5 利用治疗关系培训慈悲

利用治疗关系培养同情心

想象一下，如果你想学习冲浪。你会选择那些只谈论你上周的冲浪尝试以及下周可以尝试做些什么不同的课程吗？还是会选择让你有机会在教练面前练习冲浪，以便她可以在你练习新动作时指导你的课程？此外，你会选择那些主要讨论冲浪理论的课程，还是大部分时间都用来实践的课程？最后，你会选择一个技术娴熟的冲浪者作为老师，还是一个读过许多冲浪书籍、观看过重大比赛并熟悉术语但从未能站在冲浪板上的老师？

在治疗中，就像冲浪一样，最好的学习是通过体验获得的，最有效的练习是在治疗师能够即时观察和指导的情况下进行的，而这位治疗师本身具备她被雇佣传授的技能。因此，在训练来访变得更加同情和自我同情时，疗程中的实践是关键，而治疗师自身的同情心和自我同情心也是必不可少的。

自我批评和自我羞愧是与自己和个人经历互动的有害形式。从接受与承诺疗法（ACT）的角度来看，它们是由各种不灵活性过程造成的。与自我评判性思维融合以及对厌恶体验的不接纳，会强化一种局限于过去和现在负面内容的自我感觉。难以接触价值观和参与有价值的行为也会削弱自我价值感，使来访更加陷入内心的挣扎，陷入无效行为、自我贬低和个人历史耻辱的痛苦循环中。通过增加灵活性，来访可以学会如何驾驭负面思想、厌恶体验和自我贬低故事的波涛，从而朝着有价值的生活方向前进。

在很大程度上，治疗过程中发生的事情都是在治疗关系的背景下发生的。正如上面冲浪的例子所示，无效行为最好直接观察，而不是通过来访重构的口头叙述来过滤。同样，有助于来访进步的技能最好在疗程中练习，让临床医生能够指导来访采取更加同情和自我同情的态度。这种对当下（治疗）时刻的重视非常适合运用操作性学习原则，这些原则侧重于提供即时的结果。本章将描述如何在疗程中使用操作性学习原则，帮助来访熟练地驾驭自我批评的思想和羞耻的自我导向情绪，以实现有价值的生活。

自我同情作为同情的条件

从接受与承诺疗法（ACT）的角度来看，同情和自我同情是高度相关的。真正地同情他人意味着真正地自我同情，反之亦然（Hayes, 2008c）。无论是对他人的同情还是自我同情，都意味着拥抱困难的情绪，注意到评判性的想法而不被其纠缠，连接一个灵活的观察自我的感觉，并温柔地将个人的历史带入到与深层价值观相联系的生活中。此外，实践同情和自我同情是治疗师技能的核心部分。就像对来访一样，这些品质最好通过培养同情心的灵活性以及对任何可能出现的困难体验和自我评判给予善意和自我验证来培养。

使用正向强化训练同情

功能情境方法根植于学习理论原则，特别是操作性学习的原则。无数实验表明，正向强化是行为修正中最有效的工具。正向强化是指两个事件之间的关系，其中一个事件在某个行为之后发生，从而增加了该行为在未来发生的概率。动物模型显示，强化事件的有效性取决于它与行为的时间接近程度。强化物越接近行为，它在未来使该行为更有可能发生的效果就越强。重要的是要记住，正向强化和负向强化表示一种算术运算，即后果被添加到或从环境中减去，而不是强化物本身具有正向或负向的价值或感觉。例如，有时父母会对孩子的行为进行长时间的批评，结果发现被批评的行为实际上增加了。在这种情况下，批评起到了正向强化的作用，尽管这对孩子和父母来说可能感觉是负面的。当应用于非语言动物时，正向强化相对简单，而动物在影片中完成的奇妙复杂行为证明了它的有效性（Pryor, 2009）。在这种情况下，强化物包括物理或生理事件。然而，当涉及到言语人类时，衍生关系反应使得强化变得更加复杂。通过衍生关系反应，内在体验（如身体感觉、情绪或图像）和象征性刺激（如词语或想法）的功能会以复杂的关系网络所规定的方式进行转换，这些网络本身是由独特且复杂的个体历史产生的。

一旦衍生关系反应起作用，就变得更难识别在哪些情境下某一事件会起到强化作用。例如，对于一位来访来说，赞美可能会增加被赞美的行为，而对于另一位来访来说，赞美可能会起到惩罚（即减少）行为的作用。在后一种情况下，很可能是来访的言语历史已经将赞美的功能转变为惩罚性的后果。这并不否定正向强化的力量或有效性，但它确实使临床医生的任务更加复杂。因此，临床医生特别需要注意他们的行为可能对来访产生强化或惩罚功能的潜在影响。

功能分析心理治疗与同情

功能分析心理治疗（FAP）对于那些希望在来访中培养和训练同情心和自我同情心的临床医生来说特别具有吸引力。它既可以作为模型，也可以作为一系列技术，将操作性学习原则应用于治疗，特别是应用于治疗关系。FAP关注临床相关行为（CRB），即在疗程中表现出的、与疗程外行为功能相似的行为。临床相关行为主要分为两类：

CRB1：表示来访的有问题行为
CRB2：表示相对于CRB1有所改善的行为

FAP邀请治疗师和来访注意CRB1，并让来访在一个强化环境中练习CRB2：即治疗关系。临床相关行为是根据个体情况进行定义的。例如，表达批评可能是一个难以自信的来访的CRB2，但对于一个因经常批评他人而导致人际关系受损的来访来说，这可能是CRB1。在FAP中，治疗师培养对来访行为的意识，有勇气邀请来访注意到何时可能存在临床相关行为，并且在密切注意治疗师行为的强化（或惩罚）功能的同时，充满爱意地强化CRB2。治疗师提供治疗关系作为一个神圣的空间（Tsai & Kohlenberg, 2012），这是一个安全的情境，来访可以在其中尝试新行为而不用担心受到过度惩罚的后果或关系破裂。这种充满爱意和强化的情境非常适合帮助来访处理自我羞愧和自我憎恨，同时探索同情心和自我同情心的实践。

FAP使用行为修正工具来促进CRB2。其中一个最重要的工具是通过逐步逼近进行塑造。在塑造过程中，首先观察现有的行为库，并寻求强化朝向期望行为的最微小步骤。当进一步的步骤被采取时，新的步骤会被优先强化，而不是之前的步骤，如此类推，直到行为完全形成。因此，在以表达批评思想为CRB2的例子中，治疗师最初会强化对她行为的任何负面反应，然后是任何形式的批评言语，最后只强化那些可能被他人接受的批评（例如，包括对被批评者的同理心验证）。一旦行为准备好“上路”，治疗师就会鼓励并促进改进后的行为在治疗关系之外的来访生活中泛化。

FAP的五条规则

Kohlenberg和Tsai（1991）提出了五条临床规则来指导FAP的实践。最近，他们将FAP描述为基于觉察、勇气和爱（Tsai等人，2008）。正如你将看到的，这些品质与FAP的五条规则高度相关。

规则1：注意CRB。 FAP邀请治疗师和来访识别CRB。注意CRB意味着对来访行为的觉察。这种觉察包括存在感、正念和共情连接。

规则2：引发CRB。 FAP要求CRB必须在场，以便对其进行处理。引发CRB需要治疗师和来访的勇气。双方都被邀请保持诚实和真实，承担风险，展示脆弱性，提出大胆的问题，并温和地面对回避。

规则3：对CRB做出应答。 治疗师寻求强化CRB2，同时适当地回应CRB1。这本质上是富有同情心的，并且是爱的表现。通过真正关心并温柔地照顾来访，不懈地支持他们，真诚地认可他们，在他们的困难和进步中深刻地欣赏和尊重他们，治疗师可以最有效地强化改进的行为，并帮助来访改变问题行为。

规则4：注意你的行为的强化效果。 这一条规则要求治疗师更加觉察，观察她的干预是否起到了强化作用。在这里，愿意轻视解释并询问来访她的行为对他们产生了什么影响是有帮助的。

规则5：促进改进行为的泛化。 最后这条规则意味着治疗师要帮助来访认识到CRB的功能与生活中的行为功能之间的相似性，并鼓励在疗程外遇到类似前因时适当冒险。

应用这些规则鼓励来访更加留心当下自己的行为，并帮助他们在注意到自己难以应对的行为导致进一步自我批评和羞愧时将其识别为CRB1。促进对这些行为的正念，并将其视为可教的时刻，可以是促进同情和自我同情的一种强有力的方式。

最后，这些规则并不是僵硬的规定，而是更像是一种温和的邀请，尝试新的行为。如果你通过这样做接触到了更深层次和更有效的治疗关系这样的强化物，你可能会发现自己经常使用它们。

临床案例：注意自我批评的思维并从中解脱

自我批评的思维往往非常活跃，并会利用一切可能的机会来加剧自我憎恨。在下面的例子中，Sam被邀请在疗程之间的一周内注意到他为接近对他重要的人和事物所采取的行动，以及他为了逃避不想思考或感受的事情所采取的行动。

治疗师：那么，你注意到了什么？来访：我从来没有意识到我有那么多逃避的行为。这太可悲了。[CRB1] 治疗师：我注意到你在贬低自己。当你和其他人在一起时，你也会这样贬低自己吗？（应用FAP规则1：注意CRB，并提供疗程内外行为之间的平行对比。）来访：是的，我总是因为缺乏自尊而贬低自己。（确认CRB1。） 治疗师：那么对自己严厉是一种接近行为还是逃避行为？（应用FAP规则1：注意CRB。）来访：我想是逃避行为。……看，我又来了！[CRB1] 治疗师：哎呀！这很严厉。那么，注意到你的接近行为和逃避行为——这是接近行为还是逃避行为？（应用规则2和3：引发CRB和对CRB做出应答。）来访：接近？[CRB2] 治疗师：我注意到的是，你很容易被自己的批判性思维所困，然后就像你自己拿起棒球棒开始打自己一样。（应用规则1，但错过了应用规则3：强化CRB2的机会。）来访：是的。你看？我告诉过你。[CRB1] 治疗师：（做了一个手势，好像要去拿椅子后面的想象中的棒球棒。）它又来了！（应用规则3：对CRB做出应答。）来访：（笑）好的，我现在看到了。[CRB2] 治疗师：那么，当你的心灵递给你棒球棒时，你能注意到并告诉我们吗？（应用规则2：引发CRB。）来访：我想我可以做到。[CRB2] 治疗师：那么告诉我这一周里你有哪些接近行为。（应用规则2和3：引发CRB和强化CRB2。）来访：我给父母打了电话，带儿子去散步，还和妻子讨论了一起出去吃饭的事。[CRB2] 但是，其实并没有做什么……[CRB1] 哦，棒球棒又来了！[CRB2]（笑。） 治疗师：如果你不拿起棒球棒，你会怎么说？（应用规则2和3：引发CRB和强化CRB2。）来访：我很高兴做了这些事情，我觉得很自豪。[CRB2] 治疗师：很好，Sam。你觉得这次交流怎么样？（应用规则4：注意治疗师行为的强化效果。）来访：一开始很难，但我认为我掌握了技巧，在拿起棒球棒之前就能抓住自己。而且确实有所不同。 治疗师：我也很高兴你能注意到你的接近行为。（应用规则3：强化CRB2。）你愿意在接下来的一周继续这样做，即使你的心灵试图联合起来对付你吗？（应用规则5：促进改进行为的泛化到疗程外的生活。）

在这个交流中，治疗师专注于当下的过程，并邀请来访也这样做。治疗师提供了疗程内外行为之间的平行对比。当来访提供解释（缺乏自尊）时，治疗师没有陷入内容，而是继续关注CRB，逐渐塑造一个CRB2，即注意到对自己严厉的CRB1，并在下一句话中强化命名接近行为而不贬低它们的CRB2。

在疗程中塑造同情心

FAP治疗师的态度是对她的来访、他们的痛苦以及他们的学习历史抱有深切的同情。将行为视为学习历史的结果，她不会让来访为他们的痛苦、想法或情绪负责，并准备好陪伴他们度过痛苦，走向更可行的行为。认识到行为是学习历史的结果，她明白提供一个安全的学习环境（即治疗关系）可以帮助来访在疗程之外选择更有效的行为，为他们的关系和生活设定新的方向。

FAP鼓励治疗师自然地强化来访，注意她的心如何对来访的改善行为作出反应，并让他们知道她是真诚的感受。正如ACT一样，FAP治疗师也向来访的痛苦敞开心扉，深愿看到这种痛苦减少，并勇敢地站在来访身边与他们一起面对痛苦。FAP治疗师承诺以真诚和善意回应她的来访，包括愿意与他们一起哭泣。

临床案例：使用FAP原则促进同情心

下面的例子展示了治疗师如何使用FAP原则来促进同情心。Joe是一位教师和社区活动家，深受深刻的自我羞愧感困扰。尽管他获得了博士学位，并且是社区中受人尊敬的一员，但Joe一生都有一种无法动摇的冒名顶替者的感觉，认为自己不配得到别人的尊重。他的社区参与是基于他的价值观，但他总觉得自己不如他的同龄人：不够聪明、不够英俊、读书不多。直到今天，他认为自己获得博士学位是一种侥幸，并确信自己在研究生院时是同辈中最愚钝的一个。现在六十岁了，他感到自己的认知能力正在下降，并抱怨注意力不足和记忆力减退。

来访：我认为人们应该更加努力工作。[CRB1] 治疗师：你确实一生都在努力工作，不仅是在教学方面，还有作为社区活动家的工作。（应用规则2：引发CRB。）来访：（看起来不舒服。）其实我没有那么努力工作，我只是因为宗教信仰才参与社区活动。[可能是CRB1，严厉地评判自己和他人] 治疗师：我注意到你的内心对自己和他人都很严厉。这种情况只是在这里发生，还是在其他地方也会出现？（应用规则1：注意CRB，并提供疗程内外行为之间的平行对比。）来访：嗯，你知道，这就是我的教育方式。我们过去很辛苦。但即便如此，我还是最懒散的那个。[CRB1] 但是，是的，我妻子总是说我对我女儿太严厉了。不过，我对孙女们尽量特别好。她们真是太可爱了！[CRB2，用于塑造] 治疗师：很高兴听到你对孙女们很温柔。想到你要生活在这样一个批判性思维的重压下，让我感到难过。我想知道，在你内心深处，你想成为的人是否会说出你头脑中最苛刻的想法。我是说，我知道宗教对你来说意义重大，我想问的是：如果你可以选择，你会选择被看作是一个严厉的人，还是一个更有同情心的人？（应用规则3：强化CRB2，并试图进一步塑造CRB2。）来访：有同情心吧。[CRB2，用于塑造] 治疗师：如果没有人知道，或者这不仅仅是名声的问题，而是你对他人真正的影响，你会选择与你严厉的思维保持一致，还是采取一种更有同情心的立场？（应用规则3：旨在进一步塑造CRB2。）来访：同样的，我会选择有同情心。[CRB2] 治疗师：听到你说这些话非常感人，尤其是当我知道你的内心随时准备着攻击你的时候。（应用规则3：自然地强化CRB2。）我们能不能利用这段时间帮助你按照你希望的方式，以更富有同情心的方式行事呢？这样会不会有所改变？（应用规则2和3：引发和强化CRB2。）来访：你觉得我能做到吗？[可能是CRB2] 治疗师：我相信你能做到，而且我会在这里帮助你。（应用规则3：强化CRB2。）

在对话中，治疗师专注于在疗程中出现的临床相关行为，而不是来访关于疗程外生活的描述。通过密切关注来访的进展并引入价值观，治疗师能够引导他采取更具同情心的立场，并选择同情作为有价值的方向。

帮助来访接受他人的同情

治疗关系在许多方面都是独特的。与“正常”的关系不同，它不是为了自身而存在；这是一种专业关系。然而，与其他专业关系不同，由于其性质——来访将他们最困难的个人问题和脆弱性带入这个空间——这种关系不能仅限于表面的关系，在这种关系中，治疗师作为一个人隐藏在职业距离的表象之后。FAP鼓励治疗师向来访敞开心扉，建立一种深度不亚于甚至超过外界生活中的关系。然而，治疗关系仍然显著不同于其他关系，因为它始终服务于来访的治疗目标和最佳利益。在这种关系中，治疗师可以利用自己的反应来塑造来访更富有同情心的行为。

具有根深蒂固的自我批评和羞愧历史的来访，可能是由于童年创伤的结果，通常会与最痛苦形式的自我憎恨、羞愧和内疚融合在一起。身体或性虐待的历史往往会导致受害者感到内疚。当虐待是由照顾者实施时，受害者常常感到自己是罪有应得，并背负着沉重的内疚和羞愧负担。这种羞愧和内疚使得真正接受来自他人的真诚关怀和同情变得极其困难。在这种情况下，建立深刻的治疗关系可以提供一个环境，使来访逐渐开放自己，首先从治疗师那里接受同情，然后逐步激发对自己本身的同情。

临床案例：使用治疗关系塑造接受和同情

在下面的摘录中，治疗师邀请他的来访联系过去引发羞愧的情境。Clare小时候多年来遭受父亲的身体和情感虐待。她一直背负着与虐待相关的沉重内疚和羞愧负担。尽管她已经向家人提到过虐待，并且很久以前就疏远了父母，但她仍然难以接触围绕自己经历的复杂感受。Clare和她的治疗师已经在人际问题上工作了六个月多，现在她觉得准备好处理虐待的问题了。

来访：

我感到非常内疚，因为我感觉自己利用了自己的身体。从那以后我一直恨它。

治疗师：听到这个我很伤心。你愿意闭上眼睛，回忆一下你童年时让你感到羞愧的一个场景吗？

来访：我可以试试。

治疗师：你在哪儿？多大了？

来访：我十二岁，在父母的客厅里。我父亲在那里。

治疗师：你能看到周围有什么？

来访：我能看到沙发。我能看到墙上的画和透过凸窗照进来的阳光。我看到我的父亲坐在他的躺椅上。他在看报纸。他没有注意到我。

治疗师：你能注意到你的感受是什么吗？（停顿）你在想什么？（停顿）你会怎么做？

来访：我感到无聊。我……（停顿）我在摆出挑逗性的姿势。（开始轻轻地抽泣）我感到非常羞愧！这真的很难！

治疗师：我们能不能在这里暂停一下？我希望你能留在那个十二岁的克莱尔身边。你愿意陪她并感受她的感受吗？

来访：（轻声说）好的……

治疗师：想象我们可以一起去见她。你可以看到她所看到的，听到她所听到的，感受到她所感受到的。（停顿）我们可以问她，“你现在需要什么吗？”

来访：（用小女孩的声音说）我只是想玩。我想出去玩。我想见到人，开心地玩！（哭泣）

治疗师：是的，你只是想出去玩。你想见到人。这些是一个十二岁女孩完全正常的需要。你需要关注。这也是一个十二岁女孩完全正常的需要。（停顿）而你知道唯一能得到关注的方式就是你正在做的事情。

来访：（哭泣）是的。

治疗师：克莱尔，你觉得我们应该谴责那个小女孩吗？

来访：不，当然不应该。……她不知道有更好的方法。

治疗师：我们可以做些什么来帮助她？

来访：我可以拥抱她，告诉她我爱她吗？

治疗师：让我们这样做吧。给她一个拥抱，告诉她你爱她。（眼中含泪，显然被来访的痛苦所感动）她只需要被看见、被爱，并感到安全。还有其他话可以对她说吗？

来访：只要告诉她我爱她，这不是她的错。（哭泣）

治疗师：不是她的错。这只是她知道如何做的方式。（停顿）克莱尔，慢慢来，当你准备好时，你可以和我一起回到这个房间，睁开眼睛。

来访：（睁开眼睛）

治疗师：我非常感动，你有勇气和我一起回到那里。你现在感觉怎么样？

来访：我信任你。我觉得你是一个好人。这是我第一次意识到我不必因为发生的事情和我所做的事而恨自己。我当时不知道更好的方法。这些事情我理智上都知道，但这是第一次我能真正感受到它。

治疗师：你怎么可能知道得更好呢？经历过你那种经历的人怎么可能知道得更好呢？

来访：是的。

治疗师：你觉得现在当内疚感出现时，你能回去给那个小女孩她所需要的支持和爱吗？

来访：我可以试试。至少现在我知道我不必恨我自己和我的身体。

利用治疗关系训练同情视角

结合以同情为中心的ACT（接受与承诺疗法）和FAP（功能性行为分析），可以产生非常强大的干预措施，让来访通过换位思考直接体验同情，最终达到自我同情。随着他们更好地意识到在疗程中变得更加同情和自我同情时自己做了什么，他们在治疗关系之外也更有可能这样做。

从ACT的角度来看，换位思考涉及邀请来访尽可能地从他们当前的经历转换到一个不同的时空视角，尽可能充分地接触他们过去某时某地的经历或他人的经历。采用他人的视角是同理心定义的一部分。在不同时间和地点采取自己的视角可以帮助培养对自己在那些情境中的同理心和同情心。结合这些不同的换位思考方面，可以为临床医生提供一种强有力的手段来训练同情心和自我同情心。

临床案例：利用治疗师的经验引发换位思考

在这个例子中，我们回到Joe的故事，他是一个教师和社区活动家，担心认知衰退和注意力缺陷。这次对话之前已经过去了两周，而Joe的治疗师迟到了十五分钟。这是因为他记错了Joe的预约时间，对他来说这种情况相当常见。在接下来的对话中，他们正在讨论Joe的人际风险日志，这是一个受FAP启发的练习，要求来访每天记录至少一次有意承担的人际风险。

来访：我注意到你今天迟到了。这让我很生气，因为我本来就很紧张了。 治疗师：我非常抱歉让你感到不安。我知道迟到可能会让人感到不被尊重。你能告诉我更多关于你的感受吗？来访：我只是觉得你不重视我的时间。我一直在努力准时，但你却迟到了。 治疗师：我能理解为什么你会这么想。如果我是你，我可能也会有同样的感受。事实上，我确实犯了一个错误，记错了你的预约时间。我想知道，如果我们能从我的角度来看看这件事，会怎么样？想象一下，如果你是我的话，你会怎么看待这个情况？

来访：嗯，如果是我的话，我会感到很尴尬，因为我犯了错误。而且我会很着急，因为我知道这会影响别人。 治疗师：是的，这就是我当时的感觉。我感到很尴尬，并且很着急。我非常在意我的工作和我的来访。那么，你现在有什么想法呢？来访：我现在明白，你并不是故意要迟到。你也有你的困难，就像我一样。 治疗师：正是这样。我们都可能犯错，而且我们都有我们的挑战。你能试着从这种视角来看待你自己的情况吗？比如，当你对自己的表现感到不满时，你能试着从一个更宽容的角度来看待自己吗？

来访：我想我可以试试。有时候我觉得自己必须完美无缺，但我现在意识到，每个人都会犯错。 治疗师：非常好。当我们能够对自己和其他人抱有更多的同情心时，我们就能更好地应对生活中的挑战。你愿意尝试在接下来的一周里，当你对自己过于苛刻时，试着从一个更宽容的角度来看待自己吗？来访：好的，我会试试看。

治疗师：你的人际风险日志记录得怎么样了？

来访：大约一个星期里，它确实很有效，我感觉自己能够与他人建立联系。但后来我意识到这一切都是表面的，因为我把一个认识的女士的名字叫错了。我总是犯同样的错误，比如忘记别人的名字。在我这个位置上，这是不可接受的。我永远无法真正与他人建立联系。

治疗师：哦，是啊，我们都会犯错。……五分钟前我迟到了十五分钟。这正是我会觉得自己是个笨蛋并且非常自我批判的那种情况。但当我到达时，你对我非常好，立刻让我感到轻松。

来访：（笑）其实我当时确实想过，你是故意迟到的，就是为了向我展示，我不应该因为一个小错误而严厉地评判你！

治疗师：不，那真的是个错误。我搞砸了。你知道，这种错误对我来说太常见了。但真的，我立刻感到了你的接纳——以至于我那种在这种情况下对自己非常苛刻的习惯似乎消失了。

来访：嗯，每个人都会犯错，而且你还有其他优点……

治疗师：当然，但这是一个我经常犯的错误，所以特别有意义的是，尽管你已经几次经历过这种情况，你仍然能以如此善意的方式接受我。（停顿）Joe，我想请你想象一下，用你刚才看我的眼光来看待自己。但现在，我希望你能想象自己被传送到那个你叫错女士名字的情境中。当你这样做时，试着从一点距离外观察自己。慢慢来……（停顿）你看到了什么？

来访：（停顿）嗯，我看到一个善良的人。他想帮忙，却把名字叫错了。……一个有弱点的人。我看到一个我很喜欢的人，一个对他来说并不容易的人……（停顿。他的脸柔和下来，看起来有些悲伤。）

治疗师：是的，Joe。这个人就是我所认识的Joe：一个有弱点的人，但也是一个热心肠、按价值观生活的人。一个让我感动的人……

来访：是的，确实如此。

治疗师：我必须告诉你，我现在有点泪目。这是我们开始合作以来，我第一次看到你给自己一些你对他人所给予的同情心，而这正是让你选择这个职业的原因。仿佛你终于允许自己看到自己是一个和其他人一样的普通人……

来访：是的，确实如此。（停顿，然后笑了）但你知道，我的头脑并不认同。它还在试图告诉我，我不配因为我的错误而被原谅。

治疗师：当然，这就是头脑会做的事情。你能描述一下你刚才从那个更有同情心的角度看待自己时做了什么，感觉如何吗？

来访：嗯，我放松了我的肩膀，放松了我的胸膛，我觉得我的心稍微打开了……（停顿）这很难说清楚。我在想是不是现在在重构这些感受……

治疗师：虽然难以表达，但你的确知道怎么做。看看你能否再做一次。那么你站在那位女士面前，把她的名字叫错了。好的，放松你的肩膀和胸膛……

来访：（停顿）好的，我明白了。（停顿，然后笑了。）

治疗师：谢谢你尝试这样做。我想邀请你在接下来的一周里注意自己是否能在某些时候做到这一点，并把它记入你的人际风险日志，可以说是对自己的一种人际风险。

来访：好的，我会这么做的，即使我还不太确定要怎么做。

这段对话标志着乔在治疗中的一个转折点，这是他第一次以深切同情的方式对待自己。他不仅仅是对自己和他的记忆失误说了一些同情的话；而是从情感上做到了这一点。当治疗师看到他明显变得柔和时，他感到触动并表达了这一点。

在这次交流中，治疗师邀请乔通过用看待治疗师错误时的视角来看待自己在产生羞愧和自我批评的情境，从而转变视角。这里的关键在于从体验的角度而不是理智的角度邀请视角的转换。随后，治疗师通过公开分享乔的自我同情行为如何影响了他（CRB2），以及邀请乔注意到他是如何将同情指向自己的，来强化乔的新行为，从而促进这种行为在治疗关系之外情境中的泛化（FAP规则5）。

正如讨论的那样，在ACT模型中，灵活的视角转换是心理灵活性的一个关键组成部分。根据我们的经验，视角转换练习通常会引发来访的自我同情。例如，邀请来访体验性地回到特别痛苦的童年事件中，去见那时的自己，并对那个受伤或害怕的孩子说些什么或做些什么，通常会引发对该孩子及其痛苦更加同情的行为，就像与克莱尔的对话中所展示的那样。

临床案例：使用“自我作为背景”训练更具自我同情的态度

其他视角转换的方法也可以帮助来访以更加同理心和自我同情的态度面对当前的生活困难，如与迈克的对话所示。迈克正在接受严重强迫症（OCD）的治疗，伴随强烈的羞耻感和自我贬低。迈克在ACT模型中取得了很好的进展，特别是他已经非常擅长使用矩阵来整理他的经历。由于将经历分类到矩阵的不同象限意味着能够观察自己的经历，而不是与其融合，这种能力表明了采取观察者视角的能力。

治疗师：我对你在注意到你的“趋近”和“回避”行为以及五感体验与内心和心理体验之间的区别方面取得的进步印象深刻。

来访：是的，但当我晚上睡觉前检查炉子时，还是会卡住。

治疗师：我们现在来看看这个问题。想象一下，你现在坐在我对面的你，可以以某种方式传送到今晚你在厨房里的自己面前。有没有什么你可以对自己说的话，可以帮助你应对强迫症和强迫行为？慢慢来，一旦找到了要说的话，就像你在厨房里遇到那个有强迫想法和检查冲动的自己一样说出来。

来访：好吧：“别傻了！你知道这没用。”

治疗师：在厨房里的你会怎么接收你说的话？

来访：不太好。

治疗师：有效吗？

来访：没有。

治疗师：你是用什么样的语气说的？

来访：严厉的，我想。

治疗师：当你在厨房里卡住时，你需要被这样说话吗？

来访：我需要被更温柔地对待。

治疗师：那么，你现在和我在一起时，能否更温柔地对那个在厨房里因强迫症而卡住的自己说话？你能说什么？

来访：（停顿）我可以这样说：“我知道这些想法让你感到非常焦虑，很难受。”

治疗师：在厨房里的你会怎么接收这句话？

来访：感觉好一些。我觉得被理解了。好像有些东西变得柔软了一些。

治疗师：你还可以说些什么？

来访：我可以鼓励自己去做一些对我来说重要的事情，而不是进行一系列的检查。

治疗师：在厨房里的你会怎么接收这个建议？

来访：我能听到。感觉好像我可以做到。

治疗师：还有其他可以做的事情吗？

来访：我可以去抚摸我的猫，花时间陪我的伴侣。

治疗师：这对你会重要吗？

来访：是的，因为检查炉子是为了确保我的伴侣和我的猫不会因为我引起的火灾而丧生。所以这实际上是为了照顾他们。

治疗师：听起来不错。你现在能回到这一刻吗？看到你在这里和现在的自己与在厨房里的自己之间的对话，我感到很感动。特别是你随着对话的进行，对自己越来越友善，并转向对你来说重要的事情。我感觉到的是，在情况越困难的时候，你越需要被温柔地对待，并且你的困难情绪需要被认可。你觉得这合理吗？

来访：是的，我想这是真的。我确实有对自己苛刻的倾向。

治疗师：那么我们继续练习像这里一样更温柔地对待自己，怎么样？

来访：那会很好。

治疗师：我想知道，当你在厨房里时，你认为能够像刚才那样对自己说话的概率有多大？

来访：可能70%吧。

治疗师：我很期待听到你注意到的情况。

治疗关系中的同情

总之，本章讨论了临床医生如何最大化利用治疗关系，并使用操作性学习原则来帮助来访培养同情心，转变他们对自我批评的想法和羞耻的自我导向情绪的反应。我们探讨了自我同情作为同情的前提条件，并强调了相关的行为原则。在这些原则中，我们研究了通过正强化来培养同情和自我同情，应用功能性行为分析（FAP）的原则来培养同情，使用解离技术应对基于羞耻的自我批评，以及通过疗程中的互动具体塑造同情。我们还回顾了帮助来访接受他人同情并最终将这种同情转向自己的治疗过程。

利用FAP的原则，治疗关系可以提供一个理想的环境，使人们能够即时注意到自我批评和羞耻，并温和地塑造对自己和他人的更友善的行为。从接受与承诺疗法（ACT）的角度来看，同情和自我同情是高度相关的，两者都是无价的。在本章中，我们展示了治疗关系如何以不同方式促进对自我和他人的更具同情心的行为。FAP所强调的成分和过程扩展了临床医生的意识，在当下塑造同情和自我同情，同时也鼓励来访将这些品质和行为融入日常生活中。这通过训练灵活的视角转换来实现，包括在面对引发羞耻的情境或刺激时，向自己和他人表达同情。

本章知识点阐述

知识点进一步阐述

实践的重要性：

体验式学习：与单纯的理论讲解相比，实际操作和体验更能促进学习。在治疗中，通过实时的互动和练习，来访可以更好地理解和内化新的技能。
即时反馈：治疗师能够在来访练习时提供即时反馈，帮助他们纠正错误，增强正确的行为模式。

治疗关系的作用：

安全和支持：良好的治疗关系为来访提供了一个安全和支持的环境，使他们能够更开放地探索自己的内心世界，并尝试新的应对方式。
示范作用：治疗师通过自身的行为和态度展示同情心和自我同情心，为来访提供了一个积极的榜样。

操作性学习原则的应用：

即时奖励：通过在来访表现出同情或自我同情的行为时给予即时肯定，可以增强这些行为的发生频率。
逐步练习：治疗师可以通过设计一系列逐步递进的练习，帮助来访逐步掌握新的技能，并在实践中不断改进。

自我批评与自我羞愧的处理：

识别模式：帮助来访识别和理解他们的自我批评和自我羞愧模式，认识到这些模式是如何影响他们的行为和情绪的。
解构与重新构建：通过解构来访的自我评判性思维，帮助他们看到这些思维的功能，并重新构建更加积极和建设性的自我对话。

灵活性的培养：

接受与承诺：鼓励来访接受自己的负面情绪和体验，同时承诺朝向自己的价值观行动，从而打破无效的行为循环。
价值观澄清：帮助来访明确自己的核心价值观，并根据这些价值观制定具体的目标和行动计划，提高生活的意义和满足感。

通过以上方法，治疗师不仅能够帮助来访减少自我批评和自我羞愧，还能培养他们的同情心和自我同情心，使他们在面对生活中的挑战时能够更加灵活和坚韧。这种综合的方法强调了治疗关系的重要性和实际操作的价值，为来访提供了一个全面的支持系统。

知识点进一步阐述

同情与自我同情的关系：

相互关联：同情和自我同情在本质上是相互关联的。真正的同情他人需要首先对自己有同情心，反之亦然。这意味着在帮助他人之前，先学会善待自己。
情感接纳：同情和自我同情都涉及接纳困难的情感，而不是逃避或否认它们。这种接纳有助于建立一个更加灵活和适应性强的自我形象。
价值观导向：同情和自我同情还意味着将个人的历史与深层价值观联系起来，从而在生活中找到意义和方向。

正向强化的基本原理：

定义：正向强化是指在一个行为之后提供某种奖励，从而增加该行为在未来再次发生的可能性。
时间接近性：强化物与行为之间的时间间隔越短，强化效果越明显。及时的反馈可以显著提高行为的重复率。
正向与负向强化的区别：正向强化是通过添加积极的后果来增加行为的概率，而负向强化是通过移除不愉快的后果来增加行为的概率。两者都是增加行为的发生率，但机制不同。

正向强化在治疗中的应用：

即时反馈：在治疗过程中，治疗师可以通过即时的正面反馈来增强来访积极的行为模式。例如，当来访表现出同情或自我同情的行为时，立即给予肯定。
个性化策略：每个来访的情况都是独特的，同样的强化物对不同的来访可能有不同的效果。治疗师需要根据来访的具体情况来调整强化策略。
避免意外后果：有时，看似负面的反馈（如批评）也可能无意中起到正向强化的作用。治疗师需要仔细观察并调整自己的行为，以确保达到预期的效果。

衍生关系反应的影响：

复杂性：在言语人类中，由于衍生关系反应的存在，强化变得更为复杂。内在体验和象征性刺激的功能受到复杂关系网络的影响，这些网络由个体的独特经历构成。
个体差异：同一个强化物对不同的人可能有不同的效果。例如，赞美可能对一些人是正向强化，而对另一些人则是负向强化。治疗师需要了解每个来访的背景和历史，以便更好地理解他们的行为模式。
细致观察：治疗师需要密切注意他们行为对来访可能产生的强化或惩罚功能，以确保干预措施的有效性和适当性。

通过以上方法，治疗师不仅能够有效地使用正向强化来促进来访的积极行为，还能更好地理解和处理复杂的个体差异，从而提供更加个性化和有效的治疗方案。

知识点进一步阐述

功能分析心理治疗（FAP）的基本概念：

临床相关行为（CRB）：FAP关注的是在疗程中出现的、与疗程外行为功能相似的行为。这些行为可以分为两类：CRB1（有问题的行为）和CRB2（改善后的行为）。
治疗关系的重要性：FAP强调治疗关系本身是一个重要的治疗工具。治疗师需要创造一个安全和支持的环境，使来访能够尝试新的行为而不担心负面后果。

行为塑造技术：

逐步逼近：通过逐步逼近，治疗师从来访现有的行为库开始，逐步强化每一个朝着期望行为迈进的小步骤。这种方法有助于逐步建立和巩固新的行为模式。
强化策略：治疗师不仅需要强化来访的新行为，还需要注意自己的行为如何影响来访。这意味着治疗师必须对自己的行为保持高度的觉察，并确保其行为对来访产生积极的强化作用。

同情与自我同情的培养：

安全空间：治疗关系被视为一个神圣的空间，来访可以在其中自由地探索和实践新的行为模式，尤其是那些涉及同情心和自我同情心的行为。
情感支持：治疗师通过提供情感支持和正向反馈，帮助来访克服自我羞愧和自我憎恨，从而更好地接纳自己和他人。

行为泛化：

泛化过程：一旦来访在治疗关系中建立了新的行为模式，治疗师会鼓励来访将这些行为泛化到日常生活中。这有助于来访在真实情境中应用学到的技能，从而实现长期的行为改变。
持续支持：治疗师在整个过程中提供持续的支持和指导，确保来访能够成功地将新行为融入日常生活，并在遇到挑战时获得必要的帮助。

通过这些方法，FAP不仅能够有效地帮助来访改变行为，还能促进他们的情感健康和个人成长。治疗师通过创建一个安全和支持性的环境，以及运用行为塑造技术，可以帮助来访发展出更加积极和适应性强的行为模式，从而提高他们的生活质量。

知识点进一步阐述

觉察的重要性：

意识与正念：规则1强调了觉察来访行为的重要性。这种觉察不仅包括对行为本身的注意，还包括对行为背后情感和动机的理解。正念练习可以帮助来访更好地理解自己的内在体验，从而为改变提供基础。
共情连接：觉察还涉及建立共情连接，即治疗师能够深入理解来访的情感状态，并与之共鸣。这种连接有助于建立信任和安全感，使来访更愿意开放自己。

勇气的作用：

真实性和脆弱性：规则2强调了勇气在治疗过程中的重要性。治疗师和来访都需要有勇气去面对和表达真实的感受和想法，即使这些感受和想法可能令人不安或具有挑战性。
承担风险：勇气还意味着愿意承担风险，尝试新的行为模式。这包括提出大胆的问题，以及在必要时温和地面对回避行为。这种勇气有助于打破旧有的行为模式，促进个人成长。

爱与关怀：

无条件的支持：规则3强调了治疗师对来访的关爱和支持。通过真诚地认可和尊重来访，治疗师可以创造一个安全和支持性的环境，使来访感到被理解和接纳。
强化积极行为：治疗师通过强化来访改善的行为（CRB2），并在适当的时候回应问题行为（CRB1），展示了对来访的爱和关怀。这种做法有助于增强来访的自信心和自我价值感。

行为效果的反馈：

持续评估：规则4要求治疗师持续评估自己的行为对来访的影响。这意味着治疗师需要保持开放的态度，愿意接受反馈，并根据来访的反应调整自己的方法。
灵活应对：治疗师应该愿意轻视自己的假设，并询问来访对其行为的感受。这种灵活性有助于确保治疗的有效性，并避免无意中强化负面行为。

行为泛化的意义：

实际应用：规则5强调了将治疗中学到的行为模式应用于日常生活的重要性。治疗师帮助来访认识到疗程内外行为的相似性，并鼓励他们在现实生活中应用所学的技能。
持续支持：为了促进行为的泛化，治疗师需要继续支持来访，并在他们面临现实生活中的挑战时提供指导。这种持续的支持有助于巩固治疗成果，并促进长期的行为改变。

通过遵循这些规则，治疗师不仅可以帮助来访识别和改变问题行为，还可以培养他们的同情心和自我同情心。这些规则强调了觉察、勇气、爱和持续支持的重要性，为治疗提供了全面而有效的框架。

知识点进一步阐述

觉察与认知解离：

觉察的重要性：治疗师通过引导来访注意自我批评的思维模式，帮助他们认识到这种模式是如何影响他们的行为和情绪的。这种觉察是改变的第一步。
认知解离：来访学会了将自我批评的思维视为一种“棒球棒”，而不是将其视为真实的自我。这种认知解离有助于来访从自我批评中解脱出来，从而减少其负面影响。

FAP规则的应用：

规则1：注意CRB：治疗师注意到来访的自我批评行为（CRB1），并通过询问来访是否在其他情境中也有类似行为，建立了疗程内外行为之间的联系。
规则2：引发CRB：治疗师通过提问和对话，促使来访在当下展示自我批评的行为，从而有机会对其进行干预。
规则3：对CRB做出应答：治疗师通过温和地指出来访的自我批评行为，并鼓励来访注意到这种行为，同时强化来访的积极行为（CRB2）。
规则4：注意治疗师行为的强化效果：治疗师询问来访对整个交流的感受，以评估自己的行为是否起到了预期的强化作用。
规则5：促进改进行为的泛化：治疗师鼓励来访在未来一周继续练习注意到自我批评的行为，并在日常生活中实践新的应对方式。

自我批评与自我同情：

自我批评的影响：自我批评常常导致消极情绪和行为，如羞愧、沮丧和回避。通过识别和改变这种模式，来访可以减少自我伤害。
自我同情的培养：通过练习注意到自我批评的行为，并学会与其保持距离，来访可以逐步培养出更加自我同情的态度。这包括接受自己的不完美，给予自己更多的宽容和支持。

行为改变的过程：

渐进式改变：治疗师通过逐步引导来访注意到自我批评的行为，并强化积极的行为模式，帮助来访逐步改变旧有的行为模式。
持续支持：治疗师在整个过程中提供持续的支持和反馈，确保来访能够有效地学习和应用新的行为模式，从而实现长期的行为改变。

通过这样的方法，治疗师不仅帮助来访识别和改变自我批评的行为模式，还促进了自我同情心的发展。这种综合的方法强调了觉察、认知解离和行为改变的重要性，为来访提供了一个全面的支持系统。

知识点进一步阐述

同情心的培养：

治疗师的角色：FAP治疗师通过展示深深的同情心，帮助来访理解并接受自己的痛苦。治疗师不会责怪来访，而是提供支持，帮助他们在痛苦中找到前进的道路。
安全的学习环境：治疗师创造一个安全和支持性的环境，使来访能够探索新的行为模式。这种环境有助于来访在疗程之外也能选择更有效的行为，从而改善他们的生活。

FAP原则的应用：

规则1：注意CRB：治疗师注意到来访对自己的严厉评判，并询问这种评判是否也在其他情境中出现。这有助于来访意识到自己内在批评的普遍性。
规则2：引发CRB：通过提问和对话，治疗师促使来访在当下展示自我批评的行为，从而有机会对其进行干预。
规则3：对CRB做出应答：治疗师通过温和地指出来访的自我批评行为，并强化来访展现出的积极行为（如对待孙女的温柔），同时引导来访思考更富有同情心的选择。
规则4：注意治疗师行为的强化效果：虽然在这个例子中没有直接体现，但治疗师可以通过询问来访对交流的感受来评估自己的行为是否起到了预期的强化作用。
规则5：促进改进行为的泛化：治疗师鼓励来访在未来继续练习更富有同情心的行为，并将其应用于日常生活中，从而实现长期的行为改变。

自我批评与自我同情：

自我批评的影响：自我批评常常导致消极情绪和行为，如羞愧、沮丧和回避。通过识别和改变这种模式，来访可以减少自我伤害。
自我同情的培养：通过练习注意到自我批评的行为，并学会与其保持距离，来访可以逐步培养出更加自我同情的态度。这包括接受自己的不完美，给予自己更多的宽容和支持。

行为改变的过程：

渐进式改变：治疗师通过逐步引导来访注意到自我批评的行为，并强化积极的行为模式，帮助来访逐步改变旧有的行为模式。
持续支持：治疗师在整个过程中提供持续的支持和反馈，确保来访能够有效地学习和应用新的行为模式，从而实现长期的行为改变。

知识点进一步阐述

治疗关系的独特性：

专业与个人的平衡：治疗关系是一种特殊的专业关系，它既要求保持一定的专业界限，又需要治疗师展现出真实的人性和同情心。这种平衡有助于创建一个安全和支持性的环境，让来访能够探索深层次的情感和个人问题。
服务来访的目标：治疗关系的核心在于服务来访的治疗目标和最佳利益。这意味着治疗师的所有行动和干预都必须以促进来访的福祉为出发点。

同情心的培养：

治疗师的角色：治疗师通过展示真实的关心和同情，帮助来访学会接受来自他人的同情。这包括治疗师本人的同情以及来访对他人同情的接受。
逐步开放：对于那些因童年创伤而深陷自我批评和羞愧的来访，治疗师需要耐心地帮助他们逐步开放自己，先是接受治疗师的同情，然后是学会对自己产生同情。

应对羞愧和内疚：

理解根源：治疗师需要深入了解来访的羞愧和内疚感的根源，通常是童年时期的创伤经历。通过这种方式，治疗师可以帮助来访认识到这些负面情绪并不反映他们的内在价值。
重塑认知：治疗师通过重塑来访对过去的认知，帮助他们重新评估自己的经历，从而减轻内疚和羞愧感。这可能涉及挑战来访的错误信念，如认为自己应该受到虐待等。

临床实践中的应用：

建立信任：治疗师通过建立信任和安全感，使来访能够在治疗过程中更加开放和诚实。这种信任是治疗成功的关键。
情感支持：治疗师提供持续的情感支持，帮助来访处理复杂的情绪。这包括倾听、理解和共情，以及提供实际的建议和指导。
逐步暴露：对于像Clare这样的来访，治疗师可能会采用逐步暴露的方法，帮助来访逐渐面对和处理过去的创伤记忆。这种方法有助于减少恐惧和焦虑，增加对当前情境的掌控感。

通过这些方法，治疗师不仅帮助来访识别和改变自我批评的行为模式，还促进了自我同情心的发展。这种综合的方法强调了觉察、认知解离和行为改变的重要性，为来访提供了一个全面的支持系统。

知识点进一步阐述

创伤记忆的处理：

情感体验的重要性：在这个案例中，治疗师引导克莱尔回忆起一段让她感到羞愧的记忆，而不是直接回到虐待的时刻。通过这种方式，治疗师帮助克莱尔重新体验当时的情感，并从中获得新的视角。这种情感体验对于理解和处理过去的创伤至关重要。
共情与理解：治疗师鼓励克莱尔从一个小女孩的角度来看待当时的处境，认识到在那个年龄，她并没有其他选择。这种共情的理解有助于减轻她的自责感，并为她提供了一种新的看待自己的方式。

自我同情的培养：

接受与原谅：治疗师帮助克莱尔认识到，她当时的行为是出于对关注的需求，而不是出于恶意或错误。通过这种认识，克莱尔能够逐渐接受自己，不再因为过去的行为而自责。
情感支持：治疗师通过提供情感支持，如拥抱和表达爱意，帮助克莱尔感受到被接纳和被爱。这种支持有助于建立一个安全的环境，使克莱尔能够逐步放下内心的负担。

治疗关系的力量：

信任与安全感：治疗师通过持续的支持和理解，建立了与克莱尔之间的信任关系。这种信任使得克莱尔能够在治疗过程中更加开放和脆弱，从而促进了深层次的情感处理。
专业与个人的平衡：治疗师在保持专业性的同时，也展现了真实的情感反应，这有助于增强治疗关系的真实性和深度。治疗师的眼泪和情感流露显示了他对克莱尔痛苦的深切共鸣。

认知与情感的整合：

理性的认知与情感的体验：虽然克莱尔之前理智上知道她不应自责，但只有通过情感体验，她才能真正感受到这一点。治疗师通过引导克莱尔进入具体的情境，帮助她将理性认知与情感体验结合起来，从而实现更深层次的治愈。
行为改变的基础：通过这种情感体验，克莱尔不仅能够更好地理解过去的自己，还能在未来面对类似情绪时，采取更积极和支持性的行动。这种转变是长期行为改变的基础。

知识点进一步阐述

同情视角的重要性：

换位思考的作用：通过换位思考，来访可以学会从不同的角度看待问题，从而减少自我批评和负面情绪。这种方法有助于来访理解他人的情感和处境，同时也能更加宽容地对待自己。
增强同理心：通过采用他人的视角，来访可以更好地理解他人的情感和动机，从而增强同理心。这对于建立良好的人际关系非常重要。

自我同情的发展：

自我接纳：通过换位思考，来访可以学会从一个更宽容的角度看待自己的不足和错误，从而促进自我接纳。这种自我接纳是自我同情的基础。
情感调节：当来访能够从一个更宽容的角度看待自己时，他们更能有效地调节自己的情绪，减少自我批评带来的负面影响。

治疗关系的应用：

示范作用：治疗师通过展示自己的脆弱性和错误，为来访提供了如何处理类似情况的榜样。这种真实性的展现有助于增强治疗关系的信任度。
共同探索：治疗师和来访一起探讨不同的视角，帮助来访发现新的理解和解决方案。这种合作的方式有助于来访在日常生活中应用这些技能。

实际应用：

日常生活中的实践：鼓励来访在日常生活中练习换位思考，特别是在面对自我批评时。通过这种方式，来访可以在实际情境中逐渐培养出更富有同情心的态度。
持续的支持：治疗师提供持续的支持和反馈，确保来访能够在实践中不断进步，并逐步内化这些新的思维方式。

知识点进一步阐述

自我同情的培养：

换位思考的重要性：通过引导来访从一个更宽容的角度看待自己，就像他们对待他人一样，治疗师帮助来访学会自我同情。这种方法有助于来访减少自我批评，增强对自己的接纳。
身体语言的作用：治疗师注意到来访在练习自我同情时的身体变化（如放松肩膀和胸膛），并鼓励来访重复这些动作。这种身体上的调整可以帮助来访更好地体验到情感上的释放和放松。

治疗关系中的真实性和接纳：

治疗师的真实示例：治疗师通过分享自己的错误和感受，展示了真实性和脆弱性。这不仅建立了信任，还为来访提供了处理类似情境的榜样。
来访的接纳：来访对治疗师的接纳态度也反映了他在人际关系中的进步。这种接纳有助于减轻自我批评，增强自我价值感。

认知解离与行为改变：

认知解离：当来访能够从一个观察者的角度看待自己的行为时，他们更容易将行为与其内在价值区分开来。这种解离有助于减少因错误而产生的自我贬低。
行为改变：通过持续练习自我同情，来访可以在日常生活中逐步改变自我批评的行为模式，逐渐内化新的思维方式。

实际应用：

日常生活中的实践：治疗师建议来访在日常生活中继续练习自我同情，并将其记录在人际风险日志中。这种实践有助于来访将新的技能融入日常生活中，促进长期的行为改变。
持续的支持与反馈：治疗师提供持续的支持和反馈，确保来访能够在实践中不断进步，并逐步克服内心的障碍。

知识点进一步阐述

自我同情的发展：

情感上的自我同情：乔不仅是在理智上对自己表示同情，而且是从内心深处感受到这种同情。这种情感层面的自我同情比单纯的言语表达更加强烈和有效，因为它触及了个体的情感核心。
身体语言的变化：治疗师注意到乔的身体语言变化，如脸部表情的柔和，这表明乔在情感上有所放松，开始接纳自己。这种身体上的变化是自我同情的重要标志。

视角转换的作用：

从体验出发：治疗师引导乔从一个不同的视角看待自己犯错的情境，这种方式强调了体验的重要性。通过体验性的视角转换，乔能够更好地理解和接纳自己的行为，而不仅仅是理智上的理解。
观察者视角：通过采用观察者的视角，乔能够从外部观察自己的行为，而不是完全沉浸在其中。这种分离有助于减少自我批评，增强自我同情。

治疗师的反馈与强化：

情感共鸣：治疗师通过表达自己被乔的行为所感动，增强了乔的自我同情行为。这种正面反馈有助于巩固新的行为模式。
行为识别：治疗师邀请乔注意到自己是如何向自己表达同情的，这有助于乔在未来的情境中重复这种行为，从而实现行为的泛化。

ACT模型中的心理灵活性：

灵活的视角转换：ACT模型强调灵活的视角转换，即能够在不同的情境中采取不同的视角。这种灵活性有助于个体更好地应对生活中的挑战，减少情绪困扰。
矩阵工具的应用：迈克熟练使用矩阵工具来整理自己的经历，这表明他能够从观察者的角度审视自己的思维和感受，从而减少了与负面情绪的融合。这种技能对于培养自我同情和心理灵活性至关重要。

实际应用：

日常生活的实践：治疗师鼓励乔在日常生活中继续练习自我同情，并将其记录下来。这种持续的实践有助于乔将新的行为模式内化，逐渐改变自我批评的习惯。
长期支持：治疗师提供持续的支持和反馈，确保乔能够在实践中不断进步，并逐步克服内心的障碍。这种支持对于长期的心理健康非常重要。

知识点进一步阐述

自我同情的发展：

温和的自我对话：通过引导来访采用更温和、支持性的语言与自己对话，治疗师帮助来访减少自我批评，增强自我同情。这种温和的态度有助于来访更好地处理焦虑和强迫行为。
情感共鸣：当来访使用更温和的语言与自己对话时，他感受到被理解和接纳，从而减轻了内心的紧张和焦虑。这种情感上的变化有助于来访更加积极地面对问题。

视角转换的作用：

时空转换：治疗师通过让来访想象自己从当前情境传送到未来的情境中，帮助来访从不同的角度看待自己的行为。这种视角转换有助于来访更好地理解自己的行为模式及其影响。
观察者视角：通过将自己置于观察者的角色，来访能够更客观地看待自己的行为，而不是完全沉浸在其中。这种分离有助于来访识别和改变不健康的行为模式。

治疗师的反馈与强化：

正面反馈：治疗师通过表达对来访进步的认可，增强了来访的自我同情行为。这种正面反馈有助于巩固新的行为模式。
行为评估：治疗师邀请来访评估自己在未来情境中重复这种行为的可能性，这有助于来访设定实际目标并增加行为改变的成功率。

ACT模型中的心理灵活性：

灵活的视角转换：ACT模型强调灵活的视角转换，即能够在不同的情境中采取不同的视角。这种灵活性有助于个体更好地应对生活中的挑战，减少情绪困扰。
价值观导向：治疗师引导来访关注对他来说重要的事情，如照顾伴侣和宠物，从而帮助来访将注意力从强迫行为转移到更有意义的活动上。这种价值观导向的方法有助于提高生活的整体满意度。

实际应用：

日常生活的实践：治疗师鼓励来访在日常生活中继续练习更温和的自我对话，并将其应用于具体的场景中。这种持续的实践有助于来访逐步改变自我批评的习惯。
长期支持：治疗师提供持续的支持和反馈，确保来访能够在实践中不断进步，并逐步克服内心的障碍。这种支持对于长期的心理健康非常重要。

知识点进一步阐述

同情与自我同情的关系：

相互关联：同情和自我同情是密切相关的。同情通常是指对他人的痛苦感到关切，并愿意采取行动减轻其痛苦；而自我同情则是指以同样的方式对待自己。两者都是心理健康的重要组成部分。
前提条件：自我同情是培养对他人的同情的一个重要前提。如果一个人不能善待自己，那么他也很难真正地同情他人。因此，培养自我同情是治疗过程中不可或缺的一部分。

正强化的作用：

行为改变：通过正强化，治疗师可以鼓励来访表现出更多的同情和自我同情行为。例如，当来访成功地对自己的负面想法进行解离时，治疗师可以通过表扬或认可来强化这种行为。
持续激励：正强化不仅有助于立即改变行为，还可以为来访提供持续的激励，使他们在未来继续表现出同情和自我同情的行为。

FAP原则的应用：

情境感知：FAP强调在治疗过程中实时注意到来访的自我批评和羞耻情绪。通过这种方式，治疗师可以在这些情绪出现时立即介入，帮助来访采用更健康的方式来应对。
行为塑造：FAP还涉及通过逐步引导来访改变行为模式来塑造新的行为。例如，治疗师可以通过角色扮演或模拟情境来帮助来访练习更友善的自我对话。

ACT视角下的同情：

心理灵活性：ACT强调心理灵活性，即能够在不同情境下灵活调整自己的思维和行为。这种灵活性对于培养同情和自我同情至关重要。
解离技术：ACT中的解离技术可以帮助来访从不同的角度看待自己的想法和情绪，从而减少自我批评和羞耻感的影响。通过这种方式，来访可以学会更客观地观察自己的内心体验，而不是被它们所控制。

日常生活中的实践：

习惯养成：通过疗程中的训练，来访可以将同情和自我同情的行为逐渐内化，形成习惯。治疗师可以通过设定具体的练习任务，如每天记录一次自我同情的行为，来帮助来访将这些技能应用到日常生活中。
持续支持：治疗师提供的持续支持和反馈对于巩固新行为非常重要。通过定期检查和评估来访的进展，治疗师可以确保来访在实践中不断进步，并逐步克服内心的障碍。

5 Using the Therapeutic Relationship to Train Compassion Imagine that you wanted to learn to surf. Would you choose lessons in which all you did was talk about your surfing attempts over the past week and what you could try to do differently in your next week of surfing? Or would you rather take lessons in which you got a chance to practice surfing in front of your coach so she could guide you as you practice new moves? Furthermore, would you choose lessons in which the teacher mostly talked about the theory of surfing, or in which most time was devoted to practicing? Finally, would you pick a teacher who is a technically proficient surfer, or one who has read numerous surfing books, been a spectator at major competitions, and knows the lingo but could never stand up on a board?

In therapy, as with surfing, the best learning occurs through experience, and the most effective practice is that which can be observed and coached in the moment by a therapist who herself possesses the skills she is hired to impart. Thus, when it comes to training clients to become more compassionate and self- compassionate, in-session practice is key, and compassion and self-compassion on the part of the therapist are a must.

Self-criticism and self-shame are damaging forms of interacting with one’s self and one’s personal experience. From an ACT point of view, they are a function of various inflexibility processes. Fusion with self-judgmental thoughts and nonacceptance of aversive experiences feeds a sense of self that is limited to the aversive content of one’s past and present experience. Difficulty in con- tacting values and engaging in valued actions also undermines self-worth, getting clients further into their heads and keeping them stuck in a painful cycle of ineffective action, self-depreciation, and shameful hatred of personal history. By increasing their flexibility, clients can come to learn how to surf the waves of negative thoughts, aversive experiences, and self-denigrating stories so they can move in valued life directions.

To a large extent, what happens in therapy happens in the context of the therapeutic relationship. And as is the case in the analogy of surfing above, ineffective behavior is best observed directly, rather than through the filter of clients’ reconstructed verbal accounts. Likewise, the skills that will help clients progress are best practiced in session, allowing clinicians to coach clients toward a more compassionate and self-compassionate stance. This emphasis on the present (therapeutic) moment is ideally suited to using operant learning prin- ciples, which are focused on providing consequences in the moment. This chapter will describe how operant learning principles can be used in session to help clients become adept at surfing self-critical thoughts and shameful self- directed emotions as they navigate toward a valued life.

Self-Compassion as a Condition of Compassion From an ACT perspective, compassion and self-compassion are highly related. Being truly compassionate implies being truly self-compassionate and vice versa (Hayes, 2008c). Both compassion for others and self-compassion imply embrac- ing difficult feelings, noticing judgmental thoughts without becoming entangled in them, connecting with a flexible sense of an observing self, and gently carry- ing one’s history forward into a life of engagement with deeply held values. Furthermore, practicing both compassion and self-compassion is a central part of a therapist’s skill. And just as for clients, these qualities are best fostered by cultivating compassionate flexibility and extending kindness and self-validation to whatever difficult experiences and self-judgments may arise.

Using Positive Reinforcement to Train Compassion The functional contextual approach has its roots in learning theory principles and, more particularly, in the principles of operant learning. Countless experi- ments have shown positive reinforcement to be the most effective tool of behav- ior modification. Positive reinforcement denotes a relationship between two events in which the event that follows a behavior increases the future probability of the behav- ior. Animal models have shown that the effectiveness of the reinforcing event depends on its temporal proximity to the behavior. The closer the reinforcer is to the behavior, the more effective it is likely to be in making that behavior more probable in the future. It can be important to remember that positive and negative reinforcement denote an arithmetic operation in the sense that a con- sequence is added to or subtracted from the environment, rather than the rein- forcer having a positive or negative valence or feeling. For example, sometimes parents will criticize a child’s behavior at length only to find that the behavior criticized actually increases. In such cases, criticism serves as a positive rein- forcer, even though it may feel negative to both child and parent. Positive reinforcement is fairly straightforward when applied to nonverbal animals, and the marvelously elaborate behaviors that animals accomplish on film attest to its effectiveness (Pryor, 2009). In such contexts, reinforcers consist of physical or physiological events. However, when it comes to verbal humans, the effects of derived relational responding make reinforcement much more complex. Through derived relational responding, the functions of inner experi- ences (such as bodily sensations, emotions, or images) and symbolic stimuli (such as words or thoughts) are transformed in ways that are governed by complex relational networks, which themselves are the product of unique and complex individual histories.

Once derived relational responding comes into play, it becomes harder to identify the contexts in which a given event will be reinforcing. For example, with one client a compliment might serve to increase the behavior compli- mented, whereas for another client it will have the effect of punishing (i.e., decreasing) the behavior. In the latter case, it is probable that the client’s verbal history has served to transform the functions of compliments into a punishing consequence. This does not negate the power or effectiveness of positive rein- forcement, but it does make the clinician’s task more complex. It is therefore particularly important for clinicians to pay close attention to the potential rein- forcing or punishing functions their behavior may have on clients.

Functional Analytic Psychotherapy and Compassion Functional analytic psychotherapy can be of particular interest to clinicians seeking to foster and train compassion and self-compassion in their clients. It can serve as both a model and a series of techniques that apply operant learning principles to therapy and, specifically, to the therapeutic relationship. FAP focuses attention on clinically relevant behavior (CRB), meaning in-session client behaviors that are functionally similar to their behaviors outside of session. There are two main classes of clinically relevant behavior: • CRB1, denoting instances of client problematic behavior • CRB2, denoting improved behavior as compared with CRB1 FAP invites both therapist and client to notice CRB1 and the client to prac- tice CRB2 within a reinforcing environment: the therapeutic relationship. Clinically relevant behaviors are defined idiographically. For example, expressing criticism might be a CRB2 for a client who has difficulty being asser- tive, but a CRB1 for a client whose relationships are negatively impacted by a high propensity to criticize others. In FAP, the therapist cultivates awareness of client behavior, has the courage to invite the client to notice when clinically relevant behavior might be present, and lovingly reinforces CRB2 while paying close attention to the reinforcing (or punishing) functions of therapist behavior. The therapist offers the therapeutic relationship as a sacred space (Tsai & Kohlenberg, 2012), a safe context in which clients can try out new behavior without fear of overly punishing consequences or a break in the relationship. Such a loving and reinforcing context is ideally suited to helping clients work through self-shame and self-hatred while exploring the practice of compassion and self-compassion.

FAP uses behavior modification tools to promote CRB2. One of the most important of these tools is shaping by successive approximations. In shaping, one first observes the behavioral repertoire such as it is and seeks to reinforce the slightest step in the direction of the desired behavior. When a further step is taken, that new step is reinforced in preference to the previous step, and so on, until the behavior is fully shaped. So in the example of expressing critical thoughts as CRB2, the therapist will initially reinforce any sign of a negative reaction to her behavior, then any form of critical speech, then only critical speech that is likely to be well received by others (for example, including empathic validation of the person criticized). Once the behavior is ready to be taken “on the road,” the therapist encourages and promotes generalizing the improved behavior into the client’s life beyond the therapeutic relationship.

The Five Rules of FAP Kohlenberg and Tsai (1991) have proposed five clinical rules to guide the practice of FAP. More recently they have described FAP as being based on awareness, courage, and love (Tsai et al., 2008); and, as you will see, these quali-ties are highly relevant to the five rules of FAP.

Rule 1: Notice CRB. FAP invites both therapist and client to identify CRB. Noticing CRB implies awareness of client behavior. This awareness implies pres- ence, mindfulness, and empathic connection. Rule 2: Evoke CRB. FAP requires that CRB be present so that it can be worked on. Evoking CRB requires courage on the part of both therapist and client. Both are invited to be honest and authentic, take risks, show vulnerability, ask bold questions, and gently confront avoidance. Rule 3: Respond contingently to CRB. The therapist seeks to reinforce CRB2 while responding appropriately to CRB1. This is inherently compassionate and a demonstration of love. By truly caring for and gently tending to clients, tire- lessly supporting them, authentically acknowledging them, and deeply appreci- ating and respecting them in both their difficulties and progress, therapists can most effectively reinforce improved behavior and help clients modify problem- atic behavior. Rule 4: Notice the reinforcing effects of your behavior. This invites more awareness as the therapist seeks to observe whether her interventions have been reinforcing or not. Here, a willingness to hold interpretations lightly and ask clients how her behavior has impacted them is helpful. Rule 5: Promote generalization of improved behavior. This last rule implies awareness, courage, and love as the therapist helps clients recognize similarities in the functions of CRB and the functions of behavior in outside life and encourages appropriate risk taking in the presence of similar antecedents outside of session.

Applying these rules encourages clients to become more mindful of their behavior in the moment and can help them identify as CRB1 those clinically difficult moments when noticing their unworkable behavior leads to further self-criticism and shame. Promoting mindfulness of such behaviors and concep- tualizing them as teachable moments can be a powerful way to promote com- passion and self-compassion.

Finally, these rules are not meant as rigid prescriptions but more as gentle invitations to try new behavior. If by doing so you contact your own reinforcers in the shape of deeper and more effective therapeutic relationships, you may find yourself using them regularly.

Clinical Example: Noticing the Self-Critical Mind in Action and Defusing from It The self-critical mind is often hyperactive and will use everything it can to fuel the fires of self-hatred. In the example below, Sam had been invited to notice, over the week between sessions, actions he took to move toward who and what is important to him and actions he took to move away from what he didn’t want to think or feel.

Therapist: So, what did you notice? Client: I had never realized how many away moves I engage in. It’s pathetic. [CRB1] Therapist: I notice you’re putting yourself down. Do you also put yourself down when you’re with other people? (Applies FAP rule 1: noticing CRB and offering a parallel between client behavior in and out of session.) Client: es, I’m always putting myself down because of my lack of self-esteem. Y (Confirms CRB1.) Therapist: And is being harsh on yourself a toward move or an away move? (Applies FAP rule 1: noticing CRB.) Client: I guess an away move. …See, I did it again! [CRB1] Therapist: Ouch! That’s harsh. How about noticing your toward and away moves—is that a toward move or an away move? (Applies rules 2 and 3: evoking CRB and responding contingently to CRB.) Client: A toward? [CRB2] Therapist: What’s showing up for me is how easy it is for you to get hooked by your critical mind, and then it’s as if you grabbed the bat yourself and started banging away on yourself. (Applies rule 1, missing an opportu- nity to apply rule 3: reinforcing CRB2.) Client: Yes. You see? I told you. [CRB1] Therapist: (Makes a gesture to go grab an imaginary baseball bat behind her chair.) Here it comes again! (Applies rule 3: responding contingently to CRB.) Client: (Laughs.) Okay, I see it now. [CRB2] Therapist: So how about noticing when your mind hands you the bat and just letting us know? (Applies rule 2: evoking CRB.) Client: I think I can do that. [CRB2] Therapist: So tell me about your toward moves over the week. (Applies rules 2 and 3: evoking CRB and reinforcing CRB2.) Client: I called my parents, took my son for a walk, and talked to my wife about going out to dinner together. [CRB2] But really, it wasn’t much… [CRB1] Oh, here comes the bat! [CRB2] (Laughs.) Therapist: So if you didn’t grab the bat, what would you say? (Applies rules 2 and 3: evoking CRB and reinforcing CRB2.) Client: That I’m glad I did these things, and I feel proud. [CRB2] Therapist: Great, Sam. How was this whole exchange for you? (Applies rule 4: noticing the reinforcing effects of therapist behavior.) Client: At first it was hard, but I think I got the hang of it and could catch myself before going for the bat. And it’s true that it makes a difference.

Therapist: I’m also happy you could notice your toward moves. (Applies rule 3: reinforcing CRB2.) Would you be willing to continue doing that over the week, even when your mind tries to gang up on you? (Applies rule 5: promoting generalization of CRB2 to life outside of session.) In this exchange, the therapist is focusing on present-moment processes and inviting the client to do the same. The therapist offers a parallel between in- session behavior and potential problematic behavior outside of therapy. When the client offers an explanation (lack of self-esteem), the therapist does not get into the content and instead remains focused on CRB, gradually shaping a CRB2 of noticing the CRB1 of being harsh on oneself, and reinforcing the CRB2 of naming toward moves without depreciating them in the next breath.

Shaping Compassion in Session The stance of the FAP therapist is one of deep compassion for her clients, their suffering, and their learning history. Seeing behavior as the result of a learning history, she does not hold her clients responsible for their suffering, their thoughts, or their emotions and stands ready to walk with them through their suffering and toward more workable behavior. Seeing behavior as the result of learning history, she appreciates that providing her clients with a safe learning environ- ment (the therapeutic relationship) can help them choose more effective behav- ior outside of session, setting a new course for their relationships and their lives.

FAP invites the therapist to reinforce clients naturally, noticing how her heart responds to their improved behavior and letting them know how she gen- uinely feels. As in ACT, the FAP therapist also opens her heart to her clients’ suffering with a deep wish to see that suffering diminish and a courageous will- ingness to stand by her clients and their suffering. The FAP therapist makes a commitment to responding with authenticity and kindness to her clients, including being willing to cry with them.

Clinical Example: Using FAP Principles to Promote Compassion Below, we illustrate how a therapist can use FAP principles to promote compas- sion in an example from a session with Joe, a teacher and community activist who is beset by deep self-shame. Although he obtained a PhD and is a well- respected member of his community, Joe has gone through life with an unshak- able sense of being a fraud and undeserving of others’ regard. His community involvement is a function of his values, but he has always felt inferior to his peers: less intelligent, less handsome, less well-read. To this day, he feels he received his PhD by some sort of fluke, being certain he was the dullard among his peers in graduate school. Now, at the age of sixty, he feels his cognitive abili-ties are declining and complains of attention deficit and an impaired memory. Client: I think people should work harder. [CRB1] Therapist: You sure have worked hard all your life, not just teaching, but also as a community activist. (Applies rule 2: evoking CRB.) Client: ( Looks uncomfortable.) I didn’t work that hard, really, and I only got involved in my community because of my religious beliefs. [Probable CRB1, harshly judging himself and others] Therapist: I’m noticing that your mind is being harsh on both you and other people. Does it happen just in here or does it show up elsewhere? (Applies rule 1: noticing CRB and offering a parallel between in- and out- of-session behavior.) Client: ell, you know, that’s the way I was educated. We had it hard. But W even so, I managed to remain the laziest of the bunch. [CRB1] But yeah, my wife always tells me I’m too harsh on my daughters. Mind you, I try to be extra nice to my granddaughters. They’re so sweet! [CRB2 to shape] Therapist: It’s lovely to hear that you’re sweet with your granddaughters. And it makes me sad to think you have to live under the yoke of such a criti- cal mind. I wonder if, deep down, the person you want to be gives voice to the most critical thoughts your mind comes up with. I mean, I know religion means a lot to you, and I wonder: If you could choose, would you choose to be known as harsh, or more as a compassionate person? (Applies rule 3: reinforcing CRB2 and seeking to shape further CRB2.) Client: Compassionate, I guess. [CRB2 to shape] Therapist: And if no one ever knew or if it wasn’t a question of reputation but of the impact you really had on others, would you choose to align with your harsh mind or with a more compassionate stance? (Applies rule 3: aiming to further shape CRB2.) Client: The same. I would be compassionate. [CRB2] Therapist: That is so touching to hear you say this when I know your mind is waiting to ambush you at any second. (Applies rule 3: naturally rein- forcing CRB2.) How about we use our time here to help you behave in this more compassionate way, as you’d like—could that make a difference? (Applies rules 2 and 3: evoking and reinforcing CRB2.) Client: Do you think I can do it? [Probable CRB2] Therapist: I’m sure you can, and I’m here to help. (Applies rule 3: reinforcing CRB2.)

In this dialogue, the therapist focuses on clinically relevant behavior as it shows up in the room rather than on what the client is saying about his life outside of therapy. By paying close attention to how the client progresses and by introducing values, the therapist is able to get him to move to a more compas- sionate stance and choose compassion as a valued direction.

Helping Clients Accept Compassion from Others The therapeutic relationship is peculiar in many ways. In contrast to “normal” relationships, it does not exist for its own sake. It is a professional rela-tionship. Yet unlike other professional relationships, and due to its nature— being a space into which clients bring their most difficult personal problems and vulnerabilities—it cannot be limited to a surface relationship in which the cli- nician as a person remains hidden behind a veneer of professional distance. FAP invites clinicians to open their hearts to their clients and foster relationships that are every bit as deep as relationships in outside life, and often deeper. Yet the therapeutic relationship remains significantly different from other relationships in that at all times it is in the service of the client’s therapeu-tic goals and best interests. Within such a relationship, clinicians can use their own reactions to shape more compassionate behavior in clients.

Clients with deeply ingrained histories of self-criticism and shame, perhaps as a result of childhood trauma, are commonly fused with the most painful forms of self-hatred, shame, and guilt. Histories of physical or sexual abuse often lead to a sense of guilt on the part of the victim. In cases of physical or sexual abuse at the hands of a caregiver, it is not uncommon for victims to feel they deserved it and carry a crippling burden of guilt and shame. That shame and guilt can make it exceedingly difficult to truly accept genuine care and compas- sion from others. In such cases, establishing a profound therapeutic relationship can provide a context in which clients can gradually open up to compassion and care—first to receiving it from the therapist, and then to evoking that com- passion from themselves, toward themselves.

Clinical Example: Using the Therapeutic Relationship to Shape Acceptance and Compassion In the following extract the therapist invites his client to connect with a past situation in which shame arose. As a child, Clare was for years sexually and emotionally abused by her father. She has been carrying a crippling burden of guilt and shame related to the abuse. Although she has mentioned the abuse to others in her family and distanced herself from her parents long ago, it is still difficult for her to contact her tangled feelings around what she has been through. Clare and her therapist have been working on interpersonal issues for over six months, and she now feels ready to address the abuse.

Client: I feel so guilty because I feel like I used my body. I’ve hated it ever since. Therapist: It makes me sad to hear this. Would you be willing to close your eyes and bring to mind one of the situations from your childhood that you feel ashamed of? Client: I can try. Therapist: Where are you, and how old are you? Client: I’m twelve and in my parents’ living room. My father is there. Therapist: What can you see around you? Client: I can see the sofa. I can see the pictures on the walls and the sunlight through the bay window. I see my father sitting in his recliner. He’s reading a newspaper. He’s not paying attention to me. Therapist: Can you notice what you are feeling? (Pauses.) What you are think- ing? (Pauses.) What do you do? Client: I feel bored. I… (Pauses.) I am striking provocative poses. (Starts sobbing softly.) I feel so ashamed! This is really hard! Therapist: Could we just pause here for a minute? I want you to stay with that twelve-year-old Clare. Would you be willing to stay with her and how she feels? Client: (Speaks softly.) Okay… Therapist: Imagine that we could both go together and meet her. You can see what she sees, hear what she hears, and feel what she feels. (Pauses.) Could we just ask her, “What do you need right now?” Client: ( Speaks in a little-girl voice.) I just want to play. I want to go outside and play. I want to see people and have fun! (Sobs.) Therapist: Yes, you just want to go outside and play. You want to see people. Those are perfectly normal needs for a twelve-year-old girl. You need attention. And that’s a perfectly normal need for a twelve-year-old girl. (Pauses.) And the only way you know how to get attention is by doing what you’re doing. Client: (Sobs.) Yes. Therapist: Clare, do you think we should condemn that young girl for that? Client: No, of course not. …She doesn’t know any better. Therapist: What could we do to help her? Client: Could I just hug her and tell her I love her? Therapist: Let’s do that. Give her a hug and tell her that you love her. (Has tears in his eyes, obviously moved by the client’s pain.) She just needs to be seen and loved, and to feel safe. Is there something more you can tell her? Client: Just that I love her and that it’s not her fault. (Sobs.) Therapist: No, it’s not her fault. It’s all she knows how to do. (Pauses.) Clare, take your time, and when you feel ready, you can come back to this room with me and open your eyes. Client: (Opens her eyes.) Therapist: I feel so moved that you had the courage to go there with me. How are you feeling now? Client: I trust you. I think you’re a good person. It’s the first time that I’ve realized I don’t have to hate myself for what happened and what I did. I didn’t know any better. I’ve known these things intellectually, but this was the first time I could actually feel it. Therapist: How could you have known any better? How could anyone who’d been through what you went through know any better? Client: Yes. Therapist: Do you think that now, when guilt shows up, you can go back and give that little girl the support and love she needs? Client: I can try. At least now I know I don’t have to hate myself and my body. In this exchange, the therapist invited Clare to go back not to a moment of abuse, but rather to an episode that evoked the most shame for her: her pro- vocative bids for attention from her father and abuser, the only way she could get some of the attention she craved. In contact with that memory, the therapist invited Clare to take the little girl’s perspective and notice that, at the time, she did not have other options. From that experiential realization, and with gentle coaching from her therapist, Clare got to feel that she was not to blame for what happened, nor for the behaviors that have brought her the most shame over the years and fed her deep hatred of her body and sexuality. Such a realization could not have arisen through intellectual discussion or argument. The experiential element was essential to the work, and the therapist used the strength and sacred space of the relationship and the sense of trust within it to ease Clare into this very difficult experience.

Using the Therapeutic Relationship to Train Compassionate Perspective Taking Combining compassion-focused ACT and FAP can lead to very powerful inter- ventions in which clients can directly experience, through perspective taking, compassion and ultimately self-compassion. As they become better aware of what they do when they become more compassionate and self-compassionate in session, they are more likely to do it outside of the therapeutic relationship. From an ACT position, perspective taking involves inviting clients to shift as fully as possible from the perspective of their here-now experience to a different spatial and temporal perspective, contacting as fully as possible their own expe- rience there-then or someone else’s experience. Taking someone else’s perspec- tive is part of the definition of empathy. Taking one’s own perspective at a different time and place can thus help foster empathy and compassion for oneself in those other situations. Combining these different aspects of perspective taking can provide the clinician with a powerful means of training compassion and self-compassion.

Clinical Example: Using the Therapist’s Experience to Evoke Perspective Taking In this example, we return to Joe, the teacher and community activist who is worried about cognitive decline and attention deficits. Leading up to this dia- logue, it has been two weeks since Joe’s previous session, and Joe’s therapist was fifteen minutes late to this session. He’d made a mistake when writing down Joe’s appointment time, a fairly common occurrence for him. In the dialogue that follows, they are discussing Joe’s interpersonal risk log, a FAP-inspired exer-cise in which the client keeps a daily record of intentionally taking at least one interpersonal risk.

Therapist: How did it go with keeping an interpersonal risk log? Client: It worked really well for about a week, and I did feel that I was able to connect with others. But then I realized that all of this was super- ficial because I called a lady I know by the wrong name. I keep on making the same mistakes, like forgetting people’s names. In my position, that’s unacceptable. I’ll never be able to really connect with other people. Therapist: Oh yeah, the mistakes we make. …Five minutes ago I got here fifteen minutes late. That’s exactly the type of situation in which I feel like a jerk and where I get really self-judgmental. But when I got here you were really nice about it and immediately made me feel at ease. Client: ( Laughs.) Actually, it did cross my mind that you’d done it on purpose just to show me that I don’t judge you harshly because of a small mistake! Therapist: No, it really was a mistake. I goofed up. It’s the kind of mistake that’s all too frequent for me, as you know. But it’s true that I immediately felt accepted by you—so much so that my habit of coming down really hard on myself when that happens sort of dissolved. Client: Well, everyone can make mistakes, and you have other qualities… Therapist: Sure, but this is one mistake I make too often, so it’s particularly meaningful to me that, having been on the receiving end of it a few times, you could still accept me with such kindness. (Pauses.) Joe, I’d like to ask you to imagine that you’re looking through the eyes with which you looked at me when I goofed up. But now, I’d like you to imagine being beamed back to the situation in which you called that lady by the wrong name. As you do so, look at yourself as if you were witnessing the scene from a little distance. Take your time… (Pauses.) What do you see? Client: ( Pauses.) Well, I see a kind man. He wants to help and he gets the name wrong. …A man with his weaknesses. I see a man I rather like, a man for whom it’s not easy… (Pauses. His face softens and looks sadder.) Therapist: Yes, Joe. This man is the Joe I know: a man who has his weaknesses, but also a warmhearted man who lives by his values. A man I feel touched by… Client: Yes, it’s true. Therapist: I have to tell you that I’m getting teary right now. It’s the first time since we’ve started working together that I’ve seen you give yourself the compassion that you have for others, and that made you choose your line of work. It’s as if you finally allowed yourself to see yourself as a human being like any other… Client: Yes, it’s true. (Pauses, then laughs.) But you know my mind doesn’t agree. It’s still trying to say I don’t deserve to be forgiven for my mistakes. Therapist: Sure, that’s what minds do. Could you describe what you did just now when you looked at yourself from that more compassionate perspec- tive, and how it felt? Client: Well, I relaxed my shoulders, I relaxed my chest, and I think I opened my heart a tiny bit… (Pauses.) It’s not easy to say. I wonder if I’m not reconstructing it now… Therapist: Not easy to say, and yet you knew how to do it. See if you can do it once again. So you’re standing in front of that lady and you get her name wrong. Okay, relax your shoulders and chest… Client: (Pauses.) Okay, I see. (Pauses, then laughs.) Therapist: Thanks for trying this. I want to invite you to see if you can notice yourself doing some of that in the coming week and include it in your interpersonal risk log, only now as an interpersonal risk you are taking with yourself, so to speak. Client: Okay, I’ll do that, even if I’m not too sure how I’ll do it.

This dialogue marked a turning point in Joe’s therapy, being the first time that he behaved in a deeply compassionate way toward himself. He did not just say compassionate words about himself and his memory lapses; he did so from a place of feeling. When the therapist could see him visibly soften, he felt touched and expressed that.

In this exchange, the therapist invited Joe to shift perspective by looking at himself in the situation that generated shame and self-criticism from the per- spective he took when looking at the therapist’s mistake. Here again, the key to this intervention was inviting the shift in perspective from an experiential rather than intellectual place. The therapist then reinforced Joe’s new behavior by openly sharing how Joe’s self-compassionate behavior impacted him (CRB2) and by inviting Joe to notice what he had done to direct compassion toward himself, thereby promoting generalization to situations outside the therapeutic relationship (FAP rule 5).

As discussed, within the ACT model, flexible perspective taking is a key component of psychological flexibility. In our experience, perspective-taking exercises often elicit self-compassion in clients. For example, inviting a client to experientially return to particularly hurtful childhood events to meet the child she was then and give or say something to that hurt or frightened child typically evokes more compassionate behavior toward that child and her suffering, as illustrated in the dialogue with Clare.

Clinical Example: Using Self-as-Context to Train a More Self-Compassionate Stance Other approaches to perspective taking can also be useful in training clients to approach their present life difficulties from a more empathic and self- compassionate stance, as illustrated in this dialogue with Mike, who is in therapy for severe OCD accompanied by intense shame and self-disparagement. Mike has made good progress with the ACT model and, in particular, has become quite adept at sorting his experience with the matrix. Because sorting into the different quadrants of the matrix implies being able to look at one’s experience, rather than being fused with it, an ability to do this indicates a capacity to take the observer perspective.

Therapist: I’m quite impressed by the progress you’ve made in terms of noticing your toward and away moves and the difference between your five- senses experience and inner and mental experience. Client: Yes, but I still get stuck when it comes to checking the stove before going to bed at night. Therapist: Let’s look at that now. Imagine that you, as you are sitting across from me right now, could somehow be teleported to meet you, as you will be in your kitchen tonight. Is there something you could tell yourself that may help you with the obsessions and compulsions? Take your time, and once you’ve found something to say, just say it as you would if you were in your kitchen, meeting the you who’s having obsessions and the urge to check. Client: Okay: “Don’t be stupid! You know it’s no use.” Therapist: How do you, in the kitchen, receive what you just said? Client: Not well. Therapist: Does it work? Client: No. Therapist: What tone of voice did you speak in? Client: Harsh, I guess. Therapist: Is that how you need to be spoken to when you’re stuck in the kitchen? Client: I need to be spoken to more gently. Therapist: Could you, as you are here with me right now, speak more gently to the you that’s stuck with your obsessions in the kitchen? What could you say? Client: ( Pauses.) I could say, “I know it’s hard to have these thoughts and feel so much anxiety.” Therapist: How do you, in the kitchen, receive this? Client: Better. I feel heard. It’s like something is softening up a bit. Therapist: What else could you, here with me, tell you in the kitchen? Client: I could encourage myself to choose to do something important to me rather than my series of checks. Therapist: How do you, in the kitchen, receive that? Client: I can hear it. It feels like I could do it. Therapist: What else could you do? Client: I could go pet my cat and spend time with my partner. Therapist: Would that be important to you? Client: Yes, because checking the stove is about making sure my partner and my cat don’t die in a house fire caused by me. So it’s really about taking care of them. Therapist: That sounds great. Would you now come back to this moment? It was touching to see this dialogue between you, here and now, and you, there and then in the kitchen. I was particularly touched by how you became kinder to yourself as the conversation went on and you turned toward what’s important to you. What showed up for me is that it seems the more difficult the situation, the more you need to be spoken to gently and have your difficult emotions validated. Would that make sense to you? Client: Yes, I guess that’s true. I have had a tendency to treat myself harshly. Therapist: So how about we continue practicing treating yourself more gently, the way we’ve been doing here? Client: That would be nice. Therapist: I wonder how you would rate the probability that you will be able to speak to yourself in the way you’ve just done when you’re there in your kitchen. Client: Maybe 70 percent. Therapist: I’m looking forward to hearing what you notice.

Having established the therapeutic relationship as an experiential model of a more compassionate relationship in prior sessions, in this session the therapist invites Mike to generalize this ability through some perspective-taking work. Guiding Mike carefully through several shifts between here-now and there-then perspectives, the therapist helps him notice the functions of different ways of speaking to himself, particularly a harsh and judging stance versus a gentler stance. By the end of the exchange, Mike has been able to practice a kinder stance (CRB2) and notice its reinforcing functions. The therapist then con- cludes the exchange by asking Mike to assess the probability of engaging in a similar perspective-taking exercise when next besieged by obsessions. No matter what estimate the client provides, the therapist reinforces it, given that simply paying attention to whether or not one engages in the targeted behavior increases the probability of doing it.

Compassion in the Therapeutic Dyad In summary, this chapter addressed how clinicians can maximize the benefits of the therapeutic relationship and use operant learning principles to aid clients in cultivating compassion and transforming their responses to self-critical thoughts and shameful self-directed emotions. We explored self-compassion as a condi- tion for compassion and highlighted relevant behavioral principles. Among these, we examined positive reinforcement to cultivate compassion and self- compassion, applying FAP principles to cultivating compassion, using defusion with shame-based self-criticism, and specifically shaping compassion through in-session interactions. We also reviewed the therapeutic process of helping clients accept compassion from others and eventually turn that compassion toward themselves.

Using the principles of FAP, the therapeutic relationship can provide a context that is ideally suited to noticing self-criticism and shame in the moment and gently shaping kinder behavior toward self and others. From an ACT per- spective, compassion and self-compassion are highly related and both are invalu- able, and in this chapter we demonstrated different ways in which the therapeutic relationship can be used to foster more compassionate behaviors toward self and others. The components and processes that are emphasized in FAP expand the clinician’s awareness and shape compassion and self-compassion in the moment, while also encouraging clients to incorporate these qualities and behaviors into daily life. This is done through training in flexible perspective taking, including extending compassion to oneself and others when faced with shame-eliciting situations or stimuli.