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Psicoterapia analítica funcional (FAP) como intervenção complementar em casos de dependência de substâncias

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Psicoterapia analítica funcional (FAP) como intervenção complementar em casos de dependência de substâncias

Abstract

A FAP é uma psicoterapia comportamental cujo objetivo é desenvolver o repertório interpessoal dos clientes. Ela utiliza a relação terapêutica como fonte de informações para realizar a conceituação de caso e como mecanismo de mudança clínico, quando o terapeuta apresenta consequências diferenciais para comportamentos relevantes. A FAP pode ser utilizada como um tratamento complementar para dependência de substâncias, visto que há chance de dependentes de substâncias apresentarem deficits e/ou excessos no repertório interpessoal que inibem o acesso a reforçadores e os mantêm em contato com a estimulação aversiva de origem social. A restrição de repertório auxilia na instalação e progressão da dependência (aumenta a frequência de comportamentos de consumir substâncias) e intensifica os problemas interpessoais (diminui as oportunidades para aprendizagem de repertórios efetivos). Quando os deficits e excessos se generalizarem na relação com o psicoterapeuta como CRBs1, este pode utilizar a FAP para modelar repertórios mais efetivos, os CRBs2. As consequências reforçadoras positivas não só fortalecem os CRBs2, mas também marcam a função discriminativa do psicoterapeuta para esses comportamentos. Ao entrar em contato com outras relações interpessoais extrassessão, os progressos psicoterapêuticos se generalizam, produzindo novos reforçadores. O fortalecimento de repertório amplia as possibilidades para que o usuário se recupere.
Functional Analytical Psychotherapy (FAP) as an adjunct treatment to substance
dependence cases
Alan Souza Aranha1
Claudia Kami Bastos Oshiro2
Elliot Cozzens Wallace3
Abstract
Functional Analytic Psychotherapy (FAP) is an analytical-behavioral based therapy that was
developed with the purpose of solving interpersonal repertoire problems. Its application can
be conducted under two methods, either only with FAP or combined with other
psychotherapies. Proponents of FAP argue that the therapeutic relationship is an opportunity
for the client's problem behaviors to be observed and evaluated, enabling for (a) further
development of the case formulation and/or (b) modification of behaviors of interest in-
session. Substance dependence is a complex psychopathology that affects all areas of the
client's life, including the interpersonal repertoire. Interpersonal behavioral deficits and
excesses decrease access to positive reinforcers and, at the same time, increase contact with
aversive stimulation of social origin, increasing the probability of relapses. The purpose of
this chapter is to describe FAP as an adjunct intervention in cases of substance dependence.
The FAP psychotherapeutic model, the fundamentals of its application to treat cases of
substance dependence and the empirical evidence that support the effectiveness of the therapy
will be presented.
Keywords: Functional Analytic Psychotherapy; chemical dependence; adjunct intervention;
behavior therapy; psychopathology.
1 University of São Paulo. alansaranha@gmail.com
2 University of São Paulo. claudiaoshiro@usp.br
3 University of Washington. elliotcw@uw.edu
Introduction: Functional Analytic Psychotherapy (FAP)
FAP is a psychotherapy based on the philosophy of Radical Behaviorism and the
conceptual aspects of Behavior Analysis (Kohlenberg & Tsai, 1991; Skinner, 1945, 1953;
1957, 1974). FAP intends to develop the client's interpersonal repertoire, making them more
capable of producing positive reinforcement and eliminating aversive stimuli in its social
context. To accomplish this goal, FAP therapists propose that the psychotherapeutic
relationship be used as (a) a source of additional information about the client's behaviors and
(b) a mechanism for clinical change (Tsai et al., 2009).
The authors of FAP argue that a portion of human suffering occurs as a result of
problems in interpersonal repertoire: contact with the social environment evokes problematic
patterns of interaction, either with an increase in aversive stimulation density or in the
scarcity of positive reinforcers. The individual seeks a psychotherapist in order to receive
assistance to feel better and because it is a social relationship, the deficits and excesses
presented in the individual's daily life are generalized to the psychotherapeutic relationship.
This is the ideal scenario to evaluate the client's repertoire and strengthen more effective
behaviors in-session. When the client establishes a healthier relationship with the
professional, generalization strategies can be outlined so that the therapeutic progress are
transposed to the out-of-session context and the individual establishes healthier relationships
with his or her peers (Kohlenberg & Tsai, 1991).
There is a classification of possible therapist and client behaviors that occur in a FAP
therapy session. Having regard the client's behaviors, the main ones are named clinically
relevant behaviors (CRBs). A CRB1 is a behavior that occurs in-session, which is
functionally similar to the out-of-session problem behavior; CRB2 is a therapeutic progress;
and a CRB3 is a verbal report of the client's behavior and the variables of which it is a
function. The description of the client's own behaviors and the contingencies of
reinforcement that control them helps the client to emit the skills learned in the presence of
the psychotherapist in situations that evoke his or her problem behaviors outside the session
(Kohlenberg & Tsai, 1991).
It is important to clarify the relationship between CRBs and out-of-session problem
behaviors. Both behaviors are perceived as part of the same response class, defined as
responses that produce the same consequences, regardless of their form (Catania, 1998/1999).
A person can eat using a fork and knife, spoon or with his hands. All topographies would be
in the "lunch" response class, as they produce the "food" consequence. The difficulties of the
client must be understood in the same context. The psychotherapist may identify that the
client's problem behaviors are associated with the aggressiveness with which he addresses
people (e.g., offending, increasing tone of voice), but should not expect the client to emulate
similar topographic behaviors in-session (e.g., expressing offenses or increasing tone of voice
toward the psychotherapist). Firstly, the therapist should understand the function of the
aggressiveness - to cause harm, to draw attention, to avoid - and then hypothesize which
responses may contain the same function in therapy. There are several possible topographies
to annoy, call attention to, or avoid professional’s interventions.
Having regard the therapist's behaviors, the Five Therapeutic Rules are instructions on
how the clinician should behave in-session to assist his client. They are a systematization of
the functional analysis for the therapeutic relationship (Kohlenberg & Tsai, 1991; Tsai et al.,
2009): (1) observe the emission of CRBs, (2) evoke CRBs, (3) contingent responding to
CRBs, (4) evaluate the intervention, and (5) program the generalization of behaviors.
Rule 1: The first rule refers to the activity of identifying CRBs (Tsai et al., 2009). In
the case conceptualization stage, it consists of the psychotherapist observing and relating the
client's behaviors that occur in-session with the problem behaviors that occur outside the
session. Briefly, three questions can be raised:
1. How can problem behaviors both described by the client and identified by the
therapist be generalized to the context of the session?
2. How do the observed CRBs occur in the client's daily life?
3. What are the functions of these behaviors? Or what are the antecedents and
consequences of all the behaviors of the response class, inside and outside the
session?
In the intervention, with the knowledge of the function of the CRB1s, Rule 1 proposes
to pay attention to the CRBs and to proceed with the other rules. If the professional is not
under control of the relevant behaviors of the client that occur in-session (under control of not
very relevant behaviors or the topography of the CRBs), he will face challenges in managing
them therapeutically.
Rule 2: CRBs may occur in-session due to the social nature of the psychotherapeutic
relationship (by processes of generalization and stimulus equivalence). A person who
behaves according to the demands of the social group to avoid the negative evaluation (e.g.,
using a psychoactive substance to not be disapproved), is likely to be under control of the
possible negative evaluations that the psychotherapist has about such individual in-session
(e.g., following the therapist's requests to change the time of the meeting, agreeing with the
therapist's analyses). The professional may also manipulate different events in order to
intentionally evoke the CRBs, as mands ("could you behave in a certain way?") (Callaghan &
Follette, 2008; Vartanian, 2017), structured exercises (Nelson et al., 2016), and free
association (Tsai et al., 2012). Rule 2 aims to increase the frequency of CRBs in-session and
the number of opportunities to apply the third rule (Vartanian, 2017).
Rule 3: Consistent with an analytic-behavioral model, FAP holds that the behaviors
of any individual are selected for their consequences (Skinner, 1953). It is postulated that
Rule 3 is the FAP's mechanism of clinical change, the therapist's contingent responding to the
client's CRBs. The professional should present aversive consequences to weaken CRB1s
(punishment, extinction), but mainly present positive reinforcing consequences to strengthen
CRB2s. The available consequences are the therapist's own actions in-session (Kohlenberg &
Tsai, 1991).
It is important to stress that the psychotherapist's behaviors are also defined by their
functions - their effects on the client's repertoire - and not by their topographies. The
inexperienced therapist may praise his client believing that this is a "positive reinforcement"
or criticize him to "punish unwanted behavior", but interventions have different functions
depending on the history of contingencies of reinforcement and the CRBs identified in case
conceptualization. For the individual who express feelings of low self-esteem, a compliment
can be an aversive stimulus ("my therapist is an actor", "he just wants to please me"). On the
other hand, for the person who has a history of family conflicts and social isolation, criticism
can have a conditioned reinforcing function by pairing with attention opportunities. The
professional's criticism does not decrease the frequency of unwanted behavior, but evokes a
chain of discussions and an increase in the frequency of the problematic pattern. It is
necessary for the FAP therapist to build intervention strategies which are sensitive to the case
conceptualization and to judge its results throughout the therapeutic process.
Rule 4: The only way to know if the case conceptualization was correct and if the
intervention had a successful repercussion is to evaluate its effects. This is accomplished in
FAP, both by asking the client directly ("what did you feel when I explained it to you?") and
by considering the change in CRB frequency. In a research environment, the frequency of
CRBs can also be recorded with the Functional Analytic Psychotherapy Rating Scale
(FAPRS) (Callaghan & Follete, 2008).
Rule 5: CRB2s built in-session should be generalized in the client's out-of-session
relationships, the ultimate goal of psychotherapy. Generalization can be facilitated with
homework ("you were able to express your opinions to me. What do you think about trying to
reproduce this behavior with your husband?") and discussions about the functions of client
behavior in-session ("I believe you agree with my analysis of your fear that I will judge you.
Is it similar to what you told me about smoking marijuana so no one makes fun of you?").
[FIGURE 1]
Other categories of behavior can occur in FAP sessions. For example, throughout the
psychotherapeutic process the client will discuss problem behaviors and, progressively,
improvement behaviors emitted outside the session (O1 and O2, outside CRB1s and outside
CRB2s). In turn, the therapist will be able to respond to these descriptions (RO1 and RO2,
response to outside CRB1s and response to outside CRB2s). Explanations of other categories
can be checked in the FAPRS categorization system (Callaghan & Follette, 2008).
Which clients can benefit from FAP strategies? In the first book published,
Kohlenberg and Tsai (1991) argued that interpersonal problems would be the ideal targets of
psychotherapy, such as intimacy and personality disorders. Thus, it is possible to find studies
discussing the application of FAP to problems in the interpersonal repertoire, such as
Borderline Personality Disorder (Oshiro, Kanter & Meyer, 2012), Histrionic Personality
Disorder (Callaghan, Summer & Weidman, 2003), Oppositional Defiant Disorder (Xavier,
2018) and Social Anxiety (Lovo, 2019). In the same period, authors described FAP
application for other clinical conditions, such as Major Depression (Kanter et al., 2006), Post-
traumatic Stress Disorder (Lima, 2017), Obsessive-Compulsive Disorder (Vandenberghe,
2007), Panic Disorder with Agoraphobia (Pezzato, Brandão, & Oshiro, 2012), among others.
One of the psychiatric conditions studied in recent years was substance dependence, which
will be discussed in this chapter.
Substance Dependence
The psychopathologies described in mental health diagnostic manuals, such as the
International Classification of Diseases (WHO, 2018) and the Diagnostic and Statistical
Manual of Mental Disorders-5 (APA, 2013), are conceptualized by behavior analysts as
respondent and operant responses in the individual's repertoire. These psychopathologies are
differentiated from other behaviors only by the harm they cause to the social environment and
to the person who behaves (Banaco, Zamignani & Meyer, 2010; Vilas Boas, Banaco, &
Borges, 2012). The analytic-behavioral therapist is interested in describing all the behaviors
that contribute to the repertoire classified as psychopathological, identifying the
contingencies that maintain these behaviors and proposing strategies to change them (Banaco
et al., 2012).
In this regard, it is worth mentioning an example of the functional analysis of
depression provided by Ferster (1973). The author described that among the responses that
would characterize the depressive pattern, the following stand out: reduction in performance
(decrease in the frequency of activities that produce positive reinforcement and eliminate
aversive stimulation), excessive ineffective escape behavior (they do not remove aversive
stimuli from the environment, keeping the subject in contact with the stimuli), and "bizarre
and irrational" behavior (rituals and stereotypes). Contingencies of reinforcement that
maintain depression would be difficulties in discriminating the environment (not evoking
adequate responses to produce positive reinforcement and eliminate aversive stimulation),
unfavorable environment for the development of effective behaviors, reinforcement schemes
that require high frequency of responses (leading to extinction and inactivity), changes in the
environment (absence of antecedents that evoke the available repertoire), and emotional
changes that compete with operants (decreasing access to positive reinforcement). In the light
of the above, the main goal of the treatment would be the construction of an appropriate
repertory to manipulate the present contingencies, removing the client from the depressed and
stereotyped condition. One purpose of psychotherapy would be to refine the verbal
description of the client about the environment, improving his discrimination of relevant
antecedents that would consequently evoke positive and negative reinforced responses.
In order to understand substance dependence, it is first necessary to operationalize the
relationship between the individual and the drug into respondent and operant components.
Two important respondent phenomena are the withdrawal syndrome and tolerance. A
psychoactive substance has the function of an unconditioned stimulus (US) that elicits two
unconditioned responses (UR), its pharmacological effect and the compensatory responses
that reestablish the homeostasis of the organism (e.g., when administering heroin, the user
feels a decrease in sensitivity to pain and later an exaggerated sensitivity to pain). Friends,
places of use, feelings, etc. (NS, neutral stimuli), are paired and acquire conditioned function
(CS) for aversive compensatory conditioned responses (CR), the withdrawal. Contact with
CS elicits unpleasant physical symptoms and the user experiences craving to use again. When
the drug is consumed in the same or similar environments, a new respondent conditioning
occurs (US-CS pairing) and, consequently, abstinence syndromes perpetuate over time.
Tolerance occurs when the user administers the drug in contact with the previously
conditioned CSs and, with the compensatory effects present, the effect of the drug is smaller.
The individual begins to demand increasing amounts of the substance to achieve the desired
effects (Benvenuti, 2004, 2007; Siegel, 2005).
In an operant contingency, substance consumption is evoked by antecedents
(discriminative stimuli and reflexive establishing operations) and selected by consequences
(positive and negative reinforcement). In the context of being in a bar with peers (physical
and social discriminative stimuli), drinking alcohol can lead to drunkenness (positive
pharmacological reinforcement) and group attention (positive social reinforcement). The use
of alcohol can also be solitary (besides the pharmacological effect, it can have a conditioned
function by pairing between alcohol and social reinforcement). Difficulties that the client
experiences and withdrawal syndrome (aversive stimuli as antecedent) may lead him/her to
consume substances to temporarily reduce contact with these stimuli (negative
reinforcement). Private events such as feelings and thoughts are paired with the original
aversive stimuli and begin to evoke escape-avoidance behaviors (conditioned aversive stimuli
as antecedents) (Borloti, Haydu, & Machado, 2015; Higgins, Heil, & Sigmon, 2007; Miguel
et al., 2015).
Most of those who administer drugs themselves are sporadic or occasional users who
do not produce serious consequences for themselves and others (Laranjeira, 2012), which is
essential to label consumption as psychopathological (Banaco et al., 2010; Vilas Boas et al.,
2012) (for a list of consequences of substance abuse, see Tonigan & Miller, 2002). The basic
processes explain certain situations where use brings harm. For example, withdrawal
syndrome can be a relevant variable for consumption to become harmful; the unpleasant
physical symptom evokes escape responses to eliminate such state, negatively reinforcing the
use. At the same time, the contact between the substance (US) and the environment (CS)
maintains the respondent conditioning and, consequently, the withdrawal on future occasions.
The very behavior that removes the syndrome allows it to perpetuate, sustaining the cycle of
abuse (Banaco & Montan, 2018). However, it is worth noting that this is only one of the
possibilities for a dependent pattern to manifest itself. The existence of the abstinence
syndrome is not essential for the use of the substance to become pernicious (APA, 2013;
Higgins, Heil & Sigmon, 2007; Rush, Tremblay & Brown, 2019).
Researchers study which other possible variables, besides the respondent conditioning
associated with escape-avoidance behaviors, influence a portion of the population to develop
relevant compulsion (Bernardes, 2008; Garcia-Mijares & Silva, 2006; Heyman, 1996; Wilson
& Byrd, 2004). Another critical variable for the development of substance dependence is
when a person who exhibits excess behavior under control of short-term consequences at the
expense of long-term consequences may experience problems with their consumption (APA,
2013; Higgins et al., 2007; Madden & Bickel, 2010). In a context where the client may emit
two responses that produce different reinforcers - smoking marijuana to "relax" or studying
for the vestibular at the end of the year - he will probably emit the behavior that produces
immediate consequences. Even in contact with aversive consequences (e.g., losing the school
year, not starting a professional life), the user will continue to emit short-term responses (e.g.,
smoking) at the expense of the long term (e.g., studying). Problem solving (Moos, 2007;
Silva & Serra, 2004; Wilson & Byrd, 2004), frustration tolerance (Guilhardi, 2010/2013,
2018; Marlatt & Donovan, 2009), and sensitivity to the consequences that he/she produced to
others (Costa & Valerio, 2008; Guilhardi, 2010/2013; 2018) are some repertories that, when
little or badly elaborated, can facilitate the progression of the psychopathology.
Both deficits and excesses in the interpersonal repertoire that the client manifests are
risk factors that can lead to substance dependence (Aranha & Oshiro, 2019; Marlatt &
Donovan, 2009; Wilson & Byrd, 2004). A young person may feel judged by his friends, not
have many day-to-day activities, and suffer due to family conflicts. Drug use would decrease
his sensitivity to criticism (making him neutral or less aversive), give him something to do
when he is idle (e.g., smoking marijuana alone), and guarantee him a tool to forget the
problems he experiences at home (e.g., sniffing cocaine and being more under control of
pharmacological effects than family contingencies). The reinforcement promoted by the
substance strengthens the use behavior and marks the antecedents as evocative stimuli. In
situations with similar difficulties, planning, search, and use behaviors occur and are again
reinforced. The cycle decreases the space for the client to learn how to deal with the problems
and, as a result, makes him/her more and more dependent on the substance (Banaco &
Montan, 2018; Holman et al., 2012; Ribeiro & Laranjeira, 2012). Psychotherapeutic
intervention focusing on interpersonal repertoire would provide access to new sources of
positive social reinforcement (e.g., expressing feelings, creating intimacy), physical
reinforcement (e.g., meeting groups with interests in games and sports), and escape-
avoidance behaviors (e.g., seeking help, dealing with criticism). The antecedent that evoked
unwanted responses will now evoke alternative responses that will be progressively
consolidated in the client's repertoire, moving him away from drug use (Aranha & Oshiro,
2019; Gifford, Ritsher, McKellar & Moos, 2006; Holman et al., 2012; Rachlin, 1997).
For clients who suffer from withdrawal syndrome, interpersonal intervention
promotes important complementary improvements. The same antecedents that evoke the use
have conditioned stimuli function (CS) that elicit the syndrome. When the subject is exposed
to these stimuli and emits alternative behaviors instead of consuming the substance (US), the
process of respondent extinction occurs, making the unpleasant physical symptoms less and
less intense (Gifford et al., 2011; Holman et al., 2012).
FAP is a behavioral psychotherapy whose goal is to develop the interpersonal
repertoire of clients. It uses the therapeutic relationship as a source of information to perform
case conceptualization and as a mechanism for clinical change when the therapist presents
differential consequences for relevant behaviors (Tsai et al., 2009). FAP can be used as a
adjunct treatment for substance dependence, since there is a chance that substance dependents
have deficits and/or excesses in the interpersonal repertoire that inhibit access to reinforcers
and keep them in contact with aversive stimulation of social origin. The repertory restriction
helps in the installation and progression of dependence (it increases the frequency of
substance-consuming behaviors) and intensifies interpersonal problems (it decreases the
opportunities for learning effective repertories). When deficits and excesses become
generalized in the relationship with the psychotherapist as CRB1s, the psychotherapist can
use the FAP to model more effective repertories, the CRB2s. The positive reinforcing
consequences not only strengthen the CRB2s, but also mark the psychotherapist's
discriminative function for these behaviors. By encountering other interpersonal out-of-
session relationships, the psychotherapeutic progress becomes generalized, producing new
reinforcers. The strengthening of the repertoire broadens the possibilities for the user to
recover (Aranha & Oshiro, 2019; Holman et al., 2012). If the client exhibits withdrawal
symptoms, the respondent extinction may also occur in-session. The psychotherapist's
behaviors have both discriminative and eliciting functions (Kohlenberg & Tsai, 1991),
causing the syndrome to continue. When CRB2s are emitted and produce social enforcers and
not drugs, there is a break in US-CS conditioning. In addition, the operant generalization of
CRBs helps to have a higher frequency of responses that do not result in drug use outside the
session and, as a result, a higher likelihood of respondent extinction in the natural
environment (Gifford et al., 2011).
[FIGURE 2]
The Application of FAP to Substance Dependence
Articles related to FAP and substance dependence offer possibilities for the
application of psychotherapy to the population. We will describe the main studies published,
emphasizing the CRBs identified, the proposed interventions, the benefits of applying the
FAP within the treatment plan and the results obtained.
Pedersen et al. (2012) presented a clinical case of a client who met the diagnostic
criteria for Posttraumatic Stress Disorder (PTSD), dysthymia, alcohol dependence, bulimic
behaviors, and characteristics of Dependent Personality Disorder. PTSD symptoms
(traumatic reexperience, hyperexcitability and avoidance) were related to a history of sexual
abuse and threat to physical integrity. The proposed treatment included two steps. In the first
stage, Cognitive-Behavioral Therapy (CBT) for substance dependence, bulimia and PTSD
was conducted, and in the second stage, CBT was added to FAP with a focus on interpersonal
difficulties.
The first phase was effective in eliminating bulimic behavior, promoting abstinence
from alcohol, and decreasing PTSD symptoms, except for social avoidance behaviors.
Deficits in the interpersonal repertoire led the client to isolation and relapse from alcohol use.
At this time, researchers chose to add FAP to intervene on the repertory deficits, identifying
as CRB1s: difficulty in discriminating the appropriate context to self-disclosure, avoidance
behaviors from interpersonal contexts, and not reinforce behaviors of approaching by others.
The expected CRB2s were listed as: discriminating opportunities to expose oneself
emotionally, building intimacy by discussing positive and negative experiences, asking how
the client could behave to be more reinforcing, and reinforce the disclosure of others. The
goals of promoting CRB2s were to decrease escape behaviors and increase the participant's
probability of obtaining social reinforcement. Instruments for PTSD symptoms and
interpersonal functioning were used. After nine months of FAP, results of the instruments
ascertained that reexperience and hyperexcitability remained stable, however the frequency
of avoidance behaviors decreased and self-disclosure behaviors increased. A clinical
evaluation pointed to increased frequency and effectiveness of social connections, abstinence
from alcohol, decreased use of health services, decreased dependence of the therapist, and
increased accountability for his choices and well-being (Pedersen et al., 2012).
Since this is not a specific study for substance dependence, Pedersen et al. (2012) did
not describe the relationship between interpersonal deficits and alcohol use. It can be
conjectured that substance abuse had two functions: in the absence of significant social
connections, as a response that produced positive reinforcement stimuli, and, under control of
the same history of PTSD symptoms, negatively reinforced escape behavior. The
development of the social repertoire increased the positive reinforcers available to the
participant, changed the aversive function of social interactions and consequently decreased
the frequency of drinking. The FAP strategies were not made explicit, only the CRBs and
those that were targeted for intervention.
Paul, Marx and Orsillo (1999) conducted a research targeting deviant sexual behavior
and substance abuse. The client met the diagnostic criteria for marijuana abuse and
exhibitionism. Given that he was exposing himself in public, the judiciary system ordered the
client to be submitted to mandatory psychotherapy. Initially, the psychotherapist investigated
the sequence of events that led to the sexual pattern; when driving and using marijuana, the
client was looking for a woman he considered attractive, which produced in him an intense
desire to adopt exhibitionist behavior. After expressing the exhibitionist behavior, he would
returned to his house, where he would smoke, masturbate, and reminisce the exhibitionism
event.
A functional analysis evidenced that deficits in the interpersonal repertoire would be
one of the variations for the maintenance of problematic sexual activity and drug abuse. The
client experienced anxiety when he was around women (he had never met or had sexual
intercourse with one). Exhibitionism ensured access to social enforcers that the client would
not otherwise produce, but he needed to consume marijuana so that social disapproval would
not inhibit him. The pharmacological effect of the substance also acquired a negative
reinforcement function when used in the presence of feelings of loneliness and inadequacy
(Paul et al., 1999).
The client became aware that the cycle of dependence and public exposure brought
losses in the academic and social areas, besides producing feelings of inadequacy and guilt.
Exhibitionist tendencies and impulses became aversive (indicating that the exhibitionist
behavior was imminent), but attempts of self-control failed. "Holding on" did not modify the
contingencies maintaining the problem behaviors, leading the client to relapse. Due to
attempts to control private events, Acceptance and Commitment Therapy (ACT) was
proposed (Hayes, Wilson, & Strosahl, 2012), with the following purpose: acceptance of
sexually deviant thoughts and feelings, reduce the frequency of exhibitionist behavior, reduce
the frequency of marijuana use, and increase social connections. Changes in intensity and
frequency of impulses related to exhibitionist behavior, episodes of exhibitionism,
masturbation, and marijuana use were recorded with self-monitoring, and symptoms of
anxiety and depression recorded with standardized inventories. In six months of ACT,
increased connections with women and decreased social anxiety were observed, but the
results for exhibitionism were insufficient. The authors decided to add FAP strategies (Paul et
al., 1999).
Rule 1: The therapist identified that attempts of self-control outside the session were
functionally similar to the avoidance behaviors of not talking about exhibitionism in-
session, so these were conceptualized as CRB1s. Both were inefficient responses to
minimize access to aversive stimulation (desire to express exhibitionist behavior and
report the desire for exhibitionism). The proposed CRB2s were to acknowledge and
report feelings, thoughts, and exhibitionist tendencies in-session.
Rule 2: The therapist intentionally evoked self-disclosure about exhibitionism and
addiction to marijuana.
Rule 3: The therapist presented verbalizations with possible positive reinforcement
function ("I'm feeling closer to you" and "I'm enjoying getting to know you better")
contingent the client's self-disclosure. Later, he started to reinforce any self-
disclosure. The goal was to improve social skills and increase the probability that the
new repertoire would become generalized in the client's relationships with third
parties.
Rule 4: It served the purpose of recognizing the effect of the intervention on the
client's repertoire. Upon one month of FAP treatment, the client revealed that he was
using marijuana on a daily basis and committed to reducing the frequency.
Rule 5: Whenever possible, the therapist would describe the CRB1s in relation to the
client's learning history and the parallel between disclosure oneself in-session and
accepting private events outside the session. It was also discussed how smoking
marijuana facilitated him to manifest exhibitionist behavior.
As a result, the frequency of exhibitionist urges decreased from an average of
four/five impulses to two per week, masturbation decreased from seven to three times per
week, with changes in the content of the fantasies (he stopped imagining the exhibitionist
behavior), and smoking marijuana decreased from seven to four days a week. In the 6-month
follow up, the urges to express exhibitionist behavior occurred twice a month and the use of
marijuana once a week. Finally, his stage of anxiety and depression were no longer at the
clinical level, there was a possible generalization of CRB2s with a greater social connection
in the academic context, and the client began to date a girl.
The study by Paul et al. (1999) demonstrated how the principles of FAP can be
included in complex clinical cases involving drug abuse. In the context of clinical private
service, clients with severe difficulties and in multiple areas are more the rule than the
exception (Kazdin, 2008). FAP was helpful for the therapist identify target behaviors that
occurred in-session and intervene on them, producing encouraging results.
Gifford et al. (2011) studied how behavioral therapies could enhance the results of
drug treatment for harmful tobacco use. Two groups received 10 weeks of the bupropion
antidepressant, however, pre-established ACT and FAP strategies were added to the
experimental group. Psychotherapies occurred weekly, with one group meeting and one
individual meeting. The ACT intervention consisted of accepting unpleasant physical
symptoms (abstinence syndrome) that increased the probability of relapses. The application
of FAP aimed to create circumstances within the therapeutic context for unpleasant physical
symptoms to be evoked (Rule 2), effective avoidance behaviors under the control of aversive
stimulation (asking for help instead of smoking, accepting physical symptoms) to be
reinforced in-session (Rule 3), and discussing how tolerating aversive stimulation in-session
was functionally similar to tolerating aversive stimulation out-of-session (Rule 5).
The researchers recorded changes throughout the process and in post-treatment.
Process measurements were symptoms of nicotine abstinence, mood swings, experiential
avoidance, acceptance, and therapeutic relationship; and the outcome records included client
satisfaction and objective measurement for nicotine. The data pointed to a higher proportion
of abstinence after the intervention and at the 12-month follow-up for the experimental group
and that the underlying hypothesized processes (acceptance and therapeutic relationship)
were responsible for the change. Such study conducted by Gifford et al. (2011) provided
more robust results on the relationship between interpersonal interventions focusing on the
therapeutic relationship and improvement regarding substance consumption.
[FIGURE 3]
Holman et al. (2012) conducted a study with the purpose of integrating empirically
validated treatments for depression and smoking with FAP strategies. The intervention
combined Behavioral Activation (Martell, Addis & Jacobson, 2001), Smoking Cessation
(Perkins, Conklin & Levine, 2008), and ACT (Hayes et al., 2012). FAP was applied as an
opportunity to modeling behaviors that impacted depressed mood and smoking urges; a
repertoire that produced positive social reinforcement was incompatible with depressed and
nicotine-dependent behaviors. Five participants received 24 sessions of psychotherapy. Self-
reported measures for depression, smoking, psychiatric symptoms and interpersonal
functioning, and objective measures for nicotine were recorded. The results revealed that four
of the five clients were exempt of the diagnostic criteria for major depression, significantly
decreased the symptoms manifested, and improved interpersonal functioning. One of the
clients had his diagnosis maintained, but his symptoms were moderately decreased and his
interpersonal functioning was increased. Three of the five patients abstained from smoking,
one presented significant changes (from an average of 13.2 to less than one cigarette a day)
and the last patient had moderate changes (a 25% to 50% decrease in use).
Holman et al. (2012) used a number of pre-established sessions and interventions and
only the FAP was conducted ideographically. The advantages of adding FAP to the protocols
were (a) to identify problem behaviors that could go unnoticed and not be targets for
intervention and (b) to relate them to treatment for nicotine dependence. In addition to the
overall results, the researchers presented how the FAP intervention was performed and the
possible progress observed.
In the first case example, the therapist identified that the client presented counter-
control behavior when he felt obliged to perform a certain task. The escape function seems to
have been learned in a context where trusting someone was followed by punishment. The
behavior made treatment difficult, as the client had to adopt the psychotherapist's instructions
to stop smoking. It was conceptualized that intimacy avoidance behaviors were CRB1s, while
acceptance of support and care were CRB2s. Initially the professional discussed that the
client would like to create intimacy with people, but was afraid and ended up preventing this
relationship (Rule 5). Later, he actively promoted CRB2s assisting the client to divide the
number of cigarettes he would consume during the week (to progressively decrease
consumption) and direct recommendations to perform activities for the therapist and not for
himself (influencing the client to "do for the other"). As a result, the client complied with part
of the smoking cessation protocol and felt that the therapist was "on his side" - a feeling that
usually did not emerge in his relationships.
The second client presented difficulty expressing his needs due to the fear of causing
conflict or disappointment. Asking for help in difficult situations is a significant behavior in
the treatment because the individual ensures access to social reinforcers instead of the
pharmacological effects of nicotine. Thus, requests made in-session were considered CRB2s.
During one session, the client requested if he could postpone the day of his last cigarette
since he had been through a stressful week. Would this be considered an escape behavior to
keep smoking (CRB1) or a cry for help (CRB2)? The therapist used the case
conceptualization and understood the response as an example of self-knowledge and
expression of needs. The professional reinforced the behavior by stating that "the client knew
the right moment to stop smoking". As a result, the client quit smoking weeks later and a
possible generalization occurred when he was more assertive with his family.
Previous research provided relevant data on the use of FAP for substance dependence,
but methodological issues made it impossible to state the exclusive impact of psychotherapy
on this population, since it was applied in conjunction with other therapies and there was no
record of behaviors in-session (the studies recorded drug abuse and reporting on symptoms).
In this regard, Aranha, Oshiro and Wallace (2020) intended to evaluate the isolated effect of
the FAP and its hypothesized mechanism of clinical change (the therapist's contingent
response to CRB2s) for substance dependence. A single-case A/A+B quasi-experimental was
proposed, where A= Analytical-Behavioral Therapy strategies (Meyer et al., 2010),
prioritizing the analysis of external contingencies of reinforcement to the session, and B=
FAP, prioritizing the modeling of CRBs. 20 sessions were recorded and transcribed for
participant 1 and 18 sessions for participant 2. The FAPRS instrument (Callaghan & Follette,
2008) was applied to categorize the behaviors of two therapist-client dyads into 5 sessions at
each stage, and there was record of drug abuse three months before and three months after the
procedure. Clients were assisted at a voluntary admission clinic which included medical
consultations, lectures on chemical dependence, cognitive-behavioral psychotherapy,
psychoanalytical group therapy, Alcoholic/Narcotics Anonymous group meetings, family
group counseling, and physical exercises. FAP sessions were applied individually, focusing
on modeling CRB according to case formulations.
The first participant was diagnosed with Alcohol Use Disorder and sought help for
"fights with relatives". In reality, other areas of his life were also affected: unemployment,
expulsion from his parents' home, conflicts with his sister and son-in-law, distance from
friends, and 20 years without romantic relationships following his divorce. It caught the
psychotherapist's attention (Rule 1, observe CRBs) that the client did not express his feelings
and opinions (CRB1s). The same behavior occurred with the other professionals ("he is very
closed off") and with his daughter ("I would like my father to talk more"). It was
hypothesized that the deficit in the repertoire minimized his access to social and emotional
reinforcers and increased the alcohol reinforcer value (Heyman, 1996). The therapeutic goals
outlined were to express feelings and opinions (CRB2s). The vignette illustrates how the
psychotherapist strengthened the client's CRB2s in-session:
T: And what did you feel at the time? (Rule 2, intentionally evoking CRBs)
C: Well, I was very upset with myself, hurt. Just my daughter, who has always fought, is
always fighting, always, you know... it's... doing everything for my good, for my well-
being... and there comes a point that says, "I got tired. Enough of causing trouble." I have
to walk with my own legs, I have to become aware of everything I've done, of all the results
I've brought to myself and to people (CRB2, express feelings and opinions)
T: Can I say something I feel now?
C: You may.
T: In these sessions that we're talking, that we've been talking about certain issues, talking
about your family, we also talked about certain strategies on not drinking again, we talked
about your new house. But it's the first time I feel that you talk with emotion about a
subject. I mean, with a very real emotion, a very real emotion... I can feel it, I can feel you
talking about the impact that your daughter had telling you "I can't stand it anymore".
While you are telling me about it, it is possible to see that impact here in session. You've
even changed your countenance a bit (Rule 3, positively reinforce CRB2).
The second participant was diagnosed with Cocaine Use Disorder and sought
hospitalization for the consequences that cocaine and crack caused in his professional routine.
It was identified a change in the client's pattern of consumption depending on his marital
status. When single, (a) he increased drug use and (b) opted to smoke crack over sniffing
cocaine. The psychotherapist sought to understand which problems in the interpersonal
repertoire decreased the probability that his relationships would remain stable and intensify
dependence. He observed that the client was in conflict with professionals at the clinic for not
understanding their intentions (for example, resocialization should occur at lunch time with
his family, but he should return before night falls. The client was irritated with the
imposition). The client had difficulty in establishing relationships between the behavior of
others and the contingencies of reinforcement. Functionally similar behavior occurred in-
session (CRB1s) when he reported not understanding his spouse's complaints. In fact, the
client performed certain tasks at home, ended up going out with friends and overloading his
wife. More conflicts were caused and increased the probability of cocaine/crack use. This
excerpt exemplifies how the researcher modelled the establishment of more effective
relationships between events in-session (CRB2s):
T: I mean... let's start backwards. What do you think would justify, from a [professional]
point of view, not letting someone out [in re-socialization]? Not that she won't let... she
does, but you must to come back. Goes out and return (Rule 2, intentionally evoking
CRBs).
C: She made this decision because I think it was made in the meeting here, with all the
members, i.e., the whole team there (CRB2, the client relates the behavior of the
professional with a discussion between professionals).
T: Maybe (Rule 3, positively reinforce CRB2).
C: Then, just like that, it's gone. Then I picked it up and talked like this... I started to think:
"the guys are going out so much, not getting in trouble or anything like that", there is a
limit, I think, but each case is a case (CRB2, the client discriminates the individual reasons
he can go out to lunch and come back, while other residents can't go out or can go out and
come back the other day etc.).
T: That's it: each case is different, but let's look at what possibly led [a professional] to do
that. She has a lot of experience (Rule 3, positively reinforcing the previous behavior and
Rule 2, evoking new relationships between events).
The results indicated that the introduction of FAP, specifically the therapist's
contingent responding to CRB2s, followed the progress and there was a decrease in substance
consumption for both participants. Participant 1, who stayed longer in psychotherapy,
obtained maintenance in the frequency of CRB2s and lower rates of drug use in the follow
up. The study provided by Aranha, Oshiro and Wallace (2020) strengthened data from
previous research on the relationship between the FAP intervention and changes in use
patterns and, most importantly, explained that the relationship is likely to be achieved due to
changes in the frequency of CRBs in-session. For a detailed description of the case
conceptualizations, refer to Aranha (2017) and Aranha & Oshiro (2019).
Final Considerations
The goal of this chapter was to describe the FAP model to substance dependence and
the evidence of its efficacy and effectiveness. Since substance dependents have difficulties in
interpersonal repertoire that increase the frequency of drug use, FAP intends to develop the
interpersonal repertoire of clients, using the therapeutic relationship as the main vehicle for
change. When the user's problem behaviors become generalized in the session, it is possible
to modeling more effective repertories and, later on, to trace strategies of transposition to the
out-of-session context. Interpersonal progress is expected to decrease substance consumption.
The description of FAP conceptual framework for addiction and the research data were
intended to promote an additional tool for therapists who work with chemical addicts and
want to increase the chances of psychotherapeutic success.
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