB2s). METHOD Tim is a 35-year-old single male who works in the e-learning industry. He sought therapy because he was feeling lost, full of angst and a failure within the context of starting a new job 3 months previously. He became reliant on obsessional rumination, self-criticism and engaged in negative judgments about his indecision which stemmed from his inability to tolerate uncertainty and the fear of the unknown. He expressed a fear of vulnerability, sadness, and guilt as these feelings also were closely related to painful past experiences of physical health problems and being unfaithful in his relationship on one occasion. …