Functional Analysis in Behaviour Therapy

situationally specific 03002_Kulz_englisch_Web.indd 4 04.09.14 11:32 Verhaltenstherapie 2014;24:211–220 Functional Analysis in Behaviour Therapy 5 tection from responsibility, interpersonal regulation and obsession/compulsion as occupation. The particular assessment of the relevant areas can provide valuable starting points; however, the individual meaning in the context of a person’s life should in any case be taken into account. The relevance of functionalities has been pointed out many times in the context of obsessive-compulsive disorder [Ecker, 2005; Baumeister and Angenendt, 2007]. OCD therefore also seems virtually predestined for consideration in terms of functions of symptoms, because here mental events and behaviours manifest themselves contrary to the person’s own value system and/or better judgment, and therefore generate special explanatory requirements in those affected. The two-stage model of Hoffman and Hofmann [2008] is an impressive model of functions in OCD, one often found helpful by those afflicted; a seemingly insoluble problem is symbolically moved from the ‘stage of life’ (e.g., the effort to gain independence from a domineering spouse) to the ‘auxiliary stage’ of OCD (e.g., contamination fears, with excessive washing and disinfecting rituals throughout the home). In our own study [Külz et al., 2010], we evaluated the treatment records over a 7-year period of all inpatients with newly diagnosed OCD at the Department of Psychiatry and Psychotherapy of the University Hospital of Freiburg, for the above-mentioned functionalities. 63% (n = 168) of the reports contained explicit information about these functionalities of OCD symptoms, and in 53% of these, according to the clinicians doing the evaluations, the symptoms served the function of affect regulation. On an interpersonal level, the desire for differentiation and autonomy was particularly common (42%). Looking at functional analysis, several aspects of the therapeutic process can be identified, of which these are the 4 key areas: – Expansion of perspective and insight into the problem by identification of an actively formative role of the symptom; – Emotional relief for the patient by illumination of validation of the problem behaviour and its meaningfulness in the context of his or her individual life; – Identification of relevant therapy goals and the content of the therapeutic regimen by definition of associated problem areas; – Increased compliance and prevention of non-response or relapses because of conscious and unconscious resistance to improvement of the symptom. This makes it clear that functional analysis is already highly significant in the first stages of the therapeutic process: Only if the problem behaviour is made comprehensible, in discussion between patient and therapist, can the basis for a trusting therapeutic alliance be created. Similarly, individual motivation to change and the relevant goals are first fully developed by taking into account a symptom’s function. Hayes and Follette [1992] already pointed out 20 years ago that classical diagnostics, which puts the focus on symptoms but not on the function of a behaviour, ultimately falls short systems theory perceives as a general phenomenon should also be taken into account in the analysis of human behaviour. With this in mind, it seems particularly relevant to think about the hypothetical nature of functional considerations and to remain open to new insights into the treatment process, in terms of adaptive determination of functionalities. Functional Analysis in the Treatment Process Because newer diagnoses (e.g., ADHD) are gaining in importance and there is greater need for economy of time as well as structured interventions that are also tailored to the individual needs of those affected, a functional analysis that is as comprehensive as possible and simultaneously time-efficient appears more necessary than ever. Information sources for functional analysis are usually primarily patient descriptions in clinical interviews and observations by the patient and others. Behavioural protocols have also proven useful, as they allow the specific description of symptomatic behaviour in everyday situations. For the anamnestic recording of functionalities, graphic representations are also recommended, listing relevant life events and conditions at the time of symptom onset. Questionnaires and behavioural inventories are also available for particular problem areas. Among these are the Motivational Assessment Scale (MAS) [Durand and Crimmins, 1992] and the Questions About Behaviour Function (QABF) Scale [Matson and Volmer, 1995; Matson et al., 2012; Bienstein and Nussbeck, 2009], which were originally designed for people with mental disabilities. The MAS, for example, used a 7-point Likert scale with 16 items to assess 4 functions of behaviour (sensory stimulation, escape, gaining social attention, acquiring something specific). However, it should be noted that questionnaires only offer a very specific approach to the problem and cannot entirely replace direct observation. Notably in the area of auto-aggressive behaviour, several studies have attempted to assess the functions of self-injury, through various survey instruments (self-reports, laboratory tests). In an article reviewing 18 studies [Klonsky and Mühlenkamp, 2007], selfpunishment proved to be the most important function of selfinjurious behaviour, while only modest evidence was found for anti-dissociative and anti-suicidal functions, as well as socalled sensation seeking and the need to set interpersonal boundaries or to exert influence. The authors call attention to the initial results, according to which different functions of self-injurious behaviour should have different clinical implications (e.g., level of suicide risk), and therefore should provide important evidence for differential interventions. Recently a questionnaire for functions of symptoms was developed and validated for obsessive-compulsive disorder in a sample of 120 patients (Patricia Kulla, data so far unpublished). Factor and item analysis of the data yielded 5 areas of functions: stabilization of self-esteem and achievement, emotion regulation, proacy. tner nger that