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125
INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY
2012, VOL. 7, NO. 2–3
Posttraumatic Stress Disorder (PTSD) is an anxiety disorder
resulting from the experience of a traumatic event (e.g., sex-
ual assault, military combat, natural disaster) with resulting
emotions of fear, helplessness, or horror (Diagnostic and Sta-
tistical Manual of Mental Disorders 4th edition, Text-Revision;
DSM-IV-TR, American Psychiatric Association, 2000). PTSD
is characterized by re-experiencing symptoms (e.g., ashbacks,
nightmares), avoidance (e.g., avoiding thinking or talking about
the trauma, avoiding situations that remind one of the trauma),
and hyperarousal (e.g., hypervigilance, irritability). Nearly 70%
of Americans have experienced a traumatic event and approxi-
mately 6.8% of the population meets criteria for PTSD (Kessler
et al., 2005), with higher prevalence rates among women and
combat veterans (Kulka et al., 1990; Resnick, Kilpatrick, Dansky,
Saunders, & Best, 1993; Tanielian, & Jaycox, 2008).
Cognitive-behavioral interventions have been developed to
help individuals who are struggling with PTSD. e most wide-
spread and empirically supported are Prolonged Exposure (PE;
Foa, Hembree, Rothbaum, 2007) and Cognitive Processing
erapy (CPT; Resick & Schnicke, 1993). PE is an empirically
supported behavioral treatment for PTSD that has been dem-
onstrated to help alleviate symptoms of PTSD through in-vivo
and imaginal exposure exercises. In-vivo exposure involves the
client approaching avoided situations gradually to learn skills to
cope with anxiety. Increased exposure to feared situations makes
it more possible to engage those over time (i.e., habituation to
evocative stimulus conditons). Imaginal exposure involves the
repeated processing of the traumatic memory during therapy
sessions in order to experience the trauma related feelings and
thoughts that have been avoided. By repeated exposure to the
feared memory and other private events, clients gain new skills
in tolerating anxiety and learn ways to experience these private
behaviors without avoiding. CPT is a cognitively-focused in-
tervention that also can contain an emotional processing com-
ponent where clients write about the traumatic event in detail.
is allows clients to experience the natural emotions that rise
from the process without engaging in avoidance coping. In addi-
tion, CPT focuses on restructuring trauma-related maladaptive
thoughts about the meaning of the traumatic event, the self, oth-
ers, and the world that maintain symptoms (e.g., “No one can
be trusted,” “Because I walked down the street with him and he
raped me, I cannot keep myself safe”). While these treatments
have been shown to greatly benet those who suer from PTSD
in reducing targeted symptomatology (Chard, 2005; Foa et al.,
2005; Resick, Nishith, Weaver, Astin, & Feuer, 2002), retention
of clients in treatment has been a concern; approximately one-
h of clients drop out of cognitive-behavioral treatments for
PTSD (Hembree et al., 2003). In a review of dropout in stud-
ies of PTSD treatments, Schottenbauer and colleagues (2008)
reported dropout as high as 50% for PE, CPT and other cog-
nitive-behavioral interventions. Although researchers suggest
symptom exacerbation aer beginning imaginal exposure in PE
does not lead to attrition (Foa, Zoellner, Feeny, Hembree, & Al-
varez-Conrad, 2002), it is unclear why so many clients dropout
Functional Analytic Psychotherapy as an Adjunct to Cognitive-Behavioral
Treatments for Posttraumatic Stress Disorder: Theory and Application
in a Single Case Design
1Eric R. Pedersen, 2Glenn M. Callaghan, 2Annabel Prins, 1Hong Nguyen, & 1Mavis Tsai
1University of Washington, Department of Psychology, & 2San Jose State University, Department of Psychology
Abstract
Evidence-based treatments for Posttraumatic Stress Disorder (PTSD) may be enhanced by Functional Analytic Psychotherapy (FAP;
Kohlenberg & Tsai, 1991; Tsai et al., 2009). As PTSD can include a variety of problems with interpersonal relationships (e.g., trust
of others), manualized treatments may not afford clinicians enough time and exibility to work on reinforcing client improvements in
interpersonal functioning during sessions. Avoidance, which works to alleviate anxiety in the short-term but may lead to distress and
complications in the long-term, can manifest in therapy when patients do not return after the initial sessions of treatment or when
they block emotional content during targeted emotional processing work. Thus, it is important for clinicians to understand how to
use the therapeutic relationship to reduce avoidance symptoms of PTSD in session and reduce dropout rates. FAP can be useful
in this regard as an adjunct to efcacious cognitive-behavioral treatments of PTSD. A case study utilizing FAP after a cognitive-
behavioral intervention for PTSD is discussed to present an analysis of how FAP may have contributed to client improvements in
avoidance symptoms and in interpersonal relationships outside of therapy. Theory behind FAP is discussed to convey how this
therapy can be a useful adjunctive treatment for PTSD.
Keywords
Functional Analytic Psychotherapy (FAP), Posttraumatic Stress Disorder, single case design, interpersonal closeness, avoidance
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126 PEDERSEN, CALLAGHAN, PRINS, NGUYEN, & TSAI
therapeutic alliance before the dicult trauma-related mate-
rial is discussed (Keller, Zoellner, & Feeny, 2010). Additionally,
providing an adjunctive intervention following an empirically-
supported treatment for PTSD may be benecial in reducing
persistent symptom expression.
FUNCTIONAL ANALYTIC PSYCHOTHERAPY
In an eort to prevent dropout and promote symptom reduc-
tion through a strengthened therapeutic alliance, we propose
that Functional Analytic Psychotherapy (FAP; Kohlenberg &
Tsai, 1991; Tsai et al., 2009), a behavioral intervention focused
on the therapeutic relationship as the major vehicle of change,
may be of use as an adjunct to cognitive-behavioral therapies for
PTSD. FAP is an ideal potential treatment for clients diagnosed
with PTSD because it provides a structure for the development
of a strong and supportive therapeutic relationship. is rela-
tionship can facilitate in-vivo exposure, directly address client
avoidance coping strategies, and build interpersonal repertoires
that have been aected by trauma. FAP may be particularly use-
ful for victims of interpersonal trauma (e.g., rape, intimate part-
ner violence, or childhood sexual or physical abuse) because
these traumatic events can dramatically inuence how survivors
develop and maintain interpersonal relationships following the
experience (Kohlenberg, Tsai, & Kohlenberg, 2006). Because
the trauma can involve a violation of trust in a relationship with
someone that the survivor knew, survivors may question their
own judgment about whom to trust in future interactions, in-
cluding therapists. Developing a strong therapeutic relationship
may also decrease chances of therapy dropout as clients engage
in dicult exposure treatments, as they may develop the skills
to discriminate the therapist as a person who has their best in-
terests and safety at heart. Below, we describe proposed FAP
guidelines for the treatment of PTSD resulting from interper-
sonal trauma which include clinically relevant behaviors (CRBs)
associated with PTSD and the ve FAP rules that guide therapy.
FAP GUIDELINES FOR TREATMENT OF PTSD
Clinically Relevant Behaviors. A major premise of FAP is that clients
will express behaviors in-session that are associated with their
problem outside of therapy. For clients who have developed
PTSD from experiencing interpersonal trauma, these behavior-
al patterns may include issues with shame and self-blame, trust
and intimacy, and avoidance of trauma related memories and
stimuli. FAP dierentiates these behavioral patterns into three
categories: 1) client problems that occur in session (CRB1); 2)
client improvements that occur in session (CRB2); and 3) cli-
ent interpretations of behavior (CRB3). It is important to note
that CRBs are determined based on the client’s learning history
and the function of the behavior for that particular individual
instead of a priori knowledge of the behavior or its function
(Tsai et al., 2009). at is, a CRB1 for one client can be a CRB2
for another. For example, asking for a therapist’s home phone
number (e.g. to contact the therapist outside of regular session
time in case of an urgent issue) could be a CRB1 for a client who
struggles with maintaining boundaries within relationships and
a CRB2 for a client who struggles with articulating her needs to
others.
of these intensive treatments. Nevertheless it is important for
clinicians and researchers to examine how to reduce dropout
rates through enhanced cognitive-behavioral approaches. Strat-
egies to accomplish this may focus on building trust between
the therapist and client.
THERAPEUTIC ALLIANCE
In cognitive-behavioral interventions for PTSD, clinicians ask
clients to discuss feelings and thoughts they are trying to avoid.
In essence, clients are asked to approach the situations they fear
the most. It seems reasonable to assume that a strong therapeu-
tic alliance must be at the core of this type of cognitive-behav-
ioral intervention, especially since compared to those without
PTSD, individuals with PTSD report more eort strategically
attempting to avoid emotional expression around others (Ro-
emer, Litz, Orsillo, & Wagner, 2001). e therapeutic alliance
can be conceptualized as the working relationship between cli-
ent and therapist that allows not only compliance from the client
toward suggested tasks and skills building, but an ability for the
client to engage in interpersonal behaviors that may occur more
typically in developed and trusted relationships (Kohlenberg
& Tsai, 1998; Tsai, Kohlenberg & Kanter, 2010). e therapist
simply urging the client to trust him or her, however, may elicit
a variety of behaviors from the client that do not approach the
feeling of trust based on the client’s own learning history. Con-
sider how these types of trust issues could emerge in-session as
a male therapist encourages a female sexual assault victim to feel
more comfortable around men again, or a social worker at the
Veteran Aairs Healthcare System encourages a combat veteran
suering from PTSD to trust an authority gure again. When
the issue of trust with others emerges between the therapist and
the client, the therapeutic relationship itself can function as a
microcosm related to how the client interacts with similar peo-
ple outside of session, in the “real world.” e client may begin
to withdraw, detach, and eventually leave the relationship (i.e.,
drop out of therapy) just as he or she would when other rela-
tionships in their life become too intense, intimate, or dicult.
e therapeutic relationship is a major contributor to behav-
ior change (Aveline, 2005) and a central component in PTSD
treatment as recommended by the American Psychiatric As-
sociation (2004). It is possible, then, that interventions focus-
ing on enhancing the therapeutic alliance may be benecial for
clients in cognitive-behavioral treatment for traumatic stress.
Research suggests therapist warmth may be particularly impor-
tant in behavioral treatments such as systematic desensitization
(Morris & Suckerman, 1974) and exposure therapy (Morrison,
2010). While manualized treatments promote the use of thera-
pist warmth and highlight the importance of the therapeutic
relationship, it is possible that utilizing techniques that focus
on the therapist-client relationship specically may be bene-
cial with this population. Moreover, due to concerning dropout
rates and non-response to treatment, Schottenbauer and col-
leagues (2008) suggest that researchers begin examining modi-
cations to existing empirically supported treatments for PTSD
in an eort to increase retention and promote lasting symptom
relief. Augmented cognitive-behavioral therapy may allow for
more time to process the role of avoidance and build up the
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127
FUNCTIONAL ANALYTIC PSYCHOTHERAPY AS AN ADJUNCT TO COGNITIVE-BEHAVIORAL TREATMENTS FOR POSTTRAUMATIC STRESS DISORDER
engage in a specic behavior and the consequences for doing
so. For victims of childhood trauma at the hands of caregivers,
persistent avoidance of emotions and detachments from others
may hinder subsequent relationships as they become emotion-
ally intense. us, the therapeutic relationship may be the rst
healthy relationship clients have experienced (Kohlenberg et al.,
2006; Follette, LaBash, & Sewell, 2010). CRB3s are important
in therapy because they allow clients to be aware of the contin-
gencies inuencing their behavior, which may facilitate them to
alter their environment to elicit more social reinforcement from
others; engendering closer, more intimate relationships.
The Five Rules of FAP in Treating PTSD. FAP theorists developed ve
rules of FAP to observe and reinforce clinically relevant behav-
iors in the therapy room with the goal of generalizing these be-
haviors to the outside world (Kohlenberg & Tsai, 1991). ese
FAP rules have been applied specically to clients with PTSD
(see Kohlenberg et al., 2006) and are reviewed below.
Rule 1: Watch for CRBs. is rule is arguably the most impor-
tant rule of FAP. erapists need to be able to recognize
instances of problematic behaviors in order to punish and
extinguish them. ey also need to be aware of adaptive
behaviors in order to reinforce and shape improvements.
Further, being aware of CRBs also increases the chance that
therapists will reinforce and extinguish these behaviors
naturally.
e therapist’s personal reaction in-session to the client’s be-
havior can act as a barometer for CRBs to the extent that these re-
actions resemble how people in the client’s life respond to them.
Moreover, it is this specic focus on in-session content that may
require an additional focus on the therapist’s own repertoire. It
is imperative for therapists to be aware of their own learning
histories and personal biases to ensure that their reactions to
the clients reect clients’ CRBs and not the therapists’ personal
issues. is is especially important for FAP therapists working
with PTSD clients. Trauma-focused therapy can be emotionally
dicult for therapists of all theoretical orientations, but particu-
larly dicult for FAP therapists due to the intense nature of the
therapeutic relationship and focus on interactions within the
therapeutic environment. As such, FAP therapists may be more
vulnerable to vicarious traumatization, burn-out, and some-
times less eective emotional reactions to clients, especially if
the therapists have themselves been victims of interpersonal vi-
olence (Jenkins & Bard, 2002). us, FAP therapists need to be
particularly aware of their personal histories, limits, behavioral
excesses, and decits with FAP clients. is may be especially
important during trauma account readings in CPT or imaginal
exposures in PE, as clients may be avoiding important content
about the trauma that therapists also may wish to avoid (Mor-
rison, 2010). erapists need to be aware of both their own T1s
(therapist problem behaviors) and the client’s CRB1s and to not
collude with the client’s avoidance which would ultimately un-
dermine the ecacy of the intervention. erapists should seek
self-reection, consultation, and supervision with colleagues to
bring not only an awareness of their own avoidant behaviors in
session but an improved response to being present to that pain
and being eective with clients in the context of that history.
Rule 2: Evoke CRBs. e nature of a FAP therapeutic relation-
A recurring issue faced by clients who have experienced in-
terpersonal trauma is having diculty in developing or main-
taining close relationships. Having been psychologically hurt
or physically injured in previous interpersonal relationships,
a client may try to avoid close connection to others as a self-
protective strategy. Further, this client may also have a sense of
mistrust of her own internal experience and judgment aer be-
ing betrayed by someone she trusted in an environment that she
previously considered safe. CRB1s for this client may include
(but are certainly not limited to) cancelling multiple sessions
aer an intimate disclosure, talking little in therapy, not convey-
ing emotional experience connected to the trauma, threatening
to quit therapy, and having diculty in communicating needs
and wants to the therapist. It is important to be aware of CRB1s
because they correspond directly to the client’s presenting prob-
lems and will be the target of cognitive behavioral interventions.
In addition, by becoming aware of each client’s particular prob-
lematic in-session behaviors, the therapist can respond to these
as they occur, commenting on the function of the behaviors and
how they t in the conceptualization of the client’s problems
and targeted improvements. Moreover, the therapist may even
anticipate with the client when these problematic repertoires
may occur during dicult times in therapy to both provide a
context for understanding them and to encourage an alternate,
more eective repertoire (CRB2) as they begin to occur.
Improvement in therapy is marked by decreases in CRB1s
and increases in CRB2s. CRB2s for the client mentioned above
may include showing up to sessions consistently (especially in
dicult periods of treatment), discussing vulnerable informa-
tion regarding the trauma, expressing aect when distressed,
telling the therapist when he or she is hurt by something the
therapist said, and asking the therapist to increase session time
when he or she is in a crisis. CRB2s are oen rare or of low
strength at the beginning of the therapy. us, it is important
for therapists to have a clear case conceptualization in order to
recognize these CRB2s as they occur to most eectively shape
and reinforce them in-session. As avoidance of emotions are
a hallmark symptom of PTSD (i.e., avoiding trauma-related
emotions such as fear, emotional numbing, detachment from
others), failing to show up for appointments (or dropping out)
will likely be a CRB1 for many clients diagnosed with PTSD.
Becoming aware of these behaviors as symptomatic of PTSD is
covered in the manuals for both PE (Foa et al., 2007) and CPT
(Resick, Monsoon, & Chard, 2008). However the time-limited
structure of these therapies may not allow therapists and cli-
ents enough time to process the avoidant behaviors that occur
within the therapy session. ese may be a potential barrier to
treatment with respect to eectively decreasing targeted symp-
toms and preventing dropout.
Another marker of improvement in therapy is the occur-
rence of CRB3s, which are discussions of the function of cli-
ent behaviors and how in-session behavior relates to daily life.
An example of a CRB3 may include telling the therapist that
having an honest and trusting relationship with the therapist
helped him or her realize that not all close attachments lead to
betrayal and pain, thereby allowing the client to reach out and
trust others in her life. Here, the client would be able to state the
conditions under which he or she was more likely to be able to
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128 PEDERSEN, CALLAGHAN, PRINS, NGUYEN, & TSAI
aect you?” It is important to be aware of the timing of
these questions. Asking these questions before the conclu-
sion of an intense in-session interaction may disrupt the
interaction – making it more likely the therapist and client
are talking about behavior change instead of engaging in it
in vivo. ese process questions should be held until aer
the natural conclusion of those interactions to prevent un-
intended disruption.
Client’s recalling traumatic material will no doubt elicit some
emotional response from the therapist (Wilson & Lindy, 1994);
however, responding to the patient with matched negative af-
fect predicts poor treatment responses (Safran, Muran, Sam-
stag, & Stevens, 2002. Additionally, if therapists are drawn into
the patient’s maladaptive interpersonal patterns (e.g., hallmarks
of PTSD such as avoiding emotional content of the traumatic
memory or suppressing expression of strong emotion such as
fear or love), negative outcomes or dropout may occur (Rasting
& Beutel, 2005). us, Rule 4 is particularly important for PTSD
patients as the therapist may unintentionally punish emotional
expression by the client or respond aversively to the point that
clients are less likely to present the material openly. A therapist’s
response that is the least bit disdainful when a client is discuss-
ing an interpersonal trauma such as rape may evoke shame or
guilt and could lead to continued avoidance of the traumatic
memory. While the therapist’s response may be quite natural, it
is critical to temper its expression so that it is most useful in the
context of the FAP intervention.
Rule 5: Provide functional analytically informed interpretations and im-
plement generalization strategies (Interpret and Generalize). Inter-
preting client behaviors in terms of its function as it relates
to the client’s individual learning history is an important
part of FAP. For example, a client who has been physically
abused by her husband could report experiencing a feel-
ing of betrayal by her therapist when the therapist has to
leave for a vacation, and the client may then threaten to quit
therapy. In this case, a FAP therapist may oer the interpre-
tation that the client is feeling abandoned by the therapist
because of her past experience of being abandoned by the
people she cares most about (her husband). Following Rule
5, the therapist would help the client recognize that the cli-
ent may feel like leaving a relationship in contexts where
she was feeling betrayed or abandoned, and that leaving the
relationship would have short-term advantages, but that
it would be more costly in the long run, as she would no
longer have a source or intimate connection (i.e., social re-
inforcement). e therapist would then help the client dis-
criminate a dierent response under these conditions that
may have a dierent corresponding set of outcomes. at
is, the the client can engage in a behavior that is less escape-
driven or reactionary and the consequences on the thera-
peutic relationship would be more intimacy enhancing. In
sum, Rule 5 helps clients nd solutions to their problems
and facilitate generalization of progress in therapy to daily
life.
ship is very evocative for clients with PTSD. is is because
FAP therapists encourage trust, closeness, and honest ex-
pressions of emotions which oen evokes fear, anxiety, and
avoidance in clients who have been hurt in previous rela-
tionships. Disclosures of emotional reactions by therapists,
done strategically to be evocative and to elicit CRBs, oen
bring up topics or feelings that clients with PTSD may at-
tempt to avoid. For example, a therapist who discloses
that he or she cares about the client may evoke feelings of
mistrust, fear, anxiety, and shame in a client who has been
sexually abused as child by a caretaker. Evoking CRBs is
important in that it allows the presentation of CRB1s so
that these repertoires can be changed and supplanted with
CRB2s, a more eective repertoire for the client both in-
session and outside of therapy.
Rule 3: Reinforce CRB2s naturally. It is particularly important
for therapists working with clients who have experienced
interpersonal trauma to reinforce behaviors in a genuine
and natural way (Fester, 1967; 1972). Having experienced
abuse, betrayal, manipulation and trauma at the hands of
people they trusted, clients diagnosed with PTSD may be
especially sensitive to contrived reinforcers and disingenu-
ous behaviors from the therapist (Kohlenberg et al., 2006).
For example, a client may feel invalidated if a therapist re-
sponds to an emotional disclosure regarding a traumatic
experience with, “It is good that you are feeling this way”
or “ank you for telling me this.” Clients may feel that the
therapist does not genuinely understand them, care about
them, or empathize with them. A more natural and rein-
forcing response would be the therapist physically leaning
in, listening intently, nodding, and reecting back the emo-
tionality and content of the client’s disclosure. us thera-
pist should avoid using “pre-packaged” reactions, such as
“thank you for sharing,” and instead, he or she should react
in ways that are more natural and appropriate to the context
of the situation and the client-therapist relationship. In fact,
these reactions are meant to reect more real-world situa-
tions that others outside of therapy would give the client.
By providing empathic and natural responses that sound
less like a therapist and more like a person the client would
interact with, the FAP intervention may have a higher like-
lihood of both feeling good to the client and reinforcing
behavior that will generalize to daily life relationships.
Rule 4: Observe the potentially reinforcing effects of therapist behav-
ior in relation to client CRBs. Rather than assuming that their
behavior meant to be reinforcing actually is reinforcing,
therapists should carefully observe whether their behavior
actually increases or decreases clients’ targeted responses.
For example, a therapist who means to be empathic and
reinforcing by saying, “It’s upsetting to me that your moth-
er treated you so poorly” may notice that the client shuts
down and does not disclose any further aer this therapist
response. Such client withdrawal suggests the therapist’s
statement was actually punishing. FAP guidelines also en-
courage therapists to explicitly inquire about how their be-
havior inuences the clients. Questions can include, “How
did what I just say feel to you?” or “How did my reaction
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129
FUNCTIONAL ANALYTIC PSYCHOTHERAPY AS AN ADJUNCT TO COGNITIVE-BEHAVIORAL TREATMENTS FOR POSTTRAUMATIC STRESS DISORDER
Template (FIAT; Callaghan, 2006). Information about the case
formulation is provided below.
e therapist in this case (third author A.P.) was an experi-
enced clinician with considerable expertise in treating clients
using both empirically supported and manualized cognitive
behavioral treatments for PTSD. e therapist received weekly
supervision in FAP by an experienced FAP supervisor and re-
searcher (second author G.M.C).
TREATMENT
is was a long-term treatment for a client with a great deal of
distress. e intervention occurred in two stages. Stage 1 was a
standard treatment for PTSD using cognitive-behavioral thera-
py, while Stage 2 represented the initiation of FAP with a focus
on interpersonal diculties and in-session responding to tar-
get behaviors. e adjunctive use of FAP following a cognitive
behavioral intervention is consistent with FAP-enhanced treat-
ments for major depressive disorder and other problems (e.g.,
Kanter, et al., 2009; Kanter, Schildcrout, & Kohlenberg, 2005;
Vandenberghe, & Ferro, 2005).
Treatment during the rst three years (Stage 1) included ex-
posure to the client’s trauma history, intensive outpatient treat-
ment for substance abuse, and cognitive-behavioral treatment
for bulimia. e client was prescribed trazodone and uoxetine
during this period. Treatment during Stage 1 was successful in
reducing re-experiencing and hyperarousal symptoms of PTSD
(see Figure 1). In addition, the client was successful in maintain-
ing sobriety for 3 years and purging behavior was eliminated. At
the start of year 4, the client experienced a relapse of substance
abuse and reported signicant isolation and detachment from
others. is suggested a need for an interpersonal focus in ther-
apy and indicated the use of FAP as an adjunctive treatment.
e patient consented to the initiation of FAP and the collection
of additional assessment data for the intervention. e targeted
areas for therapy included increasing interpersonal closeness
through disclosure of her experiences to others. From a FAP
perspective, these would be understood as behavioral problems
related to the contextual control of a repertoire of disclosure, es-
cape and avoidance of that behavior, and an inability to respond
eectively to others’ disclosures in an interpersonal context.
In FAP, the main outcome for therapy is not simply the reduc-
tion of problematic behaviors but an increase in interpersonally
eective repertoires. For this client, that means she would not
SINGLE CASE STUDY FOR A CLIENT WITH
PTSD USING FAP AS AN ADJUNCTIVE
INTERVENTION
As discussed, PTSD can include a variety of problems with in-
tra- and interpersonal experiences (Galovski & Lyons, 2004;
Monson, Ta, & Fredman, 2009). While empirically-supported
treatments for PTSD appear to be most eective in reducing
core symptoms of PTSD including re-experiencing, hyper-
arousal symptoms, and avoidance (Foa, Davidson, & Frances,
1999; Foa, Keane, Friedman, & Cohen, 2009), higher avoidance
levels of emotional intimacy are oen present in individuals
with PTSD and are rarely targeted in treatment. ose who are
more severe (i.e., those who may need treatment the most) may
still benet from treatment aer manualized, time-limited treat-
ments are concluded (Schottenbauer et al., 2008). Some trau-
matic events such as early childhood assault may be particularly
resistant to 10 to 15-session manualized treatments (Hembree,
Street, Riggs, & Foa, 2004). e following case example dem-
onstrates how a clinical focus on those interpersonal skills and
decits that contribute to client suering can provide signicant
improvement above and beyond a standard protocol for symp-
tom reduction. Data intensive single case designs provide an
opportunity to examine detailed change for interpersonal prob-
lems targeted in FAP and may create hypotheses testable with
larger populations aected by a specic type of problem (e.g.,
Callaghan, Summers, & Weidman, 2003).
CLIENT AND THERAPIST INFORMATION
e client was a 41-year-old female veteran with PTSD symp-
toms related to several sexual assaults while in the military and
a robbery at gunpoint. e client initially sought treatment for
PTSD symptoms related to the robbery. e Clinician Adminis-
tered PTSD Scale (CAPS; Blake et al., 1995; Weathers, Keane, &
Davidson, 2001) at intake yielded data consistent with diagnosis
of PTSD. In addition, the client also met criteria for co-morbid
alcohol dependence, dysthymic disorder, features of dependent
personality disorder, and bulimic behaviors. Apart from the di-
agnosis, the client reported long-standing existential concerns
related to living life in face of death and living life with integrity
(e.g., a life without secrets). A full case formulation was devel-
oped for the client using Functional Idiographic Assessment
Table 1. Targeted behaviors for intervention using the FIAT system.
Problems with under-disclosing
(contextual control)
Failure to Disclose
(escape or avoidance)
Failure to solicit or respond to others’ disclosure
(repertoire problem)
Problem responses
CRB1s and Outside 1s
Cannot identify appropriate
context to disclose
Social isolation related to non-
disclosure
Engages in partial
disclosure and then
escapes
Avoids opportunities to
disclose
Changes focus of conversation when others
disclose about themselves (turns focus on self
or unrelated topic)
Improved responses
CBR2s and Outside 2s
Discriminate opportunities for
disclosure
Increased social interaction with
self-disclosure
Discusses both positive
and negative experi-
ences with others to
build intimacy
Asks others what they would like or how she
can be supportive
States appreciation for disclosure
Note: CRB1s = in-session problem behaviors. Outside 1s = outside of session problem behaviors. CRB2s = in-session improved behaviors. Outside 2s = outside of session improved behaviors.
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130 PEDERSEN, CALLAGHAN, PRINS, NGUYEN, & TSAI
problematic behaviors. Examples from the FIAT-Q module for
Disclosure include “I do not want to share things about my-
self with others;” “I have diculty making conversation with
people;” and “Aer I share something personal about myself, I
downplay the importance of what I’ve disclosed.”
e FIAT Daily Assessment (FIAT-DA) was used in the last
two months of Stage 2 for monitoring experiences with inter-
personal closeness to examine targeted improvements and
diculties. is is a purely idiographic template that required
the client to document specic interpersonal opportunities
for disclosure that were either eective or problematic. Table 1
summarizes the target areas developed in the FIAT assessment
system that were then tracked with the Questionnaire and the
Daily Assessments.
RESULTS
Changes in PCL. Figure 1 shows changes in Avoidance and detach-
ment behaviors measured by PCL before and aer implementa-
tion of Stage 2 FAP intervention. As can be observed, Avoidance
behaviors decreased over the 9 months with FAP while Re-ex-
perience and Hyperarousal symptoms remained stable.
Changes in FIAT-Q. Figure 2 shows changes in the FIAT-Q assess-
ment of interpersonal closeness and disclosure behaviors af-
ter implementation of FAP as plotted against changes in PCL
Avoidance/Detachment symptom scores. When problems with
interpersonal closeness (i.e. disclosure) decreased, so did inter-
personal avoidance and detachment (see Figure 2).
only increase disclosure and social interactions, but she would
learn to discriminate when, where, and with whom to engage
in that behavior. In addition, she would develop repertoires for
eectively disclosing her own experience and respond to oth-
ers in a way that would allow them to know she listened and
understood what they had shared, creating more opportunities
of social reinforcement. A very brief summary of the case con-
ceptualization developed for targeted behaviors is presented in
Table 1 using terminology from the FIAT system. e therapist
provided FAP for 9 months (once per week for 1-hour sessions)
as Stage 2 treatment. e focus of the intervention was on re-
duction of problematic interpersonal behaviors and develop-
ment of more eective pro-social behaviors.
ASSESSMENTS
e PTSD Symptom Checklist (PCL; Blanchard, Jones-Alex-
ander, Buckley, & Forneris, 1996) was administered pre-treat-
ment and every three months thereaer for both Stage 1 and
Stage 2. e PCL is a symptom based nomothetic device that is
scored with respect to symptom severity (5 indicates the client
is “extremely” bothered by symptoms, 4 indicates “quite a bit,”
3 “moderately,” 2 “a little bit,” and 1 “not at all”). Scores are pre-
sented as averages for specic symptom clusters.
In order to focus on the dierent aspects of interpersonal
functioning, the FIAT-Q was used to monitor progress for tar-
geted interpersonal behaviors every three months during Stage
2. e FIAT-Q consists of a series of statements using a Likert
scale consisting of six options ranging from 1 (strongly disagree)
to 6 (strongly agree). Higher scores indicate higher levels of these
Figure 1. Changes in PCL Subscale Scores Over Time.
Note: PCL = PTSD Symptom Check List.
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131
FUNCTIONAL ANALYTIC PSYCHOTHERAPY AS AN ADJUNCT TO COGNITIVE-BEHAVIORAL TREATMENTS FOR POSTTRAUMATIC STRESS DISORDER
DISCUSSION
is detailed single case study demonstrates the use of FAP as an
adjunctive intervention to address the problematic interperson-
al behaviors oen found in clients who meet criteria for PTSD.
e cognitive-behavioral treatment applied before FAP was ef-
fective at reducing core symptoms of PTSD (re-experience and
hyperarousal), but the interpersonal problems (avoidance and
detachment symptom cluster) were diminished much less so
and reached plateau. Following the FAP intervention, the inter-
personal aspects of the client’s problems also showed a decrease
on the interpersonal items of the PCL, while the other problem
areas remained clinically improved. e total score on for PTSD
symptom problems decreased over the course of the Stage 1 in-
tervention, but the FAP intervention showed improvement for
symptom-based problems. FAP targeted behaviors decreased
over time during this intervention but show much greater vari-
ability. is can be seen with the Daily Assessments of the cli-
ent’s behavior. e general trend for these data is improvement,
but the variability suggests a need for continued assessment of
both improvement and problem behaviors. Generalizable con-
clusions to other clients diagnosed with PTSD cannot be drawn
from a single subject design such as this. Furthermore, this was
a treatment of long duration and possesses threats to internal
validity that are inherent in any complex time series design.
Confounding variables exist in this type of study that could have
occurred during the course of the treatment, limiting our ability
to make strong assertions related to causality.
Target Behaviors. Figure 3 shows changes in proportions of re-
sponding for problematic and pro-social behaviors for one spe-
cic targeted domain of interpersonal behaviors of the FIAT
(Disclosure). Assessment occurred daily by the client for last 2
months of treatment using FIAT-DA). e proportion of self-
reported improvement and problematic target behaviors are
plotted in Figure 3. ese proportions are the number of re-
ported improvements or problem behaviors for the week divid-
ed by the total behaviors reported for that week. Figure 3 shows
a decrease in the proportional amount of social withdrawal and
declining opportunities for self-disclosure of experience and an
increase in frequency of disclosure of both positive and chal-
lenging aspects of experience. Notice that a decrease in prob-
lem behavior does not dictate that the client would necessarily
improve. e client’s increase in pro-social behavior of disclos-
ing is the necessary indicator of improvement given her case
formulation. Signicant diculties with disclosure can be seen
in Figure 3 for Targeted Assessment 6. ese were addressed
directly in that session (including an aversive reaction by a per-
son the client disclosed to), and improvements were observed in
Targeted Assessment 7, where these problem behaviors for that
week evidenced a oor eect for the measure.
Broad Assessment. Aer initiation of FAP, the client increased
her overall frequency and eectiveness in social contacts. She
was able to maintain complete abstinence from alcohol, she de-
creased utilization of health care services, she evidenced a de-
creased dependence on therapist, and she increased responsibil-
ity for her own choices and well-being.
Figure 2. Changes in Targeted Areas for FAP intervention for Interpersonal Closeness and Avoidance.
Note: PCL = PTSD Symptom Checklist; FIAT-Q = Functional Idiographic Assessment Template-Questionnaire.
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132 PEDERSEN, CALLAGHAN, PRINS, NGUYEN, & TSAI
study. It is possible eects would have been dierent in the rst
phase of treatment if either PE or CPT was used. Both have
demonstrated ecacy and eectiveness in research trials but are
limited by dropout rates and continued symptom expression for
some clients. us, it will be important to examine the ecacy
of FAP-enhanced PE and CPT, specically, to determine if FAP
as an adjunct to these treatments can reduce dropout rates and
avoidance symptoms, promote more generalizable intimacy in
relationships, and enhance trust in others. In the present case
study, the client had multiple traumas (i.e., several sexual as-
saults, physical assault). While PE and CPT focus on one trau-
matic event (i.e., the DSM-IV-TR Criterion A event), FAP may
be particularly useful for complex traumas with multiple events
of assault, molestation, or combat (Kohlenberg et al., 2006) and
for traumatic events that involve interpersonal processes.
We encourage more research with treatments that utilize
FAP techniques before, during, and aer cognitive-behavioral
techniques such as exposure and emotional processing of trau-
matic content. e case study presented here incorporated FAP
principles aer the implementation of cognitive-behavioral
techniques. It is possible that the process of therapy with the
therapist (e.g., exposure to trauma-related memories in ses-
sion) served to enhance the therapeutic relationship and led to
symptom reduction in the later phase assessed. us, there is
a need for research trials comparing FAP-enhanced therapies,
Because empirically supported treatments of PTSD may be
limited in their ability to address complex interpersonal prob-
lems, this single case design supports further exploration of FAP
as an adjunctive or second stage treatment much like those seen
in FAP-enhanced interventions for other behavioral problems.
e focus that FAP brings to interpersonal decits helps de-
crease the understandable detachment and avoidance behaviors
that may result from interpersonal trauma and promotes a more
eective social repertoire.
CONCLUSION
Using a single case study, FAP appeared to be ecacious in re-
ducing symptoms of PTSD related to avoidance through target-
ed work using the therapeutic relationship as a mechanism of
change. It is theoretically possible that FAP-enhanced cognitive
behavioral interventions can promote greater avoidance reduc-
tion and promote emotional closeness with the therapist that
can generalize to other relationships (Kohlenberg et al., 2006).
It should be noted the treatment discussed in this article was a
general cognitive behavioral treatment, and although FAP has
shown to be ecacious when applied to cognitive behavioral
treatments for other disorders (Kanter, et al., 2009; Kanter et
al., 2005; Vandenberghe, & Ferro, 2005), the therapist did not
utilize a PTSD-specic cognitive behavioral therapy in this case
Figure 3. Changes in Proportion of Targeted Behaviors (Disclosure of experience to others) using FIAT Daily Assessments Averaged at 1 Week Intervals During Stage 2
Treatment
Note: Targeted Ass’t = targeted behaviors for assessment (issues related to disclosure).
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133
FUNCTIONAL ANALYTIC PSYCHOTHERAPY AS AN ADJUNCT TO COGNITIVE-BEHAVIORAL TREATMENTS FOR POSTTRAUMATIC STRESS DISORDER
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per lend credence to the treatment of PTSD with FAP, and is
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134 PEDERSEN, CALLAGHAN, PRINS, NGUYEN, & TSAI
AUTHOR INFORMATION
ERIC R. PEDERSEN
Department of Psychology
University of Washington
Center for the Study of Health & Risk Behaviors
1100 NE 45th St, Suite 300, Box 354944
Seattle, WA 98195
Email: epeder@u.washington.edu.
GLENN M. CALLAGHAN
Department of Psychology
San Jose State University
One Washington Square,
San Jose, CA 95192-0120
Email: glenn.callaghan@sjsu.edu
Phone: (408) 924-5610.
ANNABEL PRINS
Department of Psychology
San Jose State University
One Washington Square
San Jose, CA 95192-0120
Email: annabel.Prins@sjsu.edu
Phone: (408) 924-5671
HONG V. NGUYEN
Department of Psychology
University of Washington
Box 351525
Seattle, Washington 98195-1525
Email: hongy2@uw.edu
MAVIS TSAI
Independent Practice and Department of Psychology
University of Washington
Box 351525
Seattle, Washington 98195-1525
Email: mavis@u.washington.edu
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