The increasing demand for psychiatrists to provide medication only has captured the attention of both professional and lay audiences.1-3 We wonder, however, about the many psychiatrists who lament this constricting role and the potential minimization of genuine and mutually rewarding professional relationships when medication management is the more lucrative clinical activity. In the context of managing medications only, how many of us are growing weary of “doctor abuse,” endless patient “complaining,” patients who “just don’t listen,” or the avoidance of using preferred medications because of prior authorization hassles. And, how do you feel about your nonprescribing mental health associates who seem to have deeper and more meaningful relationships with their patients?
Rather than arguing for more time for psychotherapy, this article explores the use of functional analytic psychotherapy (FAP)—a behavioral, evidenced-based approach to psychotherapy that can add psychotherapeutic benefit to your existing brief approaches during medication checks.3,4 We believe that these brief patient encounters can be powerfully psychotherapeutic without replacing existing skills or treatment modalities.
What is functional analytic psychotherapy?
FAP is in-session psychotherapy that has its roots in behavioral therapy. While a focus on in-session demonstrations of patient problems is key (also an important feature of psychodynamic psychotherapy), FAP is practical and parsimonious and is based on accepted behavioral principles. FAP contends that problematic behaviors experienced by patients in their daily lives will eventually appear in the relationship with their psychiatrist. When these behaviors occur, your personal reactions to them become important sources of feedback for your patient. FAP has precise, elegant, and research-based sets of procedures. More information can be found on the FAP Web site.
During the initial psychiatric assessment by an FAP-oriented psychiatrist, a real yet professional relationship is emphasized and a specific agreement is made that when problematic behaviors appear within a session, feedback will be provided in a caring fashion. As with personal relationships, patients are encouraged to provide feedback to you as well.
FAP holds that interpersonal relationships are universally important and assumes that the patient-psychiatrist relationship is one such relationship, yet different in that useful behaviorally contingent feedback is provided. Feedback occurs in session and is most likely to lead to behavior change over time both in session and in the outside world.5
There are 3 basic axioms to FAP:
• Instances of problematic behavior that occur in session that are similar to problems experienced by patients in their daily lives are clinically relevant behaviors 1 (CRB1)
• Improvements observed during medication checks are clinically relevant behaviors 2 (CRB2)
• Statements made by the psychiatrist that link patient behavior to consequences are clinically relevant behaviors 3 (CRB3)
A patient who has difficulty in maintaining relationships and who is demanding of and rude to the psychiatrist exhibits CRB1. After the psychiatrist’s feedback, if the patient shows improvement, he or she exhibits CRB2. When the psychiatrist states, for example, “you know, when you tell me that you are struggling and are giving me feedback on my last medication idea, and are open to new ideas, that makes me feel really focused on you and your problems and on how to better help you . . . and in fact, I do have an idea for a medication change that I feel very hopeful about,” this is viewed as a CRB3. This positive feedback is focused on shaping a more appropriate patient behavior.
With FAP, noticing and responding to behaviors that occur in session (CRBs) is central to promoting healthy behavioral changes. Using many elements of supportive psychotherapy, patients who show improvement during sessions are genuinely praised. In-session behavioral improvements show that the therapy is working.
The following Case Vignette is an example of how FAP mindfulness was not part of the psychiatrist’s style in conducting a medication check.
Sandra is a 55-year-old, twice-divorced white high school teacher who is being treated for chronic anxiety and recurrent depression. Earlier in her life, she received extensive psychotherapy for overreactivity to aversive stimuli, mood instability, intrusiveness, and short-lived interpersonal relationships. She made some progress, and the therapeutic contract was revised to provide medication checks with supportive psychotherapy, conducted on an as-needed basis. During previous psychodynamically informed psychotherapy, she had had difficulty with boundary management. She now complains of back pain for which her primary care physician prescribed narcotic analgesics.
The psychiatrist asks her to rate her mood on a 1 to 10 depression/happiness scale. She rates her mood as 1 and demands a dose increase in her medication. She resists lithium augmentation strategy and claims that she is not “bipolar.” She also demands a referral to another primary care physician who “knows better” or to a pain specialist. The psychiatrist feels pressured, quietly angry, and exhausted, but complies with the patient’s requests.
What is the psychiatrist to do when faced with such a difficult patient? In FAP, self-awareness is potentially very important in treatment. When feeling “dread” about a patient, the psychiatrist is urged to be aware of his or her feelings. The psychiatrist might view his feeling of dread as meaningful data; it may be the very thing that the patient is struggling with in her daily life, which manifests in the doctor-patient relationship. The desire to comply with the patient’s demands and “get rid” of the patient, while understandable from the point of view of terminating a punishing interaction, in fact rewards this patient’s behavior and repre-sents a lost opportunity.
In the case example, an FAP-oriented psychiatrist might openly discuss his feelings, comparing them with feelings likely experienced by others in the patient’s life, and urge her to alter her behavior. If positive change occurs in follow-up medication checks, the psychiatrist would genuinely praise the patient and discuss his changed feelings toward her. Positive changes observed in the medication check are likely to generalize in her daily life.
What does it take to be an FAP-oriented psychiatrist?
Adding FAP to your practice requires, first and foremost, that you pay very close attention to the behavior of the patient in session and to the emotional impact of that behavior on you. FAP also requires that you are willing to view your emotional reactions to your patients as potentially useful data that may be representative of how others in the patient’s life feel about him or her. When this is the case, special opportunities for amplifying these private reactions in the service of providing feedback to the patient arise.
The essential FAP skills for the treating psychiatrist involve increased mindfulness and focused inner attention to one’s thoughts, feelings, and behaviors. It is also essential that the FAP psychiatrist has courage and compassion, because interventions that are interpersonal and focused on the doctor-patient relationship can feel uncomfortable. The FAP psychiatrist must be willing to be more human and open in accurately hearing the thoughts and feelings of others, and must be courageous in sharing these patient-related thoughts and feelings directly with the patient. Using an FAP orientation, the doctor-patient relationship becomes more of a real, yet safe, relationship. FAP may be difficult for the psychiatrist at first, but with practice, the needed skills can be mastered.
In addition, the FAP-oriented psychiatrist needs to pay special attention to the patient’s history and recognize that past significant life events may be contributing factors to the patient’s special sensitivities and behaviors. Input from other professionals, when available, can also help in gaining insight into the patient’s behavior. Moreover, it is essential to assess where and how in the patient’s life relationship problems show up. Both the patient and the psychiatrist need to be vigilant for instances of similar problems that occur during treatment. A careful assessment of the hopes, dreams, and life values of the patient will help in making treatment decisions. Interventions can be designed to reduce suffering and promote a life that is emotionally deep, rich, and full of what the patient cherishes. Occasionally, hour-long appointments can be used to explore deeper issues.
The rewards of being an FAP-oriented psychiatrist
FAP can facilitate a closer and more meaningful, yet professional, relationship with the patient. In our personal experience and in our observation while supervising residents, medication checks augmented with FAP are likely to be more reward-ing. We believe that the augmentation of effective pharmacotherapy with FAP will reduce symptoms and help patients live lives that are more meaningful and more connected to their life values.
And, of course, the psychiatrist benefits from participating in this process. Such relationships are like-ly to contribute to a greater sense of wholeness and meaning for the psychiatrist, with less stress and consequently less likelihood of burnout.
1. Olfson M, Marcus SC. National trends in outpatient psychotherapy. Am J Psychiatry. 2010;167:1456-1463.
2. Harris G. Talk therapy doesn’t pay, so psychiatry turns to drug therapy. New York Times. March 5, 2011. http://www.nytimes.com/2011/03/06/health/policy/06doctors.html. Accessed May 5, 2011.
3. Pies RW. Psychotherapy is alive and talking in psychiatry. Psychiatr Times. 2011;28(4):1, 9-10.
4. Kohlenberg RJ, Tsai M. Functional Analytic Psychotherapy: Creating Intense and Curative Therapeutic Relationships. New York: Plenum Press; 1993.
5. Tsai M, Kohlenberg RJ, Kanter JW, et al. A Guide to Functional Analytic Psychotherapy: Awareness, Courage, Love, and Behaviorism. New York: Springer; 2009.