Functional Contextualism sits at the heart of Acceptance and Commitment Therapy (ACT) as an essential element in understanding individuals difficulties and helping practitioners collaboratively design effective interventions with their clients. Despite this, F.C. is not always well understood which may be explained, in part, because it contrasts significantly with the way psychological problems are traditional conceptualised in western medicine.
For decades, the dominant approach to mental health diagnosis has been syndromal, as can be seen in diagnostic manuals such as the DSM-IV and the ICD-10. Conceptualising psychological difficulties in this way classifies experiences like anger, anxiety, sadness, shame, guilt, or intrusive thoughts and memories, as symptoms causal to the development of a psychological disorder. Measures have been designed to identify experiences, relevant to a specific syndrome, and cut off points established to distinguish between the presence of a given disorder and the absence of it. Syndromal conceptualisations seek to understand the topography of a disorder and its boundaries - which is to say the point at which the given constellation of symptoms, which define the disorder, are considered significant enough to warrant a clinical diagnosis. Treatments which adhere to this conceptualisation are designed with the aim to reduce symptoms to a level below the cut off point, usually by targeting them directly.
Importantly, the boundaries of a clinical syndrome (psychological disorder) are established by statistical averages for the population, with an assumption that experiences of the wider population can give useful information in identifying variables to be targeted at the level of the individual. However, applying the statistical averages of a large population likely lacks the sensitivity needed to identify the specific context of individuals' experiences of their symptoms, and responses to them. The potential is therefore to miss specific, contextually dependent, processes that may maintain the disorder for a given individual.
Functional Contextualism (F.C) is an alternative approach to conceptualisation. It begins from the standpoint that any behaviour - that is to say, anything an organism does, consciously or otherwise, - can only be understood in relation to the context in which it occurs. It is the function that a behaviour has for the individual, i.e., what the behaviour achieves for the individual, in a given context , that is of interest to the functional contextualist conceptualisation. For e.g., the function of running, as a behaviour, can be understood differently once we know the context. Running as part of an daily exercise regime, intended to improve fitness, is likely to feel very different than running in order to escape a pack of wild dogs.
In contrast to a syndromal conceptualisation, where the aim is reduce the symptoms which make up the syndrome, a functional contextualist conceptualisation would focus on the relationship the individual has to their symptom. For e.g., from a syndromal perspective, reducing the frequency of self-critical thoughts, to below the cut off point, would be considered a legitimate goal of treatment, whereas a functional contextualist approach would seek to understand the relationship the individual has to their self-critical thoughts - i.e. what behaviour occurs in response to the experience of a self-critical thought and what is the impact of that response?
ACT interventions then seek to change the relationship to the symptom/experience, rather than to change the experience (such as the self-critical thought.) directly. So, rather than reduce the frequency of a given thought by changing the content of it - such as via cognitive restructuring in Beckian CBT - , we may attempt to change the relationship to the thought, through cognitive defusion, allowing for more flexibility in response to it and disrupting rigid responses which may be maintaining the problem.
In Acceptance and Commitment Therapy (ACT), a central concept is experiential avoidance. In brief, this is the unwillingness to have, and subsequent avoidance of, private experiences (Thoughts, Images, Memories, Emotions, Sensations) which are understood to maintain psychological distress by maintaining an aversive relationship with those experiences. Experiential avoidance also functions to generate unworkable and inflexible behavioural responses, in relation to those personal experiences, because the less willing an individual is to have their personal experiences the more restricted their behaviour will become in order to avoid coming in contact with them. This can be unworkable both because these strategies rarely succeed in long term cessation of experience, but also because those behavioural strategies frequently function to adversely impact their lives in unintended ways.
For e.g., avoidance of anxiety in PTSD, when it occurs in the context of public spaces, can lead to an increase in hyper-awareness in response. Hyper-awareness (i.e continually checking the environment for danger) functions to increase momentary sense of safety but also functions to maintain the sense of threat, prolonging and intensifying the experience of anxiety. Hyperawareness, as a anxiety control strategy, may also function to reduce the ability of the individual to remain present, and therefore interact socially, impacting their ability to engage in meaningful and purposeful activity in their lives. From an ACT perspective, it is the relationship, and response, to the anxiety that is unworkable and the maintaining factor in the individual's difficulty. The aim of an ACT intervention then, would not be to attempt to eliminate anxiety directly (as may be indicated by a syndromal conceptualisation of PTSD) but to change the relationship to it sufficiently that the behaviour (in this case, hyperawareness) is disrupted to allow for alternative workable responses. In ACT, those workable responses would be those which improve the individual's ability to engage in self chosen, values driven, activity. As we can see, understanding the function of the response (hyper-awareness) to the symptom (anxiety) is useful in identifying the maintaining behaviour it may be useful to change through our interventions. We can also see that identifying this alternative target for change may require an alternative intervention when compared to a syndromal conceptualisation.
To illustrate this we may see that, when conceptualised from syndromal perspective, an intrusive memory may be seen as the root cause of the distress an individual is experiencing. An intervention may be used with the intention of reducing the frequency of these intrusive memories directly. However, from a functional contextual perspective, we would consider the relationship the individual has with the memory as the maintaining factor in both the maintenance of distress and the functional impact that PTSD has in their lives. Using a functional analysis of the response to the intrusive memory we could work to identify the behaviours the individual responds to it with. Those behaviours will vary, both between individuals, and between specific contexts, and so functional analysis improves our ability to respond with nuance to the individual in front of us, rather than attempting to fit them into norms for a population, which may miss important contextual information.
For example, one individual may respond to an intrusive memory by attempting to block it out. The function may be to escape the fear they experience alongside the memory, in the short term, but also to increase the frequency and intensity of the memory, as it rebounds in medium term. The result is the short term reinforcement of the blocking behaviour, in response to these experiences, creates a cycle which maintains the symptom and related distress, despite it's unworkability in eliminating the experience in the medium to long term.
Another individual may respond to the intrusive memory by ruminating on a self-critical thought that expresses self-blame or worthlessness. The function of this behaviour may be to avoid direct contact with the original memory, and associated emotional pain,in the short term, but also to encourage disconnection from others, and therefore reduce fear of rejection (again, in the short term), whilst reducing the individual's ability to engage in meaningful social activity into the long term.
A third individual may replay the memory over and again in an attempt to problem solve the incident and to arrive at a more palatable outcome. The function may be to both avoid the pain associated with memory of the original memory, in the short term, and to disconnect them from the present moment, and the opportunity to be active in their own lives, further impacting their mood in the medium to long term.
A purely topographical, syndromal, conceptualisation may miss the nuance of these responses and their differing functions, losing the opportunity to respond effectively to maintaining factors for a specific individual. In practice, individuals often develop a variety of strategies, depending on the context in which the experience occurs, but the key, from a functional contextual perspective, is to identify the specific function(s) of a given behaviour, in a given context, in order to be able to tailor interventions to most effectively disrupt behaviours involved in maintaining the problem.
Importantly for Acceptance and Commitment Therapy practitioners, the central importance of reducing experiential avoidance, in order to increase the range of flexible responses an individual can engage in, in response to unwanted private experiences, as a mechanism for change in our work, means that functional contextualism as an approach, and functional analysis as the skill, are vital for understanding our clients' difficulties and in identifying which behaviours will be most efficacious to target, and therefore how best to help our clients reach their goals.
Christian Hughes is a Psychotherapist, Clinical Supervisor, and Clinical Trainer, specialising in Acceptance and Commitment Therapy, with expertise in Trauma & PTSD and a special interest in Moral Injury.