Ind Psychiatry J. 2021 Jan-Jun; 30(1): 55–61.

PMCID: PMC8395566
Published online 2021 Jun 4. doi: 10.4103/ipj.ipj_10_20: 10.4103/ipj.ipj_10_20 PMID: 34483525

Application of functional analytic psychotherapy to manage schizophrenia

Usri Sengupta and Amool Ranjan Singh

Department of Clinical Psychology, RINPAS, Ranchi, Jharkhand, India

Address for correspondence: Dr. Amool Ranjan Singh, Department of Clinical Psychology, RINPAS, Kanke,
Ranchi, Jharkhand, India. E-mail: [email protected]

Received 2020 Jun 24; Revised 2021 Mar 19; Accepted 2021 Apr 22.

Copyright : © 2021 Industrial Psychiatry Journal

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Abstract

Introduction:

Cognitive behavioral therapy (CBT) and third-wave CBT approaches have been shown to ame‐
liorate symptoms of schizophrenia. However, this study uses the functional analytic psy‐
chotherapy which focuses on the environmental causes of behavior which includes the client's
present environment as well as his history of past interactions with it, to bring about a change
in the client and reduce the symptoms. This therapy has never been used earlier with patients
having schizophrenia in India; therefore, it was taken up for this study.

Methodology:

A pre–post design with control group was used in the present study. Ten patients were taken.
Positive and Negative Syndrome Scale for measuring symptoms of schizophrenia,
Schizophrenia Quality of Life Scale for assessing quality of life, Coping Response Inventory-
Adult form for assessing coping skills, Apathy Evaluation Scale-Clinician Version for assessing
apathy, Family Adaptability and Cohesion Evaluation Scale for assessing perceived interper‐
sonal relationship were used for assessment pre- and postintervention. Fifteen sessions were
done with each patient within a period of 10 months at the rate of one session per week. Chi-
square test, Wilcoxon signed-rank test, and Mann–Whitney U-test were used for the analysis of
data.

Results:
Significant improvements were found in positive symptoms, general psychopathology, ap‐
proach coping mechanisms, psychosocial and motivation domains in quality of life, and per‐
ceived cohesion in family among the patients postintervention.

Conclusion:

Functional analytic psychotherapy is an effective method for treating patients having

schizophrenia with the application of its specifically modified rules for use with patients having
psychosis.

Keywords: Cognitive behavioral therapy, functional analytic psychotherapy, schizophrenia,

third-wave cognitive behavioral therapy

Schizophrenia is usually treated with therapies such as cognitive behavioral therapies, mindful‐
ness-based therapies, social skills training, interpersonal psychotherapy, and family therapy.
However, functional analytic psychotherapy has never been used earlier in patients having
schizophrenia in India. Therefore, this approach was taken up for use in the present study to
bring about greater effectiveness in the interpersonal realm of the patients having schizophre‐
nia. This eventually aims to result in better perceived interpersonal relationship in the patient
and thereby helps them improve quality of life and coping skills of the patients.

This psychotherapy originates from radical behaviorism and “contextualism.” It demands ex‐
planation of why we act the way we do to taking into account the unique history of the individ‐
ual up to that moment in time. It focuses on the environmental causes of behaviour which in‐
cludes the client's current environment and his history of interactions with it. In this approach
of psychotherapy, the problematic client behaviours are collaboratively identified and gradu‐
ally shaped towards greater effectiveness as they show up as occurring within the client-thera‐
pist relationship. The therapist provides honest feedback and reinforcement of client's behav‐
ior occurring right in the moment in his interaction with the therapist (called “clinically rele‐
vant behaviors”), so that the client can use this immediate feedback to modify his ways of relat‐
ing to the therapist and consequently to others outside the sessions. That is, maladaptive be‐
havior and thoughts, if corrected within the session, may be generalized by the patient outside
the therapy session when relating to other people. As a result of this, the client's general per‐
ceptions alter significantly with change in his patterns of interpersonal interactions. The ther‐
apy breaks the barrier between behaviour therapy and psychoanalytic psychotherapy and in‐
tertwines them for better management of patients. A study on quantitative analysis of func‐
tional analytic psychotherapy by Singh and Brien[1] revealed that the therapy shows signifi‐
cant in-session changes in subjects' behavior patterns, which was successfully generalized out‐
side the session with appropriate reinforcement. In a study conducted by Dixon et al.[2] on
functional analysis and treatment of inappropriate verbal behavior, differential reinforcement
of alternative behaviors was given, where each appropriate verbal utterance was followed by
reinforcement in the form of showing an interest into it while at the same time ignoring the in‐
appropriate behaviors. Results indicated a decrease in the number of inappropriate utterances
and an increase in appropriate utterances. Landes et al.[3] evaluated the effect of active com‐
ponents of functional analytic psychotherapy, evoking client's clinically relevant behavior, con‐
tingently responding to behavior, and generalizing improvement with favorable results reveal‐
ing that active components of functional analytic psychotherapy improved the targeted behav‐
ior. Weeks et al.[4] used functional analytic psychotherapy, in which positive reinforcement of a
client's effective behavior proved to be a powerful mechanism of change for the person.

In the present study, functional analytic psychotherapy was applied on the patients having
schizophrenia to see its effects on the variables of positive and negative symptoms of
schizophrenia, apathy, coping skills, quality of life, and perceived interpersonal relationship.
Coping skills intervened in this study include the approach coping (problem-focused) and
avoidance coping (emotion-focused) techniques and the domains of quality of life includes the
Psychosocial Domain, the Motivation Domain and the Energy and Symptoms domain. The do‐
mains of perceived interpersonal relationship include adaptability (perceived chaotic family)
and cohesion (perceived enmeshed family).

METHODOLOGY

Thirteen male patients from the inpatient department of our institute, within the age range of
20–40 years, who studied up to at least 10th standard, belonged to middle or lower socioeco‐
nomic status, who were married and had children, without the history of significant neurocog‐
nitive impairments, substance abuse, traumatic head injury, and comorbid psychiatric condi‐
tions, were taken by the method of purposive sampling, out of which 3 dropped out during
preintervention assessment. Written consent was taken from all of them. A pre–post design
with control group was used. The study was undertaken after clearance from the department
of clinical psychology of our institute.

Description of test materials used

Positive and Negative Syndrome Scale (PANSS) Positive and Negative Syndrome Scale (PANSS)
[5] is a 7-point rating scale having 30 items for evaluating the presence and severity of positive
and negative symptoms and general psychopathology of schizophrenia. The marking on the
scale is done based on the patient's perceptions of his thoughts, experiences, and beliefs in the
week prior to assessment. Its internal reliability ranges from 0.73 to 0.83.

Apathy Evaluation Scale- Clinician Version Apathy Evaluation Scale-Clinician Version developed
by Marin[6] is an 18-item 4-point Likert type scale. It detects apathy based on changes in three
basic areas: observation of (overt) activity, thought content, and emotional responsiveness. Its
reliability is around 0.94 and validity is around 0.76.

Family Adaptability and Cohesion Evaluation Scale Family Adaptability and Cohesion Evaluation
Scale (FACES)[7] measures perceived interpersonal relationship in family based on two main
domains, namely cohesion (high score on which indicates enmeshed nature of family) and
adaptability (high score on which indicates chaotic nature of family). Its reliability is around
0.84 and validity is around 0.70.

Schizophrenia Quality of Life Scale Schizophrenia Quality of Life Scale (SQLS) developed by
Wilkinson et al.[8] is a self-administered scale having 30 items. It has three domains, namely
psychosocial, motivation and energy, and symptoms. The scale focuses upon the perceptions
and concerns of patients having schizophrenia. It has been specially designed to be used in
clinical trials and evaluation of clinical interventions. Its reliability is around 0.93 and validity is
around 0.78.

Coping Response Inventory-Adult form Coping Response Inventory-Adult form (CRI-A) devel‐
oped by Moos[9] measures eight specific coping strategies to stressful life circumstances,
namely logical analysis, positive reappraisal, seeking guidance and support, problem solving
(which together constitutes the approach or adaptive coping) and cognitive avoidance, accep‐
tance-resignation, seeking alternative rewards, emotional discharge (which together consti‐
tutes the avoidant or maladaptive coping). Its internal consistency reliability is around 0.74.

Brief description of techniques used in therapy

The following techniques were used as per the module of functional analytic psychotherapy
developed by Dykstra et al.[10] for patients having schizophrenia.

Expanded rationale technique Here, the rationale was made to express the therapist's views
about the causes and intervention of schizophrenia. Here, the patient's perception about the
nature of his interpersonal relationships was discussed. The system of artificial reinforcement
to be used in sessions in the form of token economy in case of demonstration of desirable be‐
havior patterns on part of the client was delineated, relating it with therapist's natural course
of emotional cues in the due course of time. The rationale served to prepare about what he
should expect to encounter during the therapy session and structured the nature and style of
intervention used by the therapist.

Cognitive rationale technique The therapist provides an explanation of the cognitive distor‐
tions and its origins. He focuses on the cognitive distortions which were found to be main‐
tained in the patient's ways of relating with the therapist during interactions, in terms of how
the patient interprets the therapist's behavioral expressions, how he expresses delusional con‐
tent in his speech, and how accurately he can detect therapist's emotional cues, and were
trained within the session using the therapeutic relationship. The effect of such distortions on
the patient's perception of surroundings in terms of situations and people within and outside
the therapy session and maladaptive behaviours occurring as a result of that were assessed
and intervened in the sessions. Patient was trained with techniques of formal mindfulness to
have better conscious control over his thoughts, emotions, and to develop compassion.

Behavioral rational technique Here, cognition was explained in terms of overt behavior. It was
explained as an activity of thinking, planning, believing, reacting, and categorizing, placing the
degree of control exerted by cognition on the client in a continuum. It varied as per his clinical
history of learning the behavior during some situation in the past which can similarly be un‐
learned during modification of observable behaviors within the repertoire of therapeutic rela‐
tionship. Using the behavioral rationale technique, the patient was thus taught to identify his
thought, analyze it, and consequently reacting to it. Social skills training was employed in group
setting to obtain better results. Thereafter, to improve patient's social attribution, he was also
trained to decipher facial expression using 10 pictures from Ekman's picture stimuli (pictures
of facial affect) to improve his socioemotional cue perception.
Greater use of client–therapist relationship Here, the therapist deliberately introduced some
conflicting situations within the repertoire of therapeutic relationship to elicit similar reactions
from the patient as he reacts during similar situations in his daily life circumstances and there‐
after corrects the maladaptive behaviors within the session itself, so that the patient can learn
to react and behave similarly in future in his daily life circumstances outside the sessions.

Training of social skills The functionally analytic way focuses upon the social skills, both verbal
and nonverbal like communication, expressiveness, postures, and so on, as manifested in ses‐
sion during the interaction of the patient with the therapist. Thereafter, the maladaptive behav‐
iors with respect to such social skills were intervened as manifested within the repertoire of
the therapeutic interaction with demonstration from the therapist.

Role playing The patients were made to practice the learned skills in the form of role playing
in groups of five. Imaginary situations were introduced and they were made to interact with
each other according to it, thereby recreating a potential real-life situation within the therapeu‐
tic milieu with necessary directions from the therapist. In this way, the patients mastered the
social skills they exercised in sessions, so that they can apply the same in their interpersonal
interactions outside the session. Thereafter, therapist focused on gradual initiation of general‐
izing the learned skills and modifying clinically relevant behaviors for better community
integration.

Learning community integration The patients were helped to apply the learned skills in role
playing and within the therapeutic milieu in their regular interactions with other people and
provide a feedback of the experience to the therapist, so that it can be modified within his in-
session behavioral repertoires. Altered and improved perception of social situations, improved
communications, emotional expressions, and so on as needed for adequate community living
were exercised with the patient.

Maintaining adaptive behavior patterns The therapist discussed with the patient mainly about
the environmental variables that often impact the client's behavior in his current surround‐
ings. Focus of intervention here was kept on the ways to use the skills learnt in therapy situa‐
tion in collaboration with therapist in order to improve interpersonal relationship and be‐
havioural patterns within family and thus function better in the community.

Statistics used for analysis of data

The study involved a small group of individuals. Therefore, nonparametric statistics was used.
Version 20 of the IBM Statistical Package for the Social Sciences (SPSS) was used for the analy‐
sis. Chi-square test was used to assess the sociodemographic variables. Wilcoxon signed-rank
test assessed both the magnitude and direction of the difference between baseline assessment
and postintervention assessment. Mann–Whitney U-test compared the differences in the cho‐
sen measures between the control group and the experimental group since the data in control
and experimental groups are unpaired observations of two independent groups of equal sizes.
RESULTS

Analysis of data showed no significant difference in the sociodemographic correlates among

the patients belonging to both experimental and control groups on the variables of age, educa‐
tion, occupation, type of family, socioeconomic status, marital status, duration of illness, and
duration of treatment. The baseline assessment of the participants, belonging to both experi‐
mental and control groups, showed that there was no significant difference in the clients in
variables of apathy, coping skills, quality of life, and perceived interpersonal relationship.
Postintervention assessment showed that there were significant variations in certain subdo‐
mains of scales measuring positive and negative symptoms and general psychopathology, cop‐
ing skills, quality of life, and perceived interpersonal relationship in the patients belonging to
the experimental condition. However, no significant difference was found in apathy
postintervention.

The data of clients belonging to the experimental group postintervention are shown. The data
on the variables in which there were significant changes post intervention are shown in the
study.

DISCUSSION

Table 1 shows scores on PANSS in the experimental group before and after intervention.
Mindfulness exercises helped the patients to focus upon their moment's experiences, control
their anger and impulsiveness. This, in turn, helped them to cope with the associated distress.
It also reduced the intensity of the psychotic symptoms as the patient learnt to read emotional
cues of the therapist within the session. Patient also learnt to identify therapist's overt expres‐
sions with the help of the pictures of emotional expressions given in Universal Facial
Expression of Emotion by Paul Ekman. Thereafter, he was gradually able to read emotional
cues of other patients in group within session and later on was able to accurately comprehend
emotional cues of others outside session. This further helped to decrease his delusional expe‐
riences, suspiciousness, and expressed hostility. The trustworthy therapeutic relationship be‐
tween the patient and therapist was generalized outside the session, resulting in decreased
suspiciousness. The improved trust in turn improved interpersonal relationship and decreased
anxiety, guilt, and depressive feelings. This indicates that the therapy was effective in reducing
some significant symptoms of schizophrenia. A study done on quantitative analysis of func‐
tional analytic psychotherapy by Singh and Brien revealed that functional analytic psychother‐
apy shows a fairly effective and significant in-session change in the subjects' behavior patterns,
which was successfully generalized outside the session with appropriate reinforcement.

Table 1 also shows scores obtained by the patients of experimental condition on different do‐
mains of CRI-A before and after intervention. The mean scores were significantly higher in the
domains of logical analysis, positive reappraisal, seeking guidance and support, and problem
solving among the approach coping strategies among patients in the experimental group post
intervention. This indicates that the patients were able to logically analyze difficult interper‐
sonal and other situations within their family and outside as they have learned in the in-ses‐
sion practices with their therapist and are able to rationally think and converse in a conflicting
situation and appraise old conflicting situations in a new light post intervention. That is, they
were able to reconstruct the dynamics of old interpersonal relationships as they generalize
therapeutic relationship outside the session due to improved emotional cues' reading and bet‐
ter interpersonal perceptions that they learned through role playing within sessions as well
and were thus able to cope better during times of conflicts. Their scores in problem solving
was greater post intervention compared to pre-intervention assessments phase as they were
able to seek more guidance and support from other people in their surroundings, due to in‐
creased generalized trust within and outside family relationships. As a result, their score in the
domain of seeking guidance and support has also increased post intervention. The scores in
the domain of acceptance or rejection have significantly reduced post intervention, which indi‐
cates that the patients were able to relate with other people better with a reduced fear of
whether they will be accepted or rejected in an interpersonal situation. This may be because
they have been able to fearlessly relate with the therapist during the sessions, which instilled a
confidence in them to relate the same way with others. The scores in the domain of emotional
discharge have significantly reduced post intervention, which indicates that post intervention
they were better able to control their anger outburst and had a grip on their emotional ex‐
pressions, which might be attributed to mindfulness practices. Greater use of problem-focused
coping strategies was associated with high levels of self-efficacy and better performance on a
measure of sustained attention emphasizing perceptual processing.[11] In a study conducted
by Andres et al.,[12] efficacy of coping-oriented therapy approach was tested. It was found that
the patients' overall social functioning improved along with the extent of the cognizance of the
disorder. The patients also mastered active problem-focused coping strategies immediately af‐
ter the completion of therapy. In a cross-sectional study by Avery et al.[13] on role of effort,
cognitive expectancy, appraisals and coping style in the maintenance of negative symptoms of
schizophrenia, all the psychological variables had significant partial correlations with some of
the measures of negative symptoms.

Table 1 also shows scores obtained by the patients of experimental condition in the domains of
the FACES scale. It is seen that the score in the domain of adaptability is significantly lower post
intervention compared to baseline, which indicates that the patient perceived his family to be
less chaotic post intervention, which led to improvement in his interpersonal relationships
both. This might be because the patient was able to adequately generalize the nature of inter‐
relatedness and trust with the therapist among his interpersonal relationships outside the ses‐
sions, which post intervention were perceived to be more trustworthy, embracing, and less
threatening to the patient. Corrigan and Toomey[14] conducted a study examining the rela‐
tionship between receiving, processing, and sending skills along with social cue perception in
patients with schizophrenia who presented with deficits in interpersonal problem solving, so‐
cial cue perception, visual vigilance, verbal memory, conceptual flexibility, and psychiatric
symptoms. Significant relationships were found between sensitivity to social cues and receiv‐
ing, processing, and sending skills. Recognition and recall skills were also associated with prob‐
lem-solving skills. In a study by Hewitt and Coffey,[15] the authors reviewed the evidence on
necessity and sufficiency of therapeutic relationships when working with people with
schizophrenia. The findings suggested that therapeutic relationships characterized by facilita‐
tive and positive interpersonal relationships with helpers had benefits.

Table 2 shows the comparison of difference scores between experimental and control condi‐
tions in the domains of quality of life as measured by SQLS. It shows that difference score is
significantly higher in the experimental group in the domains of psychosocial and symptoms,
which indicates that post intervention there was a significant improvement in these domains in
patients of experimental group. In a study by Domenech et al.,[16] it was found that the factors
which were mostly associated with health-related quality of life were alteration and reduction
in the negative symptoms of schizophrenia.
Table 2 also shows the comparison of difference scores between experimental and control
conditions in the domains of coping skills as measured by CRI-A. The patients who received in‐
terventions had significantly higher difference scores in approach coping strategies such as
logical analysis, seeking guidance and support, and problem solving and in avoidance coping
such as acceptance or rejection and emotional discharge. This indicated that the intervention
produced significant changes in both the approach and avoidance coping styles in the experi‐
mental group in these domains. This may be related to a study by Schlier et al.[17] on fostering
coping as a mechanism of symptom change in cognitive behavioral therapy for psychosis, in
which the cognitive and behavioral efforts to manage taxing external and internal demands
created a mechanism of change in cognitive behavioral therapy. A continuous improvement in
suspicious, negative symptoms and depression over the course of CBT was preceded by the
improvement in coping and improvement in negative symptoms and depression predicted sub‐
sequent improvement in coping.

Clinical implications

The present study indicates that along with the medicinal treatments, third-wave psychother‐
apy like functional analytic psychotherapy brings about significant improvements in the differ‐
ent domains of impaired functioning among the patients having chronic schizophrenia.
Therefore, the patients should be regularly enrolled in psychotherapeutic management within
and outside institutionalized setup to bring about an improvement in their prognosis. However,
the study was conducted with limited sample size, which is its primary limitation. In future, the
study may be replicated with a larger sample size considering both male and female patients to
see differential impacts upon gender along with sufficient follow-up sessions.

CONCLUSION

The findings state that functional analytic psychotherapy brought improvements in variables
such as symptoms, perceived interpersonal relationship, quality of life, and coping strategies
except in apathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

Firstly, I am highly grateful and indebted to Dr. (Prof.) Amool Ranjan Singh, Professor,
Department of Clinical Psychology, RINPAS, Ranchi for guiding me through the entire process
of conducting and completion of the research. I am also grateful to all the patients of RINPAS
who agreed to provide me with the data and cooperated with me in the process of therapy and
research. I also thank the staffs of RINPAS namely, Nirmal Ji and Late Tara Kumari Prasad,
Librarians for helping me access the relevant books and articles as and when I needed for the
research. I express sincere gratitude to my seniors, Mr. Sarin Dominic, PhD Scholar of Clinical
psychology, RINPAS, Mrs. Amble Tom, PhD Scholar of Clinical Psychology, RINPAS and Ms.
Meenakshi Gupta, former MPhil Scholar of Clinical Psychology, RINPAS for helping me with the
statistical calculations.

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Figures and Tables

Table 1

The scores on scales during baseline assessment and assessment postintervention


Variables Subjects, mean±SD Wilcoxon sign rank test

Baseline Postintervention Significant Mean Z P

assessment (n=5) assessment (n=5) rank

PANSS

Positive Syndrome 34.6±2.96 19.8±6.01 − 3.00 2.03* 0.042

Scale

+ 0.00

Negative 69.8±1.92 62.6±6.02 − 3.00 2.02* 0.043

Syndrome Scale

+ 0.00

General 123.6±25.70 95±10.04 − 3.50 1.76* 0.04

Psychological Scale

+ 1.00

SQLS

Psychosocial 41±12.17 13±3.89 − 3.00 2.02* 0.043

+ 0.00

Symptoms 19±11.64 3.6±3.78 − 3.00 3.03* 0.042

+ 0.00

CRI-A

Logical analysis 28.6±3.64 60.8±2.94 − 0.00 2.06* 0.039

+ 3.00

Positive 35±3.74 58±2.45 − 0.00 2.03* 0.042

reappraisal

+ 3.00

Seeking guidance 33.4±6.10 62.6±8.35 − 0.00 2.02* 0.043

and support

+ 3.00

Problem solving 34.4±5.13 61.2±3.83 − 0.00 2.03* 0.042

+ 3.00

+ 5.00

Acceptance or 67.6±3.84 41.4±2.88 − 3.00 2.03* 0.042

rejection

+ 0.00 
*Significant at 0.05 level. “n” - number of participants in each condition; PANSS – Positive and Negative Syndrome Scale;
SQLS – Schizophrenia Quality of Life Scale; CRI-A – Coping response inventory-adult form; SD – Standard deviation

Table 2

The scores on scales during assessments postintervention in patients belonging to experimental group and control
group

Variables Subjects, mean±SD Mann-Whitney U test P

Experimental Control Mean rank U Z

group (n=5) group (n=5)
Experimental Control
group group

FACES

Adaptability 28.6±10.07 9.69±4.33 7.20 3.80 0.000 2.22** 0.001

SQLS

Psychosocial 27.8±13.33 3.6±5.94 8.00 3.00 0.000 2.61** 0.009

Symptoms 13.4±10.03 1.4±5.53 7.90 3.10 0.000 2.5** 0.01

CRI-A

Logical analysis 33±1.34 2.2±7.91 3.00 8.00 0.000 2.69** 0.007

Positive 11±23.58 6.6±8.99 4.20 6.80 0.001 1.36** 0.007

reappraisal

Seeking guidance 26.6±4.56 2.8±5.35 3.00 8.00 0.000 2.62** 0.008

and support

Problem solving 26.8±3.70 3.70±2.60 3.00 8.00 0.000 2.65** 0.008

Acceptance or 26.2±3.56 3.2±3.76 8.00 3.00 0.000 2.61** 0.009

rejection

Emotional 26.4±6.98 8.4±8.32 7.80 3.20 0.000 2.4** 0.01

discharge

**Significant at 0.01 level. “n” – Number of participants in each condition; FACES – Family Adaptability and Cohesion
Evaluation Scale; SQLS – Schizophrenia Quality of Life Scale; CRI-A – Coping response inventory-adult form; SD –
Standard deviation