Measuring intimacy as a contextual behavioral process: Psychometric development and evaluation of the Awareness, Courage, and Responsiveness Scale

Highlights

• A contextual behavioral self-report measure of relational intimacy was developed.

• The measure demonstrated strong validity and reliability across six samples.

• The measure predicts psychiatric distress and quality of life in a clinical sample.

• Validity of use in dyadic research is supported.

Abstract

High quality relationships are essential to psychological health and well-being, and relational intimacy is a core feature of these relationships. Decades of research in relationship science have converged on a central model of intimacy wherein individuals develop close, trusting relationships with one another. Functional Analytic Psychotherapy (FAP) is a contextual behavioral intervention approach that is well-equipped to target interpersonal processes through the provision of in-session, therapist mediated reinforcement of skillful intimate relating. Single-subject level analyses of FAP's efficacy and mechanism of action are supportive; however, there is a need for group-level research to evaluate its efficacy and generalizability. This paper presents the development of the Awareness, Courage, and Responsiveness Scale (ACRS), a self-report measure of behaviors essential to intimate relating informed by contextual behavioral science principles and Reis and Shaver's (1988) Intimacy Process Model. In this five-part study, functioning of the ACRS is examined in undergraduate student samples (Studies 1–3), an adult community sample (Study 3), non-clinical dyadic relationships (Study 4), and a transdiagnostic clinical sample (Study 5). Strengths and limitations of the final measure are discussed.

Introduction

Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai et al., 2009) is a contextual behavioral psychotherapy that targets clients’ transdiagnostic constructive outcomes related to improved interpersonal functioning. With roots in early behavioral conceptualizations of the psychotherapy relationship, FAP proposes that a primary mechanism of effective psychotherapeutic change is the in-session, natural, social reinforcement of improved client behavior by the therapist. Explicit attention is paid to in-session, functionally defined clinically relevant client behavior (CRB). Based on a case conceptualization of the client's goals for treatment, problematic client behaviors that occur in-session are referred to as CRB1 and improved in-session behaviors are referred to as CRB2. The FAP therapist is trained to observe, evoke, and reinforce CRB2s, and generalize the client's in-session learning to relevant outside contexts.

Congruent with FAP's emphasis on application of behavioral principles and idiographic case formulation, research on FAP has accumulated mostly in the form of case studies, controlled single-subject designs, and micro-process investigations of the impact of FAP and FAP processes on idiographically defined interpersonal behavioral targets (Kanter et al., 2017). This research supports FAP not as an empirically supported treatment for specific disorders but as a psychotherapeutic process that can produce positive change in specific, transdiagnostic behavioral targets. A recent meta-analysis of single-subject designs concluded that FAP was effective across a range of target behaviors (i.e., CRBs; Singh & O’Brien, 2018).

Despite promising single-subject and mechanism data, there continues to be a need for group-level clinical trial research to evaluate FAP's efficacy (Kanter et al., 2017). FAP researchers, however, have noted that FAP's idiographic approach, even though it has facilitated single-subject mechanism research, renders nomothetic group research more challenging (Follette and Bonow, 2009, Maitland and Gaynor, 2012). One promising avenue for progress involves the specification of transdiagnostic interpersonal functioning outcomes that enable varying levels of precision, scope, and depth as needed for a particular functional analysis (Hayes, Barnes-Holmes, & Wilson, 2012). Although any set of client problems theoretically can be targeted in FAP, the mechanism is necessarily interpersonal, leading Kohlenberg and Tsai (1991) and others (e.g., Weeks, Kanter, Bonow, Landes, & Busch, 2012) to describe FAP as an approach that prototypically targets interpersonal functioning outcomes. In 2009, Tsai and colleagues articulated techniques that squarely targeted intimacy, employing the terms awareness, courage, and love to describe desired therapeutic processes that facilitate more intimate exchanges between clients and therapists to improve these targets.

Despite the focus on intimacy-related concerns in FAP (Maitland, Kanter, Manbeck, & Kuczynski, 2017), no model of intimacy has been advanced for use by FAP researchers or clinicians, leaving the determination of treatment targets up to individual case conceptualization (c.f., Callaghan, 2006), and leaving researchers without consensus on how to measure dependent variables in FAP outcome research. Herein, we present a model of intimacy that integrates established findings from relationship science with extant descriptions of FAP targets and processes, and propose this model as an approach for researchers and clinicians wishing to measure proximal behavioral outcomes related to intimacy.

Specifically, we employ the Intimacy Process Model (IPM; Reis & Shaver, 1988), a well-researched model of how intimacy develops which can be translated into clinical targets related to intimate relational functioning (Maitland et al., 2017). The IPM describes intimacy as a dynamic, behavioral process that is consistent with the emphasis placed on identifying behavioral actions-in-context in contextual behavioral science (Hayes et al., 2012). The model can be applied to psychotherapy or other relationships and thus is a good fit for FAP's emphasis on relational processes that occur both in therapy and in outside relationships. The constructs of this model, as will be described, map tightly on to the intimate exchanges targeted in FAP as per Tsai et al. (2009) and can be applied to the psychotherapy or other relationships. Thus, the model may be a good fit for FAP's emphasis on relational processes that occur both in therapy and in outside relationships. In fact, in a post-hoc analysis of published FAP research, 84% of published, ideographically defined FAP targets were consistent with this model (Maitland et al., 2017).

The IPM (1988) situates the intimacy process in a dyadic interaction in which two individuals are engaged in a series of reciprocal exchanges of vulnerability and empathically attuned responses to that vulnerability. Specifically, an intimate interaction begins when one individual (“Person A”) engages in a vulnerable verbal or nonverbal self-disclosure/expression with another individual (“Person B”) who, for successful intimate relating to occur, conveys understanding, validation, and care in response (referred to as “responsiveness"; Reis, Collins, & Berscheid, 2000; Reis & Gable, 2015). The extent to which both partners reciprocally engage in this pattern of vulnerability and responsiveness predicts relational closeness and is foundational to the development of close, trusting, and personally satisfying relationships over time (Canevello and Crocker, 2010, Laurenceau et al., 1998, Laurenceau et al., 2005). The IPM also suggests that multiple perceptual, motivational, and dispositional processes influence these interactions, such as an individual's ”interpretive filters” that include motives, needs, goals, and fears during the interaction.

Herein, we propose a new measure called the Awareness, Courage, and Responsiveness Scale (ACRS), based on a model that integrates the IPM's intimacy process with FAP processes, and operationalizes the constructs in the model as behavioral targets amenable to intervention (including a behavioral reformulation of the IPM's “interpretive filter”) and languaged for clinical use as described in Maitland et al. (2017). We briefly describe each of the major constructs of the model.

Tsai et al. (2009) characterized awareness as the quality of paying attention to one's own emotional reactions and the subtle emotions and behavior of the other individual in an interaction, consistent with the notion of “interpretive filters” proposed in the IPM (Reis & Shaver, 1988). In our model, awareness involves paying attention to the factors influencing an intimate interaction with the intention of gaining volitional control over behavior and increasing the likelihood of successful intimate relating. Our formulation includes both self-awareness (awareness of one's own motives, needs, and goals in the interaction) and other-awareness (awareness of the other's motives, needs, and goals). Self-awareness functions primarily to facilitate successful disclosures from Person A in the interaction, and multiple findings indicate that mindful emotional awareness improves emotional clarity, emotional expression, and relational outcomes (Atkinson, 2013). Other-awareness involves empathic accuracy and the related construct of perspective taking, which predict successful responsiveness and relational closeness (Ickes, 2000). Reis and Gable (2015) note that without empathic accuracy, the responsiveness attempts of even well-intentioned individuals may be perceived as insincere, insensitive, or out of sync with the discloser's goals and needs.

Tsai et al. (2009) describe a broad range of courageous, interpersonal risk-taking behaviors that function to increase relational closeness and improve overall functioning (e.g., committed valued action), including vulnerable self-disclosures as emphasized by the IPM. Cordova and Scott (2001) described these self-disclosures as courageous because they occur in a context of a heightened probability of punishment (e.g., rejection, criticism, embarrassment) without which intimacy would not occur. Kernis and Goldman (2006) documented the importance of authenticity in disclosure, which predicts higher relational satisfaction. Lopez and Rice (2006) defined this authenticity as “intimate risk taking” and found that it was the strongest predictor of relationship satisfaction among a number of alternate predictors (e.g., gender, self-esteem, adult attachment).

Consistent with self-determination theory (Ryan & Deci, 2002), which describes the interplay of relational and non-relational goal pursuits, Tsai et al. (2009) encourage courageous risk-taking behavior that is not necessarily intimate or relational in nature, such as any courageous self-expression or behavior that is experienced as risky but important because it is consistent with one's values, identity, and life-goals. These non-relational courageous expressions predict relational closeness, well-being, and attachment security (La Guardia et al., 2000, Patrick et al., 2007) and were important to include with vulnerable self-disclosures in our model and measurement strategy.

Tsai et al. (2009) emphasized the term “love” to describe key qualities of one's response to another's courageous behavior, consistent in many ways with Rogers (1951) client-centered therapy and with the IPM's term responsiveness, which describes Person B's response to Person A's vulnerable self-disclosure. Multiple findings identify components of responsiveness as important to intimacy, including providing responses that are experienced as understanding, validating, and caring (Canevello & Crocker, 2010), match the speaker's emotional versus instrumental needs (Cutrona, Shaffer, Wesner, & Gardner, 2007), do not undermine Person A's self-efficacy (Maisel & Gable, 2009), and express safety through synchronous emotional expression and mirroring. Longitudinal research shows that the perception of one's partner as responsive is essential to intimacy (Laurenceau et al., 1998, Laurenceau et al., 2005) and experimental research documents that responsiveness to vulnerable self-disclosure is required for the development of closeness and, as per FAP's model, functions as a reinforcing process (Haworth et al., 2015).

Most previous attempts to measure the constructs of the IPM have been limited in either their precision, scope, or depth. For example, regarding their scope, several measures are either single-item measures developed for specific studies (e.g., Laurenceau et al., 1998, Laurenceau et al., 2005; Maisel & Gable, 2009) or focus on only one IPM process (e.g., Canevello & Crocker, 2010; Pansera & La Guardia, 2012). However, research suggests that all three elements (awareness, courage, and responsiveness) are foundational to the development of intimacy. Other measures such as the Friendship-based Love Scale (FBLS; Grote & Frieze, 1994) and the Personal Assessment of Intimacy in Relationships Inventory (PAIR; Schaefer & Olson, 1981) have limited depth in that they were specifically designed for and validated on romantic partnerships, while the Relational Health Indices (RHI; Liang et al., 2002) was designed for non-romantic relationships. Extant measures differ in other ways, for example with respect to their target. The Miller Social Intimacy Scale (MSIS; Miller & Lefcourt, 1982), for example, requires the respondent to answer each item with respect to a particular individual; the Functional Analytic Psychotherapy Intimacy Scale (FAPIS; Leonard et al., 2014) asks the respondent to answer with respect to a particular individual during a one-week window. To our knowledge, no self-report measures exist that map onto the processes elaborated in the IPM that (a) define these processes as acts-in-context amenable to intervention and (b) balance the contextual behavioral values of precision, scope, and depth.

In this research, we were interested in developing a self-report measure of intimacy that is consistent with previous FAP conceptualizations and would capture the primary processes of the IPM (i.e., is precise with respect to its target) as applicable across a variety of relational dyads (i.e., has scope) and that reflects the most current findings from relationship science (i.e., has depth and integrates interdisciplinary findings). We conceptualized our constructs as skills amenable to change in FAP or other relationally oriented psychotherapies that could generalize to a wide range of situations and relational contexts. The following paper describes the development, validation, and cross-validation of the Awareness, Courage, and Responsiveness Scale (ACRS; Studies 1–3), examines its functioning in a non-clinical sample of dyads (Study 4), and examines its predictive validity in a clinical sample (Study 5). All study procedures were approved by the University of Washington Institutional Review board.