Clinically Relevant Behaviors

It is assumed that the client with complex PTSD will bring certain behavioral patterns into the therapist-client relationship. These patterns fall into three types and are referred to as clinically relevant behaviors (CRBs).

CRB1: Client Problems That Occur in Session

CRB1s are related to the client's presenting problems and should decrease in frequency during therapy. For example, a client who suffers from complex PTSD and avoids relationships because they have been hurtful may exhibit these CRBls: avoids eye contact, answers questions curtly, demands to be taken care of and then fails to come to scheduled appointments, gets angry at the therapist for not having all the answers, cancels several appointments in a row after an making an intimate disclosure.

Patient problems can also involve the thinking, perceiving, feeling, seeing, and remembering that occur during the session. For example, problems known as "disturbances of the self' (see Kohlenberg & Tsai, 1991, for an extensive discussion on how such disturbances are acquired and treated), such as "not knowing who the real me is" and dissociative identity disorder, are translated into behavioral terms (e.g., problems with stimulus control of the response "I") and conceptualized as CRB1. Clients with complex PTSD may be unable to describe how they feel or may not recall an emotional episode that occurred in the session. They may fail to perceive an aspect of the therapist that is associated with past trauma, such as denying the obvious fact that the therapist is pregnant.

CRB2: Client Improvements That Occur in Session

In the early stages of treatment, these behaviors typically are not observed or are minimally discernible. For example, consider a male sexual abuse survivor who feels withdrawn and worthless and has minimized discussion of his abuse. Consider too that he has avoided any direct discussion with the therapist about the therapist's tendency to request that his appointment time be adjusted within a particular day, even though this request made him feel extremely devalued and worthless. Possible CRB2s for him would include expressing his feelings about his abuse, talking about what the therapist does that brings up his feelings of worthlessness, and asking directly for what he needs.

CRB3: Client Interpretations of Behavior

CRB3s consist of client discussions of their own behavior and what seems to cause it; "reason giving" (Hayes, 1987; Zettle & Hayes, 1986) and "interpretations" may be part of this behavior. The best CRB3s include observation and description of self behavior and its associated reinforcing, discriminative, and eliciting stimuli. Learning to describe functional connections helps clients increase their ability to elicit reinforcement in daily life. CRB3s include descriptions of "functional equivalence"—that is, descriptions of similarities between what happens in session and what happens in daily life. Consider a client named Carol who, in response to ongoing childhood abuse, had learned to associate her emotional dependence and self-expression with being physically degraded by caregivers. This person had spent her adult life withholding her deepest feelings in relationships, and for the last few years, had struggled with the issue in therapy. After a course of FAP, in which the expression of deeply held feelings was valued and respected, Carol began taking risks in her relationships and began revealing more of these feelings. Her CRB3 was:

"The reason I'm talking more openly to people in my life is because I have learned that with you, in our therapy, when I express my vulnerability you will not hurt me, and that you will in fact respond to me in a loving, kind way. over the years I have learned that my vulnerabilities and deepest desires are respected by you. Even when I expressed to you that you have failed me in certain respects, and even when I was angry that you would not be friends with me outside of therapy, you were respectful and treated me as if what I wanted mattered. Because of these experiences with you, I really feel that I am able to be a whole person with others, handle disappointment appropriately, and not protect my deepest feelings with such vigilance."

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