J Contemp Psychother (2017) 47:173–180
DOI 10.1007/s10879-016-9352-5
ORIGINAL PAPER
Functional Analytic Psychotherapy for Nursing Home Residents:
A Single-Subject Investigation of Session-by-Session Changes
Sonia Singh1 · William H. O’Brien1 
Published online: 23 December 2016
© Springer Science+Business Media New York 2016
Abstract  Nursing home settings contain unique environ-
mental factors that may promote the acquisition and main-
tenance of problematic interpersonal behaviors. Functional
Analytic Psychotherapy (FAP) is a contextually-based
behavior therapy  that can be used to modify problematic
interpersonal behaviors via carefully provided and contin-
gent in-session responses of the therapist to client behav-
iors. Thus, FAP would appear to be a particularly well-
suited intervention approach for nursing home residents. To
date, the effects of FAP have not been reported for nurs-
ing home residents. The current single case study assessed
the effects of FAP on three nursing home residents using
a single-subject AB design. The AB design consisted of a
2-weeks baseline phase followed by a 4-week FAP treat-
ment phase. The nursing home residents completed pre-
treatment and post-treatment measures of interpersonal
relating. Client interpersonal behaviors were also recorded
during each session and coded into two categories: Mala-
daptive in-session behaviors and adaptive in-session
behaviors. Using the reliable change index and Swanson’s
dsw to evaluate questionnaire outcomes, results indicated
that all three participants reported a significant change in
interpersonal functioning. Analysis of in-session behavior
indicated that there were significant decreases in maladap-
tive behaviors and an increase in adaptive behaviors for
two clients. Finally, observed in-session behavior changes
were congruent with self-reported changes in interpersonal
behavior. These results indicate that FAP was an effective
intervention for these nursing home residents.
* Sonia Singh
rjsingh@bgsu.edu
1
126 Psychology, Bowling Green State University,
Bowling Green, OH 43403, USA
Keywords  Functional analytic psychotherapy · Single-
subject design · Nursing home residents
Introduction
Residents of nursing homes experience significantly higher
rates of behavioral and psychological problems such as
depression, anxiety, loneliness, and chronic pain relative to
non-nursing home populations (e.g., Drageset et  al. 2013;
Hager and Brockopp 2007). Nursing home residents also
commonly experience negative interactions (e.g., express-
ing and receiving aversive verbal interactions; abrupt or
hurried care) with staff members who provide care (e.g.,
Burgio et  al. 1990; Carstensen et  al. 1995). Furthremore,
negative resident-to-resident interactions have been fre-
quently observed in nursing home settings (e.g., Castle
2012; Pillemer et al. 2012).
Given heightened psychological distress and nega-
tive interactions with staff and peers, nursing home resi-
dents frequently develop communication problems (e.g.,
Heineken 1998; Lachs et al. 2013). The more commonly
observed communication problems include low rates of
verbalization, non-assertiveness, restricted communi-
cation patterns (e.g., talk focused narrowly on physical
symptoms medical needs), and/or verbal aggression (e.g.,
Burgio et  al. 1990; Heineken 1998). These communica-
tion problems can be exacerbated by the unique social
characteristics of nursing home environments. Specifi-
cally, nursing home residents are typically reinforced for
talking with care providers about physical symptoms and
medically related concerns whereas vocalizations about
other aspects of life (e.g., contemporary events, family,
likes and dislikes) are minimally and inconsistently rein-
forced and sometimes punished (Carstensen et al. 1995).
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Over time, this pattern of contingencies related to talking
can not only lead to communication problems but a deg-
radation of general social interaction skills as well (e.g.
Drageset et al. 2009).
Given these problems with communication and social
skills it is reasonable to posit that Functional Analytic
Psychotherapy (FAP), a cognitive-behavioral therapy that
is specifically designed for improving interpersonal inter-
actions, could be beneficial for nursing home residents
(Kohlenbereg and Tsai 1991; Tsai et  al. 2009). FAP pro-
poses that the in-session interaction between a therapist
and a client mirrors a client’s “outside-of-session” interac-
tions. Thus, the fundamental role of a therapist is to cre-
ate a “curative therapeutic relationship” in each session.
By curative therapeutic relationship, Tsai et  al. (2009)
mean that the therapist will carefully and systematically
use behavioral principles during therapy sessions to guide
(i.e., reinforce and shape) adaptive changes in interpersonal
behaviors.
In FAP, the term “Clinically Relevant Behaviors”
refers to in-session behaviors that are targeted for change.
According to Tsai et al. (2009), Clinically Relevant Behav-
iors are divided into three categories: maladaptive behav-
iors (labelled CRB1 in FAP), adaptive behaviors (labelled
CRB2 in FAP) that can replace the maladaptive behav-
iors, and client statements about his or her own behavior
(labelled CRB3 in FAP). The primary goal of FAP is to
decrease the occurrence of observable in-session maladap-
tive behaviors and increase the occurrence of in-session
adaptive behaviors. It is further hypothesized in FAP that
these in-session changes in behavior will then generalize to
real-world, outside-of-session, contexts.
In FAP, five general rules are used to guide to in-session
interactions with the client: (a) watch for Clinically Rel-
evant Behaviors; (b) evoke Clinically Relevant Behaviors;
(c) reinforce adaptive Clinically Relevant Behaviors; (d)
assess therapist impact on client behavior; and (e) evaluate
and generalize (Tsai et  al. 2009; Weeks et  al. 2012). The
first rule encourages the therapist to carefully attend to and
evaluate in-session interactions with the client so that the
function behaviors can be determined. The second rule is
that the therapist should attempt to systematically evoke
Clinically Relevant Behaviors during each session. The
third rule is that the therapist should consistently reinforce
adaptive Clinically Relevant Behaviors whenever they
occur during a session. The fourth rule is that the thera-
pist should assess the extent to which maladaptive Clini-
cally Relevant Behaviors and adaptive Clinically Relevant
Behaviors are changing in response to the therapist’s in-ses-
sion interventions. The final rule is that the therapist should
evaluate the extent to which in-session changes in behavior
generalize to outside-of-session interpersonal interactions
(Tsai et al. 2009).
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J Contemp Psychother (2017) 47:173–180
Consider, for example, a therapist working with a nurs-
ing home resident who displays aggressive verbal behav-
ior towards the staff during caregiving activities. In this
example, “verbal aggression” would be identified as the
maladaptive Clinically Relevant Behavior and the therapist
may hypothesize that the function of the behavior is nega-
tive reinforcement via escape. That is, the verbal aggres-
sion causes the care provider to leave his or her room and
thereby the client escapes from feelings of helplessness or
discomfort. In this example, the specific adaptive Clini-
cally Relevant Behavior could then be “discussing emo-
tional topics” with the therapist, “expressing sadness,” and
“talking in nonaggressive ways about feelings of helpless-
ness” (e.g., “I feel angry because I’m here and can’t dress
myself”). In applying the first rule during sessions with this
resident, the FAP therapist would attend to the content, pro-
cess, and function verbalizations and interactions.
When applying the second rule, the therapist would ask
or say something that is likely to evoke an adaptive Clini-
cally Relevant Behavior, such as stating that the therapist
is unable to fully understand the resident’s feelings as the
resident is describing an emotionally distressing experi-
ence. Applying rule three during sessions would involve
consistently reinforcing direct expressions of helplessness
and distress, such as crying or using emotional words. For
example, the therapist might say, “When you cry like this I
feel closer to you and I feel like I can see the real you that
doesn’t need to be strong for everyone else.” During these
interactions, the therapist would draw from his or her own
emotional responses in order to provide natural reinforce-
ment. Additionally, these verbalizations provide a model
for emotional expression for the resident. Using rule four,
the therapist assesses the resident’s reaction to receiving
therapist reinforcement. This can be accomplished by direct
inquiry and/or determining if the targeted maladaptive
behaviors decrease and/or the adaptive behaviors increase.
When applying rule five, the therapist would suggest that
the resident attempt similar interactions outside of sessions
by stating something analogous to “I wonder how your hus-
band would react if you just responded to him the way you
responded to me in here… I imagine it would make him
feel closer to you.”
FAP has been found to be effective in single subject
studies on outpatients presenting with an array of interper-
sonal problems (e.g., Callaghan et al. 2003; Landes 2008).
Additionally, a meta-analysis of these FAP outcome studies
indicated that it is effective in reducing client-specific mal-
adaptive behaviors and increasing client-specific adaptive
behaviors. Individuals within these research studies often
report lower interpersonal difficulties after completing FAP
treatment (Singh and O’Brien 2016).
As noted earlier, the unique social characteristics of
nursing home environments may give rise to problematic
J Contemp Psychother (2017) 47:173–180 175
interpersonal behaviors which, in turn, adversely affect
quality of life. Thus, FAP would be particularly well-suited
for persons in nursing home settings because it could be
used as a means for reversing the deleterious effects of its
unique the social context. As of this writing, there are no
published evaluations of FAP in nursing home settings.
The aim of the current case study was to assess the
extent to which FAP could modify interpersonal behaviors
among nursing home residents who were referred for psy-
chological assessment and treatment by their attending phy-
sician. We expected that individuals who completed a FAP
intervention would demonstrate in-session decreases in
maladaptive behaviors and increases in adaptive behaviors.
We also expected that participants would report decreases
in interpersonal difficulties outside of the FAP sessions.
Method
Participants
Three participants were referred for psychological assess-
ment and intervention by the attending physician at a nurs-
ing home in Northwest Ohio. The three participants were
identified by nursing staff as having significant, pervasive,
and long-standing, emotional and interpersonal problems.
They were also reported to be generally isolated from peers
within the nursing home setting. The consulting psycholo-
gist (second author) evaluated each patient and all three
were determined to be presenting with symptoms consist-
ent with severe and recurrent Major Depression (ICD-10:
F33.2). It was also determined that these patients would be
good candidates for FAP. All three participants were well-
oriented and not experiencing any significant cognitive
impairments. Once recruited, participants were informed of
the risks of participating and informed of audio recording
procedures. Participants consented to audio recording and
participation in research.
The therapist (first author) had no prior experience of the
patients before treatment began. Participants had received
therapy in the past by other clinicians at various points
in their lives, but they had never received FAP treatment.
Participants were not billed for therapy because services
because it was, in part, a training experience for a graduate
student (first author). However, the provision of psycholog-
ical assessments and interventions is a billable service in
skilled nursing facilities. Specifically, Medicare and most
of the major health insurance companies cover inpatient
psychological assessments and interventions when they are
provided by a licensed doctoral-level psychologist. Addi-
tionally, masters-level therapists can also be reimbursed for
inpatient mental health services when specific supervision
conditions are met (note: it is important to consult with
Medicare and individual insurance companies to deter-
mine specific rules for service provision). Unlike Medicare,
Medicaid typically does not cover inpatient psychological
assessments and interventions in skilled nursing facilities.
These services are not covered because Medicaid typically
pays a “day rate” to a facility and the day rate that includes
payment for behavioral health services. Thus, mental health
providers must make an arrangement with the medical
facility itself for payment or the patient must be seen in an
outpatient office.
The participants’ ages were approximately 31, 53, and
72  years-old. Given recent data regarding nursing home
residents, this age range is consistent with norms. The Kai-
ser Family Foundation (2010) reported that persons in the
30–65 years-old age range have been rapidly increasing in
nursing home settings over the past decade.
Participant 1 “Ted” (fictional names are used here to
identify each participant in this report and to maintain con-
fidentiality) was a 72-years-old, married, Caucasian male
who had resided at the nursing home for 3  years. He was
dependent on a ventilator due to chronic obstructive pul-
monary disease obstructive and sleep apnea. Additionally,
Ted had a number of medical conditions including: hypo-
thyroidism, hypertension, morbid obesity, renal disease,
and deconditioning. Due to difficulties with ambulation he
required the use of a motorized wheelchair. As noted ear-
lier, Ted was evaluated by the consulting psychologist at
the nursing home (second author) and was diagnosed with
ICD-10 F33.2: Major Depression, recurrent, severe. He
described that he experienced long-term problems with
feelings of isolation, episodes of depressed mood, and con-
flict with residents and nursing staff. Nursing staff members
reported he had problematic communication with nurs-
ing aides and other residents. With additional behavioral
assessment conducted by the first author, Ted’s maladap-
tive behavior was labelled “Arrogant/Disconnecting talk”
(e.g., Stating that he cannot connect with others or they are
not “on his level”) and alternative adaptive behaviors were
labelled “Connecting with others” (e.g., Describing posi-
tive relationships with others, discussing feelings and emo-
tions related to others).
Participant 2 “Brad” was a 53-years-old, divorced,
Caucasian male who had resided at the nursing home for
2  months. Brad was admitted for rehabilitation purposes
and did not plan to spend an extended period of time in
the facility. Brad was also evaluated by the consulting psy-
chologist and in addition to being diagnosed with ICD-10
F33.2: Major Depression, recurrent, severe; his diagnoses
included chronic pain disorder and alcohol abuse/depend-
ence. Brad was very guarded in his interactions with staff
and healthcare providers. They noted he would deny experi-
encing commonly experienced and expected symptoms for
a person with his presenting problems. For example, Brad
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denied that he had difficulties with alcohol use and denied
interpersonal difficulties with his family despite direct
reports from family members that Brad’s alcohol use was
severely problematic and that it significantly interfered with
family relationships. These same behaviors were observed
in his assessment sessions with the first author. Brad’s mal-
adaptive behavior was labelled “Lack of emotional expres-
sion” (e.g., lack of use of emotional words, reporting that
he had never experienced any emotional difficulties despite
clear evidence of multiple behavioral problems). His adap-
tive behavior was labelled as “Emotional expression” (e.g.,
using emotional words, discussing emotions, and acknowl-
edging difficult situations in his past or present).
Participant 3 “Robin” was a 31-years-old, single, Cau-
casian female who resided at the nursing home for 2 years.
Robin’s medical diagnoses included acute respiratory fail-
ure, pressure ulcers, spina bifida, and chronic bronchitis.
Robin also used a motorized wheelchair for mobility. Both
the consulting psychologist and staff members reported
that Robin presented with depressed mood combined with
very low rates of verbal interaction and verbal reciprocity.
She was also diagnosed with ICD-10 F33.2: Major Depres-
sion, recurrent, severe. Robin’s maladaptive behavior was
labelled “Distancing Language” (e.g., brief responses to
questions, minimal reporting of disclosing personal infor-
mation, and lengthy silences). Her adaptive behavior was
labelled “Personal Disclosure” (e.g., talking about herself,
her feelings, and difficulties).
Measures
Functional Idiographic Assessment Template
Questionnaire Short Form
The Functional Idiographic Assessment Template Ques-
tionnaire (FIAT-Q-SF; Darrow et al. 2014) is a self-report
measure of interpersonal functioning. It is composed of six
domains: interpersonal intimacy, disagreement, connection,
conflict, emotional expression, and excessive expressivity
as well as a total score. Each item (e.g., “I have problems
being close with others”) is rated on a scale of −3 to 3,
where −3 represents “strongly disagree” and 3 represents
“strongly agree.” Higher scores indicate greater inter-
personal dysfunction. In a validation study, participants
(n = 167) were adult, culturally diverse undergraduates. For
the overall FIAT-Q-SF, internal consistency (α = 0.85) and
test–retest reliability (r = .77) were good.
Functional Analytic Psychotherapy Rating Scale
The Functional Analytic Psychotherapy Rating Scale
(FAPRS; Callaghan and Follette 2008) was designed to
measure therapist and client verbal behaviors that occur in
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J Contemp Psychother (2017) 47:173–180
FAP sessions. The FAPRS uses two coders who record the
occurrence of maladaptive and adaptive behaviors and cli-
ent descriptions of behavior. In the present investigation,
each therapy session was transcribed and de-identified.
Trained independent undergraduate students then used the
FAPRS to code the occurrence of the adaptive and mala-
daptive behaviors for each client. FAPRS coders were
undergraduate students who underwent a 2-h long train-
ing session with the author. At the end of the training, the
author assigned both undergraduate students a four-page
training transcript to code using the FAPRS. Coding of
the transcripts for the current study did not occur until the
coders received an 85% accuracy on the training transcript.
The training transcript was originally created and coded by
the first author.
One undergraduate student coded all sessions for all
three participants and another undergraduate student coded
two sessions for all three participants for the purposes of
calculating reliability. Kappas ranged from 0.46 to 0.75
which indicates moderate to substantial agreement among
raters based upon guidelines identified by Viera and Garrett
(2005). These reliability statistics for the FAPRS are also
similar to those found in other FAP single-subject studies
(e.g., Callaghan et al. 2003).
Supportive Listening
During the baseline phase, the therapist engaged in sup-
portive listening for the purposes of building rapport. Dur-
ing this phase there was no purposeful shaping or punishing
of maladaptive or adaptive in-session behaviors. Supportive
listening consisted of two weekly sessions with the gradu-
ate student therapist. During these two sessions, the thera-
pist provided affirmation and empathy to the participants,
and used reflection of emotion to demonstrate supportive
listening (Jones 2011).
Functional Analytic Psychotherapy
The FAP intervention therapy consisted of 4 weekly ses-
sions with a trained graduate student therapist. Each ses-
sion was 30  min in duration. During the initial FAP ses-
sion, participants were provided with a treatment rationale.
The therapist then reviewed with the client a case concep-
tualization that outlined the unique maladaptive and adap-
tive behaviors for each participant (note: the case concep-
tualization was derived from pre-treatment assessment and
functional analyses sessions conducted by the first author
and consulting psychologist). The therapist proceeded with
treatment only after participants agreed with the ration-
ale and appropriateness of the identified maladaptive and
adaptive behaviors. The subsequent sessions focused on
identifying the maladaptive and adaptive behaviors as
J Contemp Psychother (2017) 47:173–180 177
they occurred in session, shaping adaptive behaviors, and
encouraging the clients to work on their adaptive behaviors
outside of the session.
Therapist Training
The first author of this study was the therapist for all ses-
sions. The therapist held an MA degree in clinical psy-
chology and was trained in psychological assessment and
therapy in an MA and doctoral training program. The first
author also attended several FAP trainings prior to the
study including a level II, two-day workshop; a 3-days,
FAP intensive workshop; a 2-days workshop in using FAP
and Acceptance Commitment Therapy in combination; a
two-semester FAP-oriented practicum in her MA train-
ing program; and an 8-weeks online training. The second
author was the supervising psychologist for the study. The
second author is a licensed psychologist with extensive
training in mindfulness/acceptance-based therapies and
functional analysis.
Procedure
Participants were approached by the therapist and provided
with an explanation of the intervention and procedures.
The participants then completed the FIAT-Q-SF. After
completing the questionnaire, a 2-weeks baseline period
commenced. This 2-weeks baseline consisted of support-
ive listening without therapist use of FAP intervention
techniques. Following the 2-weeks baseline period, the
four-session FAP intervention commenced. Each session
was 30 min long and scheduled on a weekly basis. Follow-
ing completion of the final session, the FIAT-Q-SF was
re-administered.
Data Analysis
The number of maladaptive and adaptive verbalizations in
each session were divided by the total number of verbali-
zations in each session. This value was then multiplied by
100 to yield percentages for each session. These percent-
ages were then graphed across the baseline and treatment
phases.
Percentage of Non‑overlapping Data (PND)
To statistically evaluate differences between the baseline
and treatment phases of the study, PNDs were calculated
(Scruggs et al. 1987). For maladaptive behaviors, the PND
was calculated by identifying the lowest of the two baseline
points for each participant and then counting the number of
treatment points below the lowest baseline point. This sum
was then divided by the total number of treatment points
and multiplied by 100 to obtain a percentage. For adaptive
behaviors, the percentage of non-overlapping data was cal-
culated by identifying the highest of the two baseline points
for each participant. Then, the number of treatment points
that were above the highest baseline points were summed
and divided by the total number of treatment points and
multiplied by 100.
The PND has been used to calculate change in several
single-subject design studies including research examining
interventions for children with neurological impairments,
individuals with autism spectrum disorder, and students
with physical disabilities (e.g., Asaro-Saddler and Bak
2012). Given the breadth of populations examined using
this method, it can be inferred that PND would capture
behavior change within the current study. Following the
guidelines of Scruggs and Mastropieri (1998), percent-
age of non-overlapping data score classification is as fol-
lows: PND < 50%, Unreliable treatment; PND 50–70%,
Questionably effective; PND 70–90%, Fairly effective; and
PND > 90%, Highly effective.
Swanson’s dsw
An important limitation of the PND is that it does not pro-
vide information about the magnitude of treatment effects.
This is because data points in the treatment phase are
dichotomously coded as either above or below the baseline
comparison point. Thus, there is no index of how far above
or below the data point lies. For example, for one client,
there may be a very slight decrease in 70% of target behav-
iors during the treatment phase while for another client
there is a very large decrease in 70% of the target behav-
iors during the treatment phase. Note that the PND for both
clients would be equivalent even though the magnitude of
treatment differs.
Given that the PND does not provide an index of magni-
tude of effect, researchers developed effect size indices that
could be used to supplement the information provided by
the PND. Swanson et  al. (1999) developed the dsw which
is a standardized difference score that is analogous to the
standardized d effect size that is in meta-analyses of treat-
ment outcome studies. Swanson’s dsw is calculated in two
steps. First, the mean of the last three treatment data points
is subtracted from the mean of the last three baseline data
points. Second, this difference score is divided by the
pooled standard deviation of the three treatment and three
baseline data points to produce a standardized mean differ-
ence. Swanson noted that this standardized mean difference
can be inflated if there is serial dependency or a correlation
between baseline and treatment data. Therefore, he recom-
mended the score be corrected by dividing it by √2(1−r)
where r is the correlation between baseline and treatment
data. This method of calculating effect sizes has been used
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178 J Contemp Psychother (2017) 47:173–180

in single-subject studies of individuals with learning dis-

abilities and studies of working and long-term memory
(e.g., Swanson and Sachse-Lee 2000; Swanson et al. 1999,
2009). The formula used to calculate Swason’s dsw pro-
vided below:
� � � √ �
d = Mt − Mb ∕ SDp ∕ 2(1 − r)

An important advantage of Swanson’s dsw is that it can

provide an estimate of treatment effect that is free from
autocorrelation. Another advantage is that the effect size is
based on the client’s level of functioning at the conclusion Fig. 1  Changes  in arrogant/difconnecting talk (MB—Maladaptive
of treatment relative to baseline which is conceptually simi- Behaviour) and connecting with others (AB—Adaptive Behaviour)
lar to the pre-/post-treatment effect sizes reported in treat- for Ted—Participant 001
ment outcome studies. Finally, the dsw can be classified into
small (d ≥ 0.20). medium (d ≥ 0.50), and large (d ≥ 0.80)
magnitudes.

Reliable Change Index (RCI)

In order to evaluate changes in questionnaire data, RCIs

were calculated (Jacobson and Truax 1991). The RCI has
been used in many investigations of cognitive behavioral
interventions (e.g., Alonso et al. 2013; Haaland et al. 2011).
To calculate RCIs a participant’s pre-treatment score was
subtracted from the participant’s post-treatment score. The
difference was then divided by the standard error of meas-
urement. The standard error of measurement was obtained
using from available normative data, such as the standard
deviation and reliability coefficient from validation studies
or studies that contained the appropriate statistics. The for-
mula for calculating the RCI is provided below:
X2 − X1
RCI =
Sdiff
Previous literature has used the RCI to measure change
across a range of clinical populations including individu-
als receiving cognitive behavioral therapy, acceptance and
mindfulness based therapies, and exposure-based treat-
ments (Alonso et  al. 2013; Haaland et  al. 2011). An RCI
score of 1.96 or higher is considered statistically significant
(Jacobson and Truax 1991).
Fig. 2  Changes in lack of emotional expression (MB—Maladaptive
Behaviour) and emotional expression (AB—Adaptive Behaviour) for
Brad—Participant 002
lowest baseline phase data point. Using the Scruggs and
Mastropieri (1998) classification scheme, a PND of this
magnitude is classified as “highly effective.” For Connect-
ing with Others, as similar pattern of results was observed.
Specifically, 100% of the treatment phase data points fell
above the highest baseline data point. Again, using Scruggs
and Mastropieri (1998) nomenclature, this PND is clas-
sified as “highly effective.” The Swanson’s dsw values for
Arrogant/Disconnecting Talk and Connecting with Others
both fell into the large range of treatment effect (dsw = 1.30
and dsw = 1.72 respectively). Finally, the RCI analysis indi-
cated that Ted reported a significant pre-treatment to post-
treatment decrease in the FIAT-Q-SF score (RCI = 3.00).

Results Outcomes for Participant “Brad”

Outcomes for Participant 1 “Ted”
Visual inspection of Fig.  1 indicated that Arrogant/Dis-
connecting Talk decreased and Connecting with Others
increased as a function of the FAP intervention. The PND
for Arrogant/Disconnecting Talk was 100% indicating that
all of the treatment phase data points were lower than the
A visual inspection of Fig. 2 indicated that Lack of Emo-
tional Expression marginally decreased and Emotional
Expression did not consistently increase as a function of the
FAP intervention. The PND analysis indicated there was a
50% reduction in Lack of Emotional Expression (Question-
ably Effective) and a 25% increase in Emotional Expression
(Unreliable treatment). The Swanson’s dsw values for Brad

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J Contemp Psychother (2017) 47:173–180 179
differed from the PND. Specifically, the Swanson’s dsw for
Lack of Emotional Expression and Emotional Expression
both fell into the large range of treatment effect (dsw = 1.56
and dsw = 2.47 respectively). Finally, the RCI scores indi-
cated a significant increase in the FIAT-Q-SF from pre-
treatment to post-treatment (RCI = −3.00).
Outcomes for Participant “Robin”
Visual inspection indicated an increase occurred in Per-
sonal Disclosure and a decrease occurred in Distancing
Language as a result of the intervention  (see Fig.  3). The
PNDs were calculated for Robin and there was a 100%
decrease in distancing language (Highly effective) as well
as a 100% increase in personal disclosure (Highly effec-
tive). The Swanson’s dsw values for Distancing Language
and Personal Disclosure both fell into the large range of
treatment effect (dsw = 1.47 and dsw = 1.17 respectively).
Finally, RCI scores indicated that Robin reported signifi-
cant decrease in the FIAT-Q-SF (RCI = 5.46).
Discussion
Both Ted and Robin reported a significant decrease in
interpersonal difficulty. Further, this change in their per-
ception of interpersonal difficulty was mirrored in their
FAP sessions. Specifically, large decreases in maladaptive
in-session behavior and large increases in adaptive in-ses-
sion behavior were observed and these in-session behavior
changes were consistent with self-reported improvements
in interpersonal functioning based on the FIAT-Q-SF
scores.
Data collected for Brad indicated that FAP produced
mixed outcomes. His responses in Swanson’s dsw indi-
cated treatment effects in the “large” range. And while lack
of emotional expression was marginally reduced accord-
ing to PND, emotional expression was not significantly
Fig. 3  Changes in distancing language (MB—Maladaptive Behav-
iour) and personal disclosure (AB—Adaptive Behaviour) for Robin—
Participant 003
increased. This lack of response to FAP was also mirrored
in Brad’s perceptions of behavior change. Specifically, his
FIAT-Q-SF scores indicated that his interpersonal difficulty
increased after treatment. It is possible that this increase
was due to enhanced awareness. When treatment began,
Brad did not believe he was experiencing any psychologi-
cal or interpersonal distress, which he stated to the therapist
repeatedly. With the implementation of FAP, it may be that
Brad became more aware of how his interpersonal behav-
iors were adversely affecting his quality of life.
Taken together, these results demonstrate how FAP was
effective for the participants within this nursing home.
Additionally, it appears that the in-session changes in
behavior were also recognized by the participants them-
selves. That is, the three clients not only displayed changes
in maladaptive and adaptive behaviors, but they also per-
ceived changes in interpersonal functioning that were con-
gruent with in-session behavior change.
Limitations and Future Directions
Several limitations are relevant to the current study. The
most prominent limitation is the use of an AB design. This
design does not allow one to rule out other variables that
may be responsible for changes in client behavior such as
local history effects and regression to the mean. A with-
drawal study (e.g., alternate sessions with the therapist
providing FAP and the associated explicit contingencies
of reinforcement/punishment for maladaptive and adaptive
in-session behaviors sessions of non-contingent therapist
responding) or multiple baseline across participants could
rule out these threats to internal validity. Additionally, the
FIAT-Q-SF was normed with undergraduate populations so
it is difficult to interpret the meaningfulness of changes in
reference to the target populations (i.e., nursing home resi-
dents). Also, it should be noted that the ability to general-
ize based on these findings is lacking because there were
only three participants in the current study. Finally, it is not
possible to determine the extent to which specific FAP ele-
ments were responsible for behavior change relative to non-
specific therapy factors (e.g., therapeutic alliance, therapist
competence).
This study provided a first step in investigating the
efficacy of FAP as a treatment for interpersonal difficul-
ties within nursing home residents. Two future research
endeavors would expand upon these results. First, treatment
outcome research using attention-placebo controls would
permit a greater understanding of the extent to which FAP
confers unique benefits to residents of nursing homes over
and above nonspecific factors. Second, the fifth rule of FAP
is generalization, which was only examined in the current
study using verbal self-report from the clients. It would be
beneficial to collect data from staff, peers, and family in
13

180
future research to assess if treatment gains are detectable
by others. Nonetheless, data from this study provide pre-
liminary evidence that FAP for individuals in nursing home
settings can be an effective intervention for interpersonal
difficulties.
References
Alonso, M., Lopez, A., Losada, A., & Gonzalez, J. (2013). Accept-
ance and commitment therapy and selective optimization with
compensation for older people with chronic pain: A pilot study.
Behavioral Psychology-Psicologia Conductual, 21(1), 59–79.
Asaro-Saddler, K., & Bak, N. (2012). Teaching children with high-
functioning autism spectrum disorders to write persuasive
essays. Topics in Language Disorders, 32(4), 361.
Burgio, L. D., Engel, B. T., Hawkins, A. M., McCormick, K., & Sch-
eve, A. S. (1990). A descriptive analysis of nursing staff behav-
iors in a teaching nursing home: Differences among CNAs,
LPNs, and RNs. The Gerontologist, 30, 107–112.
Callaghan, G. M., & Follette, W. C. (2008). FAPRS manual: Man-
ual for the functional analytic psychotherapy rating scale. The
Behavior Analyst Today, 9(1), 57.
Callaghan, G. M., Summers, C. J., & Weidman, M. (2003). The treat-
ment of histrionic and narcissistic personality disorder behav-
iors: A single-subject demonstration of clinical improvement
using functional analytic psychotherapy. Journal of Contempo‑
rary Psychotherapy, 33(4), 321–339.
Carstensen, L. L., Fisher, J. E., & Malloy, P. M. (1995). Cognitive and
affective characteristics of socially withdrawn nursing home resi-
dents. Journal of Clinical Neuropsychology, 1(3), 207–218.
Castle, N. G. (2012). Resident-to-resident abuse in nursing homes
as reported by nurse aides. Journal of Elder Abuse & Neglect,
24(4), 340.
Darrow, S. M., Callaghan, G. M., Bonow, J. T., & Follette, W. C.
(2014). The Functional Idiographic Assessment Template-Ques-
tionnaire (FIAT-Q): Initial psychometric properties. Journal of
Contextual Behavioral Science, 3(2), 124–135.
Drageset, J., Eide, G. E., Nygaard, H. A., Bondevik, M., Nortvedt, M.
W., & Natvig, G. K. (2009). The impact of social support and
sense of coherence on health-related quality of life among nurs-
ing home residents—A questionnaire survey in Bergen, Nor-
way. International Journal of Nursing Studies, 46(1), 66–76.
doi:10.1016/j.ijnurstu.2008.07.005.
Drageset, J., Eide, G. E., & Ranhoff, A. H. (2013). Anxiety and
depression among nursing home residents without cognitive
impairment. Scandinavian Journal of Caring Sciences, 27(4),
872–881.
Haaland, V. Ø., Haaland, A. T., Vogel, P. A., Launes, G., Hansen,
B., Solem, S., & Himle, J. A. (2011). The role of early mala-
daptive schemas in predicting exposure and response prevention
outcome for obsessive–compulsive disorder. Behaviour Research
and Therapy, 49(11), 781–788.
Hager, K. K., & Brockopp, D. (2007). Pilot project: The chronic pain
diary–assessing chronic pain in the nursing home population.
Journal of Gerontological Nursing, 33(9), 14.
13
J Contemp Psychother (2017) 47:173–180
Heineken, J. (1998). Patient silence is not necessarily client satisfac-
tion: Communication problems in home care nursing. Home
healthcare nurse, 16(2), 115–120.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statis-
tical approach to defining meaningful change in psychotherapy
research. Journal of Consulting and Clinical Psychology, 59,
12–19.
Jones, S. M. (2011). Supportive listening. International Journal of
Listening, 25(1), 85–103. doi:10.1080/10904018.2011.536475.
Kaiser Family Foundation. (2010). Medicare and non-elderly people
with disabilities.
Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psycho‑
therapy: Creating intense and curative therapeutic relationships.
New York: Plenum.
Lachs, M. S., Rosen, T., Teresi, J. A., Eimicke, J. P., Ramirez, M.,
Silver, S., & Pillemer, K. (2013). Verbal and physical aggression
directed at nursing home staff by residents. Journal of General
Internal Medicine, 28(5), 660–667.
Landes, S. J. (2008). Functional analytic psychotherapy for comor-
bid depression and personality disorders (unpublished doctoral
dissertation).
Pillemer, K., Chen, E. K., Van Haitsma, K. S., Teresi, J., Ramirez, M.,
Silver, S., … Lachs, M. S. (2012). Resident-to-resident aggres-
sion in nursing homes: Results from a qualitative event recon-
struction study. The Gerontologist, 52(1), 24–33.
Scruggs, T. E., & Mastropieri, M. A. (1998). Summarizing single-
subject research: Issues and applications. Behavior Modification,
22, 221–242.
Scruggs, T. E., Mastropieri, M. A., & Casto, G. (1987). The quantita-
tive synthesis of single-subject research: Methodology and vali-
dation. Remedial and Special Education, 8, 24–33.
Singh, R. S., & O’Brien, W. H. (2016). A meta-analytic review of
functional analytic psychotherapy single subject research (Ohi-
oLINK Electronic Theses and Dissertations Center, & Bowling
Green State University).
Swanson, H. L., Hoskyn, M., & Lee, C. (1999). Interventions for stu‑
dents with learning disabilities: A meta-analysis of treatment
outcomes. New York: Guilford.
Swanson, H. L., & Sachse-Lee, C. (2000). A meta-analysis of
single-subject-design intervention research for students
with LD. Journal of Learning Disabilities, 33, 114–136.
doi:10.1177/002221940003300201.
Swanson, H. L., Zheng, X., & Jerman, O. (2009). Working memory,
short-term memory, and reading disabilities: A selective meta-
analysis of the literature. Journal of Learning Disabilities, 42,
260–287. doi:10.1177/0022219409331958.
Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B., Follette,
W. C., & Callaghan, G. M. (2009). A guide to functional analytic
psychotherapy: Awareness, courage, love, and behaviorism. New
York: Springer Science + Business Media.
Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver
agreement: The kappa statistic. Family Medicine, 37(5), 360.
Weeks, C. E., Kanter, J. W., Bonow, J. T., Landes, S. J., & Busch, A.
M. (2012). Translating the theoretical into the practical: A logi-
cal framework of functional analytic psychotherapy interactions
for research, training, and clinical purposes. Behavior Modifica‑
tion, 36, 87–119.