Rule Governance and the use of Values to Facilitate Exposure for OCD

Rule Governance and the use of Values to Facilitate Exposure for OCD

by John Wesenberg, M.S., BCBA, LBA

Rule Governance and use of Values to Facilitate Exposure for OCD

Behavior is dynamic and influenced by many contingencies simultaneously. Relational Frame Theory (Hayes et al., 2001) is an extension of behavior analytic principles to the human ability to learn language/symbols and the affects of these over-riding behavioral repertoires on our behavior. This extension accounts for much of human psychopathology that had defied previous parsimonious behavior analytic explanations.

“Values” are verbal constructions of meaningful directions for our lives. For example, a person may value “being a warm father.” This is by nature something that can never be “completed” but we can also always act in accordance with this statement. Orienting to values can serve as a motivating augmental. That is, the stimulus functions of a particular stimulus may be augmented to make them more or less salient.  For example, changing a diaper may for most be a rather aversive experience but for the father who holds the value of “being a warm father” and brings this to the experience of changing diapers – diaper changing may be transformed to almost an enjoyable task!

Within the clinical context, treatment of Obsessive Compulsive Disorder may be facilitated through presenting stimuli that remind the individual of their values at key points during exposures. For example, an individual who engages in excessive washing/ cleaning compulsions due to contamination concerns may be ‘stuck’ in a loop of avoiding an aversive experience in the short term through compulsions (e.g., excessive bathing and grooming). If this individual values “being a warm father” as described above – this may be used to help facilitate new flexibility in his behavioral repertoire in the presence of normally aversive and avoided “contamination.” For example, in treatment the father may be asked to engage in exposures that involve changing mock or real diapers. The client may normally rate this as a “7” on a scale from “[not anxiety provoking at all] 0 to 10 [extremely anxiety provoking]” normally. The clinician can present the task in the context of conversation that prompts the client to attend to their values, for example “John, I know that you value being a warm father. Does loving your child and caring for them warmly mean that you will care for their basic needs?” “Can you bring your love for your child into this moment to help you move towards what matters most?” [Note: All examples are by nature topographical and function of these statements must be assessed and applied ideographically, rather than topographically.] If these statements function as a motivative augmental for the client – the client may report that their starting anxiety rating lowered, “I know that I said this was a ‘7’, but now it feels like a ‘5’ when I think of my son.” Additionally, you may see that the client is more willing to approach, maintain contact, or resist compulsions – as the aversive functions of ‘contamination’ are augmented to a more workable range for the client.

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Reference

Barnes-Holmes, Y., Barnes-Holmes, D., McHugh, L., & Hayes, S. C. (2004). Relational frame theory: some implications for understanding and treating human psychopathology. International Journal of Psychology and Psychological Therapy, 4, (2), 355-375).

Hayes, C. S., Barnes-Holmes, D., & Roche, B. (2001). Relational Frame Theory: A Post- Skinnerian Account of Human Language and Cognition. New York, NY: Kluwer Academic/ Plenum Publishers

 

Function of Instructions in a Therapeutic context

Function of Instructions in a Therapeutic context

by John Wesenberg, M.S, BCBA, LBA.

The Function of Instructions in the Therapeutic Context

Instructions, both explicit and implicit, are important to providing the best care to an individual in the therapeutic context. The difficulty is determining the interlocking contingencies needing to be shaped and strengthened in a package treatment. For this analysis, exposure and response prevention (ERP) for individual’s diagnosed with obsessive-compulsive disorder (OCD) will be the exemplar of how and when to use instructions in clinical care. Detailed, explicit instructions and feedback are important to a client in clinical care for the following reasons:

  1. Therapeutic stimuli such as exposure assignments, practice and interoceptive forms, help with fluency and maintenance of expectations for a longer, and more consistent performance. These stimuli, when arranged and taught correctly, are easily accessible, readable, understandable, and sustained in the individual’s life in and out of treatment.
  2. Instructions and feedback can be communicated in clear contingencies of reinforcement to promote behavior momentum and consistency in responding. If… then… or first… then… statements indicate when to engage in activities that maintain responding. These contingencies are strengthened by incorporating values and personal preferences. Establishing operations (abolishing and motivating effects of stimuli) are accounted for and manipulated by communicating in clear and specific rules.
  3. Direct rules will create long-lasting maintenance of buy-in and momentum for responding correctly to stimuli that evoke fears. When the patient understands the contingencies that create the tools that allow them to respond differently to fear-evoking stimuli, there is a higher probability of effective maintenance and generalization.
  4. Rules can be used as augmentals, in that rules may serve to alter the reinforcing value or punishing value of consequences. Augmentals act as an establishing operation for increases in intensity or magnitude of an exposure or new stimulus class. For example, a therapist may say to a client, “If you are able to look at another person and respond with a one word answer when that person initiates a question 80% of opportunities for a week, you are able to play the Nintendo Switch at the end of the week,” will probably result in the client seeking feedback on their responses to others, which was previously a neutral stimulus, and attempting to meet the criterion.

Now, let’s specifically look at how indirect, implicit instructions and metaphorical feedback are important to effective clinical care.

  1. Metaphors and indirect instructions allow an individual to derive flexible instructions from mapping of contingencies onto previous experiences. This prevents client’s from over-following non-functional rules rather than responding appropriately to their context and contingencies as they occur. Therapists must always be aware that they are typically perceiving a client partially through their own verbal report and possibly biased rule-governed perceptions of themselves, others, and the world. Providing direct rules can dysfunction when therapists provide instruction based on how they believe behavior functions in contexts that they cannot directly observe and manipulate. Therapists must be mindful that providing metaphorical rules can assist a client in responding and learning effectively from contingencies as they occur; rather than responding by following what the therapist ‘says’ the client learns to track their environment better.
  2. Metaphors increase the variability of how an individual responds to stimuli. Variability in responding increases the possibility for accessing new contingencies of reinforcement when responding to stimuli in the natural environment.
  3. Metaphors are also most effective in reflecting complex instructions that require that the client begin to track the functions of their own behavior in context. For example, in explaining how exposures work to provide opportunities for learning, a therapist may let the client know that exposure therapy is ‘more like learning to ride a bike’ than attending ‘talk therapy’ – that the therapist’s role is much like ‘getting the client on the bike repeatedly and instructing on how best to improve performance.’ Further, the therapist may state that much like learning a bike – verbal instructions alone will not effectively produce the complex behavioral repertoire of sensing one’s weight shifting in motion and continuously correcting one’s behavior in reaction to felt positive and negative consequences.
  4. Metaphorical feedback evoke a context for an endless opportunity of possibilities. This is exciting to an individual because of the behavioral cusps they are currently contacting and could be contacting in the future.

Reference

Houmanfar, R., Rodrigues, J., & Smith, G., S. (2009). Role of communication networks in behavioral

systems analysis. Journal of organizational behavior management, 29, 257-275, DOI:                          10.1080/016086093092102

 

An ACT Approach to Adolescent Suicide

An ACT Approach to Adolescent Suicide

by Amy R. Murrell, Ph.D.

             The paper summarized here, was written by myself and former students (Al-Jabari, Moyer, Novamo, and Connally), and published in the International Journal of Behavioral Consultation and Therapy in 2014 examines the problem of adolescent suicide from an Acceptance and Commitment Therapy (ACT) practitioner’s perspective. At the time of the paper’s publication, according to the Centers for Disease Control and Prevention (2014), approximately 4,600 young people completed suicide annually in the United States. At the time of this summary, that number is nearly 7,000 (Centers for Disease Control and Prevention, 2019). I chose to summarize this paper for two reasons: I wish that number were moving in the opposite direction, and I think the conceptualization written about here is useful.

            Of course, more adolescents attempt suicide and have ideation about suicide than complete it. Those youth are important to discuss from a functional contextual point of view, and that is what this article does. It is divided into seven major sections. The first section discusses the prevalence, antecedents, and consequences of adolescent suicidal behavior. The second introduces experiential avoidance, and the third introduces the ACT model. The next section is “the heart” of the paper, giving an ACT conceptualization of adolescent suicidal behavior. The next two sections talk about a specific client, first hypothetically and then with a case example. The final section summarizes the state of relevant empirical evidence to date (at the time of publication). Here I will cover just a bit of each section, so you get a feel for the article’s content. I am biased, but I think you should give it a read.

            The article states that there are some behaviors (e.g., substance abuse) that co-occur with and may predict suicidal ideation and attempt, but there are also individuals who have no previous diagnosis who have suicidal behavior. It is obvious, therefore, that there is no set pattern or easy prediction – with one caveat. Past behavior is the best predictor of future behavior. The costs of suicidal behavior are great. According to Yang and Lester (2007), every year in the United States alone, non-fatal suicide attempts cost about 4.72 billion dollars. The consequences go far beyond money, though. The article talks of cluster suicides, survivor guilt, and worsening negative emotional experiences. 

            This leads into the discussion of experiential avoidance (EA), noting that attempts to control, suppress, lessen, or avoid those negative emotions (or thoughts, bodily sensations, and/or places that might make them more likely) may worsen distress. Next, ACT is introduced as a treatment to address EA. In both the section on EA and the section on ACT, assumptions of functional contextualism are addressed (e.g., all behaviors serve specific purposes in specific settings). This is the perfect segue to Chiles and Strosahl’s (2005) definition of suicidal behavior as learned behavior that functions as an avoidance of – or escape from – negative emotions.

            In brief, ACT views suicide as a perfectly reasonable solution to feeling stuck or hopeless. Suicidal behavior is seen as the result of normative human language and cognition processes. The article states that normalizing suicidal behavior shifts the therapeutic context to an open and honest one that may help reduce client shame. Just as a little teaser, there is a discussion about relational framing related to thoughts of suicide and how that may bring relief. There are several intervention strategies suggested (e.g., values with specific future-oriented goals). The hypothetical client is used as a way to provide context for how suicidal behavior, in general, might be discussed. The issues of safety planning and contracting are discussed in this section as well.

            The ACT approach to these issues is different from many other clinical takes; if you don’t know it, you might find it an interesting read. A de-identified client example illustrating how defusion, values and several other ACT components were used to address suicidal behavior is the last section before empirical evidence is provided. The case example illustrates that, as is often the case, the client remains quite anxious yet she is living out her values more and thinking of suicide less.

            The data summary indicated the need for research on suicidal behavior. This is still a particular need. Fortunately, however, in the last six years the evidence for ACT with adolescents has increased. Since this paper was written, there have been 10 randomized controlled trials with participants under the age of 18. For details, see the Association for Contextual Behavioral Sciences State of the Evidence Page.

References:

ACBS State of the Evidence Page https://contextualscience.org/state_of_the_act_evidence.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2011b). Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Last Updated February 25, 2014. [cited]. Retrieved from http://libproxy.library.unt.edu:2465/injury/wisqars/fatal_injury_reports.html

Centers for Disease Control and Prevention, NCHS Data Brief, No. 352, Oct 2019 [ online]. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

Chiles, J. A. & Strosahl, K. D. (2005). Clinical manual for assessment and treatment of suicidal patients. Arlington, VA, US: American Psychiatric Publishing, Inc.

Murrell, A. R., Al-Jabari, R., Moyer, D., Novamo, E., & Connally, M. L. (2014). An acceptance and commitment therapy approach to adolescent suicide. International Journal of Behavioral Consultation and Therapy9(3), 41–46. https://libproxy.library.unt.edu:2147/10.1037/h0101639

Yang, B., & Lester, D. (2007). Recalculating the economic cost of suicide. Death Studies31(4), 351–361. 10.1080/07481180601187209

 

Exposure to Privilege

Exposure to Privilege

The Function of Privilege within Our Science and Beyond

Angela Coreil, PhD

If you’re familiar with my writing or social media, you are probably familiar with my tendency to advocate for the underrepresented and disempowered in our society. Recently, I’ve found myself in a Facebook debate about this, in my social feed, that warrants a more elaborate response. I am also a woman, in a science dominated by men in power positions, who continually seek to ‘educate’ me further when I disagree with them. So, read this post with all that in mind.

First, I’d like to acknowledge that posts on Facebook conversations are not an adequate medium for debate. Without our voices, without posture, and without other cues that reflect the complexity of our perspective we are virtually guaranteed to keep arguing even when we agree. Our specific wording, the individual’s perception of us, and the nature of the media itself are likely to drive the other’s responses more than what we’re intending to express. This is simply a result of how the contextual variables inherent in social media (e.g., anonymity, slow responsivity, lack of complexity, and a public venue) tend to function for us.

We are faceless, sometimes nameless, words on paper expressing complex ideas in bumper sticker length responses. This is in part why social media results in long, sometimes heated, and often pointless debates so frequently. We are not faced with the person behind the idea, the whole idea, cues about the person’s emotion – and are left responding mostly to our relata and words that are themselves varied in function. We miss the complexity of other’s ideas, knowledge, and experiences. This is, in large part, how words, and people, function out of context.

The post I made that began the debate was a repost of a USA Today post, entitled “All college students should take a mandatory course on black history and white privilege.” I will attempt not to recount the debate here in detail, name the individual, nor shame the individual for their perspective. I choose to believe that the individual is arguing because they, like myself, believe that our science can do a better job of moving the world forward. I choose to see us as on the same side. What occurred in the debate; however, encapsulates why I believe that our society needs “mandatory” exposure to the ideas and experiences of others and the impact of “privilege.”

We are all privileged and disadvantaged in some ways; however, those with less power in our society frequently have no way to express their perspectives without it being perceived as punishing to the majority. This is, in part, the essence of privilege. Those with power and privilege see their perspective represented all around them in their everyday experience. Those with power and privilege are more likely than those without, to be surrounded by people and experiences that reinforce their beliefs about themselves and others. Those without privilege are faced with few representations of themselves, punishing representations of themselves by the majority, and to find themselves represented in and responded to – as caricatures.

In some ways, being an underrepresented minority in like attempting to express complex ideas, about heated topics, on social media. The underrepresented are prone to be responded to based on relata. The complexity of their ‘selves’ (instead of their idea) responded to with hostility because their ‘otherness’ does not fit neatly into the boxes of those with the dominant view.

This is the influence of verbal symbolic rules, how they function interpersonally, and why I believe we should all be constantly exposed to the perspectives of others. We, in particular, need experiential exposure to minority perspectives in as many forms as possible. Some of these are going to be punishing for us, some of them are going to be overwhelming, and some of them are going to be affirming. And, we need to realize as a society that all of this is important for us to experience for our collective good. A course in white privilege or black history is a drop in the bucket. It may function for many aversively, and yet, we have to start embedding the minority experience in the lives of the majority. We are a society moving further and further away from complexity and existing in worlds that function as echo chambers. Within social media, within science, and within society – most of us have the privilege of being able to ‘unlike’, ignore, and benefit from the inherent reinforcement of our views from the dominant representations of our views surrounding us.

This is why exposure to the perspectives of disempowered minorities must be in some way “mandatory.” The coherence of those with significant privilege, in any form, is reinforced simply by existing in a world that endorses their perspective on nearly every level of their existence, all day, every day. The privileged have no reason, on mass, to decide to hear and appreciate the complexity of the minority experience. It tends to violate the sense of ‘self’ of the privileged to even hear that they/we are privileged. My colleague who debates me recognizes this and yet misses the complexity of my argument for mandatory exposure to the perspectives of minorities and our privilege.

True recognition of privilege and the perspectives of minorities that will create change means creating interventions that are embedded throughout our society. It means that media is created by minorities, it means that representations of the perspectives of minorities are embedded into our society in so many ways that they become not the expressions of an unknown caricature “other” but as part of our collective view of ourselves, our history, and our ability to change, together.

And, for the one who inspired the post, if the complexity of my perspective results in further attempts to correct me by insisting I simply need education on the basis of our science, on my feed, don’t be surprised if you get a more explicit public lesson on male privilege in our field and how your behavior functions aversively as ‘mansplaining.’ I am the female owner of a behavior analytic education site who disagrees with you, insisting that I need to educate myself in single-case design, reinforcement, and punishment because I disagree with you –  without stepping back to consider the context surrounding your behavior is an act of privilege in action.

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

RFT: Let me show you something beautiful.

RFT: Let me show you something beautiful.

AUGUST 11, 2016, original post to angela.cathey.com

Stop over thinking RFT and feel it.

I would say that sometimes it takes a different perspective to look at the tools we are given and see them quite differently. We, the second and third generation ACTers, FAPers, and rising CFTers… we are reveling, rejecting, remixing, and refining the elegance of technical masterpieces.

So, here is one of my remixes. I don’t like connecting with RFT in examples of coin size, driving, or equations about how cats = “cats” and … =Screen Shot 2016-08-03 at 11.03.28 PM

Okay, he’s cute. I’ll give you that… but he’s still a cat.

RFT is the rhythm of human thought and feeling. Just because the Internet is officially full of cats. doesn’t mean that our conceptualizations of human thought and language should be. (No offense to the cat lovers or Schrode’ [inside joke]}

So what is more human? Art.

Here’s a different way of connecting with frames. Take a moment to look at the picture below. Notice.

Screen Shot 2016-08-03 at 10.26.48 PM

Feel your eyes pulled to the highest point? The background falling away into fuzziness. There’s a feeling of being pulled upward higher. This is a visual metaphor for how a hierarchical functions. This is what connecting with values, belonging, purpose… does to your sense of the world. You tune into the higher point and the rest falls away into the distance.

Now, look at this picture.

Screen Shot 2016-08-03 at 11.17.51 PM

Notice how the pieces fall away and the whole pops forth? You notice the togetherness, the uniformity of what is actually separate pieces. When we feel in coordination with something we move towards it, we identify with it, we become in some way a reflection of the other. (This is also a bit hierarchical, but “frames” are always functional concepts so let’s stick with what ‘works’.)

Now look at this picture.

Screen Shot 2016-08-03 at 11.21.53 PM

Maybe you could technically ‘see’ that this is tree bark but that’s not likely to be what you were paying attention to. Context sensitivity is like zooming in. You see the details. You experience, and you might be hyper- sensitive to a change in the context. For example, a giant ladybug landing in the middle of this might jolt your attention more so if you’re more contextually sensitive in-the-moment.

Now look at this picture.

Screen Shot 2016-08-03 at 11.14.02 PM.png

This is a visual metaphor for coherence. See how your mind likes the fitting together of randomness into a pattern? It’s naturally reinforcing. People don’t like messes.

Now look at this:

Screen Shot 2016-08-11 at 7.33.12 AM

This is a bit like the concept of adaptive peaks. Sometimes we can miss the forest, sunrise, and distance when we’re focusing on making wishes on the dandelions we can see in the immediate path.

 

If you like learning about Relational Frame Theory, behavior analysis, principles, or the philosophy of science in different forms – let us know in the comments. If you’d like to learn more feel free to check our selection of online, on-demand, and live training events.

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

RFT: The Guerilla guide to pro-social change

RFT: The Guerilla guide to pro-social change

Original post to angelacathey.com, July 2016

Welcome to Frame Club. A Guerilla guide to pro-social change with RFT.

Screen Shot 2016-07-25 at 6.18.35 AM

The world is full of simple repetitive messaging. Everything is a bumper sticker. “Party A is evil, party B is good” and…. shootingsdiscriminationand ignorance follow.

Life and people aren’t bumper stickers. 

The repetitive simple messaging we’re privy to means that we’re deriving copies of copies of copies. That’s not good.  We’re also used to this and insensitive at times to direct contact contingencies. So, we get around rules in other ways for instance politicians can now move us more effectively through associative frame speak than through direct logic (eh hem… Drumpf for President anyone?).

And yet, we’re not doomed to idiocracy.

We know that simple low complexity derivation begets 1) rules, which leads to 2) unawareness (rule-governed insensitivity to contingencies).

When you add to that mix pain, you get: 1) avoidance, that leads of course to resilient and contagious ideas. This is why we teach acceptance by metaphor and experience. You can’t just say “accept” because you end up with a useless rigid rule and lack of awareness of the contingencies around it.

So, let’s acknowledge what’s there and why it’s there.

We all have histories of learning negative discriminatory relations about race, sex, gender, social class, body image, and a whole host of other things.

Even if they weren’t outright stated (aka you didn’t hear racist, sexist, anti-gay messaging regularly) simple repetition of any situation creates rules which spread in our minds in a variety of ways. We then deal with this in predictable ways.

Some of these rules may come about just through noticing differences and similarities between ourselves and others (Roche, Barnes-Holmes, Barnes-Holmes, Stewart, and O’Hora, 2002) and this influences our behavior.

So, we’re going to have these relations as a bi-product of our natural tendencies to categorize and organize our worlds (if we didn’t life would be a bit like 50 first dates. Where everything would be new and foreign each time we contacted it. That’s not workable. )

We’re going to have these rules in our heads about people that are painful as a result of living. We can try to wish them away but that’s just going to result in rules in the other direction then create insensitivity to direct contingencies (even if they’re as big as a gorilla in the room.)

Unfortunately, there is no erasing of relations. We all have painful thoughts that we’d rather not acknowledge.

Luckily, there’s been some great work on what this is in the social realm and what we can do about it (see Vilardaga, Levin, Hildebrant, Hayes, & Yadavia 2008, May ABA – need to log into ACBS for access) or Vilardaga, Hayes, Levin 2014 – The Flexible Connectedness Model).

We can deal with relations that are problematic in a variety of ways.

In some cases, we can simply derive new more complex relations that fade the old relations in importance; however, when the rule is more stubborn (i.e, involves any pain as it so often does when rules latch on to humans) this often won’t be enough.

We often need a shift in context (defusion, mindfulness of the contingencies of that drive our behavior in non-rule-based form). We can also combine these with combinations of context shift like this Deictic Framing Exercise (exercise by Vilardaga, Levin, Hayes, 2008 – video by Gareth Holman). This type of exercise combines several relations that move us past rule-based insensitivity including shifts in deictic and deictic related framing (temporal, hierarchial, etc.).

 This is likely to work for those who are willing to engage. 

However, we know that coherence, simplicity, avoidance of pain… all of this is self-reinforcing and we can’t expect a large portion of the population to sit down and do a perspective-taking exercise just yet. So, what can we do?

 Adapt the message or the context.

If argumentation and rule-based insensitivity are likely you need to adapt the message. Go metaphorical, go high complexity, and go associative. Feelings aren’t as easily blocked (see every perfume commercial ever made.)

Or shift the context, humor can work well at getting our attention when insensitivity is the norm (see Old Spice Muscle Pump  commercials that get our attention when we normally tune commercials out).

When humor, feeling, metaphor, aren’t practical and/or the consequences are too high, we can also reduce the accessibility of Sds (discriminative stimuli) if we know what’s pulling the problematic frames. We could be enacting this in some of our institutions (e.g., the justice system) now. We know the impact of race on judgments and sentencing and yet we just keep sending people into the justice system and pretending human bias isn’t there. When are we going to just start recognizing and adjusting to human bias tendencies to protect people? We’ll tend to engage in mass scale rule-based insensitivity to avoid contacting what’s difficult (see the DARE program and abstinence education for policies that continue to be funded despite their widely recognized ineffectiveness).

Contextual Behavioral Science and RFT can begin to mindfully examine these contingencies if we take the time to look at what’s going on with a stance of self-other compassion without blaming or shaming either party we can start from a new context where together we step forward to understand what keeps us stuck hurting ourselves and each other.

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

You and I: Understanding and measuring high impact Functional Analytic Psychotherapy (FAP)

You and I: Understanding and measuring high impact Functional Analytic Psychotherapy (FAP)

Original Post to AngelaCathey.com on July 24th, 2016
by Angela Cathey

There are many ways to understand every therapy. Here I’ll offer a granular analysis of what seems to occur in the high impact FAP. What I present here is not an opposition to the current model of FAP but a different layer of analysis. I would agree that contingent reinforcement of behavior is a key mechanism of FAP. The purpose of an RFT-level analysis is to offer additional ways to measure and understand some of the effects of FAP that are otherwise difficult to characterize and measure.

I’m focusing on the symbolic relations that are created in what I call ‘high impact’ FAP. What I’m calling to in this description is the tendency of present moment relational therapy to become more powerful and evocative than one would normally suspect of a treatment based on reinforcement of adaptive behavior via the therapeutic relationship.

Those of you who have been to a FAP intensive or are highly experienced in FAP may be familiar with the report of FAP being “life-changing”, “transformative”, etc. To some extent one would hope most treatments are experienced this way; however, the rate which participants report intense response to FAP is likely higher. And, an RFT driven analysis there are empirical logical explanations for why those that experience FAP as moving may experience it as life-altering.)

Note that RFT is about symbolic relations and their properties. Patterns of pairing (between behavior, language in any form, sensations/perceptions, contexts) can all become meaningful over time through association with important (e.g., painful, joyful) experiences.

This is no different than operant reinforcement or classical conditioning – the type of pairing, the frequency/schedule, context, etc. all affect the relations made. The only difference here is that the SD can show up more easily symbolically (via language or some other cue).

So, let’s now look at perspective (the “I”) that orients your experience. You walk through life each day seeing, doing, feeling, thinking… and each of these things becomes a part of your continuing experience. In some way, they have become paired with the “I”. Perhaps very weakly paired but paired none the less. (See RFT: The space-time of the human universe for further description of perspective).

Experiences that happen over and over, including consistencies in the way that people describe you or relate to you become a part of your “I” and your concept of the other, or symbolic “YOU”.

The way you explain what occurs in these relations gives them additional power as it becomes a symbolically ‘sticky’ way of seeing the world (i.e., coherence relations, schema). You see others through this story of yourself and yourself as well. They, similarly, have stories about themselves and others and how people relate by which they organize their experience.

Now consider that everything you do in a relationship creates associations between:

The “YOU” and “I” present, or symbolically referenced (spoken about, etc.). Further, the emotions you express, the way that you talk about yourself and others, the behaviors you emit in any respect all become attached to the “YOUs” and “Is” in the room. (Yes, plural “I”s through the sometimes distinct tracks of symbolically defined behavior (e.g., roles, contexts, etc.) serving to create classes of behavior that ‘hang’ together.

Stop and consider that for a bit… Do you often belittle yourself in your own mind or in front of others? If you do you may find that people’s behavior towards you will begin to reflect this relation or that your own behavior towards your self will become less compassionate over time.

Our learning histories, ‘sticky’self-stories, and current histories all affect our sense of self and other. And, because the “I” is theoretically the relation most complexly derived (it is always there as a part of the associations forming) transformation of the “I” can ripple through all the attached relations.

Stop and think for a minute. All your sensory experience, all your visual perceptions, all your everything is hooked right through that “I” relation. So, what if it is altered? What will you experience?

If the alteration is “good”, perhaps you feel like this?

Now let’s switch to thinking about the process of an intimate relationship, using a lovely cheesy music video metaphor that we’ll then build upon both these to discuss the complex symbolic relating that can occur in high impact FAP.

Do watch as it will help you connect to the symbolic journey we’re going on through metaphor. The Story of My Life

Imagine that the moments of your life are pictures. The experiences that reflect complexity (ERRRs) most often are a series of pictures with richly emotional colorful (good or bad) details. See the birth of your child, and the hundreds of pictures to capture the complex experiences that follow.

Now, look around your home… are there single large photos blown up… special moments you wanted to save. These are likely snapshots of complexly derived moments (see the pictures from Hawaii… feel the sand beneath your toes? Sometimes complexity is lovely.

Now there are thousands of random shots in between that capture random moments, important relationships, accomplishments… and because this is your life, not a photo album imagine that all the moments you never wanted to remember are also there. In their full, and sometimes awful glory.

That time you fell on your ass in front of a crowd…

Your worst mistakes. All of them are memorialized in all their complex and highly derived glory (because rumination derives!) in big lovely photographs you keep hidden away.

All these moments that form the history of you, your pain, your joys, your disappointments… see them all strung along the wall back behind you (in time).

Now imagine opening your heart and mind to pull out these photographs and show another. Each time that you hand a painful or joyful memory to this person a connection between you forms, a connection between both of you and the memories seen, the emotional expressions of both (YOU and I) then shape the memories and the relationship. There’s a heck of a lot of relating going on here – temporal, deictic, high complexity, transformation of stimulus functions through coordination/distinction/opposition with the other.

And, this… is just a close relationship. This isn’t even therapy.

Notice how we all are deeply affected by our relations, good or bad, to those around us.

People are a core of our experience, our ‘self’, and our world.

Now, let’s work towards understanding the complexities of high impact Functional Analytic Psychotherapy relating.

Open this and listen while you Imagine.

Let’s walk through a super simplified course of FAP via the special case of intensives. For the unfamiliar, this is 3-4 day long training of therapists who come to hone their skills together by experiential practice.

Much like most FAP treatment itself it generally begins with some sort of Life History or discussion of adaptive (CRB2) and maladaptive (CRB1) behaviors. The very discussion pulls the relations along from the past, symbolically, to accompany the present. The power of the past (pain and joy) becomes more accessible by relation.

Now you begin to hand not the pictures described above but your real present moment experience (that is sometimes still fused with pain) to your colleagues. You may be brought to tears by the transformation of stimulus functions simply involved in discussing your pain and struggles in front of another.

As you engage in this interaction the other makes out-to-in parallels creating a symbolic I-YOU relation linking to the past relations involved (to people and behaviors that can be present in the now for changing).

In doing this, you are allowing the present moment interaction to alter contingencies set in other relationships because the attachment of past and present I-YOU to in the moment I-YOU is like creating a transcendent I-YOU.

The impact of the learning experience naturally becomes stronger as the symbolically present and in vivo relations combine. Anything altered through reinforcement or otherwise, can now affect the past, the present, the “I” and the “YOU” in the present, and all other “Is” and “YOUs” relevant to these relations.

At this point, contingent reinforcement takes on a new life. You’re shaping behavior but you’re also shaping relations, which allows you to interact with and shape someone’s relating to what occurred long with someone else. The shaping of that entire chain of relation can in a sense begin to over-write the relations of the self, the other, and the world.

The result can be “magic” and leave people changed. A present moment, relational therapy, driven by behaviorism. This is powerful medicine (not without its challenges).

Intensives, in particular, may evoke strong reactions as days of present moment relating in a uniquely supportive environment while bringing in other relations and experiencing the transformation of pain from long ago… it’s a bit like flooding of the deictic relations with new, hopefully adaptive, learning.

What are your thoughts on this and the complications of what we’re describing? Let us know in the comments. If you’re interested in more writing on clincial behavior analysis, RFT, principles, or the philosophy of science – let us know. Also, check out our selection on-line, on-demand, and live training on related topics!

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

Human Attachment: The ‘Why’ of Connection

Human Attachment: The ‘Why’ of Connection

Attachment and Cooperation

by Broderick Sawyer, PhD

When we want to improve upon our ability to reach any mutual goal that involves more than one person- businesses, sports teams, government, and even 1 on 1 personal relationships- attachment theory can be particularly helpful in improving human cooperation.

Attachment Theory is more complicated than any one article, but when we focus on the process of building human relationships and day to day interacting, it becomes clear that this process is largely responsible for how we feel about ourselves, which then influences how we interact with others. That is to say: Self-image = how we feel others perceive us.

Our gift as human beings is our ability to fit into and contribute to social groups effectively, without rocking the preverbal boat by interacting in ways that are not conducive to the interaction ‘style’ of the group. If we imagine our brains as computers that need to be programmed so that we can have a final ‘version’ of ourselves by adulthood, it would then be obvious that our childhood, adolescent, and early adulthood experiences have much to do with developing our social style, via developing our self-image.

While genetics do predict certain predispositions to certain ways of behaving, let me dispel the myth that genetic traits predict who we are all the way throughout adulthood and drive humans to become ‘fixed’ beings. This is nonsense, and backed by what we call ‘neuroplasticity’: the ability of the brain to adapt to the input that it is receiving at every moment throughout our lives. If we change our environment, the people we interact with, or if bad things happen to us, our brain literally creates NEW neural pathways to adapt to new circumstances. Why does it seem like we can become ‘fixed’? Well, the more we continue on in our current circumstances, these neural pathways become stronger, which causes whatever behavior we are doing to become more of habit and way easier to do- rather than change.

One thing, however, is fixed. We all have the same capabilities for honest, compassion-driven communication, but unfortunately, evolution does not care about our abilities to be compassionate, rather, our continuing to breathe, eat, sleep, and reproduce. This does not necessarily require compassionate interaction. Thankfully, the world of psychology is a developing field that can provide us various loopholes to develop a more compassionate style of interaction, and this starts with understanding various “styles” of interacting, how they came to develop, and what this means for our interactions with others as adults.

A challenge to our readers, can you drop to the level of Relational Frame Theory and Behavior Analysis and provide an account of what’s described above in behavior analytic language?

What drives us to attachment? What maintains attachment styles? What do you see ‘underneath the hood’ in your language?

Are you interested in learning more about principles, behavior analysis, RFT, and taking an integrative look at our field? Let us know in the comments and check out our online, on-demand events!

Measurement: Why we get no R.E.S.P.E.C.T.

Measurement: Why we get no R.E.S.P.E.C.T.

“MEASUREMENT: WHY WE GET NO R.E.S.P.E.C.T.”

Psychologists, therapists, and researchers in mental health:

How many times have you been at a party and told someone you’re a psychologist only to hear, “So, you can read my mind?”… or, “Can you analyze my dreams for me?”

Why does this happen?

The public has no idea what we do. At best, we’re often perceived as paid friends or mistaken for psychiatrists.

And, maybe we can live with this but it isn’t just the public. 

The National Institute of Mental Health (NIMH) is a major funder of our research… or it used to be. The recent move towards Research Domain Criteria Initiative (RDoC) for NIH funding means that obtaining a grant for an RCT from the NIH requires that you heavily integrate investigation of possible biological factors in your study to obtain funding. This has occurred despite the fact that most of the field (psychology) agrees that biological components aren’t driving contributors in most maladaptive behavior. In fact, years of searching for specific biological profiles for diagnoses has turned up little useful information. Still we’re on the search for the right blood test, fMRI, EEG, or otherwise, that will diagnose people, why?

Because – it makes what we do ‘real’ for them.  

So, what are the consequences of this search for ‘real’… thing-y-ness in mental health?

If you’re a clinician, not seeking research funding, you may not immediately contact what this means for you. So, here’s my take: If you’re using Beckian-CBT or even ACT, you’re probably fine. We’ve already got loads of RCTs to show these ‘work’. This means you can probably count on insurance companies giving you less of a hassle for treatment reimbursement.

If, by chance, you are using anything else that has had few RCTs you might have problems eventually. If we can’t get said treatment determined an ‘Empirically Supported Treatment’ through the current standard of massive and repeated RCTs. (Eh hem.. FAP. One of the most behavior analytic in-the-moment treatments struggles with RCTs because they are based on our most effective tool (functional analysis). Functional analysis is ideographic and doesn’t easily conform to RCT methodology. This is part of the reason for the build out of the ACL model… a need to standardize functional analysis. )

Well, I’m sorry but if we have to alter a treatment that is driven by a tool we all respect then our overall measurement/methodology strategy sucks. In fact, psychoanalysts were saying this about RCTs from the beginning but when we were in a foot race with them it was a little hard to hear the truth in it.

So, what I’m getting at here is several levels of pervasive problems related to our field… but thankfully, they’re related. 

Some of you may not like what I say here. I fully expect to get a few angry emails (Save it, prove me wrong with data.).

So, here’s my analysis of what’s causing these problems:

In a word: Measurement!

In a few words: Reifying rigidity! Constructs! and lack of integration!

Okay, so I’m probably at a level of geekery here that few will understand. So, this is what I’m talking about.

So, why am I picking on constructs?

We all use constructs. We have to so we can get through the day. Clinicians can’t walk around explaining to each other from the ground-up what “psychological flexibility”, “response flexibility”, “borderline”, “depression”, or anything means. That’s impractical but we do need to continually contact the effect of this on our methods and the perception of the world. Then we need to choose our level of analysis appropriately.

If we assess only at the level of constructs without awareness of the consequences then we’re essentially shooting ourselves in the foot. 

We’ve measured mostly in constructs because measuring real behavior was HARD. We know that behavior and report of behavior vary by context (e.g., mood state bias, retrospective report bias, rule-governed behavior, and the list goes on…) so we’ve tried to standardize the heck out of measures. We’ve measured mid-level concepts that attempt to represent whole clusters of supposedly important relationships. Then, because the public wouldn’t understand this… we have to integrate symptom inventories to give it some ‘realness’. It’s a chain reaction.

When we measure constructs we need them to hold still and mean something so we apply psychometric rules that assume thing-y-ness and stability to these airy clouds of invention. Then we make it ‘real’ with symptom inventories that use diagnostic labels that the public gets, but which we know have poor as hell diagnostic reliability (not surprising since they are essentially Chinese menu style creations. Congrats! pick 5 out of 7 and ooo. la. la. you’re depressed.)

Before you get ‘depressed’ reading this let’s take a ‘beginner’s mind’ to assessment (as Todd Kashdan suggests) and look at how we can fix these problems. 

Let’s build from the ground up. 

Let’s understand our assumptions and what works. Let’s start by measuring behavior, in context, across contexts. 

Contextual Behavioral Science has been moving towards this for years. Some of our brightest minds in theory, philosophy of science, treatment, and methodology have been telling us to go there for years (e.g., Roger Vilardaga, Kelly Koerner, Todd Kashdan, Kelly Wilson, and many others.)

For the interested, here are a few citations:

Wilson, Hayes, Gregg, & Zettle (2001). Psychopathology and Psychotherapy (Chapter in Big Purple).

Wilson (2001). Some notes on constructs: Types and validation from a contextual behavioral perspective

Hughes, Barnes-Holmes, & Vahey (2012). Holding onto our functional roots while exploring new intellectual islands: A voyage through implicit cognition research ***The Relational Elaboration Coherence model and RFT based assessment***

Vilardaga, Bricker, & McDonell (2014). The promise of mobile technologies and single case study designs for the study of individuals in their natural environments.

Iwata, DeLeon, & Roscoe (2013) The FAST. Functional Analysis Screening Tool

Hurl, Wrightman, Hayes, & Virues-Ortega (2016). Does a pre-intervention functional assessment increase intervention effectiveness? A meta-analysis of within-subject interrupted time-series studies. (**Spoiler alert: Yes, it does.**)

Since you probably didn’t click on any of those:

We have better methods now. We can use technology to assess behavior (across contexts), to intervene, and to rapidly and cheaply assess behavior. Take a moment: Look at your iPhone… That thing ‘knows’ more about you than your best friend or your spouse.

So, why aren’t we using these methods? Well, I hear you. Most of us weren’t taught to create Apps in grad school, to deal with data flow that exceeds the capability of SPSS, or to understand the intersection between technology and confidentiality. For most of us, even though we let Target (who lost tons of credit card numbers. yikes!), Apple, Best Buy, Netflix, and many others track our every move we’re not utilizing this technology well in the behavioral sciences.

Essentially: Who has time to learn entire new areas of science (App design, UX, Data Science, Python, R, etc.)  in order to have better and cheaper assessment? 

It’s not that people aren’t trying. I certainly heard a lot of interest in Ecological Momentary Assessment (EMA), Ecological Momentary Intervention (EMI), Relational Frame Theory, and links from basic to applied at the CBS conference this year but these things aren’t exactly user- friendly straight out the ‘box.’

Notably: There have been some valiant efforts to create systems of assessment and data tracking that ‘work’ for clinicians and researchers.

See:

Learn2ACT an integrated system of Acceptance and Commitment Therapy (ACT) driven mobile client-client centered data collection and intervention. It tracks and logs data for multiple clients and displays it for clinicians. Big props to Ellen & Bart for taking this on from programming to testing. Release of this product is currently scheduled for some time in Fall (so show them some love and for doing all this work for us)!

Other systems in development include Matrix (ACT-driven) Apps out of Mike Levin and Beniji Schoendorff’s groups. Roger Vilardarga and Jonathan Bricker and others also have out Apps that are a bit more target specific (e.g., ACT driven for psychosis, smoking cessation, etc.) – (Forward me links to anything else that is evidence-based or getting that way and I’ll consider listing them too.)

The process of gaining an evidence base for this technology (Mental Health Smart Phone Apps: Review and evidence-based recommendations for the future development), while mastering all this tech, and paying attention to user experience (UX) AND getting people aware of these technologies is a difficult one. So, as a community I think we need to support efforts to develop technologies that make it easier for clinicians and researchers to use functional contextual behavioral assessment.

I’m working on an integrated functional analysis driven assessment platform and I need your feedback. 

My concept is a bit different but also includes EMA/EMI, as this is our best CBS consistent context sensitive assessment effort thus far.

Stay with me here:

I propose that we also go from basic research and theory and build a system that integrates what we know to the best of our ability. One that is functional analysis driven, contextually-sensitive, rapid, and user-friendly. Then we make this available such that we can funnel meta data (read de-identified behavioral data on relations) to basic and applied researchers from clinicians. After all, those RCTs aren’t even touching how to treat complicated multi-problem clients.  

Such a system would involve:

  1. Contextualized behavioral assessment (EMA/EMI and passive assessment of biometrics. Hey, we’re not going to bowl the NIH and RDOC over all at once.)
  2. Assessment of verbal/symbolic related behavior (aka… integrating what we know from RFT into understanding contextualized functional analysis driven assessment.

Note: You won’t have to go read Big Purple to use this system. We’re planning to present relations in pretty visual analytics that even clients can make sense of. We’d like to make explaining relationships (between verbal behavior and verbal behavior or verbal behavior and EMA/EMI passive behavioral data ) functional. Wouldn’t it be nice if you could such demonstrate your outcomes in forms that show you make ‘real’ change in the lives of your clients?

See previous post on RFT: Relational Frame Theory (RFT)- What’s the big deal? And, Hayes & Berens (2004) Why Relational Frame Theory alters the relationship between basic and applied behavioral psychology for why RFT is important to this. If, your mind just squealed… “but relating and frames are just constructs!” See future post on empirical logic and the difference between reifying constructs and properties.

Essentially, we need to add in RFT because we know that verbal/symbolic relations can more powerfully influence behavior in the moment than the actual contingencies. Additionally, integrating RFT allows us to step back and forth from behavior, to intervention, to level of appropriate measurement across diagnoses and therapy orientation – so maximum flexibility and applicability.

I understand that many of you may be thinking at the point… so, are we talking assessing the content of language? Word counts? 

Well, no and yes… we do look at the verbal content but we can look at functional relations indicated between verbal relating and verbal relating, or between this and other behavioral measures. I’ll save that for another post.

For now, here’s some ground work within CBS that supports the use of attempting to assess verbal/symbolic relating through language:

Atkins & Styles (2016). Measuring self and rules in what people say: Exploring whether self-discrimination predicts long-term well-being (ACBS membership needed to view).

Collins, Chawla…Marlatt (2009). Language-based measures of mindfulness: Initial validity and utility

If you’re interested in learning more about clinical behavior analysis, RFT, and advanced measurement methods – let us know in the comments below! We also have some online, on-demand training events on a variety of topics that may interest you.

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

RFT: The Space-time of the Human Universe, Part I

RFT: The Space-time of the Human Universe, Part I

Original post to angelacathey.com (June, 2016)

I’m going to start this post off by telling you a little secret. I get a little obsessive with ideas. Give me something interesting to think about and I’m a kid with a Rubik’s cube all over again. When I immersed myself in RFT I turned that Rubik’s cube so many times I dreamt in RFT. (Yes, I know that’s weird.)

While you’re adjusting to that information, let me show you why I will probably never get tired of playing with this toy. I’m going to show you several metaphorical, philosophical, and sometimes downright fun, ways to understand RFT. 

CONSTRUCTS, RELATIONS, AND THE BEAUTY OF THE UNIVERSE

First, let’s loosen your frames a bit and help you ‘connect’ more abstractly. Let’s channel Karl Sagan for a moment and teach RFT through a little astrophysics.

Imagine the earth and planets swirling about in space. They all have this rhythm and dance to how they move about each other. Imagine now that those planets are constructs (e.g., “psychological flexibility”, “courage”, “love”, “present-moment-focus”, “mindfulness”, “habituation”, “transference”, etc).

Screen Shot 2016-07-06 at 6.40.46 AM

Now looking out on the planets we are like the astronomers once were… seeing these celestial bodies in awe but not understanding their rhythms. We can ‘see’ them dancing around each other but we can’t tell why. Most of our scientific method in psychology is based around this level of mystery. We assume we know very little and that every hypothesis is a bit like glancing in the telescope and hoping we see planets crash together. If we see it, and we haven’t spent all day looking through the telescope… then that’s an important finding! And, because we can’t all watch the whole universe we each pick a few planets (constructs) to watch intensely.

Now let go of your favorite planets for a moment and zoom back… look at the big picture. See the planets moving on their orbits over the course of time…

Now drop to a different level of analysis.  In this picture, we see what we scientists later understood about planets influence each other.

Screen Shot 2016-07-06 at 6.41.44 AM

What we understood that gave us infinite and useful knowledge about space (even beyond the planets we could see) was… as Karl Sagan put it, “gravity is geometry.”

Gravity is a distortion in space-time that forms a kind of net that allows the weight of the planets to pull against each other. This is what gives them their lovely dances in relation to each other.

Screen Shot 2016-07-06 at 6.28.31 AM

RFT, and behavior analysis more broadly, is the gravity beneath our day-to-day behavior. It shows us how the constructs influenced by human verbal/symbolic behavior dance together.

This is ‘true’ in several ways:

Gravity is a very ‘real’ force to be reckoned with and yet you can’t ‘prove’ it in most contexts. We just trust that it’s there because it is useful to do so. The construct of gravity is a description of relation. It’s a useful explanation in daily life for why it would be stupid to hold the DSM-5 over your foot and drop it. Sure, you could go ask Karl Sagan for the formula and proof but in the meantime… you should probably still move your foot out of the way of the DSM.

In the same way, RFT relations can’t typically be ‘proven’ in the moment. That’s not the point in applied work though. Like the web you see below the planets, what RFT, and behavior analysis more broadly, gives us is far more powerful than a view of the actual planets. It gives a way to predict and intervene in nearly anything influenced by human thought. (If that doesn’t inspire awe … go back and read it again.)

Planets collide…

On another level, what it does is let use see the planets in a new light. They are no longer separate planets dancing unpredictably in space. They are a tiny visible piece of the universe dancing an understandable rhythm influenced by the interlocking distortion of space-time that holds them in relation to each other.

And just like this conception of gravity as space-time distortion… understanding RFT, and behavior analysis, allows us to come up with some amazing ways of understanding our universe.

If you like learning about Relational Frame Theory, behavior analysis, principles, or the philosophy of science through metaphor, or otherwise, let us know in the comments below! 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

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