Sara J. Landes

Translating the Theoretical into Practical: A Logical Framework of Functional Analytic Psychotherapy Interactions for Research, Training, and Clinical Purposes.

Functional analytic psychotherapy (FAP) provides a behavioral analysis of the psychotherapy relationship that directly applies basic research findings to outpatient psychotherapy settings. Specifically, FAP suggests that a therapist’s in vivo (i.e., in-session) contingent responding to targeted client behaviors, particularly positive reinforcement of a client’s effective behavior, should be a powerful mechanism of change. However, much of the previous literature on FAP has been theoretical, broadly defining FAP techniques rather than explicating them with the precision necessary for replication and training. In this article, the authors explicate a logical framework for turn-by-turn interactions between the client and therapist that may guide research, training, and dissemination of FAP. This molecular behavioral description of the events of the proposed logical interaction lends itself to microprocess research methodology, and a discussion of potential hypotheses to explore follows. Prescriptive, direct guidance for the application of FAP for training and dissemination purposes is given.

Lines of Evidence in Support of FAP

What empirical evidence supports FAP? On the one hand, FAP is based on a handful of basic behavioral principles that were theoretically and empirically derived from decades of laboratory experimentation. On the other, FAP has yet to be tested in a randomized controlled trial. Our belief is that the basic tenets of FAP—namely the importance of the therapeutic relationship and the use of natural reinforcement to shape client problems when they occur naturally in the therapeutic relationship—are robust, and lines of evidence in support of these principles converge from multiple and diverse areas of research. In this chapter we review these lines of evidence. It should be clear from the outset, however, that this review by no means seeks to justify the paucity of direct empirical evidence in support of FAP. Rather, we believe that the findings of this review strongly suggest that additional empirical research specifically investigating the efficacy of FAP is warranted, as it was developed from a solid foundation of principles and evidence and represents a convergence of some of the most robust findings in psychological research. While FAP is a therapy based on behavior analytic principles, at its heart it is an interpersonal therapy. FAP is based on the assumption that both the causes of, and treatment for, psychopathology are intimately related to interpersonal relationships. This assumption has substantial support in the literature with respect to depressive disorders. It is well established that interpersonal problems, troubled relationships, and lack of social support predict the onset (Stice, Ragan, & Randall, 2004), course (Lara, Leader, & Klein, 1997; Miller et al., 1992), duration (Brown & Moran, 1994) and relapse of depression (Hooley & Teasdale, 1989). Conversely, the presence of social support has protective effects (Peirce, Frone, Russell, Cooper, M Sherboume, Hays, & Wells, 1995). While several alternative therapies focus on the therapeutic relationship and associated processes, FAP utilizes basic learning principles to harness the therapist-client relationship, focusing on the establishment of a more effective

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4–23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322–1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Treating Complex Trauma Among Veterans: Three Stage‐Based Treatment Models

This article addresses the issue of complex trauma in veterans and treatments for symptom presentations resulting from complex trauma exposure. While various definitions have been proposed for complex trauma, the clinical issues related to it are relevant for veterans as they are at risk for cumulative trauma exposures such as multiple combat deployments and military sexual trauma. Several treatments were either developed to address and/or implemented with complex trauma. This article discusses three of these treatments that share a stage-based approach, focusing on the present (e.g., skills training and psychoeducation), which can then be followed, if needed, with a past-focused (e.g., exposure-based) treatment: Dialectical Behavior Therapy (Linehan, 1993), Seeking Safety (Najavits, 2002), Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy (Cloitre, Cohen, & Koenen, 2006). This article also discusses what is currently being done to address symptom presentations resulting from complex trauma exposure and challenges and possible solutions to implementing this care.

Identifying outpatients with entrenched suicidal ideation following hospitalization

The purpose of this study was to identify outpatients who experience entrenched suicidal ideation following inpatient psychiatric hospitalization. Our findings suggest that the use of a suicidal ambivalence index score was helpful at discriminating those who reported significantly greater ratings of suicidal ideation across a 1-year period of time, whereas splitting patients based upon suicide attempt history yielded nonsignificant results. Similar findings resulted from a dimensional analytic approach, as well. Application of the suicidal ambivalence index may help administrators identify patients who require more intensive clinical services to resolve their suicidal ideation.

FAP and dialectical behavior therapy (DBT) dialectical behavior therapy (DBT)

This chapter explores the intersections of Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et al., 2009 ) and Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b ) with a focus on how training and experience with each model can enhance work with the other.

Hypnosis in the Treatment of Depression: Considerations in Research Design and Methods

Abstract Depressive disorders constitute a serious problem in the United States and around the world. The appearance of practice guidelines and lists of evidenced-based therapies suggests that adequate treatments for depression exist. However, a careful consideration of what is known and not known about the treatment of depression leaves plenty of room for improved approaches to addressing this condition. Although there has been a dearth of research on the treatment of depression using hypnosis, there are several compelling arguments for the inclusion of hypnotic approaches in the array of current strategies for dealing with depression. However, traditional “gold-standard” research methods, namely randomized controlled trials, have many shortcomings for identifying the potential impact of hypnosis on depression. Other strategies, notably single-case design and benchmarking approaches, may offer a more practical solution to the problem of determining “what works for depression.”

Dialectical Behavior Therapy in College Counseling Centers: Current Trends and Barriers to Implementation

ABSTRACT The purpose of this study was to examine trends and barriers in implementation of dialectical behavior therapy (DBT) programs in college counseling centers (CCCs). Participants were 107 CCC employees who participated in an electronic survey. One third of respondents endorsed use or planned use of DBT at their centers. The most prevalent primary mode of DBT offered was group skills training. Highly endorsed barriers to implementation included productivity demands and lack of individual therapists, time for team consultation, and willingness to offer phone coaching. Suggested implementation strategies include developing community partnerships, use of virtual teams, supporting programs with campus data, and adapting DBT strategically.

Women’s preference of therapist based on sex of therapist and presenting problem: An analog study

An analog study was conducted to examine differences in women’s preference for and anticipated comfort self-disclosing to hypothetical therapists of different sexes based on the type of hypothetical presenting problem. The impact of general level of self-disclosure was also examined. Participants included female college students (n = 187). Anticipated comfort self-disclosing to male or female therapist was rated by subjects when presented with therapists of each sex with the same qualifications. Women preferred and reported higher levels of anticipated comfort self-disclosing to a female therapist. The type of hypothetical presenting problem and general level of self-disclosure also impacted anticipated comfort self-disclosing. There was an interaction between general level self-disclosure and the sex of therapist on anticipated comfort self-disclosing. General level of self-disclosure only impacted anticipated comfort self-disclosing when the therapist was male. This information is relevant for therapists or organizations that provide psychosocial services to women. Organizations may want to inquire about a client’s preferences about sex of therapist beforehand and, if possible, cater to the client’s preference.

Predicting dropout in outpatient dialectical behavior therapy with patients with borderline personality disorder receiving psychiatric disability

BackgroundRates of treatment dropout in outpatient Dialectical Behavior Therapy (DBT) in the community can be as high as 24 % to 58 %, making dropout a great concern. The primary purpose of this article was to examine predictors of dropout from DBT in a community mental health setting.MethodsParticipants were 56 consumers with borderline personality disorder (BPD) who were psychiatrically disabled participating in a larger feasibility trial of Dialectical Behavior Therapy- Accepting the Challenges of Exiting the System. The following variables were examined to see whether they predicted dropout in DBT: age, education level, baseline level of distress, baseline level of non-acceptance of emotional responses, and skills module in which a consumer started DBT skills group. These variables were chosen based on known predictors of dropout in consumers with BPD and in DBT, as well as an interest in what naturally occurring variables might impact dropout.ResultsThe dropout rate in this sample was 51.8 %. Results of the logistic regression show that younger age, higher levels of baseline distress, and a higher level of baseline non-acceptance of emotional responses were significantly associated with dropout. The DBT skills module in which an individual started group did not predict dropout.ConclusionsThe implications of these findings are that knowledge of consumer age and pretreatment levels of distress and non-acceptance of emotional responses can impact providers’ choice of commitment and treatment strategies to reduce dropout. Future research should examine these strategies, as well as the impact of predictor variables on outcome and reasons for dropout.