Using Conceptual Developments in RFT to Direct Case Formulation and Clinical Intervention: Two Case Summaries

Abstract

The current paper is part of an ongoing effort to better connect RFT with the complexities of clinical phenomena. The paper outlines two broad areas, referred to as ‘verbal functional analysis’ and the ‘drill-down’, in which we believe the basic theory is showing increasingly direct application to therapy. The paper also comprises two case summaries in which verbal functional analysis and the drill-down featured strongly in case formulation and clinical focus. Case 1 involves an adult woman who presented with paranoia, had been diagnosed with psychosis, and had an extended history of familial and other abuse. Case 2 describes a teenager who had been placed in foster care, following parental neglect. For comparative purposes and to provide exemplars of similar functional-analytic processes, both case summaries are presented in a similar format. The article attempts to illustrate how therapeutic work can be connected to the basic theory and argues that it will be important in future work to further expand these connections with ongoing developments in RFT.

Full text

Using Conceptual Developments in RFT to Direct Case Formulation and Clinical
Intervention: Two Case Summaries
Yvonne Barnes-Holmes1, John Boorman2, Joseph E. Oliver3, Miles Thompson4, Ciara
McEnteggart1, and Carlton Coulter5
1Department of Experimental, Clinical and Health Psychology, Ghent University, Belgium
2South London & Maudsley NHS Foundation Trust, UK,
3Departmentof Psychology, University College London, UK
4Department of Health and Social Sciences, Faculty of Health and Applied Sciences,
University of the West of England, UK.
5NHS London
Corresponding author: Yvonne.BarnesHolmes@ugent.be
Authors’ Note: The input to this article by the first and fifth authors was supported by an
Odysseus Group 1 grant awarded by the Flanders Science Foundation (FWO) to Prof. Dermot
Barnes-Holmes. All potentially identifying information regarding the case material has been
removed or altered.
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Abstract
The current paper is part of an ongoing effort to better connect RFT with the
complexities of clinical phenomena. The paper outlines two broad areas, referred to as ‘verbal
functional analysis’ and the ‘drill-down’, in which we believe the basic theory is showing
increasingly direct application to therapy. The paper also comprises two case summaries in
which verbal functional analysis and the drill-down featured strongly in case formulation and
clinical focus. Case 1 involves an adult woman who presented with paranoia, had been
diagnosed with psychosis, and had an extended history of familial and other abuse. Case 2
describes a teenager who had been placed in foster care, following parental neglect. For
comparative purposes and to provide exemplars of similar functional-analytic processes, both
case summaries are presented in a similar format. The article attempts to illustrate how
therapeutic work can be connected to the basic theory and argues that it will be important in
future work to further expand these connections with ongoing developments in RFT.
Keywords: Case summaries, RFT, verbal functional analysis, the drill-down
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The current paper outlines two general approaches to psychotherapy, which we refer to
as ‘verbal functional analysis’ and the ‘drill-down’, with two case summaries as supporting
examples. We present these two approaches here because they have been very much
motivated and directed by our knowledge of, and ongoing research activity in, Relational
Frame Theory (RFT). As such, we believe that these two approaches provide good examples
of how RFT is showing increasingly direct application to therapy. Before continuing,
however, we think it is important to articulate three caveats to this claim. First, there is not yet
empirical evidence to support the clinical utility of the two approaches we outline, nor to
indicate that they are more clinically useful than alternative or existing approaches. Second,
the development of our ideas is not complete, they are a beginning -- but they are at a stage
where we think they are worth sharing, based primarily on discussions with colleagues,
clinical supervision, direct work with clients, workshops, and as noted above our ongoing
research activity. Third, these ideas did not emerge directly from recent developments in the
basic science of RFT (such as those outlined in the current volume or elsewhere), and indeed
the casework described here was conducted some years prior to these developments.
We should emphasize that we do not consider what we present in the current paper to
be ‘new’ or ‘different’ from Acceptance and Commitment Therapy (ACT) as it was originally
articulated (Hayes, Strosahl, & Wilson, 1999). In some ways what we present here reflects
how the first author was trained to do ACT. This training commenced in 1998 before the
publication of the first ACT book and in the context of the writing of the first RFT book. At
that time, the scientific model for ACT was not the hexaflex, but in many ways, at least from
the perspective of the first author, it was RFT. It was almost five years later when the hexaflex
was proposed as a model for ACT and, as argued elsewhere, a drift between RFT and ACT
began (Barnes-Holmes, Barnes-Holmes, Hussey, & Luciano, 2016). In this sense, what is
presented here is not new, but old. In other words, the original therapeutic model for ACT, at
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least as it was taught in the mid to late 1990s, was largely functional-analytic, as applied to
human verbal behavior (with “verbal” redefined, in the behavioral tradition, by RFT). In our
view, the relationship between ACT and the ongoing development of RFT, as presented in the
current article, has unfolded organically, and what we present here is simply an extension of
this dialectic between theory and practice.
We recognize that others have recently attempted to present ACT largely in existing
RFT terms with little appeal to the hexaflex or any of the middle-level concepts contained
within it (e.g., Torneke, 2010). And yet others have very recently attempted to directly apply
RFT concepts to psychotherapy, although they introduced new middle-level terms to RFT
itself (Villatte, Villatte, & Hayes, 2015). While there is clearly value in these approaches, and
there will obviously be considerable overlap in this work and ours, we do believe that we are
developing a different approach to what is expressed elsewhere. Rather than applying RFT as
it was articulated in the 2001 book (Hayes et al., 2001) and/or adding new middle-level terms
to the basic theory, we are attempting to extend RFT to psychotherapy without introducing
new middle-level terms. Such an extension is an aspiration to work towards, but we are some
way from reaching that aspired goal. Nevertheless, we felt it appropriate to share where we
are at on that journey in the context of the current volume on conceptual developments in
RFT.
Overview of the Current Paper
The current paper argues that the concept of verbal functional analysis, as well as the
drill-down, highlights key ways in which RFT can be used to guide case formulation and
intervention in clinical practice. For illustrative purposes, the paper comprises two case
summaries. It is important to emphasize that, at the time of writing, both cases were
incomplete. Hence, our intention is not to present a finished piece of work or a comprehensive
illustration of verbal functional analysis and the drill-down in action. However, both therapists
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involved with the cases believed that these approaches offered a valuable means of
understanding their clients’ problems and directing their clinical intervention in an effective
manner.
For the current paper, we selected two very different, but equally complex, cases. Case
1 involves an adult woman who presented with paranoia, had been diagnosed with psychosis,
and had an extended history of familial and other abuse. In contrast, Case 2 describes a
teenager who had been placed in foster care, following parental neglect. For clarity and
comparison, we have structured the case summaries along similar lines. That is, both cases
comprise: a brief review of functional-analytic approaches to the topic if available; referral
circumstances; early history; verbal functional assessment; and therapeutic directions based
on verbal functional analyses. Throughout the case summaries, we provide specific examples
of clients’ own words, therapist statements, and supervisor questions or suggestions. Before
we present the two cases, we will first outline how we define verbal functional analysis and
the drill-down in some detail.
Verbal Functional Analysis
At this point, we should be clear in defining functional analysis to mean a basic
science or application of that science that focuses on operant contingencies and behavioral
principles more generally in attempting to both assess and treat maladaptive behavior. In
contrast, a verbal functional analysis focuses on the functions of stimuli and responses that
possess properties defined as verbal within RFT. In conducting a verbal functional analysis,
we typically, but not necessarily, operate at the level of complex relational networks, rather
than specific relational frames. Of course, specific instances of framing may be of particular
clinical interest (the case summaries contain examples) that may need to be targeted directly.
In our experience, however, conducting verbal functional analyses of relational networks and
their functions generates a sound working understanding of a client’s behavior. Working at the
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level of relational networks also appears to offer direction on how these networks can be
altered to create broad and flexible repertoires of relational responding, where this appears
beneficial. During the course of therapy, specific verbal stimuli may be identified as
participating in complex relational networks that generate narrow and inflexible responses.
For example, the word “shame” (or more precisely the relational networks in which it
participates) may elicit what appear to be subtle defensive reactions on behalf of the client,
such as turning their face away, putting their head down, and even at times questioning the
value of the therapy. As a result, the therapist may identify the verbal stimulus “shame” as
having important functional properties for the client’s behavior in and beyond therapeutic
interactions, and it is these broad properties, and the relational networks in which they
participate, that the therapist seeks to analyze (i.e., a verbal functional analysis).
Before continuing, it seems useful to outline the two main ways in which we use
verbal functional analysis in therapy. Specifically, 1. conducting a verbal functional
assessment; and 2. helping clients to verbally track (see below) the sources of behavioral
control as a core relational skill.
Verbal Functional Assessment
Clients often come into therapy asserting themselves to be depressed, anxious,
confused, worried, addicted, in marital difficulty, etc., which in a sense they are, because these
are exactly the relational networks that the wider culture has established for, and with, them.
Although categorizing and evaluating oneself in these ways may be painful and distressing,
labels such as “depressed” may also have functions of safety, justification, comfort, and so on.
As such, these verbal stimuli/responses have appetitive as well as aversive functions.
In conducting a verbal functional assessment, we often think in terms of a distinction
between less and more aversive relational networks in which the deictic-I1 participates. That
1 We use the term deictic-I to refer to the verbal self which emerges from a history of arbitrarily applicable
relational responding that typically involves learning to respond appropriately to self-referential terms (e.g., “I”,
“myself”, “me”).
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is, the less aversive networks have dominant approach or S+ functions (similar to moving
toward something), while the more aversive networks have dominant avoidance or S-
functions (similar to moving away from something). This distinction has some overlap with
distinctions suggested by Polk and Schoendorff (2014, see also Hayes et al., 1999, Hayes,
Strosahl, & Wilson, 2012; and Strosahl, Robinson, & Gustavsson, 2012).
Now consider a client who comes into therapy with problems surrounding anger.
Categorizing himself as “angry”, although itself distressing, may facilitate avoidance of a
more complex long-established issue, such as fear of rejection. Verbal functional assessment
allows the therapist to separate out the S+ and S- functions of this type of self-labeling. For
example, “angry” may have more positive emotional functions than “rejected”. Indeed, by
describing himself as “angry”, this client enables himself to avoid the more accurate
(functionally speaking) description of his behavior as involving fear of rejection. To simplify
using our example, we might refer to ‘angry’ and related self-evaluations as the S+ networks
(with both aversive and appetitive functions), while referring to ‘rejected’ as the S- networks
(with largely aversive functions). Relatively speaking, this makes it possible that the client’s
engagement with the S+ networks actually serves to reinforce avoidance of the S- networks.
In therapy, we use verbal functional assessments to guide our first steps toward dealing with
the S+ (e.g., angry) networks, because clients engage with these more readily, and thus the
therapist’s move in this direction will seem less confrontational. We are nonetheless cautious
that engagement with S+ networks likely continues to facilitate avoidance of the S- networks.
We then orient much more carefully toward the S- networks, where client defense and
challenges to the therapeutic relationship are most likely. In order to harness the behavioral
‘momentum’ previously established in the therapeutic interactions surrounding the S+
networks (during the verbal functional assessment), the therapist uses verbal functional
analyses to establish causal or if-then relations between these two sets of networks. Returning
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to the example above, the therapist might say something like, “Being angry must make it hard
for people to get close to you”. For the client, this statement relates the S+ and S- networks
for the first time, perhaps facilitating a transfer of the less aversive functions of the ‘angry’
networks to the more aversive (‘rejection’) networks, in so far as the client becomes more
willing to talk about rejection. To further this move, the therapist might say, for example,
“What if rejection lay at the end of this line of anger? How much more angry will you get if
you push loved ones away? What if being angry could cause this to happen? If you had to
choose between being angry and being rejected or alone, which would you choose?”
Overall therefore, the primary purpose of verbal functional assessment is to identify
verbal stimuli or responses that participate in specific relational networks for the client that
possess, broadly speaking, approach and avoidance functions. Doing so facilitates establishing
a strong therapeutic relationship that allows the therapist to focus on issues that may be highly
sensitive for the client, and which if broached too early in therapy could undermine the
relationship. In a more general way, getting the client to engage with issues they have tended
to avoid is important for moving toward building the psychological flexibility required for
what we describe in the next section as verbally tracking sources of behavioral control.
Verbally Tracking Sources of Behavioral Control as a Core Relational Skill
We believe that an individual’s ability to verbally track2, in an accurate and ongoing
manner, the sources of control over their own behavior (internal and external) is foundational
in establishing what we loosely describe as a sense of self. This overlap between behavior and
the sources of control is illustrated in the intersection between the circles in the Venn diagram
2 In using the term verbal “track” or “tracking”, we are not invoking the concept “tracking” as a type of rule-
governed behavior, as described in Hayes et al. (2001). Instead, we use tracking to refer to a client’s ability to
monitor the way in which their own behavior, including thoughts and feelings, is influenced by ongoing events
in their environment. In this sense, tracking may be interpreted as broadly similar to what Villatte et al. (2015)
refer to as “context sensitivity” (p. 53). We should add that we find neither concept (tracking or context
sensitivity) entirely satisfactory and anticipate that we will replace “tracking” in due course by appealing to the
dynamics of arbitrarily applicable relational responding, as articulated in a multi-dimensional, multi-level
framework (i.e., the MDML) presented in the current volume (Barnes-Holmes, Barnes-Holmes, Luciano, &
McEnteggart, in press).
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in Figure 1. Using more technical language, we would say that clients show deficits in the
ability to relate the deictic-I, and the relational networks in which it participates, to the
networks of events that functionally relate in some causal manner to the deictic-I itself.
Figure 1. Verbal tracking of the sources of control over behavior.
Consider an individual who feels angry after a bad day at work and tells herself on
such occasions that this is her partner’s fault for not providing her in general with the life she
wanted. This client’s statement, for example, “I’m angry and it’s all his fault” shows limited
verbal tracking in that she does not seek to determine the more immediate cause of her anger
on that occasion (i.e., a bad day at work). Indeed, perhaps for this client, most of her negative
emotional reactions participate in hierarchical relations with her partner (most are attributed to
him), and this strategy on her behalf has also led to a sense of lack of agency regarding
directions she wants for her own life (e.g., she may say “he stops me from doing things I
want”) and feelings of resentment, inadequacy, and frustration. As a result, the client persists
in keeping all of these emotions to herself, rather than sharing them with her partner. The
therapist might engage with this client in a verbal functional analysis of these ongoing
emotional experiences by exploring the range of possible labels (including “anger”,
“resentment”, and “frustration”) and the relational networks in which these participate.
Ideally, therapy would lead to the client, in a similar situation, being able to say to herself “I
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feel angry today, I’m not sure for now where this is coming from, so I must be careful not to
take it out on my partner, but perhaps we could talk about it together”.
In establishing verbal tracking of the causal relations between the emotional reactions
of the deictic-I and other relational networks (e.g., a bad day at work), it also appears to be
essential that these two sets of networks come to participate in a hierarchical relation (e.g.,
recognition that a bad day at work is just one of the many things that can happen to the
deictic-I). Specifically, the networks of the deictic-I should contain the networks that relate
causally to ongoing behavior. In simple terms, this enables the deictic-I to choose when,
where, and with whom to behave in a particular manner. In the example above, the client
could choose when to talk to her partner about her feelings and when not, because some of
these emotional experiences relate to him directly and some do not. In this way, the therapist,
using verbal functional analyses, aims to build broad and flexible relational repertoires with
respect to choosing, so that the client (the deictic-I) is not a victim of capricious contextual
variables, but gains a sense of control, if not over her environment, but over her reactions to it
(for empirical analyses of hierarchical relational responding, see Foody, Barnes-Holmes,
Barnes-Holmes, & Luciano, 2013; Foody, Barnes-Holmes, Barnes-Holmes, Rai, & Luciano,
2015; Gil, Luciano, Ruiz, & Valdivia-Salas, 2012; Gil-Luciano, Ruiz, Valdivia, & Suarez,
2016; Luciano, Rodriguez, Manas, Ruiz, & Valdivia-Salas, 2009; Luciano, Ruiz, Vizcaino-
Torres, Sanchez-Martin, Gutierrez-Martinez, & Lopez-Lopez, 2011; Ruiz, Hernandez, Falcon,
& Luciano, 2016; Torneke, Luciano, Barnes-Holmes, & Bond, 2016).
The Therapeutic Relationship: The Drill-down
At this stage, it seems important to emphasize that conducting verbal functional
assessment and analyses typically involve building a strong therapeutic relationship, which
should form a part of verbal functional analysis itself. For ease of communication, we cover
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this feature of therapy in a separate section, and use the metaphor of the drill-down to describe
the therapeutic behaviors involved in this strategy.
The therapeutic aims of the drill-down involve building increasingly strong repertoires
of relational responding between the deictic-I and what we describe as deictic-Others (i.e.,
loosely speaking, teaching the client to improve their perspective-taking skills).
Developmentally, the deictic-I is established in a shared and highly cooperative context in
which significant others literally construct this verbal sense of self, with you and for you. Very
young children, for example, often fail to distinguish themselves verbally from others, but
gradually through verbal contingencies, they learn to talk about themselves as separate
psychological entities, with private psychological worlds. When this ‘shared’ and
‘cooperative’ context with significant others in childhood contains high levels of what we call
relational incoherence, the relationship between the deictic-I and deictic-Others, almost by
definition, becomes unstable, unpredictable, and discontinuous (see Kohlenberg & Tsai, 1991
for a similar approach on the formation of ‘problematic selves’).
For example, imagine a child who is told at one moment that she is loved and
cherished by her parents and is then abandoned by them when they go on an alcoholic binge
for days on end. Verbally, the relations among the deictic-I HERE and NOW are, by
definition, rendered unpredictable and discontinuous in the sense that the “I” who was loved
and cherished in one place and time was subsequently abandoned. When the coherence among
the three elements of the deictic-I (I-HERE-NOW) is weakened in this way, the extent to
which it can be used as a superordinate locus from which to relate hierarchically with all of
the child’s psychological events is severely undermined. In other words, for the I to function
as a constant locus, from which to view one’s psychological world, it must develop in a
relationally stable and consistent environment. Critically, the absence of this type of
environment may also fail to establish a deictic-I that is clearly verbally distinct from others.
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The individual who grows up in this type of environment may literally state in therapy years
later “I have never really known who I am”. For the client, this is not rhetoric or metaphor.
This very statement is in the broad functional class of verbal relations in which they were
raised as children.
When an individual grows up with a verbal history in which the relationship between
the deictic-I and deictic-Others involved high levels of relational incoherence, the distinction
between I-HERE-NOW and OTHERS-THERE-THEN may fail to emerge (McEnteggart,
Barnes-Holmes, Dillon, Egger, & Oliver, 2017). We have argued that the outcome of such a
history may manifest itself in numerous ways. For example, a client may literally hear their
own thoughts as the voices of others that are not actually present. Alternatively, clients may
self-criticize using the phrases, and even the tone of voice, that their neglectful or abusive
parents employed decades ago. Relationally, the voices and behaviors of others that were
THERE and THEN are experienced as if they are HERE and NOW. Any attempt, in this type
of context, to establish the deictic-I as a constant and separate (from others) locus would be
difficult.
Our core argument is that the therapist needs to establish with the client a therapeutic
relationship that provides the predictability and consistency (i.e., relational coherence with
respect to the deictic-I) that were absent with significant others. This commences, in a sense,
with the therapist attempting to provide the highly shared and cooperative verbal context in
which a clearly distinct deictic-I is gradually established. This strategy is perhaps paradoxical
because it starts by coordinating the deictic-I (the client) with the deictic-Other (the therapist).
For example, a therapist at this point might say phrases like “I can completely understand
that”, “If I were you, I would have done exactly the same”, “I can see how lonely you must
feel”, and “Anyone in your situation, would react that way”. This can be a highly challenging
therapeutic context for the client, but also for the therapist. It is challenging for the client
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because many of the overarching functional classes of behavior (such as disclosing private
events, being vulnerable, accepting another person’s perspective and potential disapproval)
that were present in perhaps a highly aversive and threatening family environment may be
evoked in therapy. It is challenging for the therapist because they must provide the stable,
consistent, and reliable relationship that the client missed out on to this point. Indeed,
experienced therapists are often noted for their abilities to ‘absorb the perspectives of their
clients’ in a rich and full way (i.e., without pulling back, or being reactive or defensive). In a
sense, the therapist seeks to establish specific contextually controlled coordinate relations that
always remain relationally coherent between the client’s deictic-I and the therapist’s deictic-I,
the purpose of which is to build trust and a sense of safety for the client in the therapeutic
relationship. We are not suggesting that there is full coordination between I and Others
(therapist and client). Rather, the therapist must, to some extent, see what the client sees,
feels, etc., but always within the context of hierarchical relational responding from the
therapist’s deictic-I.
Central to the therapeutic relationship is the establishment of a relational repertoire in
which the client learns to relate the deictic-I located HERE-NOW to the deictic-I located
THERE-THEN. Metaphorically speaking, the therapist is taking the client by the hand and
sharing with them how it is possible to talk about the deictic-I in different ways. The therapist
may achieve this by coordinating the therapist’s deictic-I and the client’s deictic-I (both
located HERE and NOW), so that they, metaphorically speaking, share their perspectives in a
cooperative way on the client’s deictic-I as located THERE and THEN. All events, including
the client’s deictic-I located THERE-THEN now become, if only momentarily, an ‘it’, an
‘event’, or a ‘something’, that is separate from both the client and the therapist as coordinated
deictic-Is located HERE-NOW. In other words, the client and therapist sit together and
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develop a perspective on the client’s sense of self as an event or object that can be observed
and talked about, in a variety of ways.
As argued above, the drill-down is intertwined with verbal functional analyses.
Specifically, the drill-down focuses on relational processes that appear to be central to what is
often called the therapeutic alliance (see also Kohlenberg & Tsai, 1991). For us, the drill-
down metaphor works as a way of describing how we use the therapeutic relationship to ‘dig
deeper’ in a verbal functional sense into the self (we often say “drilling down into the
deictics”). For example, a verbal functional assessment might identify ‘shame’ as a critically
important verbal stimulus for a client. In doing so, verbal functional analyses allow the
therapist to assess the therapeutic relationship itself. A concrete example of this might involve
the therapist asking the client if they are willing or ready to explore the impact that the word
“shame” has on the client when uttered by the therapist. An affirmative response from the
client sets the scene for further verbal functional analyses. For example, the therapist might sit
next to the client and say “If I was you, I would have shame too”. The important point to
recognize here is that verbal functional analyses and the drill-down are dynamical in that they
should ebb and flow with each other in the course of therapy.
We fully recognize that training therapists to master the highly dynamical interplay
between verbal functional analysis and the drill-down may be challenging. In line with RFT
itself, it seems that an appropriate method for successful training in this regard is to provide
multiple exemplars of case supervision that involved this dynamical interplay. In the second
half of the current paper, therefore, we present two such exemplars (i.e., case summaries).
SUPERVISED CASE SUMMARIES
This latter half of the paper comprises two case summaries in which verbal functional
analysis and the drill-down featured strongly in case formulation and clinical focus. At the
time of writing, both cases were incomplete, but the focus on the two key strategies is clear.
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Case Summary 1: Adult with Paranoia
Functional-analytic Approaches to Paranoia
Recent approaches to paranoia, from a functional-analytic perspective (e.g., Stewart,
Stewart, & Hughes, 2016) and within ACT (e.g., Oliver, Joseph, Byrne, Johns, & Morris,
2013) have focused on sufferers’ reactions to their own experiences. For example, there is
evidence that experiential avoidance mediates, at least in part, the relationship between early
developmental experience and paranoia (Udachina, Varese, Myin-Germeys, & Bentall, 2014).
In short, the impact of a paranoid experience may depend upon how the individual reacts to it,
such that attempting to avoid the experience potentially makes its occurrence in the future
more (rather than less) likely, more frightening, and more believable.
Referral Circumstances
Marie was in her mid-40s when she first attended a community psychosis service in
the United Kingdom (UK). She was referred after a brief hospital admission for anxiety and
paranoia experienced in public. She reported frequent threatening “incidents”3 in which
members of the public (usually male) looked at, or gestured to her in an unusual or ambiguous
manner. These events made her feel extremely anxious and she typically responded by leaving
the situation or occasionally confronting the individual. The perception of these incidents
commenced several years earlier following a burglary at her apartment, and a mugging against
her that occurred shortly thereafter. Because of her anxiety and hypervigilance to threat cues
in public, Marie had become isolated and withdrawn, with only sporadic contact with several
friends and with her family who lived in a different city.
Marie concluded that the various incidents represented an organized conspiracy
(among local men, including a particular neighbor) to threaten, imprison, or kill her. Although
puzzled by this possibility at first, she concluded across time that the conspirators must see
her in an extremely negative light, such as depraved, like a “witch or a pedophile”. She
3 Speech marks indicate client’s own words throughout.
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believed that drawing attention to herself in public always led to this type of negative
perception of her by others. For example, on a recent bus journey, Marie experienced a sexual
response to the close presence of a teenage girl. Because she caught the girl’s eye, Marie
immediately became fearful that other teenagers nearby believed her to be a “predatory
lesbian pedophile”.
After events such as those concerning the teenager on the bus, Marie typically
withdrew from going out in public for an extended period in an attempt to protect herself and
to try to make sense of these experiences. These periods of withdrawal were associated with
low mood, and difficulties in maintaining social contacts and routine activities, particularly
employment. This pattern culminated in her quitting her local government job to go travelling
for several months. During her travels, her mood improved and her anxiety lessened, but upon
her return, her perception of threatening incidents recurred and rendered her unable to look for
work. During this period, she felt extremely low and isolated, and this eventually precipitated
her hospital admission.
Marie described a deep sense of loneliness and despair as her situation seemed to
worsen. She could not see how to prevent further psychological deterioration or social
isolation, or to move herself forward in life. Specifically, she felt utterly worthless at being
single and unemployed, and worried a great deal about her family’s critical judgements of her
in these regards. At times, she also felt “disgusted” with herself and recalled similar feelings
from her early childhood.
Her goals for therapy were to develop coping strategies to manage the anxiety
associated with threatening incidents. She wanted in time to return to work and increase her
circle of friends. Although she seemed highly convinced of the reality of her experiences, her
help-seeking behavior suggested some variation in her levels of conviction in this regard.
Early History
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Marie was born in a rural area in Asia. She had two older brothers. Although she
described her parents as uneducated and very traditional, the family emigrated to the UK for
stable factory work when she was aged two. Here, they continued to live within a tightly-knit
Asian community with similarly-employed families. Marie’s relationship with her parents was
distant and one in which she felt “unrecognized”. She recalled childhood incidents that
confirmed her lack of value to them and contrasted starkly with the value they placed upon
her brothers. She broadly recognized as an adult that elements of this differential treatment
were cultural.
Marie’s early enjoyment of various activities and sports also contrasted with her
parents’ narrow perception of her primary domestic duties, especially looking after familial
males. She recalled that her own needs were disregarded and that she felt “like a piece of
furniture, rather than a person”. In addition, her family was heavily dominated by her
grandfather, who was also influential within the wider community. The family (especially
Marie) all feared this individual who was extremely punitive and controlling. She recalled a
number of harsh and cruel incidents between the grandfather and various family members,
against which both of her parents seemed powerless.
These childhood family circumstances contrasted sharply with early adulthood when
Marie went to university against her parents’ wishes (at that time in the UK attendance at
third-level education was entirely supported by the State). This was a significant period in her
life when she flourished and enjoyed a very active social life. During this period, she was able
to renegotiate aspects of her relationship with her parents and became much closer to her
mother, although they did not speak at that time about her painful early experiences.
Verbal Functional Assessment
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Our aim in this section is to illustrate the verbal functional assessment undertaken with
Marie and how we used this to conceptualize her case in a manner that would then facilitate
therapeutic intervention including ongoing verbal functional analyses and the drill-down.
Inability to verbally track sources of behavioral control. At the beginning of
therapy, Marie was almost completely unable to verbally track the sources of control over her
behavior. For example, she reported that she didn’t like older men who wore dark glasses, but
could not explain why. In a sense, Marie was highly emotionally unstable and reactive, but
was often confused about the source of these emotions.
Multiple deictic-Is. Marie’s inability to verbally track the networks that controlled her
behavior appeared to perpetuate the lack of an overarching sense of a unified self. Indeed,
after some time in therapy, it appeared that she vacillated from one pattern of deictic-I
responding to another (hence, these were not organized into overarching coherent relational
networks). In short, verbal functional analyses appeared to reveal what we referred to as two
largely separate networks of deictic-Is.
The first deictic-I relational network we labeled as ‘deictic-I as victim’. In this, Marie
perceived herself to be a victim of a threatening plot by (mostly older) men in her vicinity. For
this deictic-I, Marie’s actions were strongly controlled by paranoia and fear, which she ‘dealt
with’ by concluding that she deserved the violent reproaches of others. Although elements of
this deictic-I network were aversive, other elements were appetitive because it explained for
Marie her fear of others and need for withdrawal in the interests of self-protection, hence no
confusion was experienced in how she should act in a given situation, nor in terms of how
others were perceiving her (i.e., she was sure they were horrified by her).
In contrast, the second deictic-I was judgemental, negative, harsh (e.g., “I am”...
“worthless”, “weak”, and “bad”), and even extreme (“I’m depraved”). In this network,
Marie perceived herself as a type of dangerous perpetrator (a “pedophile”) who posed a risk to
18

others (this is how she described the incident with the teenage girl on the bus). Hence, when
responding as ‘deictic-I as perpetrator’, Marie reacted to deictic-Others (especially young
females in close proximity to her) as her potential ‘victims’. Verbal functional analyses
suggested that, for Marie, this was the less aversive deictic-I network because Marie talked
about herself in this way regularly and openly. It is also important to emphasize that when
Marie was responding as deictic-I as victim, there was an almost complete lack of transfer of
functions from this network to the deictic-I as perpetrator network, or vice versa. More
informally, there appeared to be no relationship at all between the two deictic-Is. Hence, it
was practically impossible, early on, for the therapist and the client to track the contextual
variables that determined the almost complete dominance of one deictic-I network over the
other.
Vulnerability in relating deictic-I as victim-HERE and NOW with deictic-I as
victim THERE and THEN. As noted above, Marie’s deictic-I as victim appeared to have
appetitive functions (because as a victim she knew how to behave). On balance however, she
was unable to verbally track the influence of her childhood trauma on her current paranoia.
Thus, the therapist made statements such as: “It seems to me that you are just as much a
victim now as you were when you were young”. More technically, the aim was to establish a
deictic-I as victim THERE and THEN that was causally related to the deictic-I as victim
HERE and NOW. Marie reacted negatively to these statements and indicated that she felt
highly vulnerable, unsafe, and unsure about how to react. She tended, by contrast, to focus
heavily on the injustice of her past trauma. It became clear at this point that therapy needed to
focus on the therapeutic relationship in terms of coordinating Marie’s deictic-I as victim
HERE and NOW with the therapist’s deictic-I HERE and NOW, in approaching Marie’s
deictic-I as victim THERE and THEN. The reader should note, therefore, that sometimes
when working with S+ networks (in this case, Marie as victim), important aversive elements
19

may be identified unexpectedly and thus, as mentioned earlier, the therapist needs to ebb and
flow between verbal functional analyses and the drill-down.
Therapeutic Directions Based on Verbal Functional Assessment
The drill-down. In establishing the therapeutic relationship, the therapist focused
continually on providing Marie with a safe, highly shared, and cooperative therapeutic
environment. Marie appeared to find this emphasis on safety and sharing with a male therapist
highly challenging to begin with. Nevertheless, the target in therapy was to gently coordinate
Marie’s deictic-I with the therapist’s deictic-I, using many, many phrases, such as “I can
completely understand that” and “That sounds terrifying”, even when discussing Marie’s
more paranoid perceptions (i.e., the conspiracy against her). Consider the following
statements discussed in supervision as a format for the drill-down.
If I were you in such a situation, I would have felt utterly alone, unwanted, and unloved. I'd
like you to help me understand this here. I want to get a sense of the things you say about
yourself to yourself. I'm so glad you told me. That must have been so hard. It’s so good to
share this kind of thing. Notice that I am still here, and sharing this is OK.
In working on the therapeutic relationship, the therapist sought to coordinate Marie’s
deictic-I as victim HERE and NOW with the therapist’s deictic-I HERE and NOW in order to
establish a causal relation between Marie’s deictic-I as victim HERE and NOW and deictic-I
as victim THERE and THEN. More informally, the purpose was to help Marie to learn to
verbally track the influence of past trauma on current paranoia. In this particular case, the
therapist first focused on coordination between the two deictic-I as victim networks (HERE
and NOW and THERE and THEN), with many questions such as “You must have been so
lonely as a child? You must still be so lonely now?” This initial focus on coordination was
necessary because Marie found it difficult to even see a connection between these two aspects
of deictic-I as victim, and thus it would have been difficult to move on to causality and verbal
tracking. Indeed, this focus on coordination marked a critical turning point in therapy and
20

greatly facilitated Marie in learning to verbally track the influence of her past trauma on her
current paranoia. Thereafter, the therapist was quickly able to establish a hierarchical relation
with regard to deictic-I as victim, such that Marie could choose to act even when she felt
paranoid and victimized (e.g., by encouraging her to leave the house to get shopping even
when she had seen a neighbor who she perceived to be threatening in the street earlier that
day).
Once verbal tracking in deictic-I as victim networks was established, the therapist
began to explore the more aversive deictic-I as perpetrator network. Therapy focused on
enabling Marie to verbally track the variables that evoked perpetrator-related behaviors (e.g.,
when a stranger’s glance was interpreted as suspicion that she may be a pedophile). The
therapist then introduced elements of hierarchy by exploring ways in which Marie could
choose to act even when she experienced shame or paranoia that others had detected her
perceived guilt. For example, after the bus incident with the teenage girl (described earlier),
we explored the numerous possibilities of how the girl and her friends perceived the
experience. The therapist then discussed the fact that Marie could choose to act based on her
own choices and not based on the many possible interpretations others could have had about
their experiences with her.
Having begun to explore both deictic-I as victim and deictic-I as perpetrator, we
started to establish distinction relations between these two as a move towards ultimately
establishing hierarchical responding over both networks. Consider the following statement
suggested to the therapist during supervision, and designed to relate the two networks for the
first time.
I can see how you can feel like a wicked perpetrator in one moment and yet be frightened and
victimized the next.
21

When verbal tracking of the sources of control over Marie’s behavior as both deictic-I
as victim and as perpetrator was established, the therapist began to focus specifically on
contexts that facilitated ‘switching’ from one deictic-I to the other. Only by doing so, could
the therapist create a singular overarching hierarchical deictic-I who could choose to act. This
was achieved by asking Marie across several sessions to identify which deictic-I was
dominant: presently, five minutes ago, at the beginning of the session, yesterday, etc. We
explored many such exemplars, including the numerous functions attached to each of the two
deictic-Is. Indeed, the therapist identified several points in session when Marie appeared to
“switch” from one deictic-I to the other. For example, when discussing how Marie’s potential
victims are not real victims (because she never had, and in her own view never could, actually
inflict harm on another human being) Marie would often “switch” from perpetrator to victim.
The therapist discussed these switches openly, and highlighted for Marie ways in which she
could respond hierarchically from a stable and consistent deictic-I that could track the
‘switching’ itself, without either network controlling her behavior. At the time of writing,
therapy continued with Marie in working towards establishing a stable and consistent deictic-I
that contained the two deictic-I relational networks that we have labeled ‘victim’ and
‘perpetrator’.
Case Summary 2: Minor in Care
A Functional-analytic Approach to Children in Care
‘Looked after children’ (LACs) are removed from their familial homes, at least
temporarily, and placed in care (Department for Education, 2015), and many are also
categorized as needing protection from neglect (Bentley, O’Hagan, Raff, & Bhatti, 2016).
Numerous treatment paradigms have attempted to address the emotional and behavioral
difficulties that accompany living in care, and some of these appear to be functional-analytic
22

in orientation (e.g., Prather & Golden, 2009), but at the time of writing the ACT literature on
working with children in care was limited (but see Hayes & Ciarrochi, 2015).
Referral Circumstances
Charles was 15 years old when he was referred to a local child and adolescent mental
health service in the UK. The referral resulted from the teenager expressing thoughts of self-
harm and suicidal ideation to a schoolteacher, and the school raising broader concerns about
the teenager’s care. As part of the Local Authority’s subsequent investigation, Charles
allegedly stated that he should be taken into care because his mother’s substance misuse
rendered her unable to care for him. There were reports that his biological mother had been a
‘functioning’ opiate user for 20 years, and that his father experienced substance misuse and
mental health issues. Following the investigation, Charles was placed on a Child Protection
plan under the category of neglect, and his mother agreed to a voluntary placement order with
a foster carer. He lived predominantly with a highly experienced foster mother, but continued
to see his biological mother on a weekly basis. At the beginning of therapy, Charles had been
in care for eight months. The lead therapist who undertook the therapeutic work with Charles
became involved as part of the local authority referral to the Child and Adolescent Mental
Health Service. Additional information was made available from Charles’ key worker and an
adolescent psychotherapist’s report highlighting key issues. The therapist conducted a total of
seven sessions with Charles’ in his role within the Child and Adolescent Mental Health
Service.
Early History
Part of the local authority investigation queried the possibility of in-utero brain
damage resulting from maternal drinking and heroin use, but there was no medical evidence
to support this. In addition, there was no evidence of developmental disability or delay.
Charles’ biological mother reported that he had been head-banging since birth, and wore a
23

helmet to prevent injury. However, no head injuries or loss of consciousness had been
reported.
Charles is an only child. His parents apparently separated when he was eight years old,
although he could not recall ever living alone with his parents as a family unit. He
subsequently described moving home often. He had lived with both sets of grandparents at
various stages, but finally lived alone with his mother when he was 13. He had always had
close proximity to extended family on both sides. Charles’ mother was described as “quiet”.
Although reported as a somewhat neglectful parent, Charles emphasized that she “respected
my space”. He spoke very rarely of his father, occasionally describing him as “a nobody”.
Charles’ paternal family were of mixed Asian heritage, although Charles had spent all
his life in the UK. The maternal grandfather is believed to have long-standing involvement
with organized crime and had a dominant role in the family. Charles’ father was also
reportedly involved in organized crime as a result of involvement with his ‘father-in-law’.
Charles’ maternal uncle frequently collected him from his mother’s house, drove him around,
and gave him money and gifts, all of which were referred to by Charles as among numerous
“family secrets”. For example, Charles’ mother forbade him from telling his father’s side of
the family that he was in care (hence, he could not be driven home by them to the foster
home).
School. There had been sporadic school reports that Charles head butted and punched
walls, usually after being teased by peers. Several such incidents were reported shortly before
he was placed in care. Charles appeared to be managing academically. However, given that
academic success is highly valued in his familial culture, he felt ongoing pressure in this
regard (he stated that he was the most “stupid” of his cousins and was “not good at maths”).
On balance, he liked creative activities and recognized his own achievements in drawing, art,
24

and cooking. He reported feeling culturally isolated at his school, a sense of loneliness that
was exacerbated by being in care.
Verbal Functional Assessment
Inability to verbally track sources of behavioral control. The deictic-I relational
network for Charles was coordinated strongly with being in care. Being in care had many
negative evaluative functions and these functions transferred to the deictic-I in the sense that
Charles would say “Only bad stuff can happen to me because I’m in care”. Critically,
however, Charles showed little verbal tracking of the impact of these negative evaluative
functions on his behavior. For example, he did not connect his aggressive outbursts at school
to being in care.
Early in the verbal functional assessment, it became clear that the more appetitive
relational network for Charles involved anger (i.e., toward himself and others, particularly
adults), hence the therapist strenuously steered away from adult-like instructive or pedantic
dialog. This was often done with questions such as “You tell me what you think?” and I’m not
sure about that, what would you say about it?” Consistent with our previous examples, the
drill-down thus involved gently coordinating Charles’ deictic-I with the therapist’s. This was
bolstered by some non-specific disclosing by the therapist and statements such as those below
which were discussed in supervision.
If I was in your shoes right now, having experienced all that you have gone through, I would
also be feeling the same way. I can see that this is so difficult for you. I can see the pain on
your face. No-one seems to be really listening to your views. People are offering you
solutions, giving you advice, but I promise, in here, I will totally listen to your views. I know
when things have been out of control in my own life, I find them very scary. But it also makes
me incredibly angry, and I often don’t know why I’m angry, I just know that I am angry and I
can’t see how it would be any other way.
During the drill-down, using the types of statements above, Charles started to cry, but
did not become angry. As a result, the therapist gently introduced the word “vulnerable” and it
immediately became clear that the functions of the word were extremely aversive. Indeed,
25

when the word was first introduced, Charles quickly fell asleep, thus literally avoiding the
therapeutic interaction. Initially when this occurred, the therapist allowed Charles to sleep for
around 20 minutes before gently waking him.
Vulnerability in relating deictic-I HERE and NOW with deictic-I THERE and
THEN (future). As noted above, the relational network containing ‘anger’ appeared to have
appetitive functions, but the network in which ‘vulnerability’ participated had predominantly
aversive functions. The therapist used the drill-down to gradually decrease avoidance
responses to ‘vulnerability’ by focusing initially on ‘anger’. In doing so, Charles talked at
length about the future (e.g., “I can’t see my future will ever be happy”, “I watch films and see
happy endings and wonder whether that will be for me”, and “I look at Facebook and see
friends from the past looking really happy and I envy them. They are at the next level [of life’s
game] whilst I am stuck on this [unhappy] level. I wish I could be like them”). The therapist
interpreted this as avoiding the aversive functions of vulnerability in the present by focusing
on the future. In the ebb and flow between verbal functional assessment and the drill-down,
the therapist used statements such as the following, as discussed in supervision, to help
undermine avoidance of the present by focusing on the future.
What I often notice when you come into our sessions is that life is tough for you at the
moment. You seem tired and you see others as having it much easier. Perhaps most do at
present. I noticed that you were speaking about how you watch a film, and there always seems
to be a happy ending, and I see how you compare yourself with this. Yet here you are now,
coming to talk to me about these frustrations, opening up to me, someone you don’t really
know. I also see that despite all this, you are still going to school now.
Relating his biological and foster mothers as deictic-Others. Having helped
Charles begin to talk about both anger and vulnerability, thereby undermining the avoidance
functions of these stimuli in the present (i.e., for the deictic-I HERE and NOW), the therapist
continued to focus on both (anger and vulnerability). This strategy was adopted because
Charles started to talk for the first time about his biological mother (whom he refused to talk
26

about initially). In spite of her neglect, Charles spoke positively about his biological mother
(e.g., he continually emphasized the fact that she “gave me space”), and yet he spoke harshly
about his foster mother who provided him with a warm, caring environment (“I can't cope
with the current situation. This is worse than the drug stuff. [I’d] rather be in a family hunted
down by gangs than be in this house”). This issue concerning the two maternal figures was
explored in supervision and the following questions were posed to the therapist to consider.
How does he describe the key relationship with his mother? What does he say about his
relationship with the foster mother? It seems as if he somehow connects the two mothers
together? Is there any sense in which the two mother figures could be opposites? Would you
say that the more attentive the foster mother is, the more he rejects her?
Subsequent verbal functional analyses during therapy indicated that Charles did
indeed relate the two maternal figures in opposition to each other. That is, when positive
functions were attached to the foster mother (e.g., when she was kind to him) he found this
highly aversive, because this established negative functions for his biological mother. The
paradoxical aversiveness of the caring foster mother relative to the biological mother’s neglect
became the focus of ongoing therapy.
Therapeutic Directions based on Verbal Functional Assessment
At this point in therapy, several sessions had been devoted to conducting the
functional analyses that permitted our understanding of the relations between the two mothers,
and thus we had little remaining opportunity to address this issue in terms of intervention.
Nevertheless, the therapist’s initial attempt to do so involved the following statements, as
discussed in supervision.
You seem often to be angry towards your foster mother? And I noticed how you often
highlight how she is different from your mum, including how she is often asking you to do
stuff, and not giving you any peace and quiet. Is that different from how your mum was
towards you?
When these statements were emitted by the therapist, Charles was invariably non-responsive,
although at this point in therapy he was engaging with the therapist actively in many other
areas. The therapist, therefore, used the strong therapeutic relationship that had been
27

established with the drill-down to gently encourage Charles to talk about the two mothers
comparatively, with a particular focus on how he was reacting to them. The overarching
purpose here was to begin to establish verbal tracking of the sources of control over his
behavior in the context of comparing the two mothers. At this point in therapy, the therapist
no longer had access to Charles because he was moved to a different part of the social
services system, which is standard practice and did not reflect upon the therapy that was
undertaken with Charles.
General Conclusions
In the first half of the current article, we aimed to provide an RFT-based account of the
verbal functional analyses that characterize the way we have come to do therapy. The therapy
itself, and the ways in which we have sometimes talked about it, could not be considered
strictly-speaking a purely bottom-up approach in the sense that they were derived from RFT
and nothing else. However, in our view, the therapeutic work has remained closely connected
to RFT and we continue to strive to build those connections further. Indeed, this very article is
an example of that aspiration. As we continue this work, it will be important to further expand
the conceptual links with recent developments in RFT, such as the MDML framework
(presented in this volume) for analyzing relational responding. Equally, it will be important to
connect the RFT analyses presented in this paper with the therapeutic work that is conducted
with actual clients.
In an effort to show how this might be done, the second half of the current paper
attempted to illustrate the close integration between RFT-based analyses and clinical
intervention directed by these in a case study format. Specifically, we employed the concepts
of verbal functional analysis and the drill-down to guide both our case formulations and
therapeutic intervention. The two cases selected were intentionally complex and diverse to
show that these concepts at essence are functional-analytic and thus applicable to all aspects
28

of verbal psychological suffering. While neither case reached clinical completion at the time
of writing, it seemed wise to begin to share the excitement and positive change the therapists
experienced in both clients, and the clinical precision offered by these RFT-based concepts.
29

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