Commentary: Applying principles from FAP to enhance psychotherapy via case conceptualization, the therapeutic relationship, and idiographic assessment

López-Pinar and colleagues (xxxx) recently published a meta-analysis of Functional Analytic Psychotherapy (FAP; single case design studies and randomized controlled trials) in which FAP was used as a standalone intervention or combined with behavioral therapies (e.g., FAP + Cognitive Behavioral Therapy). Across seventy studies, empirical support was identified for the treatment of interpersonal behaviors and internalizing symptoms. This finding is of particular interest in light of FAP being a principle-based psychotherapy. That is, although the focus of FAP varies from person to person (as each individual presents with unique behaviors) similar principles are applied across individuals to target their suffering. In this commentary, we expand on the authors’ discussion of the relevance of FAP, and provide recommendations for applying principles central to FAP across therapeutic paradigms, with a focus on idiographic case conceptualization, the therapeutic relationship as a central change agent, and the measurement of individual change processes to guide intervention.

The structure of FAP as a principle-based intervention that is idiographic and focused on a specific individual’s needs, represents a departure from the recent predominant approach to psychotherapy and psychotherapy research. Most widely disseminated psychotherapies are nomothetic in scope, where rather than intervening at the level of an individual’s specific presentation, the intervention is based on a set of overarching rules meant to be universally applied across participants. These interventions are often created and evaluated as protocols for specific psychological syndromes. While protocols for syndromes have been extremely important in establishing and advancing evidence-based psychotherapies (EBPs), these treatments can be implemented in an inflexible manner, where interventional procedures are not appropriately modified to address the needs of the individual seeking treatment. For example, while EBPs for PTSD have been instrumental in facilitating recovery for many (Schnurr et al., 2022), some individuals continue to struggle with trauma symptoms even after a full course of a gold standard EBP (Schnurr et al., 2022). Others may prematurely terminate treatment (Schnurr et al., 2022). EBPs for PTSD can be modified to meet the needs of individual clients (Wiltsey Stirman et al, 2022), but more work is needed to better understand how to tailor these treatments to improve outcomes for those treatment refractory symptoms.

In contrast to nomothetic approaches, FAP represents an idiographic, individualized intervention that can be paired with EBPs, and is responsive to the specific behaviors maintaining an individual’s suffering because it is based on case conceptualization. Macneil and colleagues (2012) provide a global definition of case conceptualization including determining the “presenting problem, predisposing factors, precipitating factors, perpetuating factors, and protective/positive factors” to guide intervention. These principles of case conceptualization can be used to address questions about what is accounting for an individual’s presentation and maintaining it. Despite typically being one of the first skillsets taught in psychotherapy training, case conceptualization is not consistently applied as an active component of treatment in clinical trials, and it is often not revisited in practice across clinical encounters. This may be due to the perception that case conceptualization represents a singular assessment session at the start of treatment rather than an evolving process over the course of psychotherapy. Another barrier could be challenges associated with billing for clinician time. More research is needed to understand barriers associated with actively implementing case conceptualization across interventions.

One of the most striking findings reported in Lopez-Pinar and colleagues (xxxx) is the impact of FAP on clinically relevant idiographically defined behaviors. These behaviors may not have been identified, or intervened on as targets, if not for the explicit application of case conceptualization. In FAP, case conceptualization represents the ongoing process of identifying and intervening on the behaviors maintaining a client’s suffering rather than targeting a reduction in psychological symptoms themselves. The human brain is incredibly complex and can create infinite overt and covert strategies to cope with emotional pain. When one strategy stops working or is unavailable another may be applied. For instance, a client struggling with difficulties related to moral injury may present with substance use, suicidal ideation, video game playing, and rumination about their behavior as strategies to cope with their emotional pain. A treatment plan that is overly focused on targeting one of these coping strategies may not address the actual behaviors giving rise to these difficulties. One of the central elements of case conceptualization in FAP is a focus on the function of behaviors causing suffering to persist. An individual’s behavior could be facilitating external reinforcement (e.g., their environment provides support in the presence of the behavior) and/or internal reinforcement (e.g., their experience of an aversive emotion decreases in the presence of this behavior). These pathways resulting in reinforcement are conceptualized to cause the behavior to persist. Instead of focusing on getting rid of these behaviors or treating them consecutively, organizing a person’s coping behaviors into functional response classes based on the purposes they serve for that individual can facilitate simultaneous intervention on multiple behaviors maintaining suffering.

Given increased awareness about the limitations of nomothetic protocols for syndromes, there has been a movement in recent years to return to idiographic case conceptualization as an active and ongoing treatment process. For instance, Process Based Cognitive Behavioral Therapy has emerged as a transdiagnostic intervention focused on understanding and intervening on the processes maintaining client suffering (Sanford et al., 2022). Moreover, the trauma focused intervention literature provides compelling examples of attempts to incorporate this process into extant models to strengthen EBPs for Posttraumatic Stress Disorder (PTSD) and facilitate novel intervention. To address the inherent limitations of protocols for syndromes, Cognitive Processing Therapy interventionists have worked to more explicitly emphasize case conceptualization for intervention on potential treatment refractory experiences (Galovski, Nixon, & Kaysen, 2020). In addition, for individuals struggling with PTSD and comorbid suicidal behavior, Prolonged Exposure has been integrated with Dialectical Behavior Therapy with explicit case formulation and chain analysis (Harned, 2022).

Novel interventions have been developed to target domains like moral injury that are not always addressed through EBPs for PTSD. In response to the clinical complexities of moral injury, Acceptance and Commitment Therapy for Moral Injury (ACT-MI) was created to include multiple idiographic case conceptualization sessions across treatment to disrupt the factors maintaining moral injury-related suffering (Borges et al., 2022). Beyond these approaches, as Lopez-Pinar and colleagues reference in their meta-analysis, FAP has even been explicitly applied as an adjunctive intervention for PTSD symptoms, enhancing approach behaviors and interpersonal functioning via a case study. Using these interventions as a guide, we urge clinicians to explicitly explore applying case conceptualization to their psychotherapeutic framework in a manner that is theoretically and adherently consistent with their interventional evidence-informed approach. This could mean implementing a FAP-consistent evidence-based framework for engaging idiographic case conceptualization or it could mean explicitly applying principles of case conceptualization (Macneil et al., 2012) based on another specific theoretical framework.

In the case of an individual experiencing moral injury who is struggling with substance use, suicidal ideation, video game playing, and rumination, determining how these experiences impact their emotional pain and their environment is important. If it is determined that these behaviors all serve the function of avoiding their internal experience of shame, this would provide information about the focus of treatment to disrupt avoidant cycles in the future and instead create the opportunity for the client to live meaningfully. Implementing a transdiagnostic approach like FAP allows intervention on the behavioral class of avoiding shame potentially influencing multiple pathways causing suffering to persist. Intervention would likely take the form of learning new skills to approach shame, rendering the need to rely on behaviors like substance use, suicidal ideation, video game playing, and rumination unnecessary.

Another central principle of FAP providing a critical context for intervention is the explicit use of the therapeutic relationship as a change agent. As López-Pinar and colleagues (xxxx) highlight to truly understand an individual’s behavior, consideration of their social context is critical. In FAP, the therapist uses collaborative case conceptualization and functional analysis to guide intervention on the behaviors that emerge in therapy sessions, to systematically increase and decrease specific behaviors hypothesized to most meaningfully impact the client’s life. The therapist contingently responds to client behavior based on their shared working formulation. To intervene on clinically relevant behaviors, the therapist watches for behaviors in session that are hypothesized as relevant to a client’s life outside of session, engages in behavior to evoke these behaviors in session (e.g., asks questions hypothesized to evoke these behaviors), naturally reinforces effective behaviors from the client in session, notices their impact on the client’s behavior, and provide statements of functional relationships to the client (Kohlenberg & Tsai, 1991).

Related to the clinical example of avoiding shame presented earlier, the FAP therapist might learn that avoidance of shame is not only significantly impacting the client’s life in that it is a driver for substance use, consideration of suicide, and isolation, but avoidance of shame is also causing them to disengage from their relationship with their child. The therapist learns from their case conceptualization that the client’s child returning home from school is a contextual factor that triggers video game playing as their child’s presence evokes shame. Therefore, it becomes the therapist’s priority to evoke shame so that they can help to facilitate a different pattern of responding to shame in the context of an interpersonal exchange. The therapist might first observe the client changing the subject away from talking about their child and instead bring the client back to conversation about their child. They might even directly make note of this avoidance and ask a question like “what’s hard for you about talking about your child” or “what is coming up for you when I ask you about your child?” Noticing that the client continues to change the subject away from their child, the therapist might more directly use their relationship as a context for change, asking a question like, “are your responses to me similar to your responses to your child?” In addition to directly targeting avoidance, the therapist will engage in behavior that reinforces the client’s engagement with shame. When they demonstrate cues related to shame (e.g., crying), if it is conceptualized as reinforcing to the client, the therapist will gently lean in, make eye contact, and use a warm vocal tone. These subtle behaviors may demonstrate the therapist’s care for the client and more importantly, that connection is possible even in the presence of shame. Together, the client and therapist learn to interact with shame in the present moment in the context of their relationship, building new repertoires of responding to shame that can be generalized to the client’s interactions with their child. While other interventions using the therapeutic relationship to reinforce change might be theoretically consistent (e.g., Acceptance and Commitment Therapy, Dialectical Behavior Therapy) or inconsistent (e.g., psychodynamic psychotherapy) with FAP, using case conceptualization to determine how the relationship might impact change in a way that is theoretically coherent with the interventional framework is a critical element of treatment. Regardless of the therapeutic paradigm, when our clients are suffering in their social interactions, “the therapeutic relationship provides an opportunity and responsibility” for intervention (López-Pinar and colleagues, xxxx, p. 3).

Another area highlighted by López-Pinar and colleagues (xxxx) is the importance of implementing idiographic, process-based assessment techniques to track behavioral change with precision. It is notable that the studies reported in this meta-analysis extend beyond traditional RCTs and include single case design studies, as these often provide a more detailed individual analysis of the processes impacting change. A number of methodologies, old and new, facilitate process-based assessment. To facilitate functional analysis in particular, practitioners must collect data to understand the client’s behavior as an act in context, the reinforcers of that behavior, and how their formulation actually works with intervention processes designed to impact change. Functional analysis should be responsive to the client and therapist’s ever-changing context and to the strength of the contingencies reinforcing behaviors that are targeted. Methods of data collection and diagramming a functional analysis for assessment and intervention can include chain analysis and complex network analysis (Borges et al., 2022; Sanford et al., 2022). Single case design and high density ecological momentary assessment can be applied across paradigms to better observe potential mechanisms of change. Though it is FAP specific, the Functional Idiographic Assessment Template system (FIAT; Callaghan, 2006) and corresponding questionnaire facilitate a process-based evaluation of client and therapist behavior in the domains of assertion of needs, bidirectional communication, conflict, disclosure and interpersonal closeness, and emotional experience and expression. Such an approach could be adapted and serve as a framework used across other interventions to code clinically meaningful behavior for the purposes of intervening on interpersonal functioning. Future research should facilitate the integration of idiographic process-based assessment into existing evidence-based frameworks, to facilitate ongoing case conceptualization and intervention.

Despite historic concerns about the generalizability of principle-based interventions, the outcomes of this meta-analysis suggest the significance of FAP. At the heart of FAP is idiographic case conceptualization, the therapeutic relationship as a change process, and methods of measuring individual processes hypothesized to facilitate change. We urge readers to consider applying these principles to address the barriers they (and we) will inevitably encounter when faced with the limits of a manualized protocol. Additionally, the implementation of such a process-based approach to intervention comports with a movement toward precision medicine and mental healthcare. As interventionists and practitioners, we must prioritize the needs of our clients, using innovative and evidence-informed methods to target human suffering in a chaotic world. Addressing our clients’ needs includes identifying when interventions are not performing for the individual in front of us and instead using the best evidence to pivot and meet our clients where they are.