Functional analysis

Summary

Functional analysis constitutes both a theoretical foundation and a practical clinical tool within CBT. It forms the theoretical basis for exposure therapy, behavioral activation, dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT) and countless other evidence-based CBT interventions. It is a part of what is called ‘learning theory’ and stems from BF Skinners research on operant conditioning. It guides the therapist through the assessment phase and provides the blueprint for the therapy, outlining the patient’s way to change.

Background

Functional analysis is at the core of cognitive behavior therapy. Using a metaphor, one could say that it is the principal seed put into the clinical soil, that eventually grows into a large CBT tree with branches such as exposure therapy, behavioral activation, dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT) and countless other evidence-based CBT interventions. But it is not only the theoretical basis for many CBT interventions – it is also a highly practical clinical tool, that guides the therapist’s questions during the assessment phase and provides the blueprint for the therapy.

Functional analysis was born with BF Skinner’s operant psychology within what has come to be called “learning theory”. An operant (functional) analysis is an analysis of the causal factors explaining the behavior of an organism. That is why functional analysis also can be called “experimental analysis”. Skinner’s basic lab research was mainly conducted on mice and doves. A criticism of an operant perspective on human life has been that it would leave out the role of language and other complex human mechanisms. That criticism misses however largely its target.

Later developments in learning theory have developed a functional analytic theory of human language and cognition, called “relational frame theory” (RFT, developed by Steven C. Hayes, Dermot Barnes-Holmes and Bryan Roche). But already Skinner’s operant analysis actually included the analysis of what he called “verbal behavior”. This perspective, analysing thoughts and speaking as something _we do_ (that is, as behavior), rather than primarily analysing the _content_ of thought as in cognitive psychology, has actually been ground-breaking in the clinical understanding of rumination, worry, mental compulsions and other dysfunctional repetitive thinking. This behavioral understanding of thoughts and thinking has engendered numerous psychological interventions to effectively treat such problems; interventions that are the core of the most common mental health problems including depression, excessive worry and anxiety as well as obsessive-compulsive and related disorders.

Principles and practice

A functional analysis constitutes the junction between theory and the patient’s problems. Based on the operant theory of the causal contextual contingencies of human behavior and in firm empirical evidence, it guides the therapist’s understanding of what the patient is experiencing. It shows how a person’s immediate environment can explain what he or she does (or does not do). In this way, another synonym of functional analysis (next to “experimental analysis”) can also be “contextual analysis”.

In this way, functional analysis guides the therapist’s questions to the patient by focusing on the context of behavior: The therapist asks questions like “When you were doing that, what had preceded it – what happened just before? Where were you? What did you feel?” as well as “What happened then? How did the other person react? What did it make you feel in that very moment?”

ABC analysis

A functional analysis can be formalised in different ways, but one of the most common ways is through the acronym “A B C” (for Antecedent, Behavior, Consequence). As already mentioned, at the centre of a functional analysis lays what the person does (Behavior). The antecedent is, as the word implies, what precedes the behavior, and Consequence what comes after.

Here it is important to underline that the word “behavior” has a quite different, much broader definition in functional analysis than in everyday language. Whereas “behaviors”, “thoughts” or “sensations” are separate things in everyday language, they are not necessarily separated in a functional analysis. As we already touched on before (in the Background): In a functional analysis, _everything we do_ (also the things we do in our head) constitutes behavior.

An A B C analysis is thus always about a specific moment in time – it is not about the patient’s problems “in general”. This means that to perform a helpful A B C (functional) analysis, the therapist will have to help the patient delineate one specific example of his or her difficulties: “The difficulties that we have been talking about now… could we zoom in on a specific example of these problems? When did this occur last time, or a time that you remember quite clearly?”

Below will be given an example of OCD, to clarify the principles of functional analysis. Let’s start by elucidating what for many is probably the less intuitive part of functional analysis, mentioned above, namely analysing thoughts as behavior.

A patient with OCD quite often performs mental rituals (see specific article on Exposure and response prevention for OCD). In therapy with an OCD patient it becomes quite clear that what he does physically (in functional analysis called “overt” behavior), such as washing his hands repeatedly, actually is functionally equivalent to what he does in his head, in the form of mental rituals such as saying a prayer, counting to a certain number or repeating things such as “The doctor said it was only OCD, it’s only OCD, it’s only OCD” (in a functional analysis called “covert” behavior). Both these behaviors (the overt behavior of handwashing and the covert behavior of repeating things in one’s head) shares more or less the same function: of avoiding the anxiety-provoking obsession and reducing the degree of anxiety. In terms of functional analysis, they are both negatively reinforced behaviors, and the fact that one potentially can be observed by everyone (the handwashing) and one only can be observed by the patient him- or herself (the menta

l rituals), is secondary from a functional perspective. Both are repetitive and time-consuming negatively reinforced problem behavior, who maintain the patient’s debilitating emotional problem (OCD) and hinders him or her from healing.

Behaviors in relation to their consequences can be either reinforced (leading to them to increase in frequency), extinguished (the absence of previous reinforcement, leading to a decrease in frequency) or weakened (or “punished” as the theoretical term is, equally leading to a decrease in frequency). There are two types of reinforcement: positive and negative. If the consequent implies that something is added, it is positive reinforcement. If something previously present is removed, it is negative reinforcement.

Among patients with OCD, it is very common that the patient seeks reassurance from his or her close ones. For example: the patient asking her partner “Could I be contaminated by having touched the handle of the public bathroom” and her partner responding “Absolutely not, you’re safe, nothing bad will happen”, making the patient experience a sense of relief (less anxiety). If that happens again and again over time, this type of reassurance constitutes a common form of negative reinforcement.

Here is an A B C-analysis of this example above:

Continuing the example, the partner may go on to add “I know it’s difficult, but these challenges are only going to make us stronger, I will always be on your side. I love you so much” making the patient experience a sense of closeness and tenderness. If that happens again and again over time, this type of answer from the partner constitutes a common form of positive reinforcement (more closeness with significant other). Both these types of reinforcement (negative and positive) will unfortunately increase the reassurance seeking behavior of the patient, even though this is of course not the “intent” of her partner. The partner is in turn also reinforced in his reassurance giving behavior: Seeing a loved one anxious is naturally aversive, and by relieving his partners anxiety, he also relieves his own (another example of negative reinforcement, this time focusing on the partner’s and not the patient’s behavior).

These are all examples of how a functional analysis identifies the primary causal factors of problem behavior in the individual’s environment, _not_ in his or her inner life (in terms of “intents”, “personality” or other intrapsychic factors proposed by other psychological theories).

Another possibility would be if the partner answered “Oh no, I just can’t take it anymore, you have to get a grip!” with an irritated voice. If that happens over time, the seeking reassurance behavior will probably decrease, and it would constitute a common form of weakening (or “punishment” as the theoretical term is). OCD and severe emotional disorders often put a lot of strain on relationships (between spouses, but also between parents and their child, between close friends etc). Even if the “outburst” of the partner is understandable from a functional perspective (the aversive reassurance seeking from his partner will end), it doesn’t help his partner in the long run (as exposure does), and probably will lead to feelings of guild and more strain on the couple.

The functional relations of everyday life

Within a clinical context (as a therapist working with patients with mental health problems) it is easy to forget that learning theory principles discussed here are implicated in _all_ human behavior, from the smallest possible slice of everyday life: For example, when we reach for a door handle to go into a different room where we want to go, if the handle gives way and we can open the door, we are positively reinforced to do so again, whereas if it remains immovable in place (because it is locked), not making it possible to access the room where we have been able to go many times before, our behavior is extinguished (extinction: a previous positive reinforcer is no longer present) which will reduce the probability of trying again and again to open that door.

Our everyday life is full of such “small” experiences, that govern our life: Eye contact with someone we appreciate, the feeling of sunlight warming our face after a week of rain, a friend saying “I know exactly what you mean” – all of these are examples of common positive reinforcers.

Antecedents

The antecedents of behavior marks the ”availability” of reinforcement. As in the example of the locked door, this particular door (which previously wasn’t locked and therefore signaled reinforcement) now signals non reinforcement – extinction. Picking up the example of the OCD patient seeking reassurance: Her partner is an antecedent signaling reinforcement (if being reassured) whereas for instance if her mother no longer reassures her (“It won’t help whatever I say, dear”), the mother constitutes an antecedent signaling non reinforcement. Shortly put: The partner is a what is called a “discriminative stimulus" for asking for reassurance, the mother is not. The doorhandles in public bathrooms are conditioned to anxiety for the patient, and are therefore signaling negative reinforcement (conditioned to handwashing afterwards), whereas the doorhandles at home (considered “clean” by the patient) are neutral stimuli, not conditioned to handwashing or thus reinforcement. Shortly put: doorhandles outside the home are discriminative stimuli for handwashing, the doorhandles at home are not.

Changing emotional problems by working on contextual factors

In a clinical setting, from this point of view, one can say that the only way to change a patient’s behavior (like excessive handwashing, or reassurance seeking), that maintains her emotional problem (like OCD) is by changing the context. That is, working on the antecedents and the consequences. In exposure therapy (see specific article), this is precisely what we do: Exposing the above-mentioned patient to the anxiety provoking antecedent (like door handles in public bathrooms), and removing the problematic negatively reinforced consequences (the temporary relief of reassurance from her partner or from handwashing; see article on Exposure and response prevention for OCD).

Why is this contextual perspective so clinically important? Because we have direct access to the contextual factors (the doorhandles, the partner and all other contextual factors surrounding the patient), but we _do not_ have direct access to someone’s feelings or “intent”: In the above example about reassurance seeking from a partner, after the therapist has explained this functional analysis to this couple (in suitable everyday language – rarely in complicated such theoretical terms as described here), he or she says: “Can you see now how you are caught in a vicious circle: when your husband reassures you, you feel temporarily better, but in the long run, the vicious circle just makes the anxiety come back and makes you ‘dependant’ on being reassured? Therefore, I propose that from now on, when you ask for reassurance, your husband doesn’t reassure you, but rather helps you live on despite the anxiety, and see if that eventually will make you experience something new. Would you both be willing to try that out? I know it’s difficult, but this is the way out of your suffering”.

This is an example of how a functional analysis gives the therapist the rationale for an exposure with response prevention (ERP, see specific article): ERP will lead the patient to have a new experience; that when she no longer solely focuses on trying to flee or get instant relief from the anxiety (by handwashing or reassurance or other safety behaviors, see separate article), she will eventually experience something new that contradicts her fear, and that will eventually decrease her OCD related fear over time.