FEN Conference Notes

Madison, Wisconsin, April 2, 2008


Effective Behavioral Treatments for Individuals with FASD


Thane Dystra and Kim Shontz

Clinical Therapists

Trinity Services, Inc.

NOFAS Illinois Affiliate


We serve individuals with developmental disabilities; some have FASD.  We serve those who have been kicked out of other programs.  Compared to individuals with other disabilities, those with FASD ranked much higher in severity of behavior challenges.


Diagnoses of individuals with FASD served by our agency:

·        Bipolar

·        ADHD

·        Post Traumatic Stress Disorder

·        Oppositional Defiant Disorder

·        Intermittent Explosive Disorder

·        Schizoaffective Disorder


Problem behaviors observed in these individuals:

·        Impulsivity              100%

·        Problem with social skills      100%

·        Verbal aggression          92%

·        Attention deficits                83%

·        Memory deficits                83%

·        Property destruction          75%

·        Self-injurious behavior       75%

·        Grandiosity                     67%

·        Physical aggression          67%

·        Sexual issues                             50%

·        Theft                                    42%


People with FASD may repeat behaviors that lead to negative consequences.  This does not mean that they are not capable of learning from consequences.  Why do they appear NOT to learn from consequences?

·        They may not perceive the consequence as negative

·        Learning from consequences may take years

·        More likely to respond to immediate rewards than avoid consequences that are delayed or unpredictable.

·        Behavioral supports might be removed too soon or too suddenly

·        May react negatively to attempts to control them


Trinity’s treatment program uses Contextual Behavioral Interventions.


Trinity behavioral approaches based on:

·        Functional Analytic Psychotherapy (FAP)

·        Acceptance and Commitment Therapy (ACT)

·        Dialectical Behavior Therapy (DBT)


Behavioral interventions based on Cognitive Behavior Therapy (CBT):

·        Focus more on behaviors, less on cognition (thoughts)

·        Look at impact of environment (consequences) on behaviors

·        Promote mindfulness (similar to meditation process)

·        Clarify values (what makes someone tick, what motivates them?)

·        Promotes acceptance of thoughts and emotions


Cognitive behavior approach:

·        Emotional and behavioral problems are caused by errors in thinking

·        Individuals may have cognitive distortions, like all-or-none, or over-generalization

·        Thoughts are different from behaviors, thoughts cause behaviors


The therapist will try to help the individual think things out, to recognize when a cognitive distortion has occurred, using a systematic review of the situation to dispute what is sometimes called “stinking thinking.”


The five-panel technique. A-B-C-D-E


A = Antecedent

B = Behaviors and thoughts that accompany the behavior

C = Consequences, such as reactions and feelings that result from the behavior

D = Dispute the thoughts that led to the behavior

E =  Emotional consequence (new, healthier feelings are the goal)


A = She didn’t pay me back

B = I hit her

C = I got in trouble, she doesn’t like me anymore, I didn’t get paid yet

D = Dispute “It’s all her fault,” “ she is dumb,” “she made me angry”

E =  “I’m not mad anymore.”


Reference:  Feeling Good workbook by David Burns, has easy explanations and worksheets.


Comparison of three different approaches:

·        Behavioral activation

·        Behavioral activation  and automatic thoughts

·        Behavioral activation  and automatic thoughts schematic approach


Study showed that the first one was sufficient compared to combining with the other two.



A behavior can be observed in context of what happens before (stimulus) and what happens after (consequence).  The consequence reinforces the behavior.  The situation in the environment changes the behavior, or establishes the operation increases or decreases the probability of the behavior.


Stimulus -> Response -> Consequence (reinforced) -> Establishing operation


It’s important to take into account contextual factors.  We cannot look at a behavior without looking at all the environmental and cognitive factors the might affect behavior.


CBT approach sees thought as a stimulus to behavior.  This theory is incomplete.  We believe that thoughts are behaviors; thoughts are cognitive behaviors.  This belief is the basis for Contextual Behavioral Interventions that we use.


If you see “1+1=” you will think “2.”  The”1+1=” is the stimulus.  Your saying out loud the number 2 is the behavior.  The thought process led to the behavior.


Consequences can be reinforcers or punishers that increase or decrease behaviors.  Extinction takes place through withdrawal of the reinforcement.


Contingencies can be classified as:

·        Social or attention getting

·        Tangible item or a referred activity

·        Escape or avoidance

·        Automatic, sensory, or intrinsic


Shaping:  Our goal is to shape desired behaviors. Shaping is the differential reinforcement of successive approximations to a terminal behavior.  If there is a behavior you want to steer the person toward, it will probably be a gradual process.  The reinforcer will be delivered with gradual changes over the process.  This reduces the resistance, as the individual may not even notice the change over time.


It is very important for all staff to be consistent in the methods used to shape behaviors, or the technique will not be effective.


Rule governed behavior: Relationships between behaviors and consequences.  If this happens, then that will occur.  Contingencies are not needed.  No prior experience is needed, no trial and error is involved.  It is simply the If-Then rule.  “If you touch the stove, it will burn your hand.”  (Steve Hayes research)


Rules can be helpful.  “I should look both ways before I cross the street, or I might get hit by a car.”  In some cases, rules might not be helpful.  “If I smoke, I will fit in.”  “If staff won’t take me to the hospital, I will need to call 911.”


The ABC concept is helpful in understanding behavior.  Client-therapist relationships are a series of operant chains (A-B-C-D-E).  There are many informal interactions outside of the therapeutic process that might take place.  These interactions can provide stimuli and contingencies for both the therapist and the client. 


Functional Analytical Psychotherapy (FAP) can compliment Dialectic Behavior Therapy (DBT).  They both have similar approach.  FAP is for persons who have interpersonal difficulties.  FAP creates an intense relationship between the therapist and client.  FAP helps shape effective behavioral repertoires.  The relationship between the therapist and client must first be established or FAP will not be effective.


Clinically relevant behaviors (CRB’s):

1.      CRB1-: Problem behaviors that occur within the client-therapist relationship

2.      CRB2+: Improvements that occur within the client-therapist relationship

3.      CRB3: Client interpretations of factors that influence their behavior (thoughts)


CRB’s begin as hypotheses.  You must understand the client’s existing repertoire to determine if a behavior is a CRB 1 or a CRB 2.


Skinner’s taxonomy of behavior:  

·        A tact is a name or label for a public or private experience.  A person sees a dog and says “dog.”  A mand is a verbal behavior (request) that results from a particular reinforcer. 

·        A person is thirsty and says “water” expecting to be given water as occurred in the past. Intraverbal is a verbal behavior evoked by verbal stimuli.  A person responds, “Fine” when someone else says, “How are you?” 

·        Disguised mands are statements that appears to be a tact but based on the form of the behavior is really a mand.  “I’m feeling hopeless” could be a mand that is a way of asking for support.  Or it could simply be a tact.

·        Distorted tacts are verbal descriptions that are inaccurate:

o       Lying (escape/avoidance)

o       Discrimination or memory deficits

o       Denial – events not tacted because too painful to the client


Rules of FAP:


Rule 1: Watch for CRB’s.  Determine a CRB has occurred.  Monitor your own private experience related to client’s response.  Watch for subtle signs of client avoidance behavior or other effects on client.  Be alert to possible “disguised mands” that could be attention-seeking behavior or attempts to get something, like a trip to the hospital or a therapy session or financial gain.


Rule 2: Evoke CRB’s.  This is difficult to do in a sterile therapy room.  Assign homework.  Use experiential exercises.  Provide or withhold praise.  Don’t be contrived in evoking CRB’s.  That could damage your credibility.  If you lose the client’s trust, they will not want to continue with therapy.


Rule 3: Reinforce CRB 2’s:  Use natural language.  Have realistic expectations based on client’s repertoire.  Amplify feelings to increase their salience, especially with clients who have difficulty recognizing subtle social cues.  Avoid atypical reinforcers that you wouldn’t find in social environment (like points and stars).  Monitor the use of punishment or the client will not want to continue. Monitor blocking of avoidance.


Rule 4: Observe the effects of therapist behavior in response to client CRB’s.  Sometimes praise might not be an effective reinforcer as intended.  There might be other factors that impact the situation.  A client could engage in a perceived positive behavior just to invoke the praise attention, or could engage in a perceived negative behavior just to invoke the assistance.


Rule 5: Give interpretations of variables that affect client behavior.  This helps the client generate more effective rules. The ability to form cause-effect relationships makes life more predictable.  Encourage and reinforce client descriptions that are related to stimuli present in the therapy environment. If they relate an experience to you, it may or not be accurate, so you need to be careful about your response that could be a reinforcer.


Behavior Chaining:  A Behavior Chain is a process to chart and analyze the function of the behavior problem   Use a chart with spaces for consecutive behaviors and events with parallel spaces for corresponding thoughts and feelings.  Behavior chaining helps individuals in processing an incident or chain of events that triggers disruptive behavior and/or emotional dysregulation.  Assist the individual in identifying antecedents and triggers as well as consequences.  Encourage recognition of the costs and benefits of their behaviors, and develop a plan for the future.


Behavior Chain Timeline:  You can chain back in time (what happened before) or forward in time (what happened after).  Or you can start the chain with the beginning of the day.  “What happened when you woke up in the morning?”


Behavior Chain Guidelines: 

Choose a quiet and private place

Wait until the person is no longer in distress

Don’t assume you know what they will say

Don’t skip a link

Use a calm and empathetic tone of voice


Functional Analysis:  Encourage the individual to chain the events leading to the implementation of the behavior chain.  Define the problem behavior and the corresponding thoughts and feelings.  Continue until relevant antecedents are identified.


Cost/Benefit Analysis:  The process of recognizing the short and long-term costs (con’s) and benefits (pro’s) of the behavior.  There is always a cost AND a benefit.  Costs might be financial restitution, impact on relationship, increased emotional distress.  Benefits might include release of tension, revenge, gaining wanted attention.  Make a written list of all the costs, benefits, long-term consequences, and solution analysis.  Link the costs and benefits to the events on the Behavior Chain chart.


Solution Analysis:  An active attempt to generate positive behavior patterns to replace the negative behavior patterns, and to develop a plan for making those changes occur.  All aversive behaviors or feelings are treated as problems that can be solved.  This could mean changing a current behavior patters, problem solving, or accepting the problem as it is.  Help the individual learn new responses and behaviors through skills utilization and problem solving.  Encourage the individual to generalize skills to other environments.  Work with the individual to differentiate between skills usage and alternate behaviors vs. accepting the situation as it is (like having to get up early to get to work on time).  Work with the individual to identify specific skills or alternative behaviors they can use in the future.  Encourage recognition of how implementing the solution analysis would impact the cost/benefit analysis.  Role play or practice specific skills.  Provide the individual with a copy of the Behavior Chain chart and cost/benefit analysis.


Act: Acceptance and Commitment Therapy


Acceptance and Commitment Therapy for Persons with FASD:  These are unconventional concepts.  Psychological pain is normal – everyone has it.  You cannot deliberately get rid of psychological pain.  You can take steps to avoid increasing it artificially.  Accepting private experience is a step towards ridding yourself of suffering.


ACT Acronym Focus of Treatment:

·        Acceptance of private experience vs. fusion with private experience and deliberate attempts to change thoughts and feelings. 

·        Choose mindfully vs. acting on autopilot and responding to private experience in an ineffective/impulsive manner.

·        Take action consistent with personal values vs. avoiding action on the basis of ineffective rules and aversive private experience.


Why People with FASD are Perceived as Challenging:  They tend to fuse with their thoughts vs. taking a mindful perspective.  They tend to have difficulty staying with their negative emotions.  They tend to respond impulsively to immediate contingencies vs. engaging in rule-governed responding that is based on personal values.


Important Building Blocks:  Help clients distinguish between thoughts (tapes in your head) and images (pictures inside your head) and bodily sensations (heart rate, muscle tension, warmth of skin, etc.)  It is an illusion that thoughts and feelings cause behaviors.  You can have a thought or feeling without acting on that thought or feeling.  There is an important difference between having a thought and believing a thought.  You might not be able to control thoughts and feelings, but you can control your arms and legs and mouth.


Human Reasoning Abilities Allow Us to Master the External World.  However, many people with FASD are less skilled in problem solving.  In the external world, humans have excelled at changing and getting rid of the unpleasant and uncomfortable.


Values are a Compass.  Values are directions and not outcomes or goals.  You never achieve values.  Values are a personal choice.


Cognitive Fusion is taking your thoughts literally as fact.  Strategies for defusing: Externalize the “mind.”  “What is your mind telling you right now?”  Your mind is not always your friend, and you don’t always have to carry through with what your mind tells you.  Say a thought out loud over and over and over really fast, or in slow motion, until it loses its significance.  Give the individual a verbal cue.  Ask the individual to respond with “I’m having the thought that…”  Have the individual think of their room then describe their room.  Identify that as a thought.  Distinguish between buying a thought and noticing a thought.  Verbalize thoughts in slow motion.




Mindfulness Practices/Exercises: 

·        Identify what you will focus on

·        Notice ALL thoughts, images, sensations

·        When your mind wanders, return to target thought in non-judgmental manner

·        Expect some distraction

·        Success is measured by returning attention to the target


Dialectical Behavior Therapy (DBT)

·        Acceptance vs. change strategies

·        Hierarchy of treatment targets:

o       Reduce life-threatening behaviors

o       Reduce therapy-interfering behaviors

o       Reduce quality-of-life interfering behaviors


Similarities Among People with FASD and Bipolar Disorder:

·        Pattern of unstable and intense personal relationships

·        Impulsivity in at least two areas that are potentially self-damaging

·        Recurrent suicidal behaviors, gestures, threats or behaviors

·        Affective instability due to reactivity of mood

·        Inappropriate, intense anger or difficulty controlling anger


Basic Assumptions of DBT:

·        Individuals are doing the best they can

·        Individuals want to improve

·        Individuals may not have caused all their own problems, but they can solve them anyway

·        Individuals must learn new behaviors in all relevant contexts

·        Therapists treating persons with affective dysregulation need support


Validation:  Communicating to the person that his or her response makes sense and is understandable within their current life situation of the context of the situation.


Invalidating Environments:  Pervasive communication to the individual that her responses, particularly emotional displays and communication of private experiences, are incorrect, inaccurate, faulty, inappropriate, or otherwise invalid.


Characteristics of Invalidating Environments:  

·        Communication of private experiences met with erratic aversive responses: Responses are not accepted as accurate, or are not considered valid to the events, or are dismissed or trivialized, or are considered pathological

·        Escalation of emotional displays and/or communication of efforts met by erratic, intermittent reinforcement

·        Restriction of demands placed on environment


Validation is Important Because:

·        Balances acceptance and change

·        Teaches self-validation

·        Promotes progress in treatment

·        Provides feedback

·        Strengthens the relationship


Types of Validation:

·        Language

o       “I can  understand how you might feel that way”

o       “That makes sense”

·        Actions

o       Active listening (nodding, reflecting back)

o       Responding to requests, such as switching subjects if uncomfortable

·        Validate the persons actions, thoughts, physical sensations, emotions


Levels of Validation:

1.      Level One: Listening and observing

2.      Level Two: Accurate reflection

3.      Level Three: Articulating the unverbalized

4.      Level Four: Validating current behavior in terms of its antecedents

5.      Level Five: Validating behaviors as appropriate to current circumstances

6.      Level Six: Radical genuineness


Core Mindfulness Skills:

·        “What” Skills:

o       Observe

o       Describe

o       Participate

·        “How” Skills:

o       Non-judgmental

o       Focus on one thing

o       Effectiveness


Increase Distress Tolerance:

·        Distract with “Wise Mind ACCEPTS”:

o       Activities

o       Contributing

o       Comparisons

o       Emotions

o       Pushing away

o       Thoughts

o       Sensations

·        “IMPROVE” the moment:

o       Imagery

o       Meaning

o       Prayer

o       Relaxation

o       One thing at a time

o       Vacation

o       Encouragement

·        Self-soothe the five senses:

o       Vision

o       Hearing

o       Smell

o       Taste

o       Touch

·        Pros and Cons:

o       Cost/Benefit Analysis


Goals of Emotion Regulation Training:

·        Understand emotions you experience (identify, observe, describe)

·        Reduce emotional vulnerability (decrease negative, increase positive)

·        Decrease emotional suffering (let go through mindfulness, take opposite action



Notes compiled by Teresa Kellerman and posted with permission of the presenters


Fasstar Enterprises

FAS Community Resource Center