Review: Mastering the Clinical Conversation: Language as Intervention Villatte, M.

,
Villatte, J. L., & Hayes, S. C. (2015). New York, NY: The Guilford Press.

Yvonne Barnes-Holmes, Deirdre Kavanagh, Dermot Barnes-Holmes, Martin Finn,

Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium,

Authors’ Note
Correspondence should be addressed to Deirdre Kavanagh, Experimental-Clinical and Health
Psychology, Ghent University, Ghent, Belgium, Deirdre.kavanagh@ugent.be

Acknowledgements
The current manuscript was prepared with the support of the FWO Type I Odysseus
Programme at Gent University, Belgium

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 At the outset of our review, we would like to be open about our aims in taking the time

to study and publicly review Mastering the clinical conversation: Language as Intervention.

First and foremost, we have the utmost respect for the three authors and we applaud their

efforts to begin to illustrate to clinicians the potential benefits in applying Relational Frame

Theory (RFT) concepts to therapeutic contexts. This endeavor comprises issues that have

drawn our own attention, conceptually, empirically, and therapeutically for at least the last

five years. However, we do not believe that the conceptual or empirical work in RFT is, at the

present time, adequately developed to make a compelling case that understanding and

applying RFT will enhance clinical work. In truth, we believe it can, we see this often in our

clinical work, workshops, and clinical supervision. On balance, and critically, we know this is

speculation and we believe a case could be made that a book-length articulation of the

application of RFT to clinical work was perhaps a little premature, and lagged behind the

necessary conceptual and empirical advances that we feel are needed. In making this

argument, we are conscious that it could serve to exacerbate the long-standing divide between

basic researchers and clinicians, but that is not our intention. Rather, our purpose is to

promote an open dialog on the extent to which RFT can genuinely at this point contribute

meaningfully to therapy. Critically, this means that RFT ‘experts’ need to be open and honest

about the limitations of RFT as it currently stands, and to avoid potentially ‘over-selling’ the

theory to clinicians.

To put our concerns into the context of what was stated in the original (2001) RFT

text, consider the following quote that appears at the end of Part I before the book transitions

into the more speculative Part II: “if arbitrarily applicable relational responses themselves

modify how behavioral processes work, then even the most basic behavioral preparations

with human beings need to be reexamined and reconsidered. In Part II we will begin to do

some of that work, but in truth it would take dozens of laboratories many years to do what is

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needed. It is not clear that this will happen, but from the point of view of Relational Frame

Theory it is clear that it needs to be done.” (Hayes, Barnes-Holmes, & Roche, p. 154). In our

view, some of this work has been done in the intervening years, but it would be difficult to

claim that there have been dozens of RFT laboratories working relentlessly on all of the issues

that need to be addressed to mount a genuinely compelling version of so-called ‘clinical

RFT’. On balance, the authors of Mastering the clinical conversation could argue that there

was value in extrapolating from the current knowledge base in RFT in the way they have done

in the book, as part of the over-arching strategy of basic-applied reticulation within the

Association for Contextual Behavioral Science (ACBS). This, of course, will remain a matter

of opinion and the purpose of the current review is to encourage debate among those with

opinions on this issue.

Aims of the Book as Outlined by the Authors

The authors argue that the literature currently lacks a theory of language that illustrates

how language can be manipulated in the service of therapeutic benefit. Specifically, they

believe that what is needed is a “conceptual toolkit that can cast a useful light on clinical

problems and guide and empower practitioners from all therapeutic traditions” (p. 3). It is

their belief that this toolkit must “explore and explicate principles” of language (p. 5).

Furthermore, their aim is “to extend some of the implications of … relational frame theory,

into the normal work of psychotherapy” (p. 357).

Short Summary of the Book

The book contains 10 chapters. The first two may be described as historical and

provide a context for the more therapeutically-focused chapters that follow. Chapter 1(The

Power of Language) presents a summary of the basic principles of language evolution as a

unique form of learning based on the emergence of symbolic relationships among objects and

events. Chapter 2 (Language and Psychopathology) looks at the implications of RFT for

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understanding psychological suffering. The therapeutic focus begins in Chapter 3 (Symbolic

Tools of Change) in which RFT’s basic concepts are summarized. Chapter 4 (Psychological

Assessment) explores the use of RFT principles in the functional assessment of psychological

problems, without recommending “specific domains or targets of assessment” (p. 91).

Chapter 5 (Activating and Shaping Behavior Change) illustrates how language can be used to

activate and shape behavior change in a therapeutic context and specifically “focuses on how

to reconnect clients to their experience” (p. 122). Chapter 6 (Building a Flexible Sense of Self)

shows “how an RFT approach to the self can inform therapeutic techniques that foster

variability, stability, functional coherence, and a healthy sense of responsibility” (p. 169).

Chapter 7 (Fostering Meaning and Motivation) focuses on “how to use RFT principles to

help clients draw meaningful life directions and establish strong motivation to move in these

directions” (p. 207). Chapter 8 (Building and Delivering Experiential Metaphors) shows

“how to use RFT principles to choose, build, and deliver clinical metaphors” (p. 257).

Chapter 9 (Training Experiential Skills through Formal Practice) shows “how to apply RFT

principles to the use of formal experiential techniques” (p. 292). Finally, Chapter 10

(Empowering the Therapeutic Relationship) “explore[s] how the principles applied to our

clients can be useful to therapists themselves … [and] how to establish a stance that fits your

own style while remaining linked to useful RFT principles” (p. 328).

Positive Features

We prefer to open our review with a summary of positive features of the book. These

can be divided into two core areas, the broad and the specific, much of which we try to

present in the chronological order of the book.

Broad positive features. We were unanimous in the belief that Chapters 6, 7, and 8

were the book’s strongest because they would likely be very useful to clinicians, and there is

little else in this regard in the literature. The book contains prior sections on therapy, but the

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therapeutic exchanges and explanations were richer, for example in Chapter 8, than was

previously the case. As a result, some of us believed that Chapter 8 was the book’s best

written and most useful chapter.

Specific positive features. While we take issue with the writing style throughout the

book, especially in terms of RFT, we acknowledge that other concepts were summarized and

articulated in ways that we believed would be informative for readers unfamiliar with

behavioral psychology. We have listed specific examples below to illustrate this.

• Pp. 11-15 contain digestible summaries of typical learning processes, often explained

abstractly in other sources.

• P. 19 contains a very succinct example of a relational network, again not articulated

much in the literature and often done so obscurely.

• P. 21 describes anxiety, as experienced by a hypothetical client, and highlights the

utility of asking functional-analytic questions about an individual’s experience, rather

than summarizing across clients based on topographies. We reacted positively to the

explicit reference to functional analysis and the hint at the importance of individual

histories.

• P. 37 offers clinicians a very helpful summary of S+ and S- behaviors, which are

critical examples of core behavioral principles that are highly beneficial in many

aspects of therapy.

• P. 41 describes the difficult concept of rules succinctly.

• Pp. 45-46 focus on the concept of coherence. We were impressed with the articulation

of the concept’s various features. We particularly liked the analogy that coordinated

coherent networks with superhighways.

• P. 72 provides the following excerpt: “therapists must keep an eye on the effect of

their interventions and assess moment by moment and over time whether the way

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 clients respond to their experiences is consequently changing to an alteration of the

symbolic context” which clearly highlights the importance of an ongoing functional

analysis. This is again highlighted in p. 94 which contains a single clearer and more

accurate statement: “Specific behaviors can differ dramatically in form and still be

part of the same functional class; that is, they share many of the same causes and

consequences” that highlights the critical form versus function distinction.

• Pp. 180-185 contain clinical transcripts that are good and nicely annotated.

• Pp. 180-185 also provide examples of ways in which specific words illustrate the

relations and functions of clinically-relevant relational networks for an individual.

This highlights for readers the importance of an individual’s history that gives rise to

these relations and their functions. That is, words can mean different things for

different people, and understanding and contextualizing these meanings may be

beneficial in therapy.

• P. 192 refers explicitly to “therapy as a collaborative process, something that is done

with the client, not to the client.”, which we believed to be accurate and respectful,

especially in a context where therapists are working off technical terms, and may be at

risk of adhering to a deficit-based conceptual model. Indeed, this issue is highlighted

again on p. 156 with the following: “the primary goal of therapy is to gain flexibility

and broaden behavioral repertoires that sustain well-being. This approach suggests that

our work should be mostly focused on reinforcing progress toward effective actions.”

This provided a succinct and memorable summary of the Contextual Behavior Science

(CBS) approach to therapy.

• P. 193 discusses hierarchical relations and perspective-taking relations regarding the

self in ways which we believed would be helpful for readers in understanding this

difficult type of relational repertoire. The authors were explicit about the need for

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 more empirical evidence on hierarchical relations and we applauded this in the belief

that it is important to be clear and open about where our basic science currently falls

short.

• The descriptions of value, meaning, and motivation via hierarchical relations and

augmenting in Chapter 7 were clear and helpful, and breathed life into a difficult

concept, especially for clinicians not familiar with RFT.

• Pp. 264-272 contain several pieces which we found useful. First, there is a whole

section on why clinical metaphors must fit each client’s background. Second, the

authors highlight the need, when developing metaphors, to conduct functional

analyses to identify which behaviors in the target network need to be changed. Third,

working through how metaphors can be constructed with this in mind will be helpful

to clinicians.

• Pp. 282-283 juxtapose presenting a rule versus using an experiential exercise and

illustrate well how many important functions can be served by the latter over the

former.

Negative Features

In this second section of the book review, we focus attention on those features of the

book to which we collectively reacted more negatively. We have summarized these reactions

into four general concerns, each of which is discussed separately below.

There is not enough ongoing emphasis on the continuous need for functional

analysis. It came as a great surprise to us how little ongoing emphasis there was in the book

on functional analysis (i.e., analyzing the functions of arbitrarily applicable relational

responding). Admittedly, Chapter 4 is explicitly devoted to conducting a functional

assessment and does refer to functional analyses. However, this coverage of the topic seemed

very much limited (the first main mention of functional analysis only comes in Chapter 3, p.

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72). Again, p. 72 and p. 94 both contain sound descriptions of functional analysis, but overall,

we believe that the application of RFT concepts to therapy is fundamentally based on the use

of functional analysis, and this fact (the need for ongoing functional analyses) is not

adequately emphasized throughout. We believe that readers will not be able to appreciate the

centrality of ongoing functional analyses in therapy, given the way in which the book appears

to present the concept in rather discrete and specific ways.

Even where functional analysis is mentioned, references to it are at times obscure and

not particularly helpful to therapists new to the concept. Consider this excerpt from p. 137:

“Making functional sense of psychological experiences happens in two main ways: by

normalizing and accepting thoughts, sensations, and emotions as responses to a history and a

current context; and by focusing on the usefulness of ideas, concepts, and choices rather than

their essential truth.” In this case, we see little clarity in making functional sense or usefulness

as aids in assisting therapists to conduct functional analyses of the human language processes,

as conceptualized within RFT, that are deemed to be important in therapeutic interactions. In

addition, p. 199 shows some limited evidence of functional analysis as part of a therapeutic

session, although this is neither clear nor explicit.

There were transcripts (especially in Chapters 5 and 8) and sections in which we could

actually see that functional analyses were being undertaken by the therapist, and there were

numerous examples in which we believed that these functional analyses were sound and

involved analyses of language processes, as defined by RFT. This is certainly beneficial and

there is very little of this in the extant literature. In addition, p. 283 offers a good example in

which excellent therapeutic work is undertaken with the use of metaphor. Unfortunately

however, both here and elsewhere, functional analysis gets little explanation in the text, and

indeed the text on those occasions does the transcripts and the therapist(s) little justice.

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 Poor and inconsistent use of technical terms. The book’s introduction (e.g., p. 5)

indicated that the use of technical terms would be limited (middle level and folk psychology

terms are given clear and understandable preference) and there are many statements about

whether technical terms will or will not be employed at specific junctions. We completely

understand the utility of middle- and higher-level terms in certain contexts, especially when

discussing clinical phenomena. We also appreciate the difficulties in trying to keep one’s

language at a consistent and accurate basic-research level. Indeed, we applaud being explicit

about using technical terms; what is then frustrating, however, is the following: 1. technical

terms are used when it was suggested that they would not and 2. where it is indicated that they

would be used, the actual terms employed are not in fact technical terms. In short, irrespective

of what the authors say, the text vacillates almost throughout the entire book between

technical and non-technical terms. This vacillation, or the extent of it, only serves to support

our view that the book could be seen as somewhat premature. We elaborate on this below.

As RFT researchers, we were unanimous in our frustration at the development of

terms that are referred to as (RFT) technical terms, when in fact they are not. We found many

examples. Consider the following: “proper functional cues” (p. 26), “water kept popping up in

his relational network” (p. 26), and “symbolic contexting” (p. 123). Among the worst

examples are the following: “inapplicable tracking is driven primarily by essential coherence

or functional coherence relying on poor context sensitivity” (p. 109) and “In practice, RFT

principles involved in life meaning consist of two main aspects: first, the client is led to

identify or build positive overarching goals and qualities of action; second, he is encouraged

to identify broad patterns of various actions that help him engage in the direction of his

overarching goals and qualities of action” (p. 215). It may be possible in these examples for

readers to loosely identify what the authors are referring to, but the language is clearly far

from technical in an RFT sense. For instance, use of the phrase “water kept popping up in his

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relational network” (p. 26) combines a technical term (relational network) with a

colloquialism (“water kept popping up”), and compounds the conflation of the two modes of

discourse with the assertion that the individual has or possesses an actual relational network.

The experienced RFT researcher won’t be misled by this and could even appreciate the

benefits of talking loosely, but the less expert could be seriously misled into assuming that the

whole phrase is permissible as a technical concept in RFT. One might even argue that this

looseness could be damaging in terms of developing genuinely RFT-consistent therapeutic

behavior by the clinician. Let us be clear at this point that we do not object to the use of non-

technical middle-level terms and we appreciate the potential value they have in the clinical

context. Rather, it is the practice of juxtaposing such terms with the technical terms of RFT in

such a way that it can only serve to undermine a clinician’s genuine appreciation of what RFT

can and cannot achieve at the current time that causes us considerable concern.

Weak or untrue claims about RFT. In numerous places, the book appears to

misinterpret the aims of RFT. As noted previously, the theory is a basic behavioral approach

to language and cognition, and of course by virtue of this fact, it will have implications for

understanding and treating psychological suffering. Nonetheless, RFT does not make specific

claims about therapy or what it should involve, doing so is entirely abstractive. This is not

necessarily problematic, but it is not appropriate to suggest that the theory makes claims of

this sort. Consider the following statement from p. 46: “What RFT suggests is to develop an

awareness of the processes that overshadow useful contingencies and to be attentive to the

contexts that promote or undermine these processes”. The line between theory and application

is again blurred on p. 249 with the phrase “RFT therapeutic strategy”. We believe that this

will not help readers to either understand RFT or its legitimate implications for therapy.

Too little emphasis on the learning history. Similar to our surprise at the relative

absence of descriptions of functional analyses, we were very much frustrated by the limited

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emphasis placed by the book on the importance of an individual’s learning history (which

would be highly inconsistent with RFT). Admittedly, Chapter 1 explores different types of

learning and how language is learned, and we noted an example above on p. 22, but there is

little reference subsequently to the individual learning history, even throughout much of the

transcripts. In short, the learning history is covered early on and then neglected to such an

extent that a non-behaviorally trained clinician is likely to miss the importance of the

individual learning histories underpinning the transcripts. Even in places where the learning

history should have been explicitly mentioned, it was not (see examples on p. 171 and p. 198).

For instance, on p. 262, the discussion of metaphors makes no mention of the importance of

using the learning history to provide the content for the metaphor.

Conclusions

At the beginning, we considered the idea that a book such as this is premature, given

the current status of RFT, both empirically and conceptually. In our view, the book is

welcome but not timely, because it was inevitably going to be limited to a lot of speculative

prose and interpretation that extends well beyond the current capabilities of RFT. At one

level, this is not too problematic, but it should be acknowledged that only relatively

sophisticated RFT researchers will be able to identify where the boundaries lie between well-

established technical concepts and technical sounding RFT “psycho-babble”. Indeed, given

sufficient time and energy, a hostile critic could pick the book apart at a technical level,

exposing many areas in which technical and non-technical RFT concepts are conflated and

confused. We believe this would be a shame because RFT and the book itself have so much to

offer that is currently useful and positive, and potentially could change the way in which we

think about human language and cognition, psychological suffering, and psychotherapy itself.

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 Compliance with Ethical Standards

Funding: This book review was prepared with the funding from the FWO Type I Odysseus

Programme at Gent University, Belgium awarded to Dermot Barnes-Holmes

Conflict of Interest: Yvonne Barnes-Holmes declares that she has not conflict of interest.

Deirdre Kavanagh declares that she has no conflict of interest. Dermot Barnes-Holmes

declares he has no conflict of interest. Colin Harte declares that he has no conflict of interest.

Aileen Leech declares that she has no conflict of interest. Ciara McEnteggart declares that she

has no conflict of interest.

Ethical approval : This article does not contain any studies with human participants or

animals performed by any of the authors.

References

Hayes, S.C., Barnes-Holmes, D., & Roche, B. (2011). Relational frame theory: A post-

Skinnerian account of human language and cognition. New York: Kluwer Academic.

Villatte, M., Villatte, J.L., & Hayes, S. C. (2015). Mastering the clinical conversation:

Language as Intervention. New York: The Guilford Press.

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