The Psychological Record (2018) 68:27–37

https://doi.org/10.1007/s40732-018-0263-6

ORIGINAL ARTICLE

Functional Analytic Psychotherapy Enhanced Behavioral Activation

for Depression: A Concurrent and Non-Concurrent
Between-Participants Study
Oscar M. Montaño 1 & Marcos A. Montenegro 2 & Amanda M. Muñoz-Martínez 3

Published online: 6 February 2018

# Association for Behavior Analysis International 2018

Abstract
Functional analytic psychotherapy enhanced behavioral activation (FEBA) is a therapeutic approach that combines strategies
from behavioral activation and functional analytic psychotherapy to improve therapeutic outcomes in clients who lack stable
sources of reinforcement in their natural environments. In FEBA, therapists modify clients’ behaviors within the therapeutic
session and simultaneously change clients’ environmental conditions in their natural contexts. A concurrent and nonconcurrent
multiple-baseline design between participants was conducted. Four participants—2 men and 2 women—who reported depressive
symptoms were independently treated in a psychological services center by 2 male therapists. FEBA increased the frequency of
healthy behaviors (e.g., engaging in meaningful conversations with friends) in session and out of session. However, depressive
behaviors in therapeutic and natural settings did not show stable changes. The implications for implementing some of the results
of this study with clients with depression are discussed. Methodological recommendations for using FEBA with specific
populations and in other contexts are also presented.

Keywords Functional analytic psychotherapy enhanced behavioral activation . Depressive behaviors . Healthy behaviors .
Clinically relevant behaviors

Depression is one of the main causes of morbidity and mor- Torres, 2009). Different psychological approaches have devel-
tality at the global level. According to the World Health oped treatments to reduce the impact of depression in the
Organization (2012), 350 million people present with depres- general population. Nonetheless, health-care systems still
sion around the world, and it will become the second largest struggle with a significant number of treatments that have
cause of disability by 2020 (Muñoz, Le, Clarke, Barrera, & shown effectiveness but not treatment efficiency. In addition,
some treatments lack a coherent integration of therapeutic
practices and explanatory principles (Carrascoso & Valdivia,
* Marcos A. Montenegro 2007; David & Montgomery, 2011; Tolin, McKay, Forman,
marcosa.montenegrom@konradlorenz.edu.co; Klonsky, & Thombs, 2015). Behavioral activation (BA) is an
marcomon7@gmail.com
empirically based treatment that has shown positive treatment
Oscar M. Montaño
outcomes (American Psychological Association [APA],
osskarm06@hotmail.com 2015). BA is based on behavioral principles, and its proce-
dures were designed to modify contingencies of reinforce-
Amanda M. Muñoz-Martínez
amandamile@gmail.com ment. Based on behavioral theories, BA assumes that the con-
text provides positive and negative reinforcement for depres-
1
Department of Psychology, Pontificia Universidad Javeriana, sive behaviors, such as crying or complaining, and reduces the
Bogotá, Colombia rewards for or punishes healthy behaviors (e.g., social inter-
2
Konrad Lorenz Fundación Universitaria, Carrera 9 Bis 62-43, actions, hobbies; Grosscup & Lewinsohn, 1980; Lewinsohn,
Bogotá 110231, Colombia 1974; Manos, Kanter, & Busch, 2010; Martell, Addis, &
3
Department of Psychychology, University of Nevada, Reno, NV, Jacobson, 2001). To modify depressive behaviors, BA pro-
USA motes changing the relation between behavior and the
28
environment by strengthening sources of reinforcement, train-
ing new repertoires, and creating an environment that prompts
healthy behaviors (i.e., responses maintained by social rein-
forcement when individuals engage in functional activities
that increase well-being).
BA has shown high clinical significance, and larger effects
have been found particularly in participants who reported se-
vere depression at baseline (Ekers et al., 2014). BA guidelines
are helpful in promoting clients’ engagement in healthy be-
haviors; however, treatment adherence is challenging when
clients present difficulties in contacting sources of reinforce-
ment that support their healthy behavior in their natural envi-
ronment (i.e., out of session). The latter could be particularly
important when clients tend to avoid social interactions or
have lost loved ones. Kanter, Manos, Busch, and Rusch
(2008) proposed combining BA and functional analytic psy-
chotherapy (FAP), a behavior-driven intervention that focuses
on the therapeutic relationship as a primary source of rein-
forcement when clients present a low rate of social reinforce-
ment. Kanter et al. (2008) suggested that functional analytic
psychotherapy enhanced behavioral activation (FEBA) could
be a therapeutic approach helpful for clients who lack stable
sources of reinforcement in their natural environment. For
these cases, therapists could work as a preliminary source of
social reinforcement that would support the development of
skills to identify, establish, and maintain a social network in
the outside environment.
Because BA and FAP are based on behavior–analytic prin-
ciples and use similar methodological approaches in clinical
practice, it seems that they could be integrated without affect-
ing their fundamental assumptions. Whereas BA is focused on
instructing clients to use therapeutic tools in the natural envi-
ronment (Bianchi & Muñoz-Martínez, 2014; Kanter, Busch,
& Rusch, 2009; Kanter et al., 2010; Martell et al., 2001), FAP
fosters changes within the clinical setting, using the therapeu-
tic relationship to shape functional behaviors and decrease
problematic responses in session that might be generalized
to the natural setting (Fernández Parra & Ferro García, 2006;
Muñoz-Martínez & Coletti, 2015), making both therapies
complementary.
FEBA combines therapeutic efforts in session and out of
session, identifying those behaviors influenced by the same fac-
tors in both contexts (i.e., these behaviors have different topog-
raphies but serve the same function). BA provides instructions
and tools out of session to reduce depressive behaviors and
increase clients’ healthy behaviors (i.e., values goal-driven re-
sponses); FAP addresses clients’ behaviors in session and as-
sumes that clients’ behaviors are directly influenced by therapist
responses in the therapeutic setting. In FAP, therapists introduce
discriminative cues, set a motivational environment, and pro-
vide contingencies of reinforcement in session to modify cli-
ents’ problematic and target behaviors (Muñoz-Martínez &
Coletti, 2015). Clients’ target behaviors in session are called
Psychol Rec (2018) 68:27–37
clinically relevant behaviors (CRBs)—CRB1s are problematic
behaviors, CRB2s are clients’ improvements, and CRB3s are
functional interpretations formulated by clients to explain their
behavior. In the context of depression, CRB1s are behaviors
functionally equivalent to clients’ depressive responses in the
natural environment, whereas CRB2s are responses functionally
equivalent to healthy behaviors out of session.
FAP therapist responses in session are classified as thera-
peutic rules (Rs). Rule 1 (R1) involves therapists’ observa-
tions of CRBs during the session, Rule 2 (R2) is used to evoke
CRBs, Rule 3 (R3) involves contingencies of reinforcement to
increase CRB2s or to reduce CRB1s, Rule 4 (R4) is a thera-
pist’s observation of his or her own behavior as a reinforcer for
a client’s CRBs, and Rule 5 (R5) is a contextual cue that helps
clients to establish functional relations between their re-
sponses and how the world works (Kohlenberg & Tsai, 1991).
FEBA was originally designed to treat depression; howev-
er, only one case study has been reported in the literature with
a 22-year-old woman who reported interpersonal distress but
did not meet criteria for depression. The 8-week FEBA ses-
sions demonstrated significant improvements in the quality of
her relationships in diverse contexts, and these changes were
maintained at follow-up (Manos et al., 2009). These results are
promising because they demonstrated that healthy behavior
improved as a result of the client changing her social environ-
ment. Because FEBA was designed to boost therapeutic ef-
fects of BA in the treatment of complex cases of depression,
the current study explores the effects of FEBA on the depres-
sive and healthy behaviors of four participants who met
criteria for depression and presented other secondary behav-
ioral problems (e.g., interpersonal problems).
Method
Design
A concurrent and nonconcurrent multiple-baseline design
(MBL) across participants was conducted. Concurrent MBL
controls for history and maturation effects, whereas noncon-
current MBL controls only for maturation effects.
Nonetheless, nonconcurrent MBL is useful for conducting
research when participant recruitment is difficult (Hayes,
Barlow, & Nelson-Gray, 1999b). However, only concurrent
MBL provides information about historical and maturation
factors that could simultaneously affect multiple participants
(Carr, 2005). The combination of concurrent and nonconcur-
rent MBL in this study controlled for extraneous variables and
allowed a comparison of within- and between-participant
changes. To identify behavioral trends out of session and the
sequential administration of the intervention, the length of the
baselines was randomly assigned for each client on a weekly
basis before recruitment.
Psychol Rec (2018) 68:27–37
Participants
Seven participants—three women and four men—were re-
cruited from a university psychological services center. They
reported depression as their reason for seeking help, and each
met the criteria for clinical depression. Exclusion criteria were
a history of psychiatric disorders (e.g., bipolar disorder diag-
noses) and the use of antidepressant medications. Three par-
ticipants dropped out before starting the intervention (one
missed some sessions, one solved her interpersonal problems
before starting treatment, and the other did not return thera-
pists’ calls after recruitment). Participants’ demographic char-
acteristics (Table 1), daily problems and healthy goals or be-
haviors in and out of session (Table 2), and reasons for seeking
help are discussed in the following sections (no real names are
used).
Bran This participant reported a poor social network and
disclosed that he had terminated a meaningful relationship a
few weeks before seeking psychological services. Bran report-
ed the reason for consultation as “I am lost, my life does not
make sense, I feel dragged. Sometimes I want to do stuff, but
then I also want to throw everything away.” Four months
before the intake, he attempted suicide: “I took some pills with
alcohol, I was drunk when I did it, I felt silly, rejected, I did not
find meaning to anything.” Finally, Bran was looking to iden-
tify reasons for living through the therapeutic process.
Carol This participant stated that she “came to therapy because
[her] partner’s infidelity. .. made [her] feel depressed and anx-
ious.” During her pregnancy and after the birth of her daugh-
ter, Carol received messages from another woman who had a
parallel relationship with her partner. Those circumstances
affected Carol’s mood and engagement in several contexts.
Lucas Lucas reported in the assessment session: “Since
November I have experienced a deep depression, I want to
cry all the time and do nothing.” Lucas related his depressed
mood to an increment in the frequency and intensity of argu-
ments with his wife. Although he often planned strategies to
cope with conflicts, he never followed those plans when dis-
agreements arose, which made him feel frustrated and without
motivation. Finally, Lucas reported feeling upset because he
cried at least two times per week.
Table 1 Baseline Characteristics
of Participants Participant Depression severity
Bran Moderate
Carol Mild
Lucas Mild
Jess Moderate
29
Jess Jess stated:
I’m crying a lot, I don’t want to get out of bed in the
mornings, I don’t want to go to work, actually, I used to
arrive late at work. Further, I separated from my hus-
band, and I often experience strong migraines. My
mood is a bit down, I hold up a lot of things, and I’ve
been sad for a while.
Jess cried frequently before going to sleep; she also had
trouble sleeping and often woke up in the middle of the night.
She attributed her sadness to some issues with her family and
her job.
Instruments and Materials
The Zung Self-Rating Depression Scale (SDS), which has
been validated in Colombia, is a 20-item self-report scale.
The SDS evaluates the frequency of depressive symptoms
experienced by respondents within the last 2 weeks and was
used in this study to screen for depressive symptoms in the
sample as an inclusion criterion. This scale has been validated
with an adult population and has demonstrated high reliability,
with a Cronbach’salpha of 0.80 (Campo-Arias, Díaz-
Martínez, Rueda-Jaimes, & Barros-Bermúdez, 2005).
A BA activity chart format (diary log) was used during the
baseline and intervention phases to assess the frequency of
depressive and healthy behaviors out of session (Martell,
Dimidjian, & Hernan-Dunn, 2010). This is a self-record sheet
that clients used to record their weekly activities hour by hour.
Based on the data collected with the activity chart, the thera-
pists identified therapeutic targets at baseline and set up activ-
ities (healthy behaviors) at intervention. The list of value
thresholds developed by Hayes, Strosahl, and Wilson
(1999a) was used to identify domains where participants
contacted stable sources of reinforcement for maintaining
healthy behaviors (Kanter et al., 2009). Additionally,
asemistructured behavioral interview was conducted to iden-
tify historical events and contextual features that influenced
participants’ depressive behaviors. The information recovered
through the assessment was synthesized in the clinical behav-
ioral case conceptualization (CBCC; Muñoz-Martínez &
Novoa-Gómez, 2011), which helped to identify participants’
Age Marital status Baseline assigned
25 Single Concurrent
36 Cohabitation Concurrent
37 Married Nonconcurrent
28 Divorced Nonconcurrent
30 Psychol Rec (2018) 68:27–37

the effect of his behaviors on others

Expressing his feelings and describing

Expressing a willingness to talk about

functional classes and to develop an idiographic therapeutic

Asking for emotional comfort and

plan for each of them.

Talking about her feelings (e.g.,

Participants’ behaviors in session were evaluated using the

Expressing his emotions and

vulnerability and sadness)

expressing vulnerability
Functional Analytic Psychotherapy Rating Scale (FAPRS;
Callaghan, Follette, Ruckstuhl Jr., & Linnerooth, 2008), a
behavior-based coding system that provides several codes to

his discomfort

disagreements
CRB2 examples

analyze therapeutic interactions. It provides standard codes of

client (CRB) and therapist (R) behaviors in FAP therapeutic
sessions. The FAPRS was only used to code participants’
problems (CRB1s) and improvements (CRB2s) within the
therapeutic setting. Coders rated the presence or absence of
Shutting down when disagreeing

Shutting down when disagreeing

Whining about his relationships

Asking the therapist for reasons

CRBs in a 30-min interval during each session (session-level

for her partner’s infidelity

coding was followed). Therapeutic rules were observed by the

Refusing to talk about her coders during baseline, helping therapists to identify contex-
with the therapist

with the therapist

tual variables that controlled the behavior of the participants in

CRB1 examples

session. However, the coders did not rate therapeutic rules

during the research phases.
sadness

Therapist Training and Coders

Expressing his discomfort to others

Two male clinical psychology master’s degree students imple-

Expressing what she wants from

conversations with her family

Setting interpersonal boundaries

mented the intervention. They attended an ongoing FAP train-

and expressing his emotions
Examples of healthy goals or

ing group that met weekly for 2 years. A behavioral-oriented

Calling friends to hang out

Engaging in meaningful

supervisor certified in FAP and trained in BA supervised the

therapists in a 2-h weekly supervision format. The therapists
also attended a 2-day workshop led by an international expert
relationships

on FAP and BA. Additionally, the therapists received training

behaviors

on conducting functional case conceptualizations (based on

behavior–analytic principles) and implementing FEBA with
other clients for 6 months before starting this research.
The coders attended an ongoing training group on FAP led
Complaining and crying when talking

Withdrawing from social interactions

by a certified FAP trainer, where they practiced experiential

Examples of depressive behaviors
Participants’ Depressive and Healthy Behaviors In and Out of Session

Shutting down during discussions

Calling friends to talk about his

about her partner’s infidelity

exercises and studied theoretical bases of functional contextu-

Withdrawing from discussions

al therapies. They underwent multiple-exemplar training by

coding several therapeutic interactions using the FAPRS with-
in this group.
For research purposes, the therapists assigned one case to a
pair of coders. Each coding pair was provided with the partic-
sadness

CRB1 problematic behavior; CRB2 client improvement

ipant case conceptualization, and they observed the intake

session to become familiar with the participant’s presentation
in session. The therapists also provided a coding format that
Avoidance of and escape from

Avoidance of and escape from

described the CRBs for each session. Coders analyzed FAP

Attention (affection) obtained

Attention (affection) obtained

by her friends and partner
by his friends and parents
Problematic functional class

segments by conducting a 30-min interval observation

from social interactions
Avoidance of and escape

(10 min each). Based on this analysis, interobserver reliability

was established.

Procedure
conflicts

conflicts

The participants received a preliminary assessment. They

were administered the SDS to screen for depressive symp-
Participant

toms, and a semistructured interview was conducted to estab-

Table 2

Lucas

lish whether participants met the criteria for major depressive

Carol
Bran

Jess

disorder. Participants who met the criteria for depression were

Psychol Rec (2018) 68:27–37
asked to participate in this study and provided informed con-
sent. Clients who did not agree to participate in the study were
referred to other therapists within the center.
During the first session at baseline, the rationale of FEBA
was discussed with the participants, explaining the relation of
FAP and BA as behavior-driven interventions developed to
modify contingencies of reinforcement within the therapeutic
setting and in the natural environment, respectively.
Participants were trained to fill out the BA activity chart to
identify behavioral goals and targets out of session. The ther-
apists also conducted a values assessment to identify domains
of interest that represented stable sources of reinforcement for
each participant. Based on the values identified, the therapists
evaluated specific behaviors that could be targeted within the
intervention to reduce participants’ depression and increase
their well-being.
Simultaneously, the therapists also used R1 to identify
CRBs in session. In supervision, the therapists and the super-
visor assessed the participants’ CRBs by analyzing therapeu-
tic videotapes, and the supervisor prevented the therapists
from providing contingent reinforcement (R3). Videotaped
sessions were rated by coders using the FAPRS, and they
provided information regarding CRBs and rules that were ob-
served in session to the supervisor. These observations were
also discussed within the supervision meetings.
At the end of baseline, the information collected during the
evaluation was organized in the CBCC (Muñoz-Martínez &
Novoa-Gómez, 2011), and the therapists discussed the case
formulation with the supervisor before presenting it to the
participants in the first session of the intervention.
Treatment FEBA treatment (maximum of 13 weeks) was im-
plemented for each participant in a 1-h weekly session format.
The participant’s case conceptualization and treatment plan
was discussed with him or her during the first session of in-
tervention. During the first half hour of every treatment ses-
sion, FAP therapeutic rules were applied in which the thera-
pists used R2 to evoke problems (CRB1s) and improvements
(CRB2s). The therapists provided consequences (R3) to re-
duce CRB1s (e.g., differential reinforcement of alternative
behavior) and reinforcers to increase CRB2s (e.g., positive
reinforcement) in session. R5 was used to promote the gener-
alization of the client’s improvements to the natural settings
where these could be supported.
BA was implemented during the second half of the ses-
sions within the intervention phase. Based on their values
assessments, participants recorded their healthy behaviors
weekly on the BA activity chart. After the second interven-
tion session, the therapists and participants reviewed the
diary log to identify contextual factors that facilitated or
hindered goal achievement out of session. Upon partici-
pants meeting their weekly goals, therapists reinforced par-
ticipants’ performances and set behavioral goals for the
31
following week. When participants failed to complete
homework, participants and therapists conducted a task
analysis, which is “the process of breaking a complex skill
or series of behaviors into smaller, teachable units; [this]
also refers to the results of this process” (Cooper, Heron, &
Heward, 2007, p. 19). Based on the task analysis, the
events that prevented the clients from completing home-
work were identified. Subsequently, they arranged the con-
text (contingency management) to favor homework com-
pletion or selected less complex activities that were more
likely to be achieved before the next session.
Data Analysis
Visual inspection of trends was conducted to examine changes
in depressive and healthy behaviors in and out of session.
Interrater reliability (IRR) analysis was performed to establish
data consistency for CRB1s and CRB2s by reaching more
than 80% interobserver agreement (high reliability) for each
participant in 30% of the sessions coded (Table 3).
A nonoverlap analysis of all pairs (NAP) was calculated
to examine the clinical significance of FEBA. NAP evalu-
ates the precision and discriminability of overlapping data
in single-case designs as an indicator of effect size. This
method summarizes data overlapped between data points
in each phase (baseline vs. intervention), expecting larger,
nonoverlapping data points during the intervention phase
than at baseline to achieve significant effects (Parker &
Vannest, 2009).
Ethical Considerations
This research was based on APA (2002) ethical principles to
guarantee the participants’ well-being. Participants were in-
formed about research aims, participation was voluntary, and
they were allowed to drop out if they considered this neces-
sary. They signed an informed consent form in which they
authorized the sharing of personal information with the coders
and supervisor. They also authorized the authors to publish
their cases, keeping identification data confidential.
Additionally, the coders signed a confidentiality agreement
to protect participants’ information.
Table 3 Interrater
Agreement Ranges per Participant IRR percentage
Participant
Bran 83%–100%
Carol 86%–100%
Lucas 82%–100%
Jess 87%–93%
IRR interrater reliability
32
Results
To determine treatment effects on depressive and healthy be-
haviors, an analysis of frequency trends within and between
participants was conducted (Figs. 1 and 2). First, behavior
frequencies among participants were examined. The variables
that influenced participants’ behaviors (comparing concurrent
participants) and the effects of the intervention among indi-
viduals were also assessed. Second, analyses of within-
participant behaviors through the therapeutic process were
conducted. Third, the NAP was performed to establish treat-
ment effect sizes.
Between-Participant Analyses
All participants increased their frequency of healthy behaviors
and CRB2s contingent on introducing FEBA. Although
Carol, Bran, and Jess reduced their depressive behaviors in
the natural setting, Lucas did not show significant changes
in depression; this behavior maintained a stable tendency
across phases (Fig. 1).
FEBA produced different effects on CRB1s among partic-
ipants. Whereas Carol’s and Bran’s CRB1s diminished sub-
stantially, these responses did not change their trend and var-
iability for Lucas and Jess (Fig. 2). Jess’s baseline did not
show any change in trend or variability after FEBA was im-
plemented to Bran; therefore, it is likely that any historical
factor affected depressive or healthy behaviors for these two
participants, who were recruited concurrently.
Within-Participant Analyses
Bran Bran’s depressive behaviors reduced suddenly after
FEBA was implemented. Otherwise, healthy behaviors in-
creased compared to frequencies at baseline. With respect to
Bran’s CRB1 frequencies, these changed in variability and
maintained a low, stable level throughout the intervention,
whereas his CRB2s had sudden changes during treatment.
These outcomes showed positive effects on enhancing active
behaviors and reducing depressive behaviors.
Carol Carol’s depressive behaviors showed a sudden decrease
in trend after introducing FEBA; subsequently, these re-
sponses presented a low, stable tendency. Healthy behaviors
increased suddenly when treatment was implemented; they
only showed a subtle trend increase at the end of this phase.
Regarding in-session behaviors, CRB1s did not show changes
in variability or trend between baseline and FEBA, whereas
CRB2 frequencies increased at the beginning of treatment.
Nonetheless, the latter was inconsistent in level and trend dur-
ing intervention.
Psychol Rec (2018) 68:27–37
Lucas Comparisons between baseline and FEBA for de-
pressive and healthy behaviors out of session are limited
due to missing data for three sessions during baseline. In
contrast to the evaluation session, depressive behaviors
increased and maintained a stable trend throughout inter-
vention, whereas healthy responses presented a sudden
change in level and trend that stabilized at Session 4.
Assessment of CRBs provided complete information of
Lucas’s behavior throughout the research in session. Both
CRB1s and CRB2s changed their tendency and variability
after implementing FEBA. Whereas CRB1s decreased,
CRB2s increased at the beginning of the intervention and
showed a stable level at the end of this phase.
Jess Jess’s depressive behaviors decreased during baseline
after therapists attended to her crisis. After Session 3, her
depressive behaviors reduced, but no changes were ob-
served in these responses later. Nonetheless, healthy be-
havior frequencies presented a low rate during baseline
and changed suddenly upon FEBA implementation.
Regarding CRB1s, these decreased to lower levels than at
baseline during the intervention. At Session 3, at baseline,
Jess attended the session in crisis; therefore, CRB1s during
that session presented a peak. Because the crisis was asso-
ciated with Jess’s depressive behaviors, this session was
coded and kept within the analysis, although these data
altered the trend of the baseline. Finally, CRB2s improved
at intervention; however, their trend and level were incon-
sistent during treatment.
NAP: Effect Size Analysis
A NAP was conducted to examine the effect sizes of behav-
iors in and out of session (see Table 4). The NAP for Lucas’s
behaviors out of session could not be calculated because 3
data points were missing from the baseline assessment.
Healthy behaviors significantly increased during the interven-
tion for the remaining participants. Strong clinical changes
were found in Bran’s and Jess’s healthy behaviors, whereas
moderate effects were found for Carol’s. Clinically significant
changes were observed in Bran’s and Carol’s depressive be-
haviors but not in Jess’s depressive behaviors.
No parallel changes were observed between in-session
(CRBs) and out-of-session behaviors. In fact, no consistent
changes were observed in CRBs among the participants.
Carol’s and Jess’s CRB1s were significantly reduced, but no
clinically significant changes were identified in Bran’s and
Lucas’s CRB1s. However, Bran’s depressive responses were
significantly reduced in his natural environment, but his
CRB1s did not show a significant reduction. Although
Bran’s, Carol’s, and Jess’s healthy behaviors were significant-
ly enhanced out of session, only Bran’s and Lucas’s CRB2s
were clinically significant (see Table 4).
Psychol Rec (2018) 68:27–37 33

28 FEBA
Baseline Depressive behaviors
26
24 Healthy behaviors
22
20
18
16
14
12
10
8
6
4
2
0 Bran*
1 2 3 4 5 6 7 8 9 10 11 12
28
26
24
22
20
18
16
14
12
10
8
6
4
2
Carol*
Frequency

0
1 2 3 4 5 6 7 8 9 10 11 12

16

14

12

10

0 Lucas**
1 2 3 4 5 6 7 8 9 10 11 12 13

40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0 Jess**
1 2 3 4 5 6 7 8 9 10 11 12

Weeks
*Concurrent
**Non-Concurrent
Fig. 1 Frequency of depressive and healthy behaviors out of session. FEBA = functional analytic psychotherapy enhanced behavioral activation
34 Psychol Rec (2018) 68:27–37

150 FEBA CRB1

Baseline
CRB2
120

90

60

30

0
Bran*
1 2 3 4 5 6 7 8 9 10 11 12
90

60

30
Frequency

0 Carol*
1 2 3 4 5 6 7 8 9 10

90

60

30

0
Lucas**
1 2 3 4 5 6 7 8 9 10 11 12

420
390
360
330
300
270
240
210
180
150
120
90
60
30
0 Jess**
1 2 3 4 5 6 7 8 9 10 11 12
Weeks
*Concurrent
**Non-Concurrent

Fig. 2 Frequency of clinically relevant behaviors per session. FEBA = functional analytic psychotherapy enhanced behavioral activation; CRB1 =
problematic behavior; CRB2 = client improvement
Psychol Rec (2018) 68:27–37 35

Table 4 Nonoverlap Analysis of All Pairs Comparing Baseline to This research highlights the importance of using outcome-
Intervention
based assessments in addition to symptom reduction measure-
Participant Behavior NAPa 90% CI ments for evaluating therapeutic success in depression be-
cause there may not be a necessary connection between symp-
Lower Upper tom reduction and client functioning (Becker, Chorpita, &
Bran Depressive 0 −1.659 −0.341
Daleiden, 2011; Perkins, 2001). This study found that 3 out
of 4 participants significantly reduced their depressive behav-
Healthy 1 0.34 1.65
iors but that one of them did not show changes in depressive
CRB1 0.2222 −1.215 0.103
behaviors during the intervention. Nonetheless, all of them
CRB2 0.0126 0.341 1.659
increased their healthy behaviors significantly, improving
Carol Depressive 0 −1.61 −0.39
their general functioning. Therefore, FEBA has been shown
Healthy 1 0.36 1.61
to be a treatment that is focused on enhancing clients’ reper-
CRB1 0.125 −1.393 −0.107
toires, providing them with more behavioral resources to deal
CRB2 0.75 −0.143 1.143
with problematic circumstances instead of eliminating prob-
Lucas Depressive – – –
lematic repertoires as the main goal.
Healthy – – –
Even though FEBA is centered on outcome indicators, it is
CRB1 0.4688 −0.668 0.543
important for future research to explore ways to improve
CRB2 0.75 0.238 1.449
healthy behaviors while decreasing depressive responses, par-
Jess Depressive 0.025 −1.07 0.07
ticularly when depression is highly pervasive. In this regard,
Healthy 1 0.43 1.57
Kanter et al. (2008) mentioned the importance of being mind-
CRB1 0.1111 −1.349 −0.207 ful of clients’ functional classes to avoid reinforcing problem-
CRB2 0.75 −0.071 1.071 atic behaviors. Functional assessment is the procedure used by
NAP nonoverlap analysis of all pairs; CI confidence interval; CRB1 behavior therapists to examine those factors that control cli-
problematic behavior; CRB2 client improvement ents’ behaviors in different contexts independently of re-
a
NAP ranges: weak effects: 0–0.65; medium effects: 0.66–0.92; large or sponse topographies. This method has shown larger clinical
strong effects: 0.93–1.0 (Parker & Vannest, 2009). These scores should be significance, and it has demonstrated enhanced therapeutic
interpreted inversely when the research aim is to decrease the indicator outcomes (Hayes, Nelson, & Jarrett, 1987; Hurl, Wightman,
(e.g., reduce depressive behaviors and CRB1s)
Virues-Ortega, & Haynes, 2016). Thus, we recommend using
it to guide therapeutic actions when using FEBA so that both
Discussion depressive and healthy behaviors can be targeted.
To increase the reliability of the results, an idiographic
This study shows that healthy behaviors significantly in- multiple-method assessment of participants’ behaviors in their
creased after implementing FEBA in participants who met natural and clinical settings was conducted. This approach
criteria for depression. In particular, these results show that allowed therapists to determine whether clients’ behaviors
BA and FAP are complementary therapeutic approaches were controlled by similar variables in and out of session.
that primarily favor clients’ engagement in activating be- However, this study showed that after modifying the control-
haviors rather than reducing psychological symptoms. This ling contextual variables of depressive and healthy behaviors,
is likely related to FEBA’s emphasis on providing clients they did not change in the natural and therapeutic settings
with strategies to modify their environment (e.g., social simultaneously in 3 out of the 4 participants. These findings
interactions) instead of training them to change their moods need to be explored in depth in future research due to the role
or thoughts to reduce depression. The latter rationale may of functional assessment in planning therapeutic action in be-
explain why participants increased their healthy behaviors havioral therapies and the importance of identifying accurate
but still emitted depressive responses (Figs. 1 and 2). sources of influence that can be effectively modified.
However, these results should be interpreted with caution, A practical issue when BA was implemented was the iden-
as this research did not provide data about therapists’ be- tification of achievable behaviors out of session—that is, be-
haviors in session. The lack of information about the use of haviors that clients had already mastered. Although the BA
therapeutic rules makes it difficult to establish how FAP manual (Kanter et al., 2009) mentions the importance of iden-
was added to BA and whether FAP was fundamental in tifying specific behaviors linked to clients’ values as a primary
producing treatment outcomes. It is important that future target in therapy, it was difficult to establish them at the be-
studies of FEBA assess therapeutic rules and, where possi- ginning of treatment. We recommend that therapists conduct a
ble, identify whether different reinforcement parameters task analysis of therapeutic goals, where clients’ activities can
(e.g., amount, quality, delay) and the contingency of rein- be broken down into achievable small steps in a coordinated
forcement are critical for therapeutic success. and coherent manner. In this study, task analysis allowed for
36
starting with activities that the participants had already mas-
tered, engaging in activities that obtained reinforcers with
minimal effort when therapy began (Cooper et al., 2007).
Although this exploratory study supported the utility of
combining FAP and BA, this research did not conduct exper-
imental preparations to compare BA alone, FAP alone, and
FEBA. Further investigations should examine the utility of
each of these in treating depression. It is particularly important
to assess the effectiveness and efficiency of adding FAP and
BA and to identify whether one or another therapy is more or
less effective for specific clients. For instance, it would be
interesting to explore whether FEBA could be more useful
than BA alone for clients who present interpersonal problems
or a narrow social network because FAP is a therapeutic ap-
proach centered on the therapeutic relationship, where inter-
personal repertoires are directly shaped in the clinical environ-
ment (Follette, Naugle, & Callaghan, 1996).
Some limitations of this study are related to participant
recruitment due to three participants dropping out before
starting the intervention. We recommend increasing the num-
ber of participants to reduce the impact of attrition. It would be
useful to use research designs that do not require lengthy
baselines, reducing the time participants have to wait to re-
ceive treatment (e.g., complex phase-change design), or to
include crossover designs that allow phase comparisons with-
out waiting for the intervention to start with other participants
(Hayes et al., 1999a, b).
The lack of a follow-up phase was another limitation of this
study. Although the MBL controlled for history and matura-
tion threats and the between-participant comparison showed
that FEBA was likely the variable that produced clients’
changes within the treatment phase, it was not possible to
establish whether those changes were maintained after the
intervention. We recommend including a follow-up assess-
ment in future research to identify the sustainability of
FEBA effects.
Although participants were encouraged to fill out their BA
activity charts at home daily, sometimes they did not bring
them and these had to be completed during the session.
Analysis of therapeutic videos provided a simultaneous mea-
sure in session, which helped to control assessment bias
through a multiple-method strategy. Nonetheless,
implementing ecological momentary assessment (EMA) tech-
niques such as mobile apps, text messages, or e-mails for
collecting data in vivo is recommended for future research.
This research showed the utility of implementing a coher-
ent, behavior-driven intervention that coordinated efforts in
and out of session to improve clients’ healthy behaviors.
However, these findings did not allow us to establish whether
FEBA is more effective than BA alone. Therefore, it is impor-
tant to evaluate this comparison further to determine whether
adding FAP to BA helps to reduce the burden of therapeutic
procedures available and helps to refine the utility of
Psychol Rec (2018) 68:27–37
psychotherapy for treating a particular population, such as
individuals who present with depression and pervasive inter-
personal problems.
Compliance with ethical standards
The authors certify that they have no affiliations with or involvement in
any organization or entity with any financial or nonfinancial interest in the
subject matter or materials discussed in this article.
Conflict of interest The authors declare that they have no conflicts of
interest.
Human participants and Animal studies All procedures performed in
studies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and with
the 1964 Declaration of Helsinki and its later amendments or comparable
ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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