1 社会联系与治疗关系中的改变背景

第一部分

观念

第一章

社会联系与治疗关系作为变革的背景

“自我造就”这种说法是不存在的。我们是由成千上万的人构成的。每一个曾经对我们做过善事，或者对我们说过一句鼓励的话的人，都进入了我们的性格、思想以及成功的组成之中。 ——乔治·马修斯·亚当斯

花点时间思考一下你生命中最重要的互动和关系。想想那些最紧密、最快乐、最鼓舞人心的关系。也想想那些最痛苦、令人心碎的经历，最终以背叛或失望告终。

这些经历如何塑造了你？你从中学到了什么教训？别人说过的哪些话你永远不会忘记？过去形成的哪些习惯至今仍然在重复？

考虑一下在引言中提到的客户来访汤姆的情况，他在一个感觉疏远但有时又令人窒息的家庭中长大。他的母亲是一位工作时间很长的高管，她教会他情绪要被控制，问题要被解决。他对自己的情绪感到焦虑，对自己无法像她那样取得成功而感到羞愧。在中学时，一位老师鼓励了他的写作能力，给了他一种自豪感。从那时起，他珍视自己的文学才能，但同时也因为母亲怀疑它的价值而挣扎。大学里的一小群朋友让他坚定了对社会的看法——特别是商业世界——是压迫性的和不道德的。他感到与他们亲近，并对世界的许多方面感到义愤填膺。汤姆，就像所有人一样，是他所经历的关系和体验的总和。这些影响了他如何看待自己、他人以及这个世界，以及他对这些事物的感受。

花五到十分钟写下一些东西。你在关系中经历了什么并学到了什么？

功能分析心理治疗（FAP）是关于建立治疗关系，在这种关系中，你能够巧妙地、策略性地与客户来访互动，从而创造一个变革的环境。虽然许多关系可以改变生活，但治疗关系旨在通过治疗手段来改变生活。在深入探讨FAP及其治疗变革的方法之前，让我们从FAP每一刻背后的观点开始。FAP基于心理学和社会影响的观点，整合了情境行为科学（CBS）与日益增长的社会连接科学，包括社会连接如何影响心理功能。这一基础塑造了FAP对于治疗关系的概念化以及治疗师与客户来访相处时的态度。在第一章中，为了逐步过渡到FAP更具体的经验性和应用临床方面，我们将阐述这一基础。

社会联系的重要性

人类需要社会联系才能繁荣发展，而社会联系的问题可能会导致深刻的痛苦。这一陈述基于一系列已经确立的科学研究发现，强调了社会联系的基本重要性。以下是一些这样的发现：

• 拥有差劲或极其有限的社会关系对死亡率的影响与吸烟相当，是肥胖影响的两倍（Holt-Lunstad, Smith, & Layton, 2010）。换句话说，社会联系让人们保持健康并帮助他们活得更久。研究人员估计，拥有差劲或有限的社会关系对健康的负面影响相当于每天吸食十五支香烟（Holt-Lunstad & Smith, 2012）。
• 不良关系（以冲突为特征）和有限的社会关系（孤独）都会对压力激素、免疫功能和心血管功能等产生负面影响（Kiecolt-Glaser et al., 2005; Cacioppo et al., 2002）。事实上，社会支持对于一系列健康问题的结果都有关键影响，从心血管疾病到结核病再到精神分裂症（House, Landis, & Umberson, 1988）。
• 人类有大量的神经资源用于处理社会信号，这种对社会信号的敏感性在出生后的最初时刻就出现了，婴儿会转向面孔并模仿面部表情（Meltzoff & Moore, 1977）。
• 社会关系是推动复杂人脑进化的主要机制之一，并且它们与调节人体生理和情绪的生物系统密切相关（Cacioppo & Patrick, 2008; Porges, 2001）。

综观所有这些发现，进化科学告诉我们，社会功能对于我们物种的生存至关重要，并且它在遗传、生理和行为层面上塑造了我们。我们是那些能有效地与他人交往的祖先的后代，不仅是在具有明显进化意义的社会机制方面，如性互动和养育，而且是在群体层面发挥作用并促进群体福祉的各种亲社会关系行为方面，如友谊、利他主义、合作学习和解决问题（Bugental, 2000; Sober & Wilson, 1998）。我们之所以能够遍布全球，不是因为我们个体的力量或智慧，而是因为集体而言，我们连接和合作的能力使我们变得强大。（有关这一观点的引人入胜的评论，请参见Harari, 2015, 和Henrich, 2016）。

有四个核心观念对于理解进化如何塑造我们以及我们今天所面临的社会挑战至关重要：

1. 我们进化出了对小群体的敏感性和适应能力。
2. 我们也进化出了与其他群体竞争的能力。
3. 在任何关系中，我们都在努力找到亲近与疏远之间的平衡。
4. 今天的社会——也许与我们在进化历史中经历的不同——涉及在许多“内群体”和“外群体”之间、亲近与疏远之间进行导航。现代社会要求我们变得擅长在变化中建立和维持关系，并在个人需求与所属不同群体的需求之间找到平衡。

我们进化出了对小群体的敏感性和适应能力

尽管今天我们在各种各样的社会群体中运作——从家庭到社区（无论是虚拟还是现实）再到更大的单位，如城市、州和国家——但我们在数万年的时间里进化并繁荣起来的关键群体通常是小规模的。在这些群体中，最大的通常不超过著名的邓巴数字150人（Dunbar, 2010）。即使在一个拥有70亿人口的世界里，接近或低于邓巴数字的群体往往对我们影响最大。依恋科学表明，这种塑造始于我们的主要照顾者（Cassidy & Shaver, 1999）。它通过童年时期的青少年朋友和教室，一直延续到成年后与室友和浪漫伴侣的关系。我们的情绪、行为以及自我意识和目的感都经过了这些相对较小群体内部关系和联结的微妙调整。

我们与他人协调行动的能力依赖于一种强大的理解他人心理的能力。灵活连接模型（Levin et al., 2016; Vilardaga, Estévez, Levin, & Hayes, 2012）——一个正在获得实证支持的情境行为科学框架——认为，我们与他人连接的能力取决于三种不同的能力：视角转换（理解他人的视角）、共情（感受处于那个视角的感受）和接受（愿意体验处于那个视角时的感受）。这些能力是连接的心理机制。我们如此沉浸在连接的环境中，以至于很容易忘记理解他人是一项极其复杂的心理任务。

反过来，有效的人际互动支持最佳的福祉。在数千项关于这一主题的研究中（除了上述发现），出现了三个主要主题。第一个是亲密关系和亲密度非常有益（这里的“亲密度”意味着分享你不会随便与任何人分享的想法和感受）。即使我们只有一两个亲密关系，我们也倾向于更快乐、更健康，无论是在身体上还是精神上。第二个主题是感知到的社会支持很重要。再次强调，重要的不是我们有多少朋友，而是当我们需要时，是否感到有人会支持我们。第三个主题涉及社会参与——感觉我们是更大社区的一部分。这可能是大家庭、朋友圈、同事网络、教堂或其他宗教团体、俱乐部或运动队，或是志愿组织。重要的是，我们感觉自己属于一个比自己和一对一亲密关系更大的群体。

我们也进化出了与其他群体竞争的能力

当然，与他人紧密联系的另一面是我们倾向于谨慎、戒备、竞争甚至侵略地对待他人。这种倾向在我们与外部社会群体打交道时尤为明显，尤其是在那些与我们群体存在竞争或敌对关系的人面前。事实上，进化科学认为，我们在群体内部建立联系是因为高度合作的群体能够胜过其他个体和群体。换句话说，强大群体的形成是人类的重要竞争优势（这对其他社会生物也是如此）。

当处于竞争状态时，我们似乎有能力关闭支持连接的机制。我们可以去人性化和断开连接，以避免感受到伤害他人或忽视他人所带来的痛苦。这种能力是偏见、回避（他人的问题）、暴力倾向等的基础（Levin et al. 2016）。我们既有连接的能力也有断开的能力。

所有的关系都涉及在亲近与疏远之间找到平衡

一般来说，我们在自己的群体内部建立联系，而与属于外群体的其他人竞争，但我们即使在最亲近的关系和所属的小群体中也对伤害和剥削保持敏感。因此，我们不断在亲近与距离、连接与断开、开放与保持界限、给予他人与服务自己之间寻找平衡。与他人互动或受到他人影响是一把双刃剑：它可能对我们有利，也可能对我们有害。与另一个人亲近总是让我们有点脆弱，并需要一种信仰的飞跃。这是作为具有社交需求和社交脆弱性的社会敏锐人类的紧张之处。我们有许多社交情绪来引导我们度过这种紧张。当我们的需求未得到满足时，我们会生气；当我们违反了他人的需求或整个群体的需求时，我们会感到内疚或羞愧；当另一个人满足了我们的需求时，我们会感到爱和感激；当另一个人背叛我们时，我们会感到悲伤和悲痛。

我们的社会关系故事，在很多方面，是一个在亲近与疏远之间、在满足自身需求与保护自己免受伤害和脆弱性之间找到平衡的故事。因此，这是一个关于我们如何被伤害和滋养，以及由此我们如何学会与他人相处的故事。我们都携带着这种紧张，因为进化要求群体在这种平衡中挣扎才能正常运作。为了生存，我们需要编织细腻的连接线，但当保持这些连接的成本变得太高时，我们也需要能够切断它们。实际上，有时似乎正是这种能够后退和断开连接的能力——这样我们可以在适当的时候重新连接——使得关系变得坚韧和灵活。

今天的世界不同了

不仅我们都经历了人际关系的双刃剑，而且我们生活在一个与祖先所处的世界截然不同的世界中，那个世界塑造并优化了我们的社交连接机制。那个世界通常是小规模且相对稳定的，有着相当明确的世界观和社会规则。例如，1940年代出生在南非中部的一个狩猎采集部落的孩子，其生活方式与1840年代、1540年代甚至公元40年代出生的孩子非常相似。这个孩子一生中主要与相同的二三十个人互动。从2016年的角度来看，这种稳定的社会安排在过去大部分人类历史中是常态而非例外。

今天世界的社交规模要大得多。许多群体——由宗教信仰、政治观点、职业焦点、文化实践、爱好以及学校或体育归属等差异定义——交织在一起共同生活，这对我们适应和合作的能力提出了更高的要求。例如，我们经历了一次又一次的社会过渡，在其中进入新的群体，建立新的联盟，并决定信任谁并与谁结盟。这些过渡可能会持续一生，我们可能永远不会安定在一个稳定的社区中。我们的世界观可能与父母的差别如此之大，以至于很难与他们相处。同时，我们也是面对类似社会结构破坏、冲突和协商的父母的孩子。今天，我们面临的挑战使社会适应成为生活中正常的一部分。

社会背景的重要性

我们进化历史的遗产深深反映在我们的心理中。这不仅仅是说我们对他人如何与我们互动敏感，感觉更好或更糟；在所有的人际交往中，我们都在努力平衡亲近与疏远，学习关系中的教训，并带着伤痕和胜利前行。因为社会世界的导航对我们物种至关重要，所以社会关系塑造了我们。它们留下了持久的印记，影响着我们的行为和福祉。

社交连接困难与心理问题之间的联系是深刻的，并且几乎存在于所有主要的精神障碍中（Barnett & Gotlib, 1988; Beck, 2010; Horowitz, 2004; Leach & Kranzler, 2013; McEvoy, Burgess, Page, Nathan, & Fursland, 2013; Pettit & Joiner, 2006; Pincus, 2005）。因果箭头可能双向作用：社会压力源导致心理压力，而心理压力反过来又产生社会压力。因此，许多寻求心理治疗的客户来访不仅是在与自己斗争，他们还在与他人的关系中挣扎，并且往往有着长期痛苦的历史。

考虑一下马克的情况，他在八个月前失业后陷入抑郁，现在几乎完全孤立。尽管他看起来似乎自我中心且与世隔绝，但他的孤立实际上是高度人际化的。他在一个通常被忽视或批评的家庭中长大，在这种背景下，他发展出一种根深蒂固的感觉，认为自己有问题。每当他周围有人可能会负面评价他时，他就会感到轻微的焦虑和沉默。为了应对自己的不足感，他变得非常倾向于取悦他人，大多数人认为他是一个好人。然而，就像被要求说一种从未学过的语言一样，他几乎没有词汇来表达自己的需求或感受；他只知道他感到“不好”。随着抑郁的加深，来自朋友和家人的电话和电子邮件让他越来越难以承受。对他来说，避免他们的接触比与他们交谈所经历的痛苦要容易得多。现在他陷入了极度的孤独中，交替处于各种厌恶状态：严厉的自我批评和绝望；由于持续退缩而感到内疚，他知道这会让家人非常担心；以及围绕睡眠、电视和色情内容的麻木疏离，这些进一步强化了他认为自己无用的信念。

再考虑琼的情况，她因几年前的工作受伤而遭受慢性疼痛。虽然疼痛的明显原因是受伤本身，但琼目前的痛苦涉及许多人。她因为成为丈夫的负担而感到内疚，她的丈夫不仅承担家庭经济责任，还处理所有的家务。出于内疚，她偶尔在家里过度劳累，加剧了她的疼痛。当她的物理治疗师开出了一些太难的练习时，她因为羞愧没有告诉治疗师，而是连续取消了几次预约。一般来说，她避免与朋友或前同事联系，因为她感到尴尬和沮丧，不想让别人看到她“这个样子”。偶尔，她通过向孩子或丈夫发表敌意的评论来表达她的挫败感。几个月后，她符合抑郁症的标准。

在这两个案例中，虽然可以想象一个人的问题在脱离社会背景的情况下发生，但我们只有通过审视马克和琼生活中的社会背景，才能全面理解他们的痛苦故事——以及改变过程中所面临的挑战。同样，可以通过关注较窄的心理功能范围，如活动安排或接受疼痛和其他情绪，为马克或琼提供治疗缓解。但这些表面上的个人过程必然会在人际背景下展开，从接受治疗师帮助的人际背景开始。

这一点非常重要，我们再次强调：社会背景不仅对关系满意度有持续而广泛的影响，而且对一般功能——心情、压力水平、总体幸福感、目标追求、健康相关行为（如锻炼和营养）、安全感以及自我意识、意义和目的感都有影响。在CBS的语言中，社会互动是一个重要的背景，在这个背景中，我们心理学的所有其他方面都得到了塑造，无论是从发展的角度还是当前的角度。甚至我们如何对待自己也是由人际关系背景塑造的，比如父母和其他人如何对待我们，他们现在如何对待我们，以及我们如何回应他们。（当然，还有许多非社会原因导致的痛苦和苦难，如遗传因素、认知因素以及各种非社会创伤和压力源。我们并不是建议用纯粹的社会模型取代完整的生物-心理-社会痛苦模型；相反，我们试图理解社会因素的重要性并给予足够的关注。）

社会背景与整体满意度和功能之间的关系使我们有兴趣更仔细地研究连接的隐喻，即社会连接。我们经常使用诸如“亲密”或“深入”这样的比喻性术语来描述我们最具影响力的关系。事实上，衡量关系亲密程度的一种最流行的方法是让人们视觉化地描述自己的自我与他人有多少重叠——即他人的自我在多大程度上被比喻性地包含在自己的自我中（Aron, Aron, & Smollan, 1992）。关于连接的亲密或深度的这些隐喻揭示了一个简单的真理：更亲密或更私密的关系涉及更高程度的心理接触。在这些亲密关系中，我们透露更多自己，并让自己更容易受到影响。我们能够施加和接受影响——理想情况下，这种影响是支持性和有益的。同时，如果这种影响是痛苦的，或者如果我们没有学会如何接受并与他人建立有益的联系，我们的痛苦可能会加剧。痛苦的关系史塑造了我们在当前社会关系网络中的存在方式。而当前的心理痛苦往往会影晌我们如何与他人相处。

那么，当客户来访的困境干扰了他们在心理治疗核心的人际影响过程中的有效参与时，治疗中的人际过程的挑战就变得更加复杂了。例如，当马克为了避免让治疗师失望而不反馈疗程过于抽象时（而治疗师没有察觉到这种不一致），或者当琼因为羞愧而不愿意与治疗师分享她痛苦的程度时，治疗的进展很可能会受阻。而且，当与那些有重大或长期痛苦的客户来访合作时，这种挑战似乎往往是常态而不是例外。作为治疗师，我们通过治疗中的社会互动来接触整个个体——当然，他们会将他们的社会历史带到这种互动中。

社会学习

现在，从情境行为科学（CBS）的角度来看，让我们更仔细地考虑社会互动是如何塑造行为的。CBS的观点构成了FAP治疗立场的基础，并且有一些普遍的CBS原则适用于我们的社会关系。在这里，我们将只介绍一些基本概念。在下一章中，我们将深入探讨——再次强调，不是为了理论本身，而是因为CBS视角是FAP实用临床工具的关键元素。

所有行为都是学来的 CBS实践者的一般观点认为，在心理治疗中处理的行为是通过学习得来的。换句话说，行为是通过世界中的经历被塑造成其当前形式的。如果你做了某事，一定有你这样做的原因：你在先前的情境中学到了这种行为方式。 这种一般观点导致了一种非常接纳的态度：行为在其情境中总是有意义的。正如我们不会责怪台球按照物理定律滚动一样，我们也不会因客户来访的行为表现而责备他们。（这并不意味着行为不能改变，因为我们总是在进化——这就是学习的本质。它也不意味着行为总是最优的。有意义并不等于就是最优化。）

例如，如果一个客户来访告诉你她对你即将去度假感到恐惧，你可能会发现她有一段痛苦的经历，当别人离开她时发生了不好的事情。她的感受反映了这段历史，正如她试图说服你保持联系的努力一样。同样地，一个报告每天惊恐发作的客户来访可能已经学会了害怕自己身体里的恐惧信号，尽管这种对恐惧的恐惧反而导致了他不想体验到的感受。毫无疑问，客户来访们会发现了解经验如何塑造他们的行为是非常有启发性的。

社会互动在塑造行为方面的深远影响 社会互动对我们产生如此深远的影响有两个主要原因：其他人不断地提供塑造我们行为的经验，而且作为人类，我们天生就准备好被我们的社会经验深刻地塑造。随着我们在社会世界中前行，我们所走的道路很大程度上是我们与他人交往的历史的结果，这些交往塑造了一系列与我们的心理健康相关的行为，包括我们如何表达情绪、表达需求、寻找安全和保障、做出重要决定以及解决问题。过去的动力推动着我们前进，而我们目前与他人的互动则在某个方向或另一个方向上微妙地引导着我们。我们每个人也在这个过程中微妙地影响着他人；这种影响是相互的。

随着时间的推移，这种塑造的效果可以是积极的，从而发展出有效寻求他人支持、处理情绪、解决问题以及建立共同身份和意义的能力。如果是这种情况，我们可以感谢我们与他人连接的努力通常取得了足够的成功，使我们能够继续伸出援手并提高这方面的能力。我们可以感激那个相当养育的社会环境，它帮助我们处理痛苦的经历、做出重大生活决定、应对变化，或者仅仅是享受一段安静且有联结的时间。

不幸的是，随着时间的推移，他人的影响也可能是否定的，导致我们在社交参与和从上述方式（如处理情绪、做决定等）中受益的能力受限。具体来说，我们可能会形成由过去限制的关系模式。这些模式可能在短期内给我们带来某种程度的舒适感或无懈可击的感觉，但它们通常有长期的成本。正如你可能在一些深陷痛苦的客户来访身上看到的那样，这些模式可能导致一种恶性循环，其中痛苦成为与他人连接的障碍，而缺乏与他人的连接又延续了痛苦。

当然，这些都是为了说明社会互动如何影响行为而进行的广泛概括。现实情况并不是非黑即白。对于许多人来说，更准确的说法可能是我们有或多或少有效的相处方式，而我们的一些相处方式存在缺点并且需要改进。当我们处于压力之下或感觉脆弱时，这些局限性可能更加昂贵，并且可能直接与我们的痛苦有关。

利用治疗关系作为改变的背景

理解社会连接与心理问题之间的关系，以及改善的社会连接如何能带来更好的福祉，导致了对治疗关系的功能和意义的一种特别的概念化。治疗关系是影响客户来访行为的一个来源——这种影响是在当下发生的。当客户来访寻求治疗，尤其是当他们的心理问题涉及与他人相处困难时，治疗关系既是一个机会也是一个风险。

想象一下，本章前面提到的汤姆来找你。他对你的回应显得僵硬。他在表达思想时遇到困难。他似乎找不到一条穿过生活困难的道路。如果你因为他不确定而感到焦虑，或者过于急切地想要帮助他，你可能会咬住他的母亲曾经咬过的钩子：完成他的句子，提出解决方案，急于解决问题。即使出于最好的意图，你也有可能延续一种隐秘的互动，其中汤姆接收到的信息是他不如别人有能力。他可能会顺从，但仍然感到沮丧。

治疗关系中的责任与机会

让我们更明确地说：在治疗关系中，你有可能会重现并强化导致客户来访痛苦的人际问题。以下是一些其他例子：

• 一位倾向于严厉批评他人的客户来访对治疗师也是如此。治疗师退缩或防御性地回应。客户来访随之加剧了批评，并最终停止了治疗。
• 一位通常避免请求所需帮助的客户来访，在治疗过程中同样如此。治疗师不知道如何帮助她，提出了无用的建议。客户来访没有跟进这些建议，因此治疗师认为她懒惰或缺乏动力。结果，客户来访感到羞愧，甚至更不愿意请求所需的帮助，形成了持续数周的循环。
• 一位内心充满无尽反思的客户来访，倾向于以类似的方式与他人交谈，陷入乏味且抱怨不断的循环中。治疗师感受到倾听和理解客户来访痛苦的需求，同时也感到不耐烦地想要打断。当治疗师最终努力专注于行为改变时，客户来访感受到了治疗师的评判，感到更加焦虑。

然而，这种责任也是机会。本质上，治疗关系为治疗师提供了一个机会，可以打破功能失调的社会模式，并培养更有效的模式。你有机会清晰地看到客户来访带到治疗中的那些人际问题。你可以选择以治疗的方式处理这些问题，而不是仅仅重复客户来访在治疗之外与他人相处时的经历。结果可能是一个良性循环，客户来访改善了与你的关系，从而也改善了与其他人的关系，进而提升了整体福祉。

例如，对于汤姆，你可能会认识到他的社交历史塑造了他的犹豫和取悦他人的焦虑。然后，你可以温和而持久地为汤姆提供表达自己需求的机会，并找到自己的前进道路。你也可以挑战汤姆抓住这些机会。

让我们看看如何利用前面的例子来创建一个良性循环：

• 你可以同情地指出客户来访的批评是令人痛苦的，并温柔地将你的体验与客户来访推开的其他人联系起来。你可以挑战客户来访与你合作，寻找其他方式来表达他们的需求。
• 你可以注意到客户来访的被动性和羞耻感，并与她紧密合作，注意她退缩的时刻，建议她找到语言来表达她在治疗和生活中的愿望。
• 你可以向客户来访解释你在希望专心倾听和担心客户来访的故事讲述不是最有效利用时间之间的紧张感。然后，你们可以共同制定一个平衡方案，满足客户来访的需求，以便在治疗中取得进展。

FAP的两个基本支柱——功能性分析和真诚连接——相互平衡，帮助你追求为每位客户来访创造独特治疗关系的机会。

真诚、真实的治疗关系至关重要

体验一种不同的互动方式比仅仅谈论它更能有效地塑造关系行为。这再次强调了人们学习的方式；我们往往通过经验（即体验式学习）比被动接收信息更有效地学习。这并不是说谈话不重要——我们的许多互动都包含谈话——而是说体验挑战并练习不同的行为可以成为变革的强大背景。

再考虑一下汤姆。他可能只有通过与你的互动经历以及你提供的挑战，才能完全理解他与母亲的经历、历史的影响以及他取悦他人的倾向程度。更重要的是，与你在一起，他可能开始找到勇气，克服阻止他向他人明确提出请求和需求的那种焦虑感。

在治疗关系中的体验式学习是一种需要我们作为治疗师开放和直接地讨论关系中发生的事情的工作，这是一种许多治疗师觉得具有挑战性的真诚或自我披露的程度。这种直接性可能简单表现为对客户来访参与治疗方式的观察；例如，“我注意到我对您在这里想要实现的目标感到不确定。”或者，“我注意到您倾向于接受我提出的任何议程。”或者，“我注意到您对我所说的很多事情似乎相当怀疑。”

体验式学习也可能意味着向客户来访透露更多脆弱的方面或我们的反应。例如，我们可以向经常迟到的客户来访表达我们的挫败感，知道他倾向于避免面对其行为的负面后果。我们可以要求他接触我们的反应。我们可以邀请他注意到由此产生的哪些情绪或感觉。

复杂而真实的互动

因为这种互动是复杂、微妙且个性化的，所以它们必须是真诚的，这意味着治疗师是在其实际经历和对情况反应的基础上进行操作的。为什么？首先，因为任何或所有带入的反应都可能与治疗相关，治疗关系不应该比真实的人际关系简单。其次，人类具有敏锐的能力来察觉不真诚——即当他人隐藏回应或反应时。一旦察觉到不真诚，这并非中立的事实。虽然它可能不会触发原始的威胁感，但至少会触发警惕，这可能会削弱治疗关系的质量。对于那些曾经被伤害或背叛过的客户来访来说，这种反应尤其可能发生。

功能性分析帮助我们保持目标

由于真诚、真实的关系是复杂的，我们使用功能性分析（FA）来确保在治疗目标上保持正确方向。FA是一种评估过程，我们利用学习原则来理解特定行为在客户来访自身历史和生活情境中的意义。

为此，我们会考虑以下这些问题：

• 这种行为在过去是如何形成的？
• 它在过去起到了什么作用？
• 它现在起到什么作用？
• 与之相关的代价是什么？

通过这种方式，我们可以了解哪些行为代表了客户来访生活中的问题，以及哪些行为尽管看起来笨拙或不完美，但实际上代表了成长的重要步骤。（第三类行为包括那些可能吸引我们注意的行为——例如，一个显眼的名字掉包者——但并不代表任何临床上重要的问题。重要的是要区分这些行为与其他两类行为，以避免试图“治疗”不需要治疗的问题。）

反过来，FA有助于确保我们在理解客户来访问题及其所需的成长或行为改变的基础上，立即做出策略性和治疗性的响应。例如，对于汤姆，我们可能会注意到他的一些笨拙的需求表达实际上是迈向自信的重要一步。

你可能会注意到这个过程中存在潜在的矛盾：如果FA指示我们应该将某一行为视为成长（例如，汤姆应该更加自信），但我们真诚地发现这种成长行为令人不悦（例如，我们认为汤姆的要求方式是我们不愿支持的），那么我们应该抑制个人反应来促进汤姆的成长吗？

幸运的是，这种矛盾在现实中很少出现。首先，当我们花时间真正理解一个客户来访，无论是通过FA还是其他方法，我们对客户来访的反应往往会自然地与FA一致：我们对客户来访的成长步骤感到满意和高兴，因为我们理解这些步骤背后的意义和努力。同样地，当我们看到客户来访陷入自我挫败的模式时，我们会感到一定程度的真实沮丧或失望（当然伴随着同情和理解）。其次，如果你不能自然地对客户来访的成长做出积极反应，那么这种行为很可能是一个需要解决的重要问题。例如，你可以对汤姆说：“有些事情让我有所触动。你知道我支持你变得更加自信。但我注意到你有时过于直接，甚至显得严厉。你也注意到这一点了吗？”

因为真实的关系涉及两个人，在FAP的过程中，我们的反应和感知与客户来访的同样重要。因此，我们也不断对自己进行FA，精炼作为治疗师的自我认知，询问自己如何为治疗时刻做出贡献，并确保我们的方法服务于客户来访而不是自己的目的。假设是治疗师也是人，因此也容易受到客户来访的影响，正如客户来访容易受到我们的影响一样。当我们与处于痛苦中的客户来访打交道时，特别是当事情发生得很快或充满情感、复杂性或斗争时，我们可能会失去立足点。再次，FA帮助我们保持目标。

在下一章中，我们将阐述构成FAP和类似治疗方法（最显著的是接受与承诺疗法）核心的情境行为科学视角的基本实用原则。

总结

• 社交连接不良所带来的死亡风险与吸烟相当。
• 从CBS的角度来看，社会关系是塑造心理功能——情绪、动机、情感和成就——以及整个生命期间福祉的关键背景。
• 心理治疗涉及通过治疗关系的社会连接和影响过程，可以塑造客户来访的心理和社会功能的变化。
• FAP要求你在基于功能性分析的理解基础上，平衡一种与客户来访真诚、真实的关系方式。通过这样做，你可以确保你的回应是治疗性的，不会延续客户来访在人际关系中的问题。

本章知识点阐述

知识点阐述

1. 社会联系的重要性：

   • 社会联系对于个人的心理健康和长寿至关重要。缺乏良好的社会关系可能对健康产生严重的负面影响，甚至增加死亡风险。

2. 社会支持的作用：

   • 社会支持不仅是心理健康的重要因素，也是身体健康的关键。它可以帮助人们更好地应对压力，提高免疫功能，并降低多种疾病的发病率。

3. 社会信号的处理：

   • 人类大脑中有专门处理社会信号的区域，这表明社会互动在人类发展中扮演着核心角色。婴儿早期就能识别和模仿面部表情，显示出对社会信号的高度敏感性。

4. 社会关系与进化：

   • 社会关系是人类进化的驱动力之一，促进了复杂大脑的发展。这种关系不仅限于直接的生存需求，还包括更广泛的合作和互助行为，这对群体的整体福祉至关重要。

5. FAP的基础：

   • FAP基于上述关于社会联系的重要性的科学发现，强调在治疗过程中创建积极的社会联系，以促进客户来访的个人成长和变化。

6. 个人经验与社会联系：

   • 个人的经历和关系对其性格、价值观和行为有着深远的影响。了解这些背景有助于治疗师更好地理解客户来访，并在治疗过程中提供有效的支持。

7. 治疗关系的独特性：

   • 在FAP中，治疗关系不仅仅是治疗过程的一部分，更是治疗本身的核心。治疗师通过与客户来访的互动，创造了一个促进变革和支持成长的环境。

8. 社会联系与生物学：

   • 社会联系与人体的生理系统紧密相连，包括压力反应、免疫功能和心血管健康。因此，改善社会联系可以带来广泛的健康益处。

9. 社会联系的多维度影响：

   • 社会联系的影响不仅仅局限于个人层面，还涉及群体层面。亲社会行为如友谊、合作学习等对整个社群的福祉都有着积极的影响。

知识点阐述

1. 小群体的重要性：

   • 人类天生适合在小群体中生活和互动，这些小群体通常不超过150人（邓巴数字）。在这样的群体中，我们的情感、行为和自我认同得到了发展。

2. 连接与竞争的双重性质：

   • 人类既能与他人建立紧密联系，也能与其他群体竞争。这种双重性质反映了我们在进化过程中既需要合作也需要竞争的复杂性。

3. 亲密与疏远的平衡：

   • 在所有关系中，我们都需要在亲密与疏远之间找到平衡。这种平衡涉及到信任、边界设定和个人需求与群体需求之间的权衡。

4. 现代社交环境的复杂性：

   • 与过去相比，现代社会更加多样化和动态化。人们需要不断适应新的社会环境，建立新的关系，并处理不同群体之间的相互作用。

5. 社会适应的挑战：

   • 由于现代社会的快速变化，人们面临着前所未有的社会适应挑战。这些挑战包括频繁的社会过渡、价值观的差异以及跨文化沟通的困难。

6. 社交情感的作用：

   • 社交情感如愤怒、内疚、爱和悲伤等，在帮助我们处理人际关系中的紧张和矛盾方面起着关键作用。

7. 韧性和灵活性的重要性：

   • 在不断变化的社会环境中，关系的韧性和灵活性变得尤为重要。能够在适当时候断开连接并在时机成熟时重新连接，有助于维持关系的持久性和适应性。

知识点阐述

1. 社会背景对心理健康的影响：

   • 社会关系对个人的心理健康有着深远的影响。不良的社会互动可能导致心理问题，反之亦然。这种双向关系表明了社会支持和人际互动对于维护心理健康的重要性。

2. 社会隔离与心理问题：

   • 社会隔离不仅是个人问题，也反映了深层次的人际关系问题。长期的孤立可能导致严重的心理问题，如抑郁症，这些问题需要在社会背景中进行理解和治疗。

3. 社会互动与心理功能：

   • 社会互动影响着个人的情绪、压力水平、幸福感、目标追求、健康行为等多个方面。理解这些互动如何影响个人的功能，对于制定有效的治疗策略至关重要。

4. 人际关系的隐喻：

   • 人们常常用“亲密”或“深入”等隐喻来描述关系的质量。这些隐喻反映了关系中的心理接触程度，以及在这种关系中个人的开放度和易受影响性。

5. 社会背景与治疗过程：

   • 在治疗过程中，客户来访的社会背景对其参与和治疗效果有着重要影响。治疗师需要意识到客户来访的社会历史，并在治疗中加以考虑，以促进有效的治疗进程。

6. 心理治疗中的人际挑战：

   • 客户来访的某些行为或态度可能阻碍治疗的有效性，如避免反馈或隐瞒真实感受。治疗师需要识别这些障碍，并采取措施克服它们，以确保治疗的成功。

7. 社会支持与心理恢复：

   • 有效的社会支持系统可以帮助个人更好地应对心理问题。治疗师应当鼓励客户来访建立和利用积极的社会支持网络，以促进其心理恢复。

知识点阐述

1. 行为的习得性质：

   • CBS的核心观点之一是所有行为都是通过学习形成的。这意味着行为背后总有其成因，通常是基于个人过往经历的学习结果。这种观点促进了对行为的理解而非简单评判。

2. 社会互动的重要性：

   • 人类行为受到社会互动的深刻影响。这种影响不仅来自他人提供的经验，还源于人类天生具有根据社会经验进行调整的能力。社会互动塑造了个体的情感表达、决策过程及解决问题的方式。

3. 正向与负向社会影响：

   • 社会互动既可以带来正面影响，如增强社交技能和支持网络，也可能导致负面影响，比如限制个人的社会功能或引发负面情绪循环。理解这些影响有助于识别和干预潜在的问题。

4. 治疗关系的作用：

   • 治疗关系不仅是治疗过程的一部分，也是促进客户来访行为改变的重要背景。治疗师应当注意自身在治疗关系中的角色，避免无意中强化客户来访的消极行为模式。

5. 治疗中的双向影响：

   • 在治疗过程中，治疗师和客户来访之间存在着相互作用。治疗师的行为和反应可以显著影响客户来访的情绪状态和行为表现。因此，治疗师需要保持敏感和反思，以促进建设性的互动。

6. 个体差异与适应性：

   • 虽然社会互动对大多数人都有重要影响，但每个人对相同情境的反应可能不同。认识到这一点可以帮助治疗师更好地理解和满足每个客户来访的独特需求。

7. 情感与行为的联系：

   • 人们的行为往往根植于他们的情感体验。治疗师应关注客户来访的情感状态，探索其背后的根源，并通过治疗关系帮助客户来访学会更健康地表达和管理自己的情感。

知识点阐述

1. 治疗关系的责任与机会：

   • 在治疗关系中，治疗师有责任避免重现和强化客户来访已有的问题模式。同时，这也是一个机会，让治疗师能够识别并干预这些模式，促进客户来访的成长和变化。

2. 打破不良模式：

   • 通过治疗关系，治疗师可以帮助客户来访识别和改变那些导致他们痛苦的行为模式。这包括批评、回避需求表达等行为，这些行为可能阻碍个人的发展和人际关系的改善。

3. 建立良性循环：

   • 通过积极的互动和支持，治疗师可以帮助客户来访建立新的、更健康的互动模式。这不仅有助于改善治疗关系，还能推广到客户来访与其他人的关系中，从而提升整体的生活质量。

4. 功能性分析与真诚连接：

   • FAP的两个核心原则——功能性分析和真诚连接——是治疗过程中的关键。功能性分析帮助理解行为背后的功能，而真诚连接则提供了真实互动的平台，两者相辅相成。

5. 体验式学习的重要性：

   • 体验式学习强调通过实际体验来学习和改变，而不是仅仅通过理论讲解。这种学习方式更深刻，更持久，因为它涉及情感和身体的参与。

6. 治疗师的自我披露：

   • 治疗师的自我披露可以增强治疗关系的真实性和有效性。通过分享自己的感受和反应，治疗师可以帮助客户来访更好地理解自己，并促进更深层次的交流。

7. 治疗关系中的真诚：

   • 真诚的关系是治疗成功的关键。治疗师需要保持开放和诚实，这样才能建立起信任，使客户来访感到被理解和接纳。这样的环境有助于客户来访探索和解决深层问题。

知识点阐述

1. 真诚的重要性：

   • 在治疗关系中，真诚意味着治疗师根据自身的实际体验和反应来操作。真诚不仅有助于建立信任，还能使治疗师更好地理解和应对客户来访的感受和需求。

2. 功能性分析的作用：

   • 功能性分析（FA）是一种评估工具，帮助治疗师理解特定行为的功能。通过FA，治疗师可以识别哪些行为是问题所在，哪些行为是成长的迹象，从而制定更有效的干预措施。

3. 处理矛盾的方法：

   • 当FA建议的行为与治疗师的个人感受相矛盾时，治疗师应当诚实地表达自己的感受，并与客户来访共同探讨。这有助于保持治疗关系的真实性，同时促进客户来访的成长。

4. 治疗师的自我反思：

   • 治疗师也需要对自己的反应和行为进行功能性分析，以确保自己的方法服务于客户来访而非满足个人目的。这有助于保持治疗的专业性和有效性。

5. 社交连接与健康：

   • 社交连接对心理健康至关重要。缺乏良好的社交连接可能导致一系列心理问题，甚至增加死亡风险。心理治疗通过改善社交连接来提升整体福祉。

6. 治疗关系的复杂性：

   • 治疗关系是复杂且多维的，需要治疗师具备高度的敏感性和灵活性。通过功能性分析，治疗师可以更好地把握治疗的方向，确保治疗的有效性。

PA R T 1 The IdeasCHAPTER 1 Social Connection and the Therapeutic Relationship as Contexts for Change There is no such thing as a “self-­made” [person]. We are made up of thousands of others. Everyone who has ever done a kind deed for us, or spoken one word of encouragement to us, has entered into the make-­up of our character and of our thoughts, as well as our success. —­George Matthews Adams Think for a moment about the most important interactions and relationships you’ve had in your life. Think about the ones that were the most connected, joyful, and inspiring. Also think about the interactions that were the most painful and heartbreaking, ending in betrayal or disappointment. How did all of these experiences shape you? What lessons did you carry forward? What words from another person will you never forget? What habits, shaped in the past, do you repeat today? Consider Tom, the client mentioned in the introduction, who grew up in a family that felt distant yet also stifling at times. His mother—­an executive who worked long hours—­taught him that emotions were to be mastered, problems to be solved. He felt anxiety about his emotions. He felt ashamed about his ongoing inability to succeed the way she had. In middle school, a teacher encouraged his writing ability, giving him an experience of pride. From that time forward he prized his literary skill, but he also struggled because his mother doubted its value. A small group of friends in college solidified for him a vision of how society—­especially the business world—­is oppressive and unethical. He felt close to them, and he felt a righteous indignation about much of the world. Tom, like all people, is a sum of his relationships and experiences. Both affect how he sees himself, others, and the world, as well as how he feels about these things. Take five to ten minutes to write some things down. What have you experienced and learned from relationships? Functional analytic psychotherapy (FAP) is about creating therapeutic relationships in which you skillfully and strategically relate to clients in order to create a context for change. While many relationships change lives, therapeutic relationships aim to change lives therapeutically. Before we get into the specifics of FAP and its approach to therapeutic change, let’s start at the beginning, with the perspective that informs each moment of FAP. FAP is grounded in a view of psychology and social influence that integrates contextual behavioral science (CBS) with the growing science of social connection, including how social connections affect psychological func- tioning. This foundation shapes FAP’s conceptualization of the therapeutic relationship and the therapist’s stance in each moment with clients. In this first chapter, as a way of building toward the more experiential and applied clinical aspects of FAP, we lay out this foundation. SOCIAL CONNECTIONS MATTER Human beings need social connection to thrive, and problems with social connection may create profound suffering. This statement is based on a well-­established set of scientific findings that speaks to the fundamental importance of social connection. Here are a few of these findings: • Having poor or extremely limited social relationships has an effect on mortality com- parable to smoking and double the effect of obesity (Holt-­Lunstad, Smith, & Layton, 2010). In other words, social connections keep people healthy and help them live longer. Researchers have estimated that the negative health impacts of having poor or limited social relationships is equivalent to smoking fifteen cigarettes a day (Holt-­Lunstad & Smith, 2012). • Both poor relationships (characterized by conflict) and limited social relationships (loneliness) negatively impact stress hormones, immune functioning, and cardiovascu- lar functioning, among many other factors (Kiecolt-­Glaser et al., 2005; Cacioppo et al., 2002). In fact, social support is a key influence on outcomes for a range of health prob- lems, from cardiovascular disease to tuberculosis to schizophrenia (House, Landis, & Umberson, 1988). • Humans have considerable neural real estate dedicated to processing social signals, and this attunement to social signals emerges in the first moments following birth, as babies orient toward faces and mimic facial expressions (Meltzoff & Moore, 1977). • Social relationships are one of the primary mechanisms that drove evolution of the complex human brain, and they’re deeply interconnected with biological systems that regulate human physiology and emotion (Cacioppo & Patrick, 2008; Porges, 2001). Surveying all these findings, evolutionary science tells us that social functioning has been fun- damental to our species’ survival and has shaped who we are—­genetically, physiologically, and behaviorally. We are the ancestors of the humans who related effectively to others, not just in terms of social mechanisms with obvious evolutionary significance, such as sexual interactions and par- enting, but in terms of a host of prosocial relational behaviors that function at the level of groups and promote group well-­being, such as friendship, altruism, and cooperative learning and problem solving (Bugental, 2000; Sober & Wilson, 1998). We spread to cover the globe not because of our physical strength or individual smarts, but because collectively our abilities to connect and cooper- ate make us mighty. (For captivating reviews of this perspective, see Harari, 2015, and Henrich, 2016). There are four ideas that are central to understanding how evolution has shaped us and the social challenges we face today:

1. We evolved to attune to and operate in small groups.
2. We also evolved to compete with other groups.
3. In any relationship we work to find a balance between close and far.
4. The world today—­perhaps unlike the one we experienced in our evolutionary history—­ involves navigating between and across lots of “in groups” and “out groups,” close and far. The world today requires that we become skilled at forming and sustaining relation- ships across change and at balancing our own needs against the needs of the various groups to which we belong. We evolved to attune to and operate in small groups. Although today we function in a broad array of social groups—­from families to communities (virtual and otherwise) to larger units, such as cities, states, and nations—­the key groups in which we evolved and flourished for tens of thou- sands of years tended to be small. At the large end of size spectrum, they typically reached the famous Dunbar number of 150 (Dunbar, 2010). Even in a world of seven billion people, groups at or below the Dunbar number tend to be the ones that shape us the most. As the science of attach- ment shows, this shaping starts early, with our primary caregivers (Cassidy & Shaver, 1999). It continues through childhood with adolescent friends and classrooms and into adulthood with roommates and romantic partners. Our emotions, behaviors, and sense of self and purpose are fine-­ tuned to the subtleties of the relationships and bonding that develop within these relatively small groups. Our ability to coordinate our actions with others depends on a robust capacity for making sense of the minds of others. The flexible connectedness model (Levin et al., 2016; Vilardaga, Estévez, Levin, & Hayes, 2012)—­a CBS framework that is gathering empirical support—­argues that our ability to connect with others depends on three distinct capacities: perspective taking (the ability to understand the perspective of another), empathy (the ability to feel what it feels like to be in that perspective), and acceptance (the willingness to experience the feelings that come from being in that perspective). These capacities are the psychological mechanisms of connection. We are so immersed in the water of connection that it’s easy to forget that our ability to understand others is a marvelously complex psychological task. In turn, effective engagement in relationships supports optimal well-­being. Across the thou- sands of research studies on this topic (in addition to the findings cited above), three main themes arise. The first is that close relationships and intimacy are highly beneficial (here, “intimacy” means sharing thoughts and feelings that you don’t share with just anyone). Even when we have just one or two close relationships, we tend to be happier and healthier, both physically and mentally. The second theme is that perceived social support matters. Again, it isn’t how many friends we have, it’s whether we feel that there are people who will support us when we need it. The third theme involves social participation—­feeling that we’re part of a larger community. This could be an extended family, a group of friends, a network of colleagues, a church or other religious group, a club or sports team, or a volunteer organization. What seems to matter is that we feel like we belong to a group—­one that’s larger than ourselves and our one-­on-­one intimate relationships. We evolved to compete with other groups. The flip side of bonding closely with others, of course, is our tendency to relate with caution, guardedness, competitiveness, and aggression. This ten- dency has a clear role in our dealings with those outside our social groups, especially with people in competitive or aggressive relations with our groups. In fact, evolution science argues that we bond within groups because a highly cooperative group can outcompete other individuals and groups. In other words, the formation of powerful groups is a key human competitive advantage (the same is true for other social creatures). When in competition, we seem to have a capacity to turn off the machinery that supports con- nection. We can dehumanize and disconnect in order to not feel the pain of those we harm or ignore. This ability underlies prejudice, avoidance (of the problems of others), a capacity for vio- lence, and so on (Levin et al. 2016). We have a capacity to disconnect as well as to connect. All relationships involve balancing close and far. In general, we bond within our groups and compete with others who belong to out groups, but we’re sensitive to harm and exploitation even within our closest relationships and the small groups we belong to. Therefore we constantly balance closeness with distance, connection with disconnection, opening up with keeping boundaries, and giving to others with serving ourselves. Interacting with or being influenced by others is a double-­ edged sword: it might do us good, or it might do us harm. Being close to another person always leaves us a little bit vulnerable and requires a leap of faith. This is the tension of being a socially attuned human being, one with social needs and social vulnerabilities. We have a host of social emotions that steer us through this tension. Anger when our needs aren’t met. Guilt or shame when we’ve violated the needs of another, or the group as a whole. Love and gratitude when another meets our needs. Sadness and grief when another betrays us. The story of our social relationships is, in many ways, one of finding balance between closeness and distance—­between getting our needs met and shielding ourselves from harm and vulnerability. As such, it’s the story of how we’ve been hurt and nurtured and, as a result, how we’ve learned to relate to others. We all carry this tension, because evolution required groups to struggle with this balancing act in order to function. For survival, we needed to weave delicate threads of connection, yet we also needed to be able to sever them when the cost of keeping them became too high. In fact, sometimes it seems that the very ability to step back and disconnect—­so that we can come back and reconnect when the time is right—­is part of what makes relationships resilient and flexible. The world today is different. Not only do we all experience this double-­edged sword of human connection, we also live in a world that is quite different from the world of our ancestors, the one that shaped and optimized our mechanisms for social connection. That world was often small and relatively stable with a reasonably well-­defined worldview and set of social rules. For example, a child born into a hunter-­gatherer tribe in south-­central Africa in the 1940s lived a life very similar to a child born in the 1840s or 1540s or even AD 40. This child mainly interacted with the same twenty to thirty people over the course of his or her life. This sort of (from the perspective of

2016. stable social arrangement was the norm rather than the exception for most of human history. The social scale of the world today is much larger. Many groups—­defined by differences, for instance, in religious beliefs, politics, career focus, cultural practices, hobbies, as well as school or sports affiliations—­intermingle and live together, and this places many more demands on our ability to adapt and cooperate socially. For example, we experience social transition after social transition, in which we enter new groups, build new alliances, and decide whom to trust and ally with. These transitions might continue across our life span, and we may never settle down in a stable community. Our worldview might differ so markedly from that of our own parents that we have difficulty relating to them. At the same time, we are also the children of parents who faced similar disruptions to their social fabric, similar conflicts and negotiations. Today we face chal- lenges that strain our ability to socially adapt as a normal part of life. oasis-ebl|Rsalles|1490374036 SOCIAL CONTEXT MATTERS The legacy of this evolutionary history is reflected deeply in our psychology. It’s not just that we’re sensitive and feel better or worse depending on how people interact with us; in all of our human interactions we are working to balance closeness and distance, learning the lessons of our relation- ships, and carrying the scars and the victories. Because navigating the social world is so important to our species, social relationships shape us. They leave lasting marks, influencing our behavior and well-­being. The links between difficulties with social connection and psychological problems are profound and exist across almost all major psychiatric disorders (Barnett & Gotlib, 1988; Beck, 2010; Horowitz, 2004; Leach & Kranzler, 2013; McEvoy, Burgess, Page, Nathan, & Fursland, 2013; Pettit & Joiner, 2006; Pincus, 2005). The causal arrow probably goes in both directions: social stressors cause psychological stress, and psychological stress, in turn, creates social stress. As a result, many clients who seek psychotherapy aren’t just struggling with themselves, they’re struggling in relation to others and often have a long and painful history of doing so. Consider Mark, a client who descended into depression after losing his job eight months ago and is now almost entirely isolated. Although he might seem self-­absorbed and cut off, his isolation is actually intensely interpersonal. He grew up in a household in which he was typically ignored or criticized, and given this context, he developed an abiding sense that something was wrong with him. He experiences low-­level anxiety and reticence that settle into his body whenever he’s around people whom he fears will evaluate him negatively. He has coped with his sense of inadequacy by becoming very oriented toward pleasing others, and most people find him to be a nice guy. Yet, just as if he were asked to speak a language he’d never learned, he has few words for expressing his own needs or feelings; he just knows that he feels “bad.” As his depression deepened, he became increas- ingly overwhelmed by phone calls and e-­mails from friends and family members. For him, it was easier to avoid their outreach than to experience the pain of speaking to them. Now he’s frozen in excruciating isolation, alternating between various aversive states: harsh self-­criticism and despair; guilt about his continued withdrawal, which he knows worries his family profoundly; and numb detachment revolving around sleep, television, and pornography, which only reinforce his belief that he’s worthless. Or consider Joan, who suffers with chronic pain related to a work injury that occurred several years ago. While the more obvious cause of her pain is the injury itself, Joan’s suffering in the current context involves many other people. She feels guilty for being a burden to her husband, who is not only carrying the family financially but also handling all of the household chores. Driven by guilt, she periodically overexerts herself at home, exacerbating her pain. When her physical therapist prescribed exercises that were too difficult, she was too ashamed to let him know and instead canceled several sessions in a row. In general, she avoids reaching out to friends or former coworkers because she’s embarrassed and frustrated and doesn’t want people to see her “like this.” Occasionally, she expresses her frustration through hostile comments to her children or husband. Over several months, she came to meet the criteria for depression. In both of these cases, while it might be possible to imagine a version of the person’s problem occurring outside the social context, we can only appreciate the full story of suffering—­and the challenges involved in changing—­by looking at the social contexts in which Mark and Joan live. Similarly, it may be possible to provide therapeutic relief to Mark or Joan by focusing on a narrower band of psychological functioning, such as activity scheduling or acceptance of pain and other feel- ings. But these apparently intrapersonal processes necessarily play out across interpersonal con- texts, starting with the interpersonal context of accepting help from a therapist. The point is so important, we repeat it: social context has an ongoing and pervasive impact not only on satisfaction with relationships but on functioning in general—­mood; stress levels; general well-­being; pursuit of goals; health-­related behaviors such as exercise and nutrition; sense of safety; and sense of self, meaning, and purpose. In the language of CBS, social interactions are a major context in which all of these other aspects of our psychology are shaped, both developmentally and in the present. Even how we relate to ourselves is shaped by interpersonal contexts, such as how our parents and others have related to us, how they treat us now, and, in turn, how we relate to them. (Of course, there are myriad other nonsocial causes of pain and suffering, such as genetics, cognitive factors, and all sorts of nonsocial traumas and stressors. We are not suggesting replacing the full biopsychosocial model of suffering with a solely social model; rather, we seek to understand the importance of the social piece of the puzzle and to devote adequate attention to it.) This relationship between social context and overall satisfaction and functioning makes it inter- esting to look more closely at the metaphor of connection, as in social connection. We often describe our most influential relationships using metaphorical terms like “close” or “deep.” In fact, one of the most popular methods for measuring the closeness of relationships asks people to describe, visually, how much their own self overlaps with others—­how much of the other’s self is, metaphorically, included in one’s own self (Aron, Aron, & Smollan, 1992). These metaphors about the closeness or depth of connection reveal a simple truth: that closer or more intimate relation- ships involve higher degrees of psychological contact. In these intimate relationships we reveal more of ourselves and open up more of ourselves to influence. We are able to give and receive influence and—­ideally—­this influence is supportive and beneficial. At the same time, if this influ- ence has been painful, or if we’ve not been taught how to accept and benefit from connection with others, our suffering may be compounded. A painful history of relationships shapes how we exist in our current network of social relations. And psychological suffering in the present tends to impact how we relate as well. The challenge of the interpersonal process of therapy is amplified, then, when clients’ problems interfere with their effective participation in the process of interpersonal influence that lies at the heart of psychotherapy. For example, when Mark avoids giving his therapist the feedback that their sessions feel too abstract because he is afraid of disappointing the therapist (and the therapist doesn’t pick up on this misalignment), or when Joan avoids sharing the extent of her distress with her therapist because she is ashamed, the progress of therapy is likely impaired. And it often seems that this kind of challenge is the rule, not the exception, when working with clients who have sub- stantial or long-­standing suffering. As therapists, we encounter the whole person through the social interaction of therapy—­and of course they bring their social history to that interaction. SOCIAL LEARNING Now, from a contextual behavioral science (CBS) standpoint, let’s consider a little more closely how social interactions shape behavior. The CBS perspective makes up the foundation of the therapeu- tic stance in FAP, and there are some general CBS principles that apply to our social relationships. Here we’ll only introduce some basic concepts. We’ll go deeper in the next chapter—­again, not for the sake of theory per se, but because the CBS perspective is a key element in FAP’s practical clinical tools. All Behavior Is Learned The general perspective of CBS practitioners is that the behaviors we work with in psycho- therapy are learned. In other words, behaviors have been shaped into their current form by experi- ences in the world. If you do something, there is a reason why you do it: you learned to behave that way in previous situations. This general perspective leads to a very accepting stance: behavior always makes sense in its context. Just as we don’t fault the billiard ball for going where physics dictates, we don’t fault clients for how their behaviors unfold. (This does not mean that behaviors can’t be changed, because we are always able to evolve—­that is what learning is about. Nor does it mean that behavior is always optimal. Making sense is not the same as being optimal.) For instance, if a client describes feeling dread when you tell her that you’re going on vacation, you might discover that she has a history of painful things happening when others leave her alone. Her feelings reflect that history, as do her efforts to convince you to stay in contact. Likewise, a client reporting daily panic attacks probably learned to fear the signs of fear in his own body, even though this fear of fear paradoxically leads to exactly the experience he doesn’t want. As you have no doubt experienced, clients can find it illuminating to gain such perspectives on how experience has shaped their behaviors. The Profound Influence of Social Interactions in Shaping Behavior Social interactions have such a profound impact on us for two major reasons: other people constantly deliver experiences that shape our behavior, and, as human beings, we come into this world prepared to be deeply shaped by our social experiences. As we move through the social world, the path we’re on is largely a result of our history of interactions with others, which shape a whole range of behaviors related to our psychological well-­being, including how we express emo- tions, express our needs, find safety and security, make important decisions, and solve problems. Momentum from the past carries us forward, and we’re nudged in one direction or another by our present interactions with others. Each of us is also nudging others in the process; the influence is reciprocal. Over time, the effects of this shaping can be positive, resulting in the capacity to effectively seek support from others, process emotions, solve problems, and build shared identity and meaning. If this is the case, we can be thankful that our efforts to connect with others have generally met with enough success that we’ve continued to reach out and increase our skills for doing so. We can be grateful for the reasonably nurturing social environment that we have drawn upon to process painful experiences; make big life decisions; cope with change; or simply enjoy a quiet, connected time with someone. Unfortunately, the influence of others over time can also be negative, leading to limitations in our ability to engage socially and benefit from social connections in the ways just mentioned (pro- cessing emotions, making decisions, and so on). Specifically, we might end up with patterns of relating to others that are constrained by the past. These patterns may help us feel some degree of comfort or invulnerability in the short term, but they usually have long-­term costs. As you’ve prob- ably seen with some of your deeply suffering clients, these patterns can result in a vicious cycle in which suffering becomes a barrier to connecting with others, and lack of connection with others perpetuates suffering. Of course, these are broad generalizations for the purpose of illustrating how social interac- tions influence behavior. The reality isn’t so black-­and-­white. For many of us, it might be more accurate to say that we have ways of relating that more or less work well, and that some of our ways of relating have downsides and bear improvement. And when we’re under stress or feeling vulner- able, these limitations may be more costly and may be linked directly to our suffering. USING THE THERAPEUTIC RELATIONSHIP AS THE CONTEXT FOR CHANGE Understanding the relationship between social connection and psychological problems, and how improved social connection can lead to improved well-­being, leads to a very particular conceptual- ization of the function and significance of the therapeutic relationship. The therapeutic relation- ship is a source of influence on the client’s behavior—­an influence exerted in the here and now. When clients seek therapy, and especially when their psychological problems involve difficulties relating to other people, the therapeutic relationship presents both an opportunity and a liability. Imagine that Tom, from earlier in this chapter, has come to see you. His responses to you seem stilted. He struggles to articulate his thoughts. He can’t seem to find a path forward through life’s difficulties. If you become anxious about his uncertainty, or too eager to help, you might bite the same hook his mother bit: completing his sentences, offering solutions, rushing to solve problems. With the best of intentions, you risk perpetuating an insidious interaction in which Tom receives the message that he is deficient and less capable than others. He may comply and yet remain demoralized. Let us put it more explicitly: in the therapy relationship there is the liability that you may recre- ate and reinforce the interpersonal problems that are causing your client’s suffering. Here are a few other examples: • A client who tends to criticize others harshly does so with the therapist. The therapist withdraws or responds defensively. The client in turn ramps up his criticism and even- tually stops coming to therapy. • A client typically avoids asking for what she needs. The therapist doesn’t know how to help her and makes suggestions that aren’t helpful. The client doesn’t follow through on these unhelpful suggestions, so the therapist deems her lazy or unmotivated. Consequently, the client feels shame and is even less likely to ask for what she needs, creating a cycle that persists for weeks. • A client has an internal process of endless rumination and tends to talk with other people in a similar way, moving through tedious, complaining loops. The therapist feels competing urges to listen attentively and recognize the client’s pain and to interrupt in impatient frustration. When the therapist finally does make an effort to focus on behav- ior change, the client perceives the therapist’s judgment and feels even more anxious. This liability, however, is also an opportunity. In essence, the therapeutic relationship gives the therapist an opportunity to be an agent for disrupting dysfunctional social patterns and nurturing more effective ones. You have an opportunity to clearly see the interpersonal issues that clients bring to therapy. You can choose to engage with these issues therapeutically, rather than merely recapitulating what clients experience with others outside of session. The result can be a virtuous circle in which clients improve their relationship with you and thus their relationships with others, contributing to improved overall well-­being. For instance, with Tom you might recognize that his social history has shaped his reticence and anxiety about pleasing others. You might then gently and persistently present opportunities for Tom to voice his own needs and find his own way forward. You might challenge Tom to take those opportunities. Let’s look at a few other ways to create a virtuous cycle using the previous examples: • You might point out to the client, compassionately, that his criticisms are painful and gently link your experience to the experience of other people the client has pushed away. You might challenge the client to collaborate with you to find other ways to voice his needs. • You might notice the client’s passivity and shame and work closely with her to notice moments when she pulls back, suggesting that she instead find the language to articu- late what she wants in therapy and in life. • You might explain to the client the tension you feel between a wish to listen attentively and a concern that the client’s storytelling is not the most efficient use of time in session. Then you could come up with a balanced solution that meets the needs of the client in order to make progress in therapy. The two fundamental pillars of FAP—­functional analysis and genuine connection—­balance each other and help you pursue the opportunity to create a relationship that is uniquely therapeutic for each client. Genuine, Authentic Therapeutic Relationships Are Essential To experience a different way of relating is a more potent vehicle for shaping relational behavior than merely talking about it. Again, this is a statement about how people learn; we often learn more effectively through experience, also called experiential learning, than through passively receiving infor- mation. This is not to say that talking is not important—­much of our relating consists of talking—­ but instead that experiencing a challenge and practicing a different behavior can be a potent context for change. Let’s again consider Tom. He may only come to fully appreciate his experiences with his mother, the effects of his history, and the degree to which he is oriented toward pleasing other people through his experience of relating to you and the challenges you offer. More importantly, with you he might begin to find the courage to step through the sense of anxiety that has pre- vented him from making clear requests and statements of need to others. Experiential learning in a therapy relationship is a type of work that requires us, as therapists, to be open and direct about what is happening in the relationship, which is a level of genuineness or self-­disclosure that many therapists find challenging. This directness might simply manifest as an observation about how the client engages in therapy; for example, “I notice that I find myself uncertain about what exactly you want to achieve here.” Or, “I notice that you tend to acquiesce to whatever I suggest we put on the agenda.” Or, “I notice you seem quite skeptical about many of the things I say.” Experiential learning might also mean disclosing more vulnerable aspects of ourselves or our reactions to clients. For instance, we might express our frustration to a client who is persistently late, knowing that he tends to avoid contact with the negative consequences of his actions. We might ask him to make contact with our reaction. We might invite him to notice what emotions or sensations come up for him as a result. Because such interactions are complex, nuanced, and individual, it’s important that they are genuine, meaning the therapist is operating in the context of his or her actual experiences and reac- tions to the situation. Why? First, because any or all of the reactions brought to bear may be rel- evant to therapy, a therapeutic relationship shouldn’t be simpler than a real relationship. Second, human beings are equipped with a fine capacity to detect lack of genuineness—­that is, when others are withholding responses or reactions. When lack of genuineness is detected, it is not a neutral fact. Though it may not trigger a primordial sense of threat, it will at least trigger caution, and this can undermine the quality of the therapy relationship. This reaction is especially likely for clients who have been harmed or betrayed by others. Functional Analysis Keeps Us on Track Because genuine, authentic relationships are complex, we use functional analysis (FA) to stay on track regarding therapeutic goals. FA is an assessment process in which we use learning princi- ples to understand what a particular behavior represents for the client in the context of his or her own history and life situation. To that end, we consider questions along these lines: How was this behavior shaped in the past? How did it function in the past? How does it function now? What costs are associated with it? In this way, we get a handle on which behaviors represent problems in the client’s life, and which—­despite seeming clumsy or imperfect—­actually represent important steps toward growth. (A third class of behaviors includes those that might grab our attention—­for example, a client who is a conspicuous name-­dropper—­but do not represent any clinically significant issue. It’s important to discriminate these behaviors from the other two classes so that we don’t try to “treat” what doesn’t need to be treated.) In turn, FA helps ensure that we respond strategically and therapeutically to clients in the moment based on our understanding of their problems and the growth or behavior change they need. For instance, with Tom, we might notice that some clumsy assertions of his needs are actually an important step toward assertiveness. You might notice that there is a potential contradiction in this process: What if FA dictates that we should see a given behavior as growth (for example, Tom should be more assertive), yet we genuinely find the growth behavior unpleasant (for example, we experience Tom as demanding in ways we are reluctant to support)? Should we suppress our personal reaction in order to nurture Tom’s growth? Luckily, this contradiction rarely arises in reality. First, when we take the time to really under- stand a client, whether through FA or other means, our responses to the client tend to naturally line up with FA: we feel satisfaction and happiness about the client’s steps toward growth because we understand the meaning and the struggle behind those steps. Similarly, we feel some level of genuine frustration or disappointment (balanced of course with compassion and understanding) when we see clients stuck in self-­defeating patterns. Second, if you can’t naturally respond posi- tively to the client’s growth, then this behavior is likely something important to address. For instance, you might say to Tom, “Something is coming up for me. You know I’m supportive of you being more assertive. And I notice there’s a way that you’re erring on the side of being blunt, even harsh. Have you noticed that too?” Because authentic relationships involve two people, in the process of FAP our own reactions and perceptions are as important as those of the client. Accordingly, we also continuously aim FA at ourselves, refining our self-­knowledge as therapists, asking how we’re contributing to the thera- peutic moment, and ensuring that our approach serves clients and not our own ends. The assump- tion is that therapists are also human and therefore susceptible to the influence of clients, just as they are susceptible to ours. When we relate to clients in their suffering, especially if things are happening quickly or with a great deal of emotion, complexity, or struggle, we can lose our footing. Again, FA helps keep us on target. In the next chapter, we’ll lay out the essential, practical principles of the contextual behavioral science perspective that lies at the heart of FAP and similar treatments (most notably, acceptance and commitment therapy). SUMMARY • Poor social connection poses as much mortality risk as smoking cigarettes. • From a CBS perspective, social relationships are a key context for shaping psychologi- cal functioning—­mood, motivation, emotion, and achievement—­and therefore well-­ being across one’s life span. • Psychotherapy involves processes of social connection and influence, through the ther- apeutic relationship, that can shape change in the client’s psychological and social functioning. • FAP asks you to balance a genuine, authentic way of relating to your client with under- standing based on functional analysis—­a way of assessing the function of what is hap- pening in the therapy relationship for each individual client. By doing so, you can ensure that your response to the client is therapeutic and does not perpetuate the client’s problems in relationships.