Journal of Contextual Behavioral Science 7 (2018) 89–96

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Conceptual articles

Using conceptual developments in RFT to direct case formulation and T

clinical intervention: Two case summaries☆
⁎
Yvonne Barnes-Holmesa, , John Boormanb, Joseph E. Oliverc, Miles Thompsond,
Ciara McEnteggarta, Carlton Coultere
a
Department of Experimental, Clinical and Health Psychology, Ghent University, Belgium
b
South London & Maudsley NHS Foundation Trust, UK
c
Department of Psychology, University College London, UK
d
Department of Health and Social Sciences, Faculty of Health and Applied Sciences, University of the West of England, UK
e
North East London Foundation Trust, UK

A R T I C L E I N F O A B S T R A C T

Keywords: The current paper is part of an ongoing effort to better connect RFT with the complexities of clinical phenomena.
Case summaries The paper outlines two broad areas, referred to as ‘verbal functional analysis’ and the ‘drill-down’, in which we
RFT believe the basic theory is showing increasingly direct application to therapy. The paper also comprises two case
Verbal functional analysis summaries in which verbal functional analysis and the drill-down featured strongly in case formulation and
The drill-down
clinical focus. Case 1 involves an adult woman who presented with paranoia, had been diagnosed with psychosis,
and had an extended history of familial and other abuse. Case 2 describes a teenager who had been placed in
foster care, following parental neglect. For comparative purposes and to provide exemplars of similar functional-
analytic processes, both case summaries are presented in a similar format. The article attempts to illustrate how
therapeutic work can be connected to the basic theory and argues that it will be important in future work to
further expand these connections with ongoing developments in RFT.

1. Introduction basic science of RFT (such as those outlined in the current volume or
elsewhere), and indeed the casework described here was conducted
The current paper outlines two general approaches to psy- some years prior to these developments.
chotherapy, which we refer to as ‘verbal functional analysis’ and the We should emphasize that we do not consider what we present in
‘drill-down’, with two case summaries as supporting examples. We the current paper to be ‘new’ or ‘different’ from Acceptance and
present these two approaches here because they have been very much Commitment Therapy (ACT) as it was originally articulated (Hayes,
motivated and directed by our knowledge of, and ongoing research Strosahl, & Wilson, 1999). In some ways what we present here reflects
activity in, Relational Frame Theory (RFT). As such, we believe that how the first author was trained to do ACT. This training commenced in
these two approaches provide good examples of how RFT is showing 1998 before the publication of the first ACT book and in the context of
increasingly direct application to therapy. Before continuing, however, the writing of the first RFT book. At that time, the scientific model for
we think it is important to articulate three caveats to this claim. First, ACT was not the hexaflex, but in many ways, at least from the per-
there is not yet empirical evidence to support the clinical utility of the spective of the first author, it was RFT. It was almost five years later
two approaches we outline, nor to indicate that they are more clinically when the hexaflex was proposed as a model for ACT and, as argued
useful than alternative or existing approaches. Second, the development elsewhere, a drift between RFT and ACT began (Barnes-Holmes, Barnes-
of our ideas is not complete, they are a beginning – but they are at a Holmes, Hussey, & Luciano, 2016). In this sense, what is presented here
stage where we think they are worth sharing, based primarily on dis- is not new, but old. In other words, the original therapeutic model for
cussions with colleagues, clinical supervision, direct work with clients, ACT, at least as it was taught in the mid to late 1990s, was largely
workshops, and as noted above our ongoing research activity. Third, functional-analytic, as applied to human verbal behavior (with “verbal”
these ideas did not emerge directly from recent developments in the redefined, in the behavioral tradition, by RFT). In our view, the

☆
Authors’ Note: The input to this article by the first and fifth authors was supported by an Odysseus Group 1 grant awarded by the Flanders Science Foundation (FWO) to Prof. Dermot
Barnes-Holmes. All potentially identifying information regarding the case material has been removed or altered.
⁎
Corresponding author.
E-mail address: Yvonne.BarnesHolmes@ugent.be (Y. Barnes-Holmes).

https://doi.org/10.1016/j.jcbs.2017.11.005
Received 30 December 2016; Received in revised form 20 November 2017; Accepted 22 November 2017
2212-1447/ © 2017 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Y. Barnes-Holmes et al. Journal of Contextual Behavioral Science 7 (2018) 89–96

relationship between ACT and the ongoing development of RFT, as relational responding, where this appears beneficial. During the course
presented in the current article, has unfolded organically, and what we of therapy, specific verbal stimuli may be identified as participating in
present here is simply an extension of this dialectic between theory and complex relational networks that generate narrow and inflexible re-
practice. sponses. For example, the word “shame” (or more precisely the rela-
We recognize that others have recently attempted to present ACT tional networks in which it participates) may elicit what appear to be
largely in existing RFT terms with little appeal to the hexaflex or any of subtle defensive reactions on behalf of the client, such as turning their
the middle-level concepts contained within it (e.g., Torneke, 2010). face away, putting their head down, and even at times questioning the
And yet others have very recently attempted to directly apply RFT value of the therapy. As a result, the therapist may identify the verbal
concepts to psychotherapy, although they introduced new middle-level stimulus “shame” as having important functional properties for the
terms to RFT itself (Villatte, Villatte, & Hayes, 2015). While there is client's behavior in and beyond therapeutic interactions, and it is these
clearly value in these approaches, and there will obviously be con- broad properties, and the relational networks in which they participate,
siderable overlap in this work and ours, we do believe that we are that the therapist seeks to analyze (i.e., a verbal functional analysis).
developing a different approach to what is expressed elsewhere. Rather Before continuing, it seems useful to outline the two main ways in
than applying RFT as it was articulated in the 2001 book (Hayes et al., which we use verbal functional analysis in therapy. Specifically, 1.
2001) and/or adding new middle-level terms to the basic theory, we are conducting a verbal functional assessment; and 2. helping clients to
attempting to extend RFT to psychotherapy without introducing new verbally track (see below) the sources of behavioral control as a core
middle-level terms. Such an extension is an aspiration to work towards, relational skill.
but we are some way from reaching that aspired goal. Nevertheless, we
felt it appropriate to share where we are at on that journey in the
context of the current volume on conceptual developments in RFT. 3.1. Verbal functional assessment

2. Overview of the current paper Clients often come into therapy asserting themselves to be de-
pressed, anxious, confused, worried, addicted, in marital difficulty, etc.,
The current paper argues that the concept of verbal functional which in a sense they are, because these are exactly the relational
analysis, as well as the drill-down, highlights key ways in which RFT networks that the wider culture has established for, and with, them.
can be used to guide case formulation and intervention in clinical Although categorizing and evaluating oneself in these ways may be
practice. For illustrative purposes, the paper comprises two case sum- painful and distressing, labels such as “depressed” may also have
maries. It is important to emphasize that, at the time of writing, both functions of safety, justification, comfort, and so on. As such, these
cases were incomplete. Hence, our intention is not to present a finished verbal stimuli/responses have appetitive as well as aversive functions.
piece of work or a comprehensive illustration of verbal functional In conducting a verbal functional assessment, we often think in
analysis and the drill-down in action. However, both therapists in- terms of a distinction between less and more aversive relational net-
volved with the cases believed that these approaches offered a valuable works in which the deictic-I1 participates. That is, the less aversive
means of understanding their clients’ problems and directing their networks have dominant approach or S+ functions (similar to moving
clinical intervention in an effective manner. toward something), while the more aversive networks have dominant
For the current paper, we selected two very different, but equally avoidance or S- functions (similar to moving away from something).
complex, cases. Case 1 involves an adult woman who presented with This distinction has some overlap with distinctions suggested by (Polk &
paranoia, had been diagnosed with psychosis, and had an extended Schoendorff, 2014, see also Hayes et al., 1999; Hayes, Strosahl, &
history of familial and other abuse. In contrast, Case 2 describes a Wilson, 2012; Strosahl, Robinson, & Gustavsson, 2012).
teenager who had been placed in foster care, following parental neglect. Now consider a client who comes into therapy with problems sur-
For clarity and comparison, we have structured the case summaries rounding anger. Categorizing himself as “angry”, although itself dis-
along similar lines. That is, both cases comprise: a brief review of tressing, may facilitate avoidance of a more complex long-established
functional-analytic approaches to the topic if available; referral cir- issue, such as fear of rejection. Verbal functional assessment allows the
cumstances; early history; verbal functional assessment; and ther- therapist to separate out the S+ and S- functions of this type of self-
apeutic directions based on verbal functional analyses. Throughout the labeling. For example, “angry” may have more positive emotional
case summaries, we provide specific examples of clients’ own words, functions than “rejected”. Indeed, by describing himself as “angry”, this
therapist statements, and supervisor questions or suggestions. Before client enables himself to avoid the more accurate (functionally
we present the two cases, we will first outline how we define verbal speaking) description of his behavior as involving fear of rejection. To
functional analysis and the drill-down in some detail. simplify using our example, we might refer to ‘angry’ and related self-
evaluations as the S+ networks (with both aversive and appetitive
3. Verbal functional analysis functions), while referring to ‘rejected’ as the S- networks (with largely
aversive functions). Relatively speaking, this makes it possible that the
At this point, we should be clear in defining functional analysis to client's engagement with the S+ networks actually serves to reinforce
mean a basic science or application of that science that focuses on operant avoidance of the S- networks. In therapy, we use verbal functional as-
contingencies and behavioral principles more generally in attempting to both sessments to guide our first steps toward dealing with the S+ (e.g.,
assess and treat maladaptive behavior. In contrast, a verbal functional angry) networks, because clients engage with these more readily, and
analysis focuses on the functions of stimuli and responses that possess thus the therapist's move in this direction will seem less confronta-
properties defined as verbal within RFT. In conducting a verbal func- tional. We are nonetheless cautious that engagement with S+ networks
tional analysis, we typically, but not necessarily, operate at the level of likely continues to facilitate avoidance of the S- networks.
complex relational networks, rather than specific relational frames. Of We then orient much more carefully toward the S- networks, where
course, specific instances of framing may be of particular clinical in- client defense and challenges to the therapeutic relationship are most
terest (the case summaries contain examples) that may need to be likely. In order to harness the behavioral ‘momentum’ previously es-
targeted directly. In our experience, however, conducting verbal func- tablished in the therapeutic interactions surrounding the S+ networks
tional analyses of relational networks and their functions generates a
sound working understanding of a client's behavior. Working at the 1
We use the term deictic-I to refer to the verbal self which emerges from a history of
level of relational networks also appears to offer direction on how these arbitrarily applicable relational responding that typically involves learning to respond
networks can be altered to create broad and flexible repertoires of appropriately to self-referential terms (e.g., “I”, “myself”, “me”).

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(during the verbal functional assessment), the therapist uses verbal

functional analyses to establish causal or if-then relations between these
two sets of networks. Returning to the example above, the therapist
might say something like, “Being angry must make it hard for people to get
close to you”. For the client, this statement relates the S+ and S- net-
works for the first time, perhaps facilitating a transfer of the less
aversive functions of the ‘angry’ networks to the more aversive (‘re-
jection’) networks, in so far as the client becomes more willing to talk
about rejection. To further this move, the therapist might say, for ex-
ample, “What if rejection lay at the end of this line of anger? How much
more angry will you get if you push loved ones away? What if being angry
could cause this to happen? If you had to choose between being angry and
being rejected or alone, which would you choose?” Fig. 1. Verbal tracking of the sources of control over behavior.
Overall therefore, the primary purpose of verbal functional assess-
ment is to identify verbal stimuli or responses that participate in spe- herself “I feel angry today, I’m not sure for now where this is coming from,
cific relational networks for the client that possess, broadly speaking, so I must be careful not to take it out on my partner, but perhaps we could
approach and avoidance functions. Doing so facilitates establishing a talk about it together”.
strong therapeutic relationship that allows the therapist to focus on In establishing verbal tracking of the causal relations between the
issues that may be highly sensitive for the client, and which if broached emotional reactions of the deictic-I and other relational networks (e.g.,
too early in therapy could undermine the relationship. In a more gen- a bad day at work), it also appears to be essential that these two sets of
eral way, getting the client to engage with issues they have tended to networks come to participate in a hierarchical relation (e.g., recogni-
avoid is important for moving toward building the psychological flex- tion that a bad day at work is just one of the many things that can
ibility required for what we describe in the next section as verbally happen to the deictic-I). Specifically, the networks of the deictic-I
tracking sources of behavioral control. should contain the networks that relate causally to ongoing behavior. In
simple terms, this enables the deictic-I to choose when, where, and with
3.2. Verbally tracking sources of behavioral control as a core relational skill whom to behave in a particular manner. In the example above, the
client could choose when to talk to her partner about her feelings and
We believe that an individual's ability to verbally track,2 in an ac- when not, because some of these emotional experiences relate to him
curate and ongoing manner, the sources of control over their own be- directly and some do not. In this way, the therapist, using verbal
havior (internal and external) is foundational in establishing what we functional analyses, aims to build broad and flexible relational re-
loosely describe as a sense of self. This overlap between behavior and pertoires with respect to choosing, so that the client (the deictic-I) is not
the sources of control is illustrated in the intersection between the a victim of capricious contextual variables, but gains a sense of control,
circles in the Venn diagram in Fig. 1. Using more technical language, if not over her environment, but over her reactions to it (for empirical
we would say that clients show deficits in the ability to relate the analyses of hierarchical relational responding, see Foody, Barnes-
deictic-I, and the relational networks in which it participates, to the Holmes, Barnes-Holmes, & Luciano, 2013; Foody, Barnes-Holmes,
networks of events that functionally relate in some causal manner to the Barnes-Holmes, Rai, & Luciano, 2015; Gil, Luciano, Ruiz, & Valdivia-
deictic-I itself. Salas, 2012; Gil-Luciano, Ruiz, Valdivia, & Suárez, 2016; Luciano,
Consider an individual who feels angry after a bad day at work and Rodríguez, Mañas, Ruiz, & Valdivia-Salas, 2009; Ruiz, Hernández,
tells herself on such occasions that this is her partner's fault for not Falcón, & Luciano, 2016; Törneke, Luciano, Barnes-Holmes, & Bond,
providing her in general with the life she wanted. This client's state- 2016).
ment, for example, “I’m angry and it's all his fault” shows limited verbal
tracking in that she does not seek to determine the more immediate
cause of her anger on that occasion (i.e., a bad day at work). Indeed, 4. The therapeutic relationship: the drill-down
perhaps for this client, most of her negative emotional reactions parti-
cipate in hierarchical relations with her partner (most are attributed to At this stage, it seems important to emphasize that conducting
him), and this strategy on her behalf has also led to a sense of lack of verbal functional assessment and analyses typically involve building a
agency regarding directions she wants for her own life (e.g., she may strong therapeutic relationship, which should form a part of verbal
say “he stops me from doing things I want”) and feelings of resentment, functional analysis itself. For ease of communication, we cover this
inadequacy, and frustration. As a result, the client persists in keeping all feature of therapy in a separate section, and use the metaphor of the
of these emotions to herself, rather than sharing them with her partner. drill-down to describe the therapeutic behaviors involved in this
The therapist might engage with this client in a verbal functional strategy.
analysis of these ongoing emotional experiences by exploring the range The therapeutic aims of the drill-down involve building increasingly
of possible labels (including “anger”, “resentment”, and “frustration”) strong repertoires of relational responding between the deictic-I and
and the relational networks in which these participate. Ideally, therapy what we describe as deictic-Others (i.e., loosely speaking, teaching the
would lead to the client, in a similar situation, being able to say to client to improve their perspective-taking skills). Developmentally, the
deictic-I is established in a shared and highly cooperative context in
which significant others literally construct this verbal sense of self, with
2
In using the term verbal “track” or “tracking”, we are not invoking the concept you and for you. Very young children, for example, often fail to dis-
“tracking” as a type of rule-governed behavior, as described in Hayes et al. (2001).
tinguish themselves verbally from others, but gradually through verbal
Instead, we use tracking to refer to a client's ability to monitor the way in which their own
behavior, including thoughts and feelings, is influenced by ongoing events in their en- contingencies, they learn to talk about themselves as separate psycho-
vironment. In this sense, tracking may be interpreted as broadly similar to what Villatte logical entities, with private psychological worlds. When this ‘shared’
et al. (2015) refer to as “context sensitivity” (p. 53). We should add that we find neither and ‘cooperative’ context with significant others in childhood contains
concept (tracking or context sensitivity) entirely satisfactory and anticipate that we will
high levels of what we call relational incoherence, the relationship
replace “tracking” in due course by appealing to the dynamics of arbitrarily applicable
relational responding, as articulated in a multi-dimensional, multi-level framework (i.e.,
between the deictic-I and deictic-Others, almost by definition, becomes
the MDML) presented in the current volume (Barnes-Holmes, Barnes-Holmes, Luciano, & unstable, unpredictable, and discontinuous (see Kohlenberg & Tsai,
McEnteggart, in press). 1991 for a similar approach on the formation of ‘problematic selves’).

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For example, imagine a child who is told at one moment that she is located HERE-NOW to the deictic-I located THERE-THEN.
loved and cherished by her parents and is then abandoned by them Metaphorically speaking, the therapist is taking the client by the hand
when they go on an alcoholic binge for days on end. Verbally, the re- and sharing with them how it is possible to talk about the deictic-I in
lations among the deictic-I HERE and NOW are, by definition, rendered different ways. The therapist may achieve this by coordinating the
unpredictable and discontinuous in the sense that the “I” who was loved therapist's deictic-I and the client's deictic-I (both located HERE and
and cherished in one place and time was subsequently abandoned. NOW), so that they, metaphorically speaking, share their perspectives
When the coherence among the three elements of the deictic-I (I-HERE- in a cooperative way on the client's deictic-I as located THERE and
NOW) is weakened in this way, the extent to which it can be used as a THEN. All events, including the client's deictic-I located THERE-THEN
superordinate locus from which to relate hierarchically with all of the now become, if only momentarily, an ‘it’, an ‘event’, or a ‘something’,
child's psychological events is severely undermined. In other words, for that is separate from both the client and the therapist as coordinated
the I to function as a constant locus, from which to view one's psy- deictic-Is located HERE-NOW. In other words, the client and therapist
chological world, it must develop in a relationally stable and consistent sit together and develop a perspective on the client's sense of self as an
environment. Critically, the absence of this type of environment may event or object that can be observed and talked about, in a variety of
also fail to establish a deictic-I that is clearly verbally distinct from ways.
others. The individual who grows up in this type of environment may As argued above, the drill-down is intertwined with verbal functional
literally state in therapy years later “I have never really known who I am”. analyses. Specifically, the drill-down focuses on relational processes
For the client, this is not rhetoric or metaphor. This very statement is in that appear to be central to what is often called the therapeutic alliance
the broad functional class of verbal relations in which they were raised (see also Kohlenberg & Tsai, 1991). For us, the drill-down metaphor
as children. works as a way of describing how we use the therapeutic relationship to
When an individual grows up with a verbal history in which the ‘dig deeper’ in a verbal functional sense into the self (we often say
relationship between the deictic-I and deictic-Others involved high le- “drilling down into the deictics”). For example, a verbal functional
vels of relational incoherence, the distinction between I-HERE-NOW assessment might identify ‘shame’ as a critically important verbal sti-
and OTHERS-THERE-THEN may fail to emerge (McEnteggart, Barnes- mulus for a client. In doing so, verbal functional analyses allow the
Holmes, Dillon, Egger, & Oliver, 2017). We have argued that the out- therapist to assess the therapeutic relationship itself. A concrete ex-
come of such a history may manifest itself in numerous ways. For ex- ample of this might involve the therapist asking the client if they are
ample, a client may literally hear their own thoughts as the voices of willing or ready to explore the impact that the word “shame” has on the
others that are not actually present. Alternatively, clients may self-cri- client when uttered by the therapist. An affirmative response from the
ticize using the phrases, and even the tone of voice, that their neglectful client sets the scene for further verbal functional analyses. For example,
or abusive parents employed decades ago. Relationally, the voices and the therapist might sit next to the client and say “If I was you, I would
behaviors of others that were THERE and THEN are experienced as if have shame too”. The important point to recognize here is that verbal
they are HERE and NOW. Any attempt, in this type of context, to es- functional analyses and the drill-down are dynamical in that they
tablish the deictic-I as a constant and separate (from others) locus should ebb and flow with each other in the course of therapy.
would be difficult. We fully recognize that training therapists to master the highly
Our core argument is that the therapist needs to establish with the dynamical interplay between verbal functional analysis and the drill-
client a therapeutic relationship that provides the predictability and down may be challenging. In line with RFT itself, it seems that an ap-
consistency (i.e., relational coherence with respect to the deictic-I) that propriate method for successful training in this regard is to provide
were absent with significant others. This commences, in a sense, with multiple exemplars of case supervision that involved this dynamical
the therapist attempting to provide the highly shared and cooperative interplay. In the second half of the current paper, therefore, we present
verbal context in which a clearly distinct deictic-I is gradually estab- two such exemplars (i.e., case summaries).
lished. This strategy is perhaps paradoxical because it starts by co-
ordinating the deictic-I (the client) with the deictic-Other (the thera- 5. Supervised case summaries
pist). For example, a therapist at this point might say phrases like “I can
completely understand that”, “If I were you, I would have done exactly the This latter half of the paper comprises two case summaries in which
same”, “I can see how lonely you must feel”, and “Anyone in your situation, verbal functional analysis and the drill-down featured strongly in case
would react that way”. This can be a highly challenging therapeutic formulation and clinical focus. At the time of writing, both cases were
context for the client, but also for the therapist. It is challenging for the incomplete, but the focus on the two key strategies is clear.
client because many of the overarching functional classes of behavior
(such as disclosing private events, being vulnerable, accepting another 5.1. Case summary 1: adult with paranoia
person's perspective and potential disapproval) that were present in
perhaps a highly aversive and threatening family environment may be 5.1.1. Functional-analytic approaches to paranoia
evoked in therapy. It is challenging for the therapist because they must Recent approaches to paranoia, from a functional-analytic per-
provide the stable, consistent, and reliable relationship that the client spective (e.g., Stewart, Stewart, & Hughes, 2016) and within ACT (e.g.,
missed out on to this point. Indeed, experienced therapists are often Oliver, Joseph, Byrne, Johns, & Morris, 2013) have focused on suf-
noted for their abilities to ‘absorb the perspectives of their clients’ in a ferers’ reactions to their own experiences. For example, there is evi-
rich and full way (i.e., without pulling back, or being reactive or de- dence that experiential avoidance mediates, at least in part, the re-
fensive). In a sense, the therapist seeks to establish specific contextually lationship between early developmental experience and paranoia
controlled coordinate relations that always remain relationally co- (Udachina, Varese, Myin-Germeys, & Bentall, 2014). In short, the im-
herent between the client's deictic-I and the therapist's deictic-I, the pact of a paranoid experience may depend upon how the individual
purpose of which is to build trust and a sense of safety for the client in reacts to it, such that attempting to avoid the experience potentially
the therapeutic relationship. We are not suggesting that there is full makes its occurrence in the future more (rather than less) likely, more
coordination between I and Others (therapist and client). Rather, the frightening, and more believable.
therapist must, to some extent, see what the client sees, feels, etc., but
always within the context of hierarchical relational responding from the 5.1.2. Referral circumstances
therapist's deictic-I. Marie was in her mid-40s when she first attended a community
Central to the therapeutic relationship is the establishment of a psychosis service in the United Kingdom (UK). She was referred after a
relational repertoire in which the client learns to relate the deictic-I brief hospital admission for anxiety and paranoia experienced in public.

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She reported frequent threatening “incidents”3 in which members of the family (especially Marie) all feared this individual who was extremely
public (usually male) looked at, or gestured to her in an unusual or punitive and controlling. She recalled a number of harsh and cruel in-
ambiguous manner. These events made her feel extremely anxious and cidents between the grandfather and various family members, against
she typically responded by leaving the situation or occasionally con- which both of her parents seemed powerless.
fronting the individual. The perception of these incidents commenced These childhood family circumstances contrasted sharply with early
several years earlier following a burglary at her apartment, and a adulthood when Marie went to university against her parents’ wishes
mugging against her that occurred shortly thereafter. Because of her (at that time in the UK attendance at third-level education was entirely
anxiety and hypervigilance to threat cues in public, Marie had become supported by the State). This was a significant period in her life when
isolated and withdrawn, with only sporadic contact with several friends she flourished and enjoyed a very active social life. During this period,
and with her family who lived in a different city. she was able to renegotiate aspects of her relationship with her parents
Marie concluded that the various incidents represented an orga- and became much closer to her mother, although they did not speak at
nized conspiracy (among local men, including a particular neighbor) to that time about her painful early experiences.
threaten, imprison, or kill her. Although puzzled by this possibility at
first, she concluded across time that the conspirators must see her in an 5.1.4. Verbal functional assessment
extremely negative light, such as depraved, like a “witch or a pedophile”. Our aim in this section is to illustrate the verbal functional assess-
She believed that drawing attention to herself in public always led to ment undertaken with Marie and how we used this to conceptualize her
this type of negative perception of her by others. For example, on a case in a manner that would then facilitate therapeutic intervention
recent bus journey, Marie experienced a sexual response to the close including ongoing verbal functional analyses and the drill-down.
presence of a teenage girl. Because she caught the girl's eye, Marie
immediately became fearful that other teenagers nearby believed her to 5.1.4.1. Inability to verbally track sources of behavioral control. At the
be a “predatory lesbian pedophile”. beginning of therapy, Marie was almost completely unable to verbally
After events such as those concerning the teenager on the bus, Marie track the sources of control over her behavior. For example, she
typically withdrew from going out in public for an extended period in reported that she didn’t like older men who wore dark glasses, but
an attempt to protect herself and to try to make sense of these experi- could not explain why. In a sense, Marie was highly emotionally
ences. These periods of withdrawal were associated with low mood, and unstable and reactive, but was often confused about the source of
difficulties in maintaining social contacts and routine activities, parti- these emotions.
cularly employment. This pattern culminated in her quitting her local
government job to go travelling for several months. During her travels, 5.1.4.2. Multiple deictic-Is. Marie's inability to verbally track the
her mood improved and her anxiety lessened, but upon her return, her networks that controlled her behavior appeared to perpetuate the
perception of threatening incidents recurred and rendered her unable to lack of an overarching sense of a unified self. Indeed, after some time
look for work. During this period, she felt extremely low and isolated, in therapy, it appeared that she vacillated from one pattern of deictic-I
and this eventually precipitated her hospital admission. responding to another (hence, these were not organized into
Marie described a deep sense of loneliness and despair as her si- overarching coherent relational networks). In short, verbal functional
tuation seemed to worsen. She could not see how to prevent further analyses appeared to reveal what we referred to as two largely separate
psychological deterioration or social isolation, or to move herself for- networks of deictic-Is.
ward in life. Specifically, she felt utterly worthless at being single and The first deictic-I relational network we labeled as ‘deictic-I as
unemployed, and worried a great deal about her family's critical jud- victim’. In this, Marie perceived herself to be a victim of a threatening
gements of her in these regards. At times, she also felt “disgusted” with plot by (mostly older) men in her vicinity. For this deictic-I, Marie's
herself and recalled similar feelings from her early childhood. actions were strongly controlled by paranoia and fear, which she ‘dealt
Her goals for therapy were to develop coping strategies to manage with’ by concluding that she deserved the violent reproaches of others.
the anxiety associated with threatening incidents. She wanted in time to Although elements of this deictic-I network were aversive, other ele-
return to work and increase her circle of friends. Although she seemed ments were appetitive because it explained for Marie her fear of others
highly convinced of the reality of her experiences, her help-seeking and need for withdrawal in the interests of self-protection, hence no
behavior suggested some variation in her levels of conviction in this confusion was experienced in how she should act in a given situation,
regard. nor in terms of how others were perceiving her (i.e., she was sure they
were horrified by her).
In contrast, the second deictic-I was judgemental, negative, harsh
5.1.3. Early history
(e.g., “I am”… “worthless”, “weak”, and “bad”), and even extreme (“I’m
Marie was born in a rural area in Asia. She had two older brothers.
depraved”). In this network, Marie perceived herself as a type of dan-
Although she described her parents as uneducated and very traditional,
gerous perpetrator (a “pedophile”) who posed a risk to others (this is
the family emigrated to the UK for stable factory work when she was
how she described the incident with the teenage girl on the bus). Hence,
aged two. Here, they continued to live within a tightly-knit Asian
when responding as ‘deictic-I as perpetrator’, Marie reacted to deictic-
community with similarly-employed families. Marie's relationship with
Others (especially young females in close proximity to her) as her po-
her parents was distant and one in which she felt “unrecognized”. She
tential ‘victims’. Verbal functional analyses suggested that, for Marie,
recalled childhood incidents that confirmed her lack of value to them
this was the less aversive deictic-I network because Marie talked about
and contrasted starkly with the value they placed upon her brothers.
herself in this way regularly and openly. It is also important to em-
She broadly recognized as an adult that elements of this differential
phasize that when Marie was responding as deictic-I as victim, there
treatment were cultural.
was an almost complete lack of transfer of functions from this network
Marie's early enjoyment of various activities and sports also con-
to the deictic-I as perpetrator network, or vice versa. More informally,
trasted with her parents’ narrow perception of her primary domestic
there appeared to be no relationship at all between the two deictic-Is.
duties, especially looking after familial males. She recalled that her own
Hence, it was practically impossible, early on, for the therapist and the
needs were disregarded and that she felt “like a piece of furniture, rather
client to track the contextual variables that determined the almost
than a person”. In addition, her family was heavily dominated by her
complete dominance of one deictic-I network over the other.
grandfather, who was also influential within the wider community. The

5.1.4.3. Vulnerability in relating deictic-I as victim-HERE and NOW with

3
Speech marks indicate client's own words throughout. deictic-I as victim THERE and THEN. As noted above, Marie's deictic-I as

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Y. Barnes-Holmes et al. Journal of Contextual Behavioral Science 7 (2018) 89–96

victim appeared to have appetitive functions (because as a victim she experienced shame or paranoia that others had detected her perceived
knew how to behave). On balance however, she was unable to verbally guilt. For example, after the bus incident with the teenage girl (de-
track the influence of her childhood trauma on her current paranoia. scribed earlier), we explored the numerous possibilities of how the girl
Thus, the therapist made statements such as: “It seems to me that you are and her friends perceived the experience. The therapist then discussed
just as much a victim now as you were when you were young”. More the fact that Marie could choose to act based on her own choices and not
technically, the aim was to establish a deictic-I as victim THERE and based on the many possible interpretations others could have had about
THEN that was causally related to the deictic-I as victim HERE and their experiences with her.
NOW. Marie reacted negatively to these statements and indicated that Having begun to explore both deictic-I as victim and deictic-I as
she felt highly vulnerable, unsafe, and unsure about how to react. She perpetrator, we started to establish distinction relations between these
tended, by contrast, to focus heavily on the injustice of her past trauma. two as a move towards ultimately establishing hierarchical responding
It became clear at this point that therapy needed to focus on the over both networks. Consider the following statement suggested to the
therapeutic relationship in terms of coordinating Marie's deictic-I as therapist during supervision, and designed to relate the two networks
victim HERE and NOW with the therapist's deictic-I HERE and NOW, in for the first time.
approaching Marie's deictic-I as victim THERE and THEN. The reader
I can see how you can feel like a wicked perpetrator in one moment and
should note, therefore, that sometimes when working with S+
yet be frightened and victimized the next.
networks (in this case, Marie as victim), important aversive elements
may be identified unexpectedly and thus, as mentioned earlier, the When verbal tracking of the sources of control over Marie's behavior
therapist needs to ebb and flow between verbal functional analyses and as both deictic-I as victim and as perpetrator was established, the
the drill-down. therapist began to focus specifically on contexts that facilitated
‘switching’ from one deictic-I to the other. Only by doing so, could the
5.1.5. Therapeutic directions based on verbal functional assessment therapist create a singular overarching hierarchical deictic-I who could
5.1.5.1. The drill-down. In establishing the therapeutic relationship, the choose to act. This was achieved by asking Marie across several sessions
therapist focused continually on providing Marie with a safe, highly to identify which deictic-I was dominant: presently, five minutes ago, at
shared, and cooperative therapeutic environment. Marie appeared to the beginning of the session, yesterday, etc. We explored many such
find this emphasis on safety and sharing with a male therapist highly exemplars, including the numerous functions attached to each of the
challenging to begin with. Nevertheless, the target in therapy was to two deictic-Is. Indeed, the therapist identified several points in session
gently coordinate Marie's deictic-I with the therapist's deictic-I, using when Marie appeared to “switch” from one deictic-I to the other. For
many, many phrases, such as “I can completely understand that” and example, when discussing how Marie's potential victims are not real
“That sounds terrifying”, even when discussing Marie's more paranoid victims (because she never had, and in her own view never could, ac-
perceptions (i.e., the conspiracy against her). Consider the following tually inflict harm on another human being) Marie would often
statements discussed in supervision as a format for the drill-down. “switch” from perpetrator to victim. The therapist discussed these
switches openly, and highlighted for Marie ways in which she could
If I were you in such a situation, I would have felt utterly alone, un-
respond hierarchically from a stable and consistent deictic-I that could
wanted, and unloved. I'd like you to help me understand this here. I want
track the ‘switching’ itself, without either network controlling her be-
to get a sense of the things you say about yourself to yourself. I'm so glad
havior. At the time of writing, therapy continued with Marie in working
you told me. That must have been so hard. It's so good to share this kind
towards establishing a stable and consistent deictic-I that contained the
of thing. Notice that I am still here, and sharing this is OK.
two deictic-I relational networks that we have labeled ‘victim’ and
In working on the therapeutic relationship, the therapist sought to ‘perpetrator’.
coordinate Marie's deictic-I as victim HERE and NOW with the ther-
apist's deictic-I HERE and NOW in order to establish a causal relation 5.2. Case summary 2: minor in care
between Marie's deictic-I as victim HERE and NOW and deictic-I as
victim THERE and THEN. More informally, the purpose was to help 5.2.1. A functional-analytic approach to children in care
Marie to learn to verbally track the influence of past trauma on current ‘Looked after children’ (LACs) are removed from their familial homes,
paranoia. In this particular case, the therapist first focused on co- at least temporarily, and placed in care (Department for Education,
ordination between the two deictic-I as victim networks (HERE and 2015), and many are also categorized as needing protection from ne-
NOW and THERE and THEN), with many questions such as “You must glect (Bentley, O’Hagan, Raff, & Bhatti, 2016). Numerous treatment
have been so lonely as a child? You must still be so lonely now?” This initial paradigms have attempted to address the emotional and behavioral
focus on coordination was necessary because Marie found it difficult to difficulties that accompany living in care, and some of these appear to
even see a connection between these two aspects of deictic-I as victim, be functional-analytic in orientation (e.g., Prather & Golden, 2009), but
and thus it would have been difficult to move on to causality and verbal at the time of writing the ACT literature on working with children in
tracking. Indeed, this focus on coordination marked a critical turning care was limited (but see Hayes & Ciarrochi, 2015).
point in therapy and greatly facilitated Marie in learning to verbally
track the influence of her past trauma on her current paranoia. 5.2.2. Referral circumstances
Thereafter, the therapist was quickly able to establish a hierarchical Charles was 15 years old when he was referred to a local child and
relation with regard to deictic-I as victim, such that Marie could choose adolescent mental health service in the UK. The referral resulted from
to act even when she felt paranoid and victimized (e.g., by encouraging the teenager expressing thoughts of self-harm and suicidal ideation to a
her to leave the house to get shopping even when she had seen a schoolteacher, and the school raising broader concerns about the
neighbor who she perceived to be threatening in the street earlier that teenager's care. As part of the Local Authority's subsequent investiga-
day). tion, Charles allegedly stated that he should be taken into care because
Once verbal tracking in deictic-I as victim networks was established, his mother's substance misuse rendered her unable to care for him.
the therapist began to explore the more aversive deictic-I as perpetrator There were reports that his biological mother had been a ‘functioning’
network. Therapy focused on enabling Marie to verbally track the opiate user for 20 years, and that his father experienced substance
variables that evoked perpetrator-related behaviors (e.g., when a misuse and mental health issues. Following the investigation, Charles
stranger's glance was interpreted as suspicion that she may be a pedo- was placed on a Child Protection plan under the category of neglect,
phile). The therapist then introduced elements of hierarchy by ex- and his mother agreed to a voluntary placement order with a foster
ploring ways in which Marie could choose to act even when she carer. He lived predominantly with a highly experienced foster mother,

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but continued to see his biological mother on a weekly basis. At the our previous examples, the drill-down thus involved gently co-
beginning of therapy, Charles had been in care for eight months. The ordinating Charles’ deictic-I with the therapist's. This was bolstered by
lead therapist who undertook the therapeutic work with Charles be- some non-specific disclosing by the therapist and statements such as
came involved as part of the local authority referral to the Child and those below which were discussed in supervision.
Adolescent Mental Health Service. Additional information was made
If I was in your shoes right now, having experienced all that you have
available from Charles’ key worker and an adolescent psychotherapist's
gone through, I would also be feeling the same way. I can see that this is
report highlighting key issues. The therapist conducted a total of seven
so difficult for you. I can see the pain on your face. No-one seems to be
sessions with Charles’ in his role within the Child and Adolescent
really listening to your views. People are offering you solutions, giving
Mental Health Service.
you advice, but I promise, in here, I will totally listen to your views. I
know when things have been out of control in my own life, I find them
5.2.3. Early history
very scary. But it also makes me incredibly angry, and I often don’t know
Part of the local authority investigation queried the possibility of in-
why I’m angry, I just know that I am angry and I can’t see how it would
utero brain damage resulting from maternal drinking and heroin use,
be any other way.
but there was no medical evidence to support this. In addition, there
was no evidence of developmental disability or delay. Charles’ biolo- During the drill-down, using the types of statements above, Charles
gical mother reported that he had been head-banging since birth, and started to cry, but did not become angry. As a result, the therapist
wore a helmet to prevent injury. However, no head injuries or loss of gently introduced the word “vulnerable” and it immediately became
consciousness had been reported. clear that the functions of the word were extremely aversive. Indeed,
Charles is an only child. His parents apparently separated when he when the word was first introduced, Charles quickly fell asleep, thus
was eight years old, although he could not recall ever living alone with literally avoiding the therapeutic interaction. Initially when this oc-
his parents as a family unit. He subsequently described moving home curred, the therapist allowed Charles to sleep for around 20 min before
often. He had lived with both sets of grandparents at various stages, but gently waking him.
finally lived alone with his mother when he was 13. He had always had
close proximity to extended family on both sides. Charles’ mother was
5.2.4.2. Vulnerability in relating deictic-I HERE and NOW with deictic-I
described as “quiet”. Although reported as a somewhat neglectful
THERE and THEN (future). As noted above, the relational network
parent, Charles emphasized that she “respected my space”. He spoke very
containing ‘anger’ appeared to have appetitive functions, but the
rarely of his father, occasionally describing him as “a nobody”.
network in which ‘vulnerability’ participated had predominantly
Charles’ paternal family were of mixed Asian heritage, although
aversive functions. The therapist used the drill-down to gradually
Charles had spent all his life in the UK. The maternal grandfather is
decrease avoidance responses to ‘vulnerability’ by focusing initially
believed to have long-standing involvement with organized crime and
on ‘anger’. In doing so, Charles talked at length about the future (e.g., “I
had a dominant role in the family. Charles’ father was also reportedly
can’t see my future will ever be happy”, “I watch films and see happy endings
involved in organized crime as a result of involvement with his ‘father-
and wonder whether that will be for me”, and “I look at Facebook and see
in-law’. Charles’ maternal uncle frequently collected him from his
friends from the past looking really happy and I envy them. They are at the
mother's house, drove him around, and gave him money and gifts, all of
next level [of life's game] whilst I am stuck on this [unhappy] level. I wish I
which were referred to by Charles as among numerous “family secrets”.
could be like them”). The therapist interpreted this as avoiding the
For example, Charles’ mother forbade him from telling his father's side
aversive functions of vulnerability in the present by focusing on the
of the family that he was in care (hence, he could not be driven home by
future. In the ebb and flow between verbal functional assessment and
them to the foster home).
the drill-down, the therapist used statements such as the following, as
discussed in supervision, to help undermine avoidance of the present by
5.2.3.1. School. There had been sporadic school reports that Charles
focusing on the future.
head butted and punched walls, usually after being teased by peers.
Several such incidents were reported shortly before he was placed in What I often notice when you come into our sessions is that life is tough
care. Charles appeared to be managing academically. However, given for you at the moment. You seem tired and you see others as having it
that academic success is highly valued in his familial culture, he felt much easier. Perhaps most do at present. I noticed that you were
ongoing pressure in this regard (he stated that he was the most “stupid” speaking about how you watch a film, and there always seems to be a
of his cousins and was “not good at maths”). On balance, he liked happy ending, and I see how you compare yourself with this. Yet here you
creative activities and recognized his own achievements in drawing, are now, coming to talk to me about these frustrations, opening up to me,
art, and cooking. He reported feeling culturally isolated at his school, a someone you don’t really know. I also see that despite all this, you are
sense of loneliness that was exacerbated by being in care. still going to school now.

5.2.4. Verbal functional assessment

5.2.4.1. Inability to verbally track sources of behavioral control. The 5.2.4.3. Relating his biological and foster mothers as deictic-
deictic-I relational network for Charles was coordinated strongly with Others. Having helped Charles begin to talk about both anger and
being in care. Being in care had many negative evaluative functions and vulnerability, thereby undermining the avoidance functions of these
these functions transferred to the deictic-I in the sense that Charles stimuli in the present (i.e., for the deictic-I HERE and NOW), the
would say “Only bad stuff can happen to me because I’m in care”. therapist continued to focus on both (anger and vulnerability). This
Critically, however, Charles showed little verbal tracking of the strategy was adopted because Charles started to talk for the first time
impact of these negative evaluative functions on his behavior. For about his biological mother (whom he refused to talk about initially). In
example, he did not connect his aggressive outbursts at school to being spite of her neglect, Charles spoke positively about his biological
in care. mother (e.g., he continually emphasized the fact that she “gave me
Early in the verbal functional assessment, it became clear that the space”), and yet he spoke harshly about his foster mother who provided
more appetitive relational network for Charles involved anger (i.e., him with a warm, caring environment (“I can't cope with the current
toward himself and others, particularly adults), hence the therapist situation. This is worse than the drug stuff. [I’d] rather be in a family hunted
strenuously steered away from adult-like instructive or pedantic dialog. down by gangs than be in this house”). This issue concerning the two
This was often done with questions such as “You tell me what you think?” maternal figures was explored in supervision and the following
and I’m not sure about that, what would you say about it?” Consistent with questions were posed to the therapist to consider.

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change the therapists experienced in both clients, and the clinical

How does he describe the key relationship with his mother? What does he
precision offered by these RFT-based concepts.
say about his relationship with the foster mother? It seems as if he
somehow connects the two mothers together? Is there any sense in which
References
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attentive the foster mother is, the more he rejects her?
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Subsequent verbal functional analyses during therapy indicated that theory: Finding its historical and intellectual roots and reflecting upon its future
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