Psychotherapy © 2016 American Psychological Association

2016, Vol. 53, No. 3, 331–335 0033-3204/16/$12.00 http://dx.doi.org/10.1037/pst0000065

Reducing Inadvertent Clinical Errors: Guidelines From Functional

Analytic Psychotherapy

Mavis Tsai Tien Mandell

University of Washington University of Glasgow

Daniel Maitland, Jonathan Kanter, and Robert J. Kohlenberg

University of Washington
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Two common types of clinical errors, inadvertently reinforcing client problem behaviors or inadvertently
This document is copyrighted by the American Psychological Association or one of its allied publishers.

punishing client improvements, are conceptualized from the viewpoint of Functional Analytic Psycho-
therapy (FAP), a treatment that harnesses the power of the therapeutic relationship. Understanding the
functions of client behaviors such as incessant talking and over compliance can lead to more compas-
sionate and effective intervention, and a functional analysis of seemingly problematic behaviors such as
silence and lack of cooperation indicate how they may be client improvements. Suggestions are provided
for how to more accurately conceptualize whether client behaviors are problems or improvements, and
to increase awareness of therapist vulnerabilities that can lead to errors. While FAP is rooted in a
functional contextual philosophy, the goal of this article is to offer a framework that crosses theoretical
boundaries to decrease the likelihood of clinical errors and to facilitate client growth.

Keywords: Functional Analytic Psychotherapy, awareness, therapeutic relationship, functional analysis,

clinical errors

Functional Analytic Psychotherapy (FAP), a behavioral ap-
proach based on empirically supported principles, harnesses the
power of the therapeutic relationship and maximizes the genuine-
ness, intensity, compassion, and effectiveness of the therapist. FAP
therapists view each client as a microculture with complex life
stories of joy and anguish, dreams and hopes, passions and vul-
nerabilities, and unique gifts and abilities, carrying deeply rooted
cultural, social, and generational experiences in their reinforce-
ment histories (Kohlenberg & Tsai, 1991; Tsai, Callaghan, &
Kohlenberg, 2013; Tsai, Kohlenberg, Kanter, Holman, & Plummer
Loudon, 2012; Tsai et al., 2009).
At the core of FAP is its hypothesized mechanism of clinical
change— contingent therapist responding to client problems
and improvements as they occur here and now in session. In
other words, rather than talking about daily life problems that
occur elsewhere, FAP focuses on how these problems show up
in the therapy relationship. Client responses occurring within
the therapist– client relationship that correspond to those occur-
ring in their daily lives are of particular relevance and are
referred to as clinically relevant behaviors (CRBs). CRB1s are
the client’s daily life problem behaviors that occur in session
Mavis Tsai, Department of Psychology, University of Washington; Tien
Mandell, College of Life Sciences, University of Glasgow; Daniel Mait-
land, Jonathan Kanter, and Robert J. Kohlenberg, Department of Psychol-
ogy, University of Washington.
Correspondence concerning this article should be addressed to Mavis
Tsai, Department of Psychology, 351525, Center for the Science of Social
Connection, University of Washington, Seattle, WA 98195. E-mail:
mavist@gmail.com
with the therapist and are expected to decrease during the
course of therapy. CRB2s are client improvements that occur in
session. While FAP is rooted in a functional contextual philos-
ophy, our goal in this paper is to offer a framework that enables
therapists, regardless of theoretical orientation, to decrease the
likelihood of making clinical errors.
Consistent with the contextual nature of FAP, CRB1s and
CRB2s are functionally defined. That is, a CRB1 for one client,
given their history and case conceptualization, might be a CRB2
for another. For example, refusing to follow therapist suggestions
in one case might be a CRB1 (not being open to feedback), and in
another case might be a CRB2 (being assertive in expressing one’s
needs). It is precisely the contextual nature of CRB1s and CRB2s
that can lead to therapist error of inadvertently reinforcing prob-
lematic behaviors and punishing improvements.
In accordance with ongoing assessment and case conceptualiza-
tion, FAP entails implementing five therapeutic rules that empha-
size clients’ CRBs. These “rules” are suggestions for therapist
behavior that typically lead to clinical improvement by highlight-
ing therapeutic opportunities that may otherwise go unnoticed.
Very briefly, they involve: (a) being aware of clients’ CRBs, (b)
evoking CRBs, (c) reinforcing improvements, (d) being aware of
the impact of our interventions, and (e) using behavioral interpre-
tations to help clients generalize changes to daily life. A discussion
of all five rules is beyond the scope of this article; instead we will
focus the importance of being aware of CRBs because a more
accurate assessment of CRB1s and CRB2s can decrease the like-
lihood of two specific types of clinical errors that are the focus of
this paper: when therapists inadvertently reinforce CRB1s or pun-
ish CRB2s.

331
 332 TSAI, MANDELL, MAITLAND, KANTER, AND KOHLENBERG
Examples of Inadvertently Reinforcing a Problematic
Behavior or CRB1
As clinicians and supervisors, a problem that we either fre-
quently encounter or a struggle that our supervisees often raise
regarding their clients is that of incessant talking. A less obvious
problem for us to catch, but one that has negative consequences for
clients if we fail to notice it, is that of overly compliant behavior.
The possible functions of each of these problems and ways to
address them will be discussed in turn. All clinical examples
discussed have de-identified clients to maintain confidentiality,
and are composites of several clients, rather than specific interac-
tions that have occurred.
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Incessant Talking
Many clients will sit down and start talking about something
that is bothering them for almost the entire session, without giving
their therapists a chance for input. These clients lack awareness
that they are monopolizing the interaction, and it is likely that they
do this with others as well. A mistake that the authors have made
when clients speak at length is to listen compassionately, nodding
our heads and not interrupting. While this type of empathic listen-
ing may have facilitated a therapeutic alliance in initial sessions,
over time we felt frustrated that these clients were not changing
and that they seemed to use talking as a way to avoid their feelings.
To resolve the quandary, we have explored the possible functions
of incessant talking by asking, You seem to feel pressured to tell
me a lot of details—what are the unspoken needs underneath what
you’re saying? Depending on their histories, clients have reported
different motivations, including: needing to be understood and
thinking that talking and explaining more will get across their
point, the pressure release that comes with describing something in
detail, or taking up all the time in order not to get aversive
feedback. It seems that underlying this verbosity is a common need
to connect more with oneself and the other, and to be seen and
understood. Yet, they are more likely to push others away and less
likely to get what they need when they are not aware of the impact
of their talking on others. Thus, when therapists just listen com-
passionately without exploring or confronting this behavior, they
may be perpetuating or inadvertently reinforcing a CRB1.
A therapist’s responses to a client’s problem behavior must be
sensitive to the client’s current skill level. To accomplish this,
therapists can notice and disclose their own reactions (thoughts,
emotions, physiological responses) and respond to CRB1s in a
caring way. For example, we have had positive responses to a
statement like this, I know you are having a really tough time with
this situation, and that you want to tell me every detail so that I
really get what you are feeling. When you talk in paragraphs and
pages, though, it can actually obscure the essence of what you are
wanting me or others to understand. Can you summarize in one
sentence what you are feeling about what happened?
Overly Compliant Behavior
We all have had clients who are wonderful to work with—they
are always on time, pay their fees promptly, talk about their
deepest feelings, and do their homework diligently. The first
author (M.T.) had a client like this who sought help because he
could not sustain long-term relationships. Therapy seemed like it
was going really well—the client was open, vulnerable, gracious,
and appreciative, and the connection seemed particularly strong.
On the FAP session bridging form, (given to clients after every
session asking them to rate session effectiveness, connection to
therapist, and other similar variables on a scale from 1 to 10; Tsai
et al., 2009), this client always rated everything a “10,” and never
had any requests or criticisms. After 3 months of what seemed like
an ideal client–therapist relationship, M.T. realized that she had
been lulled into thinking everything was going really well and did
not question that his being a “good client” who was meticulously
compliant might be problematic. Thus, M.T. inadvertently had
been reinforcing her client’s CRB1s of overly compliant behavior.
M.T. belatedly asked if it was a pattern in his relationships to be
accommodating and sweet to create a stronger bond, but eventually
he would feel resentful and unseen, and then would leave the
relationship. He acknowledged this was happening, and she said to
him, Will you please tell me what’s hard for you to say, what might
not be working for you in our therapy? When you’re both appre-
ciative of my efforts AND candid with me about what’s not work-
ing, it increases the genuineness of our connection. He stated that
he was drinking too much and was hiding it from her because he
feared possible negative judgment. This led to him getting the help
that he really needed, along with the realization that this type of
transparency about his struggles and needs is what would make his
outside life relationships more sustainable.
Examples of Inadvertently Punishing an Improvement
Behavior or CRB2
When clients are developing new behaviors, they can be clumsy
or off putting, and it can be easy for a therapist to miss that an
improvement is occurring. An important therapeutic skill is to
increase awareness of and to shape and reinforce the CRB2s that
are inherent in the clients’ CRB1s. To illustrate this concept, we
will discuss client silence, which is on the opposite end of the
spectrum from incessant talking, and uncooperative behavior,
which sometimes may be a CRB2 in clients who are not assertive.
Silence
When asked What would you like to talk about or What are you
feeling?, some clients will shrug and stay silent or say I don’t
know. M.T. had a client who sought treatment for anxiety, depres-
sion, and conflict with his male partner because he (the client)
would not talk about his feelings. He would sit in silence for many
minutes at the beginning of sessions. This was a typical interaction
in the beginning sessions of therapy:
Therapist: What’s important for you to talk about today?
Client: [silence for about two minutes] I do not know.
Therapist: What thoughts are running through your mind?
Client: I do not know.
Therapist: What are you trying to tell me with “I do not
know?”
Client: [silence]
 REDUCING INADVERTENT CLINICAL ERRORS
Therapist: I do not know how to help you when you do not
talk to me. [This statement was a mistake in that
the client probably detected the exasperation un-
derlying it, and clammed up even more as a
result].
Client: [long silence]
Although M.T. experienced her client’s silence as a CRB1 and
was frustrated at her inability to draw him out, she worked on
seeing what CRB2s were there in the CRB1s:
Therapist: I get that it’s a big deal for you to even show up
for therapy with me, and I appreciate how you
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come consistently even though it’s so hard for
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you. I’m wondering if your silence is because you
do not quite have the words to capture what you
are feeling?
Client: Yeah.
Therapist: Would it helpful if I tried to express what I think
you might be feeling based on what you wrote in
your client data form, and you can tell me “yes”
or “no” and correct me if I’m off?
Client: Yeah.
Therapist: You wrote in your form that you felt emotionally
invaded by your mom, and that you gained con-
trol by upsetting her with your silence. Do you
think you might be trying to maintain a sense of
control with me here?
Client: Yeah.
Therapist: What can we do differently so that you can feel
more control in our relationship?
Client: I think I can process better if I do not have to look
at you. Is it ok if I turn my chair so that my back
is to you?
Therapist: Yes, of course.
Client: [shifts his chair]. This is better. Will you help me
with feeling words by giving me choices that I can
pick from?
From this point forward, M.T. was able to shape more emotional
expression from this client, who was then able to generalize his
progress by asking his more verbal partner for help with feeling
words, and by negotiating how he could feel more control in the
relationship.
Uncooperative Behavior
In another example of inadvertently punishing a CRB2, a ther-
apist consulted with the fifth author (R.J.K.) about a case in which
his client was depressed. A primary source of her dysphoric mood
seemed to be her lack of assertiveness in addressing her needs with
her husband. The following exchange took place:
Therapist: Since a cause of your depression is not saying
directly to your husband what you want, how
333
about if you practice assertion skills in a roleplay
with me? I would play the role of your husband,
you would express something you feel or want,
and then I can coach you as needed.
Client: I’m sorry, I’m uncomfortable with role playing. It
feels kind of silly.
Therapist: Maybe this is too big a step, let’s go down lower
in the hierarchy and come up with an easier
situation that we can roleplay.
In this case, the therapist made a mistake because not only was
he not aware of a CRB2—the client’s assertiveness in saying no to
his request, but even worse, probably punished it by persisting in
doing a roleplay. After consultation, this is what he said instead:
Therapist: I want to apologize for pushing a roleplay on you
last week. We absolutely do not have to do any-
thing that makes you feel uncomfortable. That
was actually quite assertive on your part to tell
me you didn’t want to do the roleplay. Let’s talk
more about how you were able to stand up for
yourself in this way, what it felt like for you, and
how you can assert yourself similarly with your
husband. How does that sound?
Client: That sounds good. I was really anxious telling
you that I didn’t feel comfortable doing a role-
play, and it’s really helpful that you can see I was
actually being assertive with you rather than be-
ing a bad client.
Empirical Support for FAP Mechanism of
Change—Reinforcement of CRB2s
While converging lines of evidence support FAP’s basic prin-
ciples (Baruch et al., 2009), reviews of FAP publications point to
a growing number of empirical investigations (García, 2008;
Mangabeira, Kanter, & Del Prette, 2012), including specific sup-
port for the notion that awareness and reinforcement of CRB2s are
beneficial (Gifford et al., 2011; Holman, Kohlenberg, & Tsai,
2012; Holman et al., 2012; Kanter, Schildcrout, & Kohlenberg,
2005; Kanter, Tsai, Holman, & Koerner, 2013; Kohlenberg,
Kanter, Bolling, Parker, & Tsai, 2002; Maitland & Gaynor, 2016;
Maitland et al., in press).
In addition to studies indicating the general effectiveness of
FAP, research focusing on the proposed mechanism of action—
effective contingent responding by therapists to client problems
and improved behaviors as they occur in the session—is particu-
larly relevant to our discussion highlighting the importance of
accurately naturally reinforcing CRB2s and gently blocking
CRB1s. This line of research mainly has used single subject design
or small N studies, and results have shown the benefits of in vivo
focus and contingent responding that increase CRB2s and decrease
in CRB1s (Busch et al., 2009; Callaghan, Summers, & Weidman,
2003; Lizarazo, Munoz-Martinez, Santos, & Kanter, 2015; Kanter
et al., 2006; Landes, Kanter, Weeks, & Busch, 2013; Maitland &
Gaynor, 2016). Additional support for the proposition that thera-
pist contingent responding increases the frequency of targeted
behavior come from laboratory-based studies where contingent
 334 TSAI, MANDELL, MAITLAND, KANTER, AND KOHLENBERG
responding by trained research assistants promoted increased feel-
ings of connectedness in participants and also improved the depth
of disclosure (Haworth et al., 2015).
Implications for Recommendations for Reducing
Clinical Errors
Therapists can decrease clinical errors by accurately conceptu-
alizing their clients’ CRB1s and CRB2s and by increasing aware-
ness of their own problem behaviors and target behaviors as
clinicians.
Accurately Conceptualizing Clients’ CRB1s
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and CRB2s
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Therapists more accurately can identify their clients’ CRB1s
and CRB2s to avoid reinforcing problems and punishing improve-
ments by attending to: (a) the antecedents, consequences, and
historical contexts that have shaped their clients’ behavior and
being aware of their CRB1s and CRB2s in the context of this
history, (b) the fact that initial CRB2s might not be easily recog-
nized as improvements (e.g., when a client who has never ex-
pressed feelings before yells at the therapist), (c) when the same
behavior can be a CRB2 in one client but a CRB1 in another client
(e.g., being late to session may be a CRB2 in a client who is
compulsively on time at cost to oneself and a CRB1 in another
client who is chronically late to everything), and (d) when the same
behavior may be a CRB2 in the earlier stages of therapy but can
become a CRB1 in later stages (e.g., willingness to ask for the
therapist’s opinion on important issues initially may be a CRB2 for
someone who is unwilling to be open to others, but can become a
CRB1 in the later stages of therapy if this client becomes so
attached he struggles with independent decision making).
Increasing Awareness of Your Own Problem
Behaviors (T1s) and Target Behaviors (T2s)
as a Therapist
It is important for therapists to pay attention to present moment
contingencies in which client and therapist are inextricably linked
in a continuous flow of strengthening and weakening of each
other’s behaviors. This improvisational dance is influenced by not
only the client’s learning history, but processed through the ther-
apists’ lens shaped by their own histories. Thus, therapist aware-
ness of their own problems behaviors (T1s) and target behaviors
(T2s) will decrease the likelihood of clinical errors. When thera-
pists are unaware of their own blind spots, they cannot as effectively
block problem behaviors or reinforce improvements in session. In
FAP training, we encourage therapists to assess their own issues by
responding to the questions below. The questions facilitate awareness
of their vulnerabilities, which may contribute to therapeutic errors in
judging whether their clients’ behaviors are CRB1s or CRB2s:
1. Are you experiencing any of these factors that may increase
your vulnerability as a therapist:
__ Lack of emotional support from social network
__ Sense of disconnection from partner
__ Lack of emotional or sexual intimacy
__ Client attractiveness
__ Triggered by similarity of client history to your own
__ Sense of burnout
__ Lack of self-care
__ Conditioned care-taking of others
__ Other (Please describe):
2. What do you tend to avoid addressing with your clients?
3. How does this avoidance impact the work that you do with
these clients?
4. What do you tend to avoid dealing with in your life (e.g.,
tasks, people, memories, needs, feelings)?
5. How do your daily life avoidances impact the work that you
do with your clients?
In sum, by increasing awareness as to what constitutes problem
and target behaviors in both our clients and ourselves, we can
decrease the likelihood of inadvertently reinforcing client prob-
lems, or punishing client improvements. We hope this framework
can cross theoretical boundaries to facilitate the impact of the
therapeutic relationship.
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Received April 1, 2016
Revision received April 20, 2016
Accepted April 21, 2016 䡲