So far we have discussed sources of variance that could extend the effects of a nomothetically derived evidence-based intervention by identifying additional factors that cause or maintain symptoms that are not part of the immediate posttraumatic response. Now let us consider observable factors that might directly compete with active treatment components of an evidenced-based intervention.
Let us take two examples. One empirically supported treatment principle for PTSD is the use of cognitive therapy, whose techniques include identifying dysfunctional cognitions and gathering and evaluating evidence for and against those cognitions. Presumably, examining this evidence will lead the patient to a more realistic and functional set of beliefs and cognitions. If that intervention did not achieve the anticipated results—and assuming that the treatment was delivered competently—then we are left considering whether there are other important causal factors that could be identified by a functional analysis. In addition to the kinds of analyses already described, we can also consider the existence of competing contingencies. Are there salient contingencies operating in the patient's environment that compete with the goals of therapy? While the therapist is diligently helping the patient identify dysfunctional beliefs and encouraging him or her to test them in the real world, there may be people in the patient's environment who are reinforcing the opposite behavior. If this is the case, the assessment issue, becomes, what is controlling the therapy-interfering behavior of these other people? Interviews, diaries, and journals may help generate hypotheses. A child who realizes his mother is vulnerable may cling to her, preventing her from doing exploratory homework. The child may even subtly support the mother's avoidance behavior. A spouse who initially worried about the victim's safety may now actually prefer a more dependent partner, and, like the child, may undermine treatment compliance.
As a second example, in an exposure-based treatment that is producing poorer outcomes than might be expected, it is important to functionally analyze what environmental contingencies might be competing with therapy tasks and goals. If the therapist had constructed an in vivo desensitization hierarchy with the patient, and the patient reports doing the in vivo exposure homework, why might the treatment not being working? Relying on theory to help guide the assessment, we recall that PTSD patients generally have very broad networks of stimuli that can produce aversive conditioned responses that might be of a larger magnitude than expected. For example, an element on the exposure hierarchy might be intimate touching with the spouse. Each time the patient reaches this level of the hierarchy, she experiences a resurgence of anxiety that interferes with extinction. A careful analysis of the reactions to this activity on the hierarchy might reveal that though the spouse is being as sensitive as possible during the task, the spouse may possess some subtle physical characteristic of the perpetrator. It might be difficult to elicit this information from the patient, because the patient does not have verbal access to what is bothersome about the task or because she tries to complete the task, believing it crucial to her spouse, but cannot reduce her anxiety sufficiently for extinction to occur. In fact, spontaneous recovery of the conditioned response could even occur at that point. We present these examples to demonstrate that a functional analysis can and should be applied to identify additional sources of control over behavior change that compete with successful treatment implementation.
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