Functional Analytic Psychotherapy (FAP) is a therapy that focuses on improving how people interact by shaping behavior through therapy conversations (Kohlenberg & Tsai, 1991). Therapists follow five rules during sessions:
- Notice problem behaviors.
- Encourage positive changes.
- Positively reinforce good changes and ignore bad ones.
- Pay attention to how therapist actions affect behavior.
- Connect therapy to everyday life for lasting change.
FAP can be used on its own or with other therapies like acceptance and commitment therapy (ACT) or cognitive-behavior therapy (CBT). Previous research shows it helps with individual problems, but no previous reviews have summarized the evidence for FAP in a quantitative way, gathering all the studies published so far about the efficacy of FAP addressing both interpersonal (e.g., avoidance of intimacy) and intrapersonal (e.g., anxiety and depression symptoms) behaviors.
Our study aimed to give a full overview of both group studies (e.g., randomized controlled trials, single-arm trials) and single-case studies that look at how well FAP works in treating different clinical outcomes.
To do this, we looked at different databases and pulled the data we needed to calculate the effect sizes for each study. Then we combined them in a random effects meta-analysis. We found 25 group studies (including 16 randomized controlled trials) and 45 single-case designs. We rated almost all studies with a high risk of bias because the participants were not blinded, we did not have enough info about their methodology, and the outcomes were self-reported.
With this potential limitation in mind, evidence from single-case studies showed that there were significant improvements in the clinically relevant behaviors selected for each case (e.g., avoidance) both within and outside therapy sessions. In addition, results from group studies showed that participants who received FAP improved significantly more than those in control groups on anxiety and depression symptoms. They also improved their marital satisfaction and fear of intimacy.
We also found that the number of studies since the last reviews has increased significantly in recent years. The number of single-case studies has doubled and the number of randomized controlled trials has tripled since the last reviews were published less than a decade ago (Kanter et al., 2017; Singh & O’Brien, 2017). This is great news for the field of clinical efficacy of FAP, as it shows that the literature is developing rapidly.
Another positive aspect is the high level of methodological rigor we observed, particularly in single-case designs. In most of these studies, the outcome was directly observed during therapy sessions by measuring the frequency of clinically relevant behaviors, often by two independent observers. This leads to less biased results and also to a more nuanced, in-depth examination of the effect of therapy than the typical clinical trial, in which outcome is measured by self-report only before and after the intervention.
The results of our review further support previous literature in this area, both by increasing the number of studies included and by improving the methodology. This contributes to the empirical support for the clinical efficacy of third wave behavioral interventions such as FAP, acceptance and commitment therapy, or dialectical behavior therapy, among others.
Our results have relevant implications for the clinical practice. First, and most obviously, attention to the client-therapist interaction, accurate identification of clinically relevant behaviors, and coherent responses to these behaviors might lead to improved client behaviors in and out of session. The concept and importance of the therapeutic alliance is central and transversal in clinical psychology. However, it has often been defined in a very vague and imprecise way, and FAP is an excellent tool to operationalize the concept, and therefore to manipulate it in a more rigorous way in therapy. With clear and direct instructions, the therapist can do things to make this therapeutic alliance the vehicle for change.
Another important clinical implication is that FAP, because of the way it is designed, allows it to be combined with other forms of therapy. This makes it very versatile, and it can enrich interventions that were already considered effective, such as first- and second-wave behavioral therapies.
Finally, our review provides an overview of the accumulated evidence for FAP and offers support for its use in addressing both intra- and interpersonal behaviors.
Nevertheless, our study results must be interpreted in light of several potential limitations, such as the aforementioned high risk of bias of the included studies and the high heterogeneity among the studies we found.
Target Article
López-Pinar, C., Galán-Doña, D., Tsai, M., & Macías, J. (2024). Meta-analysis of randomized controlled trials and single-case designs on the efficacy of functional analytic psychotherapy. Clinical Psychology: Science and Practice. Advance online publication. https://doi.org/10.1037/cps0000221
Discussion Questions
- How does the ability of FAP to be combined with other therapies enhance its versatility and effectiveness in clinical practice?
- What are the implications of the findings on the therapeutic alliance for clinical practice, and how can FAP’s structured approach to this concept benefit client outcomes?
- What are some specific strategies that therapists can use within the FAP framework to effectively reinforce positive changes and manage problem behaviors during sessions?
- How does the focus on client-therapist interactions in FAP compared to other therapeutic approaches, and what unique benefits does this focus offer?
About the Authors
Carlos López-Pinar, PhD in clinical psychology. Lecturer and researcher at the European University of Valencia. He also works as a general clinical psychologist in private practice using behavioral-based therapies. You can find him on Twitter at @_lopezpinar.
David Galán-Doña, MSc. Graduate in psychology, master’s degree in contextual therapies, master’s degree in general clinical psychology. Works as a general clinical psychologist in the private context using FAP and ACT.
Mavis Tsai, PhD is a a senior research scientist at the University of Washington. Along with Robert Kohlenberg, she is one of the creators of Functional Analytic Psychotherapy (FAP). She is the director specializing in FAP at the University of Washington’s Psychological Services and Training Center.
Juanjo Macías, PhD in clinical psychology. He applies process-based models from a contextual philosophy of behavioral science. University lecturer and researcher. Co-founder of Psicoflix and author of the FACT book in Spanish.
References
Kanter, J. W., Manbeck, K. E., Kuczynski, A. M., Maitland, D. W. M., Villas-Bôas, A., & Reyes Ortega, M. A. (2017). A comprehensive review of research on functional analytic psychotherapy. Clinical Psychology Review, 58, 141–156. https://doi.org/10.1016/j.cpr.2017.09.010
Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. Springer. https://doi.org/10.1007/978-0-387-70855-3
Singh, S., & O’Brien, W. H. (2018). A quantitative synthesis of functional analytic psychotherapy single-subject research. Journal of Contextual Behavioral Science, 7, 35–46. https://doi.org/10.1016/j.jcbs.2017.11.004