10 结构与流畅的平衡——逻辑互动的实现
第十章 平衡结构与流动——逻辑互动
行为是一个难以研究的主题，不是因为它无法触及，而是因为它极其复杂。由于它是一个过程而不是一个实体，因此很难将其固定下来进行观察。它是变化的、流动的、易逝的，因此对科学家的智慧和精力提出了很高的技术要求。 — B. F. 斯金纳
每次治疗会话开始时，治疗师并没有专注于Nick的CRB1和CRB2，也没有考虑他当天要采用什么干预措施。他的关注点更为人性化：Nick现在正在经历什么？他现在需要我做什么？我们一起要往哪里去？我能提供什么样的结构或框架来帮助我们到达那里？有没有什么重要的事情我们没有讨论到？换句话说，治疗师关注的是Nick和治疗工作的本身，而不是治疗框架中的任意特征。很多时候，最佳的关注点并不确定，Nick的反应也让治疗师感到意外，但治疗师在回应和引导Nick方面的灵活性使他们能够继续前进。
同时，治疗师和Nick逐渐建立了一个非常清晰且个性化的框架，以理解Nick正在努力实现的目标。这个框架涵盖了Nick在生活中想要成为的人以及他在治疗中激发性时刻所做的事情，例如当他不同意治疗师的意见时，当他需要不同的东西时，以及当治疗师以新的方式挑战他时。通过他们的过程，他们创造了结构。
这两个要素——结构和灵活性——都帮助了他们的治疗进展。将这些要素粘合在一起的是关系，即行为的流动——每时每刻的调谐、响应性和脆弱性——存在于Nick和治疗师之间。
在本章中，我们将考虑结构和灵活性，这是构成FAP过程的两面。一方面，有原则的有序性。如果你退一步审视本书这一部分目前为止所涵盖的所有内容，你可能会发现三个关键要素或过程构成了FAP的结构，所有这些都在塑造来访行为并推动来访朝着临床目标前进：
- 建立一个以相互脆弱性和响应性（或意识、勇气和爱）为特征的连接性治疗关系
- 将功能分析作为案例构建的主要途径
- 通过FAP的五条规则在会话中塑造具有临床相关性的行为
另一方面，过程的混乱是另一回事。任何见过整齐有序的治疗方案在接触来访后分崩离析的人都可以证明这一点。过程需要响应性、即兴创作和迭代。
FAP的实践在于平衡这两面。这种平衡——在一个真实、脆弱的人际过程中同时进行功能分析并保持一定程度的FAP规则意识——一开始可能会让人感到有些不知所措。这可能感觉像是试图一边拍头一边揉肚子……同时还跳绳。任何新的疗法都会有这种感觉。
保持在治疗互动中的根基同时关注功能分析和FAP的五条规则的一个有用比喻是基于人类学中的参与观察者的概念。我们可以用一个比喻来定义这个概念。如果当下的治疗过程是一辆过山车（有时确实如此），那么作为一个参与者就像是完全沉浸在体验中的过山车乘客。你会感受到车厢的碰撞声、安全带的重量、爬升时的期待感，以及下坠时风的呼啸声和内心的激动。你深入地接触到了乘坐体验，但可能牺牲了更广泛或更灵活的视角。
相反，作为一个观察者则像是站在地上，手里拿着记事板，仔细记录你所看到的一切，但却远离了实际的行动。从这个距离，你可能会错过一些重要的细节。参与观察者的立场则在这两个极端之间架起了一座桥梁：你在过山车上，同时也保持着对体验、周围环境以及这一刻如何融入更广阔背景的有意识觉察。
FAP要求你在治疗过程中成为一个参与观察者。FAP的五条规则是一个工具，简单到足以在高速度下记住，以帮助你在这个过程中前进。一旦你熟悉了它们，就可以开始放手，随心所欲地流动，在需要时再回到它们寻求指导。换句话说，规则不应该干扰你的互动；它们应该帮助你朝着富有成效的方向推进。
在本章中，我们将从参与者和观察者的角度讨论如何将整个FAP过程整合起来，平衡灵活性和结构。我们首先介绍一种有组织地思考五条规则流程的工具：逻辑FAP框架（Weeks, Kanter, Bonow, Landes, & Busch, 2012）。
逻辑互动
我们在第五章介绍了FAP的五条规则，并在本书的第二部分中讨论了前四条规则的各个方面。现在，我们将把所有这些规则（包括我们将在第十二章再次讨论的规则5：支持泛化）结合起来，描述所谓的逻辑FAP互动，这是一种思考FAP过程的结构。在接下来的讨论中，我们将称之为逻辑互动。
在逻辑FAP互动中，所有五条规则在一个会话中按顺序大致展开，使整个FAP模型得以应用。熟悉并熟练运用这些规则的经验丰富的FAP治疗师通常会创建出遵循这一序列的FAP互动，因为这样做有一个合乎逻辑、自然的流程。这不是巧合；这些规则正是基于这种逻辑而编写的。
典型的逻辑FAP互动开始于会话开始时，来访和治疗师讨论会话外的内容——例如，来访在过去一周的生活发生了什么。想象一个从事销售工作的来访，他每天访问来访都很困难（以下示例简化了过程）：
来访：这周我很难让自己出去。我花了很多时间只是坐在车里。
当讨论会话外的目标时，治疗师寻找并阐明这些目标与会话内过程之间的平行关系（规则1）。考虑下面的例子：
治疗师：我注意到你即使坐在这里也显得很犹豫不决。你在看着窗外。
这些平行关系可以或多或少地明确建立，有助于识别此时此刻可能发生的CRB。如果平行关系不够清晰，治疗师也可以更直接地引发CRB（规则2）：
治疗师：今天来这里时你感觉如何？你觉得和我继续这个对话怎么样？
反过来，当CRB在来访和治疗师之间实际发生时，FAP的真正互动就开始了。通常，来访对规则2（引发CRB）的回应是CRB1，因此治疗师必须再次引发，微调方法以发现或引出CRB2：
来访：没什么。老样子，不同的日子而已。[CRB1.]
治疗师：不过我在想。我觉得还有些别的东西。
来访：我只是感觉比平时沉重。我不确定发生了什么。[CRB2.]
一旦来访表现出CRB2，治疗师现在就旨在提供强化（规则3），使会话成为来访的积极且难忘的学习体验——不仅塑造来访的CRB2，还增加亲密感并加强治疗关系中的联系。此时，希望形成一个正向循环，即治疗反应产生更多的CRB2，从而带来更多的强化，如此反复。然后，治疗师可以进行规则4，询问来访在会话中的体验，并注意来访在整个会话中的反应：
治疗师：今天让我挑战你打开自己是什么感觉？
来访：感觉很好。我现在感觉很不一样。[这符合治疗师的感觉，即来访不再那么退缩。]
在会话接近尾声时，重点转向如何将在会话中形成的CRB2推广到会话之外（规则5）：
治疗师：你会从这次会话中带走什么？我们今天做了什么你可以记住并在本周继续做的事情？
FAP的实际应用
为了让你更好地理解逻辑互动中现实流程的可能性，下面我们将呈现一个更详细的例子。来访Katie和她的治疗师正在讨论一次聚会，在聚会上Katie与她有好感的女人Angela交谈。Katie说她想要告诉Angela她的感受，但她感到恐慌和困惑，经历了一种她称之为“云雾或冲劲”的感觉。这种感觉让她感到非常脆弱，她的冲动是试图避免这种感觉。结果，她没有告诉Angela她对她有好感。根据这些会话外的经历，本次会话的主要CRB目标是向他人披露脆弱性和情感。CRB1是避免这种披露，而CRB2则是任何形式的接近这种披露，即使伴随着焦虑和不适。
作为特别挑战，我们在下面的转录中移除了规则注释。我们邀请你自己进行注释。特别是，寻找五条规则、CRB1和CRB2的例子。要检查你的答案，你可以下载完整的注释转录：http://www.newharbinger.com/33513。
治疗师：恐慌和困惑是什么时候开始的？
来访：前一天晚上，当Angela说她对我有好感的时候。
治疗师：所以从那时起你就对她感到困惑了？
来访：是的。
治疗师：好的。那么现在，当你想到这件事时，你还是同样地困惑且无法接受吗？
来访：是的。（笑。）
治疗师：好的。
来访：在那种情况下，我感到很大的压力，必须表现得非常顺利，不能让我的困惑或其他任何情绪表现出来。
治疗师：如果你表现出来了会怎么样？
来访：我不知道。我的直觉是，如果我表现出这种弱点，人们就不会喜欢我。当时我只是想着，“我必须熬过这个”，并且意识到自己有几个目标。我想我只是尽量快点度过这个过程，但同时又试图达到那些目标。
治疗师：那么，这些目标具体是什么呢？
来访：我想就是不要搞砸吧。（笑。）不要让人看出我很困惑或类似的情况。
治疗师：那么，在那种情况下，如果你能记住“我害怕的是：如果我表现出困惑，她会拒绝我”，这会有帮助吗？我知道当时这种情况并不那么清晰，只有你现在谈论它时才稍微明白了一些。即便如此，在当时有这样的意识对你有帮助吗？
来访：我想我可能会哭起来。
治疗师：如果你更清楚地意识到你的困惑？
来访：是的，如果我能这么清楚地意识到。感觉太强烈了。我处理它的唯一方式就是不去处理它，甚至不去看到它。
治疗师：你是基于什么认为你会哭呢？
来访：嗯，因为我现在就有这种感觉。
治疗师：所以，当你现在开始意识到这一点时，一些情感正在浮现出来？
来访：是的，我想是这样。很难说，因为我感觉这一切都离我很远……你知道我的意思吗？感觉好像很遥远。
治疗师：好吧，让我问你一个不同的问题。你现在是不是更在场了？你在哭一点点……
来访：是的，我想是这样。
治疗师：好吧，你现在更在场了。我的意思是，这肯定是一个连续的过程，对吧？
来访：对。（开始有点哭了。）
治疗师：你现在更在场了。
来访：对。
治疗师：那么，你现在是不是有些担忧浮现出来？我是说，你是否担心我怎么看你？
来访：我确实很挣扎于表达情感这件事。
治疗师：那么你现在在担心什么呢？
来访：现在？（叹气。）我觉得我不想处于劣势——好像有一种计分的方式，会让别人获得权力。
治疗师：所以你觉得脆弱？
来访：不，我觉得自己像守门员。（笑。）我觉得自己不只是脆弱，而是……
治疗师：被攻击？
来访：是的。我觉得有一堵墙正在倒塌，而我必须阻止人们进来，因为这是危险的。
治疗师：你现在和我在一起时也有这种感觉。
来访：是的。甚至谈论这件事……我越平静地谈论它，情况就越好。我能越分析性地谈论它，情况就越好。
治疗师：那么，现在有没有一种方式，你可以不用这样做？
来访：你是什么意思？
治疗师：有没有可能你可以问我一些问题——而不是回避，只是跟我确认一下？我的意思是，如果你担心现在展示你的情感会让你变得脆弱并受到一点攻击，有没有办法你能保持住这些感受，并与我谈谈它们？
来访：（笑。）我在想我可以问你对我的看法，但那样我就得相信你说的话。
治疗师：对。你可能会，也可能不会。
来访：老实说，感觉最安全的方式就是尽可能地筑起高墙。
治疗师：嗯，这里有几个选择。一种可能是你的恐惧是真的。你刚才开始哭了，表现出更多真实的自己，因此现在可能在我面前更危险了，因为我可能会拒绝你、不理解你，或者因为这些而伤害你。如果这是真的，那么尽快远离这种情况是最好的。这是一种可能性。但另一种可能是这并不是真的。也许你可以通过坚持这种状态来发现真相。关键在于：你现在有什么办法可以和我确认一下？验证你的恐惧？而不只是筑起高墙，而是可以说，“也许我的恐惧并不真实。也许他是安全的，不会伤害我。”
来访：嗯，我立刻想到的就是问你，这对你意味着什么……
治疗师：这意味着你在哭吗？你是……
来访：不仅仅是我在哭，还包括我现在坐在这里有这么多的感受。
治疗师：好的，我明白你的问题。
来访：但我真的不想问这个问题。
治疗师：为什么呢？
来访：因为我不想在乎。这不应该重要。
治疗师：为什么不应该重要？
来访：因为我应该高于别人的看法。
治疗师：为什么应该是这样？
来访：嗯，因为这是聪明的做法？如果你不在乎，你就很傻？
治疗师：为什么？
来访：我不知道为什么。（笑。）就是这样。
治疗师：关心让你能够……
来访：这没有意义。别人不能为你做什么。他们不可靠，也很危险，所以你不应该在乎。
治疗师：好吧，你问我你刚才做的事情对我来说意味着什么，然后又收回了一些，但我还是想忽略那一部分。
来访：（笑。）为什么？！
治疗师：事实是，我不能帮你解决所有问题。我的意思是，我们的关系在某些方面是有限的，但我仍然想告诉你我对你的感受。看到你经历这些，触动了我的同理心，让我对你感到温暖。当我看到你这样时，我有一种关心你的感觉，而且我认为——这是事实——我真的喜欢这个人，并希望我能帮助她。我看到你在挣扎，这让我有点难过，因为你难过，我也喜欢你，所以我也有点难过。这只是我初步分享我的反应。
来访：这很难听。
治疗师：我说的话让你很难接受？难在哪里？
来访：在我回答之前，你说的时候，我唯一能想到的是，“你认为我不疯狂吗？”
治疗师：（停顿并长时间地用温暖的眼神看着来访。）我认为你疯狂吗？不。我为什么会认为你疯狂？
来访：（认真地哭了起来。）因为我有这么多乱七八糟的事情！
治疗师：这让你觉得疯狂是因为……？
来访：（继续哭泣。）因为我处理不了。或者因为我有——因为我有这么多乱七八糟的事情。所以你不认为我疯狂？
治疗师：（再次停顿并长时间地用温暖的眼神看着来访。）不。
来访：（还在哭。）你在想什么？
治疗师：你是担心我在想什么特别的事情，还是只是好奇，或者……
来访：嗯。我想是吧。
治疗师：好吧，我必须承认，我有一部分想法是希望这次会话有更多的时间。还有……嗯……我也在想，你以这种方式挣扎其实对你有好处。我觉得这对你是好的。
来访：是吗？怎么会呢？
治疗师：让我问你一个问题，可能会帮助你回应：你现在感觉怎么样？
来访：轻松了。疲惫了。（治疗师点头。）肯定还是紧张，但很强烈。我刚才做得还不错，但接下来我还能继续这样做吗？
治疗师：好吧。但如果你坚持刚才发生的事情呢？你一开始感到情绪化，表现了一点，也有些担忧，但你和我一起坚持了下来，一旦你听到我真正想的是什么，似乎你相信了我，基于你的反应。这为你打开了很多空间，你也真的表达了自己的感受。现在你感到轻松了，也更安全了，但仍然有些紧张。所以你通过不回避，而是检查我的想法，感到更安全了。我认为这是给你的教训。
来访：对我来说，感觉更安全似乎更多地与你的反应有关，而不是不回避——而是检查你的想法。你知道我的意思吗？
治疗师：如果我反应不同，你就不会感到更安全。如果你没有问，你可能也不会知道。
来访：对。
治疗师：对。所以问题是，外面的世界会怎么反应？你知道你的父母会怎么反应。他们最初就是给你灌输了这些观念。（来访点头。）但问题是，你如何应对其他人，比如Angela？我的意思是，这就是我提到这个问题的原因——帮助你应对Angela。那么，你能如何处理这些困惑的感觉，以及在像Angela这样的人面前展示这些感觉时的不安全感？希望这能引导你找到答案。我们的时间快到了，所以我只能把这个作为问题留给你。
从这段对话中你可以看出，随着你越来越熟悉使用五条规则和逻辑互动，你会发展出一种直觉，知道如何根据你在序列中的位置来调整会话的节奏。反过来，你会在每次会话中展现出很大的灵活性，同时保持结构。
使用半结构化的互动是一种练习逻辑互动的有效方法——同时也能练习所有的FAP技能。你可以与其他学习FAP的治疗师一起练习这种互动，或者与来访（根据你的临床判断决定何时以及如何进行）。下面是一个你可以使用的样本问题流程。不要拘泥于这个确切的措辞——你需要灵活调整以使互动流畅。
- 你现在生活中有什么重要或困扰的事情吗？
- 在那种情况下，你需要做什么——你的2是什么？
- 你如何在这里、现在与我一起练习那个2的一个版本？
- [继续引发直到CRB2出现。然后提供一个真诚的规则3的回应。]
- 与我进行这次互动是什么感觉？
- 你会从这次互动中带走什么？
以下是一个半结构化互动的例子：
治疗师：你现在生活中有什么重要或困扰的事情吗？
来访：好的，让我想想……我觉得最重要的是我一直难以处理的一件事。我的阿姨得了癌症。我几周前才得知这个消息。她住在东海岸。自从我搬到这儿以来，我就一直避免联系她。小时候我们很亲近，但我搬走后就没怎么和她说话了。
治疗师：对你来说，对她最重要的是什么？
来访：我只是需要联系她，告诉她我很抱歉，我在她身边。我爱她。
治疗师：我明白她对你有多重要。我听到你说最想为她做的是联系她，并诚实地表达她对你的意义。我说得对吗？
来访：是的。
治疗师：你愿意现在就对我坦诚地说，就像你想对她那样说吗？
来访：当然可以……但我不知道该说什么。
治疗师：告诉我我们现在这次互动对你意味着什么。
来访：意义重大。被倾听。我感受到你的关心——你在听我说，理解对我来说最重要的事情。
治疗师：你对我来说很重要。我想听听对你重要的事情。也希望你的阿姨能从你那里听到这些。
来访：是的。这就是我想要的。
治疗师：与我进行这次互动是什么感觉？
来访：它让我专注于重要的事情。我现在能感觉到我需要对她说什么。之前好像有一堵墙挡在那里。
治疗师：我很高兴你能感受到需要说的话。从这次互动中，你最想记住的是什么？
来访：只需要直接而诚实地告诉她她对我的意义。谢谢你。
治疗师的错误
关于治疗过程中的循环性，一个关键点是：治疗师也会犯错。这是不可避免的。例如，你可能会布置一个无用的家庭作业，忽略来访历史中的一个基本方面，重复预约，或者在要求来访练习呼吸正念时触发意外的恐慌发作。
我们认为，因为错误是不可避免的，并且处理错误的方式可以破坏或推动治疗进程，所以犯错实际上是治疗——或者说任何关系——的一个重要部分。
没有人是完美的。因为我们每个人都活在自己的皮囊中，我们无法完全了解他人的内心世界，包括来访。因此，在某种程度上，与他人建立联系总是向不确定性伸出援手的行为。当我们试图建立联系时，未能成功接触的方式可能和成功接触的方式一样具有教育意义和启发性。如果我们因为害怕失败而不去尝试接触，我们就根本不会建立联系。致力于伸出援手意味着有时会尝试并失败地建立联系。
反过来，建立持久的关系需要对失败、错误和失误有韧性。关键在于我们如何处理这些错误。当我们处理得当，实际上可以加强关系，加深彼此之间的纽带，并建立信任，相信这种纽带不会因错误而破裂。
尽管我们希望展示专业的一面，但治疗本质上容易出现失误和失败。这是一个经验事实。即使是最有效的治疗方法的成功率也无法否认这一点。如果人们寻求帮助的问题很容易改变，就不需要治疗师了。
专业并不在于完美；它在于能够以一种方式与来访建立联系，让治疗师和来访能够共同创造一条通往改变的道路——这条道路会穿越错误和不确定性的山丘与山谷，以及胜利和清晰的时刻。当你陪伴来访度过变化过程中的起伏时，你也赋予他们深刻体验什么是坚韧关系的机会。你不仅仅是教给他们这些，而是与他们共享这种体验。
因此，不要害怕在治疗过程中犯错。它们提供了展现人性和教授深刻道理的机会。用FAP术语来说，它们提供了引发各种CRB（临床相关行为）的机会：来访如何应对你的不足？她如何表达不满或失望？她如何请求所需？她如何原谅、合作或重建信任？
如何处理错误
理想情况下，你会立即注意到治疗中的失误并立即解决，比如说：“你知道，我刚才说的话没有道理。让我再试一次。”这种陈述的一个好处是，它也传达了一个信息，即犯错（并承认）是可以接受的。
当然，没有人能在当下察觉到所有的错误。你可以在事后处理这些失误，包括在下一次会谈中说：“我在想上周我对你说的话——我描述你现在寻求治疗的原因。当我思考这个问题和你说的一些事情时，我觉得我在某些方面误解了你。所以我想承认并为此道歉。我现在更清楚地看到你为什么在这里，我认为重要的是……” 请求重来是可以的，而且要始终给来访重来的许可。毕竟，“重来”只是“学习和成长”的另一种说法。
治疗师的错误可能导致治疗陷入僵局。在这种情况下，重要的是在我们之前提到的那种启发性对话中明确承认这一点。例如，你可以说：“我在我们陷入僵局的过程中起了作用。当你反对或不确定时，我太轻易退缩了。在那些时刻我没有清楚地理解你需要什么。对此我很抱歉，我希望做得更好。”
道歉是一件很难做好的事情。我们认为，一个好的道歉包括两个要素。首先是完全承担责任。你可能认为自己并不是问题的全部责任方，但一个好的道歉仍然会专注于你的责任。这允许对方专注于他的责任，而不会增加责备的压力。第二个要素是承诺做得更好。当然，你可能会再次犯同样的错误——毕竟你是人——但你仍然可以承诺努力做得更好。
以下是一个包含这两个要素的例子：“我想说我非常抱歉。现在我意识到我一直逼迫你，而没有看到你一直在多么努力地尝试。我把你的挫败感仅仅看作是问题的一部分，而不是意识到由于我没有完全理解你的需求而导致了这个问题。我希望做得更好。我不能保证永远不会再次犯这个错误，但我可以向你承诺我会真的努力。” 这种诚实的道歉不仅可以在当下修复裂痕，还可以作为一个很好的榜样，帮助来访学会更巧妙地道歉。
如果你作为治疗师或在个人生活中，对于错误和道歉感到特别困扰，请花些时间反思以下问题。你可以考虑请同事一起做这个练习，互相分享答案。
- 你在成长过程中从家庭中学到了哪些关于错误的知识？错误是如何处理的？你的个人经历如何影响你作为治疗师处理错误的方式？
- 你犯过哪些治疗上的错误？（例如，共情失败、边界侵犯、忘记预约、迟到开始会谈或让会谈超时。）
- 当你犯错时，你通常有什么感觉？特别是当你在来访面前犯错时？
- 来访对你有哪些不满或抱怨？（记住，这些事情可能反映了来访的脆弱性，也可能反映了你的错误。）
- 你可以做什么或已经做了什么来修复与来访的失误？
- 关于你的治疗错误，你的T1s和T2s是什么？
治疗的骨感现实
如果你难以接受治疗过程中的这些起伏，我们发现排练和反思一些关于治疗的骨感现实是有帮助的。这些现实并不符合专业会议上有时呈现的乐观画面，但它们确实是我们的工作现实。当你回顾这个列表时，请注意你的思想或心灵在哪些地方产生抵触。你如何能在这些地方找到归属？
- 来访正在尽他们所知的努力，但他们往往仍在挣扎。
- 根据他们的历史，来访就是他们应有的样子。
- 即使是最顽固、最令人沮丧或最无意义的行为，在某种程度上对从事该行为的个体来说是有道理的。
- 对治疗师来说，有用比正确更重要。
- 你不能强迫来访做你认为他们应该做的事情。
- 治疗实践有许多不足和局限性，治疗师也是如此。
- 尽管你有不足或局限，你仍然有责任成为最好的治疗师。解决那些让你困惑的问题是治疗工作的内容。
- 你在治疗中可能会犯错，而来访可能会因此感到受伤或沮丧。
- 治疗有相当高的失败率。
- 当你试图以某种方式纠正一个问题但没有成功时，有时你需要坚持下去。
- 在成功之前，治疗过程往往是痛苦且不确定的。
- 来访最难面对的事情往往是他们最需要处理的事情。
- 你的责任是教授最难的内容，这通常要求你非常清晰且体验性地理解所需。为了做到这一点，你可能需要面对自己的恐惧恶魔。
总结
- FAP（功能性分析心理治疗）过程平衡了结构与灵活性。
- 五个FAP规则的结构被封装在逻辑互动中，从规则1到规则5在一个单一互动中流动。
- 其他时候，治疗过程需要即兴发挥、迭代，并通过试错走一条非线性的路径。
- 治疗师的错误可以是治疗过程中及其进展的重要部分。为你的错误承担责任，并为来访树立灵活的责任感、诚实和承诺的习惯。
- 治疗的灵活且具有挑战性的过程对治疗师来说同样具有启发性。观察你的T1s和T2s。
知识点阐述
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结构与灵活性的平衡
- 定义：结构是指在治疗过程中建立的有序原则和框架，而灵活性则是指根据来访的即时需求和情况做出调整的能力。
- 重要性：结构提供了治疗的基础和方向，确保治疗过程有条不紊；灵活性则保证了治疗能够适应不断变化的情况，满足来访的个性化需求。
-
具体实践：
- 建立个性化框架：与来访共同创建一个清晰且个性化的治疗框架，明确治疗目标和过程。
- 保持调谐和响应性：持续关注来访的情绪和需求，及时调整治疗策略。
- 结合原则与实践：在遵循治疗原则的同时，灵活应对来访的具体情况，确保治疗的有效性。
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参与观察者的角色
- 定义：参与观察者是指在治疗过程中既深度参与体验又保持客观观察的角色。
- 重要性：这种角色有助于治疗师更好地理解和处理来访的行为，同时保持对治疗过程的整体把握。
-
具体实践：
- 沉浸体验：全身心投入与来访的互动，感受和理解来访的情绪和需求。
- 保持觉察：在互动中保持对整体治疗过程的觉察，包括功能分析和FAP规则的应用。
- 灵活应用规则：熟悉FAP规则并在实践中灵活运用，根据需要调整以促进治疗效果。
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逻辑FAP框架
- 定义：逻辑FAP框架是一种有组织地思考和应用FAP五条规则的方法。
- 重要性：该框架帮助治疗师系统地理解和实施FAP原则，确保治疗过程的一致性和有效性。
-
具体实践：
- 掌握五条规则：熟悉并牢记FAP的五条规则，以便在治疗过程中快速应用。
- 动态调整：在治疗过程中根据实际情况灵活调整规则的应用，确保治疗的针对性和有效性。
- 综合应用：将规则与实际互动相结合，确保治疗既有结构又有灵活性。
通过这些知识点，我们可以更好地理解如何在治疗过程中平衡结构与灵活性，并通过参与观察者的角色有效地应用FAP原则。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
-
逻辑FAP互动
- 定义：逻辑FAP互动是一种将FAP的五条规则按顺序整合在一个治疗会话中的结构。
- 重要性：通过这种方式，治疗师能够系统地应用FAP原则，确保治疗过程的一致性和有效性。
-
具体实践：
- 讨论会话外内容：从来访过去一周的生活经历入手，引入相关话题。
- 寻找平行关系：识别会话外行为与会话内过程之间的相似之处，帮助识别当前的CRB。
- 引发CRB：通过提问等方式直接或间接引发来访的情感和行为。
- 强化CRB2：当来访表现出CRB2时，提供积极反馈，增强其正面体验。
- 泛化CRB2：讨论如何将在会话中形成的CRB2推广到会话之外。
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FAP的实际应用
- 定义：通过具体的案例展示FAP在实际治疗中的应用，帮助理解和掌握FAP的原则和技巧。
- 重要性：通过实例分析，治疗师可以更好地理解如何在实际情境中灵活运用FAP规则。
-
具体实践：
- 识别关键行为：确定会话中的主要CRB目标，如披露脆弱性和情感。
- 应对CRB1：处理来访避免披露的行为，引导其逐步面对。
- 促进CRB2：鼓励来访表达真实感受，即使伴随焦虑和不适。
- 自我注释练习：通过自己注释转录，加深对FAP规则的理解和应用能力。
通过这些知识点，我们可以更好地理解逻辑FAP互动的结构和流程，并通过实际案例学习如何在治疗过程中有效应用FAP原则。这些内容不仅有助于治疗师更系统地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
-
识别和处理来访的困惑
- 定义：通过对话引导来访识别出他们内心的困惑，并探讨这些困惑是如何影响他们的行为和情绪的。
- 重要性：帮助来访理解自己的内心状态，从而更好地处理这些困惑。
-
具体实践：
- 探索触发点：询问来访困惑的具体情境，例如来访提到的前一天晚上与Angela的互动。
- 讨论当前的感受：询问来访当前对这些困惑的感觉，以了解其持续性和强度。
- 探讨应对策略：了解来访在过去是如何处理这些困惑的，以及这些策略的效果。
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暴露和表达情感
- 定义：鼓励来访在安全的环境中表达真实的情感，即使这些情感可能是脆弱的或不舒服的。
- 重要性：通过表达情感，来访可以更好地理解和处理自己的情绪，减少内心的冲突。
-
具体实践：
- 提供支持：治疗师通过倾听和理解来提供情感支持，让来访感到安全。
- 逐步暴露：逐步引导来访表达情感，从轻微到强烈，确保来访感到舒适。
- 强化正面体验：当来访成功表达情感时，给予积极反馈，增强其正面体验。
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处理脆弱感和防御机制
- 定义：帮助来访识别和处理他们在面对情感暴露时的脆弱感和防御机制。
- 重要性：理解并处理这些防御机制有助于来访更好地面对和处理情感。
-
具体实践：
- 识别防御机制：通过对话识别来访使用的防御机制，例如来访提到的“守门员”比喻。
- 探讨担忧：询问来访在表达情感时的具体担忧，如担心被评判或失去控制。
- 建立信任：通过建立信任关系，鼓励来访放下防御，更开放地表达情感。
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促进自我觉察和反思
- 定义：通过对话帮助来访提高对自己情感和行为的觉察，促进自我反思。
- 重要性：自我觉察能够帮助来访更好地理解自己的内在世界，促进个人成长。
-
具体实践：
- 提问和反馈：通过提问和反馈，引导来访深入思考自己的情感和行为。
- 回顾和总结：在对话中回顾和总结关键点，帮助来访巩固新的认识。
- 设定目标：与来访一起设定具体的行动目标，将新的认识转化为实际的行为改变。
通过这些知识点，我们可以更好地理解如何在治疗过程中帮助来访识别和处理内心的困惑，鼓励他们表达真实的情感，并处理脆弱感和防御机制。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
-
面对和验证恐惧
- 定义：鼓励来访面对他们的恐惧，并通过实际互动来验证这些恐惧是否真实。
- 重要性：帮助来访认识到他们的恐惧可能是过度的或不准确的，从而减少不必要的防御行为。
-
具体实践：
- 提供选项：向来访提供不同的可能性，包括他们的恐惧可能是真实的，也可能是不真实的。
- 引导探索：鼓励来访通过与治疗师的互动来探索和验证他们的恐惧。
- 建立安全感：通过治疗师的支持和理解，帮助来访感到安全，从而更愿意暴露自己的脆弱。
-
情感表达的重要性
- 定义：鼓励来访表达他们的真实情感，即使这些情感是负面的或脆弱的。
- 重要性：情感表达有助于来访更好地理解和处理自己的情绪，促进心理健康的恢复。
-
具体实践：
- 倾听和支持：治疗师通过倾听和理解来支持来访的情感表达。
- 逐步引导：逐步引导来访从轻微到强烈地表达情感，确保他们在过程中感到舒适。
- 强化正面体验：当来访成功表达情感时，给予积极反馈，增强其正面体验。
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处理羞耻感和自我价值
- 定义：帮助来访识别和处理内心的羞耻感和自我价值的问题。
- 重要性：羞耻感和低自尊常常阻碍个人的成长和发展，处理这些问题有助于提高来访的自信心和自我接纳。
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具体实践：
- 探讨价值观：了解来访的价值观和信念，特别是那些可能导致羞耻感的信念。
- 挑战不合理信念：帮助来访识别并挑战那些不合理或消极的信念。
- 建立正面自我形象：通过积极反馈和自我肯定练习，帮助来访建立更积极的自我形象。
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建立信任关系
- 定义：通过真诚和一致的行为，建立来访与治疗师之间的信任关系。
- 重要性：信任关系是治疗成功的关键，它使来访更愿意开放自己，更容易接受治疗建议。
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具体实践：
- 保持一致性：治疗师通过一致的态度和行为来建立信任。
- 透明沟通：治疗师坦诚地分享自己的感受和反应，增加透明度。
- 尊重和理解：治疗师通过尊重和理解来访的情感和经历，建立信任感。
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自我反思和成长
- 定义：通过对话帮助来访进行自我反思，促进个人成长。
- 重要性：自我反思有助于来访更好地理解自己的内心世界，促进情感和行为的改变。
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具体实践：
- 提问和反馈：通过提问和反馈，引导来访深入思考自己的情感和行为。
- 回顾和总结：在对话中回顾和总结关键点，帮助来访巩固新的认识。
- 设定目标：与来访一起设定具体的行动目标，将新的认识转化为实际的行为改变。
通过这些知识点，我们可以更好地理解如何在治疗过程中帮助来访面对和验证他们的恐惧，鼓励他们表达真实的情感，处理内心的羞耻感和自我价值问题，建立信任关系，并促进自我反思和个人成长。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
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面对现实世界中的反应
- 定义：帮助来访思考并准备面对现实世界中他人对其情感和行为的反应。
- 重要性：通过讨论和模拟，来访可以更好地准备自己，减少因未知而产生的焦虑。
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具体实践：
- 探讨已知反应：讨论来访已经了解的反应，如父母的反应。
- 模拟新情境：通过模拟与治疗师的互动，帮助来访准备面对其他人的反应。
- 建立信心：通过成功的模拟体验，增强来访在现实生活中面对类似情境的信心。
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半结构化互动的应用
- 定义：使用一系列预设的问题来引导对话，但允许根据实际情况进行灵活调整。
- 重要性：这种方法既提供了结构，又保留了灵活性，有助于来访在安全的环境中探索和表达自己的情感。
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具体实践：
- 预设问题：设计一系列开放式问题，引导来访深入探讨他们的感受和需求。
- 灵活调整：根据来访的反应和进展，灵活调整问题和互动方式。
- 逐步引导：逐步引导来访从浅入深地表达情感，确保他们在过程中感到舒适。
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情感表达和自我反思
- 定义：鼓励来访表达真实的情感，并通过对话促进自我反思。
- 重要性：情感表达有助于来访更好地理解和处理自己的情绪，自我反思则有助于个人成长和发展。
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具体实践：
- 倾听和支持：治疗师通过倾听和理解来支持来访的情感表达。
- 提问和反馈：通过提问和反馈，引导来访深入思考自己的情感和行为。
- 回顾和总结：在对话中回顾和总结关键点，帮助来访巩固新的认识。
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强化正面体验
- 定义：当来访成功表达情感或采取积极行动时，给予积极反馈，增强其正面体验。
- 重要性：正面反馈有助于来访建立自信，增加未来的积极性和主动性。
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具体实践：
- 真诚反馈：提供真诚的肯定和鼓励，让来访感受到被认可和支持。
- 具体表扬：具体指出来访做得好的地方，增强其成就感。
- 设定目标：与来访一起设定具体的行动目标，将新的认识转化为实际的行为改变。
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建立信任关系
- 定义：通过一致性和透明度，建立来访与治疗师之间的信任关系。
- 重要性：信任关系是治疗成功的关键，它使来访更愿意开放自己，更容易接受治疗建议。
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具体实践：
- 保持一致性：治疗师通过一致的态度和行为来建立信任。
- 透明沟通：治疗师坦诚地分享自己的感受和反应，增加透明度。
- 尊重和理解：治疗师通过尊重和理解来访的情感和经历，建立信任感。
通过这些知识点，我们可以更好地理解如何在治疗过程中帮助来访面对现实世界的反应，使用半结构化互动来促进情感表达和自我反思，强化正面体验，并建立信任关系。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
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治疗师犯错的必然性和重要性
- 定义：治疗师在治疗过程中难免会犯错，这些错误可能是技术上的，也可能是情感上的。
- 重要性：认识到错误是治疗过程的一部分，可以帮助治疗师更好地应对和利用这些错误，促进治疗进展。
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具体实践：
- 接受错误：治疗师需要接受自己会犯错的事实，并将其视为成长的机会。
- 及时纠正：发现错误后，应立即纠正并解释原因，以维护治疗关系。
- 反思和学习：通过反思错误，治疗师可以从中学习，提高自己的技能和敏感度。
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处理错误的方式
- 定义：正确处理错误的方式可以修复关系并促进治疗进程。
- 重要性：良好的错误处理不仅能修复当前的裂痕，还能为未来的互动提供积极的示范。
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具体实践：
- 即时纠正：在发现错误时立即纠正，并向来访解释。
- 后续跟进：在下次会谈中讨论之前的错误，进行适当的道歉和澄清。
- 承担责任：在道歉时，完全承担责任，避免推卸或找借口。
- 承诺改进：承诺在未来尽力避免类似的错误，并持续改进。
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错误作为学习机会
- 定义：治疗中的错误可以成为来访学习如何应对挫折和修复关系的机会。
- 重要性：通过观察治疗师如何处理错误，来访可以学到如何更有效地沟通和解决问题。
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具体实践：
- 示范行为：治疗师通过处理错误，示范如何面对挫折和修复关系。
- 引导来访：鼓励来访表达他们的感受和需求，帮助他们学习如何处理类似的情况。
- 共同成长：将错误处理的过程作为共同成长的机会，增强治疗关系。
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反思和自我提升
- 定义：通过反思过去的错误，治疗师可以不断提升自己的专业技能和自我意识。
- 重要性：定期反思有助于治疗师识别自身的盲点和弱点，从而不断改进。
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具体实践：
- 定期反思：定期回顾治疗过程中的错误和成功，进行自我评估。
- 寻求反馈：主动寻求同事或来访的反馈，以获得不同的视角。
- 持续学习：参加培训和继续教育，不断提高自己的专业水平。
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治疗师的自我照顾
- 定义：治疗师需要关注自己的心理健康和情感状态，以保持最佳的工作状态。
- 重要性：治疗师的情感健康直接影响治疗效果，自我照顾是维持长期职业发展的基础。
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具体实践：
- 设立界限：设定工作和个人生活的界限，确保有足够的休息和放松时间。
- 寻求支持：与其他治疗师或专业人士交流，分享经验和挑战。
- 自我关怀：定期进行自我关怀活动，如运动、冥想等，以保持身心健康。
通过这些知识点，我们可以更好地理解治疗师在治疗过程中如何处理错误，以及如何利用这些错误来促进治疗关系的发展和个人成长。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
知识点阐述
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来访的现状与努力
- 定义：来访已经在尽力而为，但由于各种原因，他们仍然在挣扎。
- 重要性：认识到来访已经尽了最大努力，可以帮助治疗师更加同情和支持他们，而不是责备他们。
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具体实践：
- 倾听和理解：耐心倾听来访的故事，理解他们的背景和经历。
- 鼓励和支持：给予来访积极的反馈和鼓励，帮助他们看到自己的努力和进步。
- 设定合理期望：根据来访的实际情况设定合理的治疗目标和期望。
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行为的合理性
- 定义：即使看似不合理的行为，对于个体来说也有其内在的合理性。
- 重要性：理解行为背后的动机有助于治疗师更好地制定干预策略。
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具体实践：
- 深入探讨：通过对话深入了解来访的行为动机和背景。
- 情境化理解：将行为放在特定的情境中进行理解，避免简单化或标签化。
- 共情：设身处地地理解来访的情感和需求，建立共情关系。
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实用性和灵活性
- 定义：治疗师应注重实用性而非仅仅追求理论上的正确。
- 重要性：灵活性和实用性可以帮助治疗师更有效地应对复杂多变的临床情况。
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具体实践：
- 适应性方法：根据来访的具体情况调整治疗方法和技术。
- 灵活应对：在治疗过程中保持开放和灵活的态度，随时调整策略。
- 实际效果：关注治疗的实际效果，而不是理论上的完美。
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治疗的局限性
- 定义：治疗实践和治疗师都有其局限性。
- 重要性：认识到这些局限性可以帮助治疗师更加谦逊和谨慎，避免过度自信。
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具体实践：
- 自我反思：定期反思自己的能力和局限性，寻求改进的机会。
- 持续学习：不断学习新的知识和技术，提高自己的专业水平。
- 求助于同行：在遇到困难时，寻求同事的支持和建议。
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错误与成长
- 定义：治疗师的错误是治疗过程的一部分，也是成长的机会。
- 重要性：承认和处理错误可以增强治疗关系，促进双方的成长。
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具体实践：
- 承担责任：勇敢地承认错误，并向来访道歉。
- 修复关系：通过真诚的沟通和行动修复因错误造成的裂痕。
- 从中学习：反思错误的原因，从中吸取教训，避免未来重蹈覆辙。
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痛苦与不确定性
- 定义：治疗过程常常伴随着痛苦和不确定性，这是通往成功的必经之路。
- 重要性：帮助来访理解并接受这一过程，可以增加他们的忍耐力和韧性。
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具体实践：
- 透明沟通：向来访解释治疗过程的复杂性和不确定性。
- 情感支持：提供情感支持，帮助来访应对过程中的痛苦和挫折。
- 共同面对：与来访一起面对困难，共同寻找解决方案。
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难点与突破
- 定义：来访最难以面对的问题往往是他们最需要解决的问题。
- 重要性：识别并解决这些难点是治疗成功的关键。
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具体实践：
- 逐步引导：逐步引导来访面对和处理这些难点。
- 提供支持：在来访面对难点时提供必要的支持和资源。
- 庆祝进步：当来访取得进展时，及时给予肯定和鼓励。
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治疗师的自我提升
- 定义：治疗师需要不断提升自己，面对自己的恐惧和挑战。
- 重要性：治疗师的个人成长有助于提高治疗效果。
-
具体实践：
- 自我反思：定期反思自己的感受和行为，了解自己的盲点。
- 个人成长：通过培训、阅读和个人体验来提升自己。
- 寻求督导：寻求督导和同行的支持，获得专业的反馈和指导。
通过这些知识点，我们可以更好地理解治疗过程中的现实和挑战，并采取相应的策略来提高治疗的效果。这些内容不仅有助于治疗师更有效地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。
C H A P T E R 10 Balance Structure and Flow— The Logical Interaction Behavior is a difficult subject matter, not because it is inaccessible, but because it is extremely complex. Since it is a process, rather than a thing, it cannot easily be held still for observation. It is changing, fluid, and evanescent, and for this reason it makes great technical demands upon the ingenuity and energy of the scientist. —B. F. Skinner Going into each therapy session, the therapist was not focused on Nick’s CRB1 and CRB2. Nor was he thinking about what intervention he was going to practice that day. His focus was much more human: What is Nick experiencing now? What does he need from me right now? Where are we going together? What structure or framework can I provide to get us there? Is there anything important that we’re not talking about? In other words, the therapist attuned to Nick and the work of therapy, not the arbitrary features of a therapy framework. There were many times when the best focus was uncertain and Nick’s responses surprised the therapist, but the therapist’s flexibility in how he responded and directed Nick kept them moving forward. At the same time, the therapist and Nick gradually built a very clear—and individualized—framework to understand what Nick was working on. The framework encompassed what Nick was striving to be in life as well as what he was working on in evocative moments in therapy, such as when he disagreed with the therapist, when he needed something different, and when the therapist challenged him in a new way. Through their process they created structure. Both of these elements—structure and flexibility—helped their therapy progress. The glue binding these elements was the relationship, the flow of behavior—moment- by-moment attunement, responsiveness, and vulnerability—between Nick and the therapist. In this chapter, we consider structure and flexibility, the two sides of the coin that make up the FAP process. On the one hand, there is the orderliness of principles. If you step back and survey everything we’ve covered so far in this part of the book, you might see that three key elements, or processes, form the structure of FAP, all of them shaping client behavior and driving the client toward clinical goals: • Creating a connected therapeutic relationship characterized by mutual vulnerability and responsiveness (or awareness, courage, and love) • Engaging in functional analysis as a primary avenue for case formulation • Shaping clinically relevant behavior in session via the five rules of FAP On the other hand, the messiness of process is a whole other thing. Anyone who has seen a neatly ordered treatment protocol fall apart upon contact with a client can attest to this. Process requires responsiveness, improvisation, and iteration. The practice of FAP is balancing these two sides of the coin. The balance—being in a genuine, vulnerable, interpersonal process while also engaging in functional analysis and keeping some level of awareness of the rules of FAP—can be a little overwhelming at first. It may feel like trying to pat your head and rub your belly…while also jumping rope. Any new therapy feels this way. A useful metaphor for staying grounded in the therapeutic interaction while keeping an eye on functional analysis and the five rules of FAP is based on the notion of the participant observer in anthro- pology. We can use a metaphor to define this concept. If the in-the-moment therapy process is a roller coaster (and sometimes it is), being a participant would be like riding on the roller coaster completely immersed in your experience. You feel the clunk of the cars, the weight of the collar, the anticipation as the cart crests the climb, and the rush of the wind and the dive of your insides as you plunge. You are in deep contact with the experience of the ride, but possibly at the cost of a broader or more flexible perception of the action. In contrast, being an observer would be like standing on the ground, clipboard in hand, taking careful notes about what you can see but being fairly removed from the action. You might miss important details from this distance. The stance of the participant observer bridges these two extremes: you’re on the roller coaster while also maintaining a mindful awareness of the experience, the surroundings, and how this moment fits into a broader context. FAP asks you to be a participant observer in the therapy process. The five FAP rules are a tool, simple enough to remember at high speed, to help you along the way. Once you’re familiar with them, you can begin to let them go and instead flow in the moment, returning to them for guidance as needed. In other words, the rules shouldn’t interfere with your interaction; they should help nudge it in productive directions. In this chapter we’ll talk about putting the whole process of FAP together from the perspec- tives of participant and observer, balancing flexibility and structure. We start with a tool for think- ing about the flow of the five rules in an organized way: the logical FAP framework (Weeks, Kanter, Bonow, Landes, & Busch, 2012). THE LOGICAL INTERACTION We introduced the five rules of FAP in chapter 5, and we’ve covered aspects of the first four in the second part of the book so far. We’ll now bring all these rules together—along with rule 5 (support generalization), which we’ll discuss again in chapter 12—to describe what has been called the logical FAP interaction, which is a structure for thinking about FAP process. In the discussions to come, we’ll refer to this as the logical interaction. In logical FAP interactions, all five rules play out, roughly in sequence, in a single session, putting the entire FAP model into play. Experienced FAP therapists who know and apply the rules well often create FAP interactions that roughly follow this sequence because there’s a logical, natural flow to doing so. This isn’t coincidental; the rules were written with this logic in mind. Typically, a logical FAP interaction starts at the beginning of the session with client and thera- pist discussing out-of-session material—for example, what happened in the client’s life over the past week. Imagine a client, working in sales, who is struggling to visit his customers each day (the examples that follow truncate the process): Client: It was difficult to put myself out there this week. I spent so much time just sitting in the car. As out-of-session targets are discussed, the therapist looks for and illuminates parallels between these targets and in-session processes (rule 1). Consider this example: Therapist: I notice you seem reticent to talk even sitting here. You’re looking off out the window. The parallels, which can be established more or less explicitly, aid in identifying CRBs that may be occurring in the moment. The therapist can also evoke CRBs more directly if the parallels aren’t sufficiently clear (rule 2): Therapist: What did you feel coming here today? How did you feel about picking up this con- versation with me? In turn, when CRBs are actively in the room, occurring in the moment between client and therapist, the dance of FAP really gets going. Often, clients respond to rule 2 (evoke CRB) with CRB1, so the therapist must evoke again, fine-tuning the approach to discover or elicit CRB2: Client: Not much. Same stuff, different day. [CRB1.] Therapist: I wonder though. I sense something else there. Client: I just feel heavier than normal. I’m not sure what happened. [CRB2.] Once the client has exhibited CRB2, the therapist now aims to provide reinforcement (rule 3), making the session a positive, memorable learning experience for the client—one that not only shapes the client’s CRB2 but also increases intimacy and strengthens the bond within the therapeu- tic relationship. At this point, hopefully a positive cycle develops in which the therapeutic response produces more CRB2, which occasions more reinforcement, and so on. The therapist may then engage in rule 4, inquiring about the client’s experience in the session and noticing how the client responds across the session: Therapist: What was it like having me challenge you to open up today? Client: It was good. I feel pretty different now. [This matches the therapist’s perception that the client is less withdrawn.] Toward the end of the session, the focus shifts toward how the CRB2 that was shaped in session can be generalized out of session (rule 5): Therapist: What will you take forward from this session? What did we do today that you could remember to do moving forward this week? FAP IN ACTION To give you a better sense of the possibilities for a realistic flow across a logical interaction, below we present a more extended example. The client, Katie, and her therapist are discussing a party at which Katie was talking with a woman named Angela whom she was attracted to. Katie said she’d wanted to tell Angela about her feelings, but she felt panicky and confused and experienced what she called a “cloud or rush” feeling. This feeling made her feel very vulnerable, and her urge was to try to avoid it. As a result, she didn’t tell Angela that she was attracted to her. Based on these out- of-session experiences, the primary CRB targeted for the session was disclosing vulnerability and emotion to another. The CRB1 was avoiding this disclosure, and the CRB2 was any form of approaching this disclosure, even with anxiety and discomfort in the moment. As a special challenge to you, we removed our annotations of the rules from the following tran- script. We invite you to make your own annotations. In particular, look for examples of the five rules, of CRB1, and of CRB2. To check your answers, you can download a fully annotated tran- script at http://www.newharbinger.com/33513. Therapist: When did the panic and confusion start? Client: The night before, when Angela said she had a crush on me. Therapist: So ever since then you just felt confusion about her? Client: Yeah. Therapist: Okay. So right now, as you think about it, are you as confused and unaccepting? Client: Yeah. (Laughs.) Therapist: Okay. Client: I feel a lot of pressure in those kinds of situations to perform very smoothly and not let my confusion or anything like that really show. Therapist: What would happen if you did? Client: I don’t know. My gut feeling is that if I show that kind of a weakness, people won’t like me. At the time, I was just thinking, “I’ve just got to get through this,” and kind of realizing that I had a couple of goals. I guess I was just trying to get through as fast as I could but still trying to hit those goals. Therapist: So, what were the goals, exactly? Client: I guess to not fuck up. (Laughs.) To not show that I was so confused or anything like that. Therapist: So would it help if during that kind of situation you were able to keep in mind, “This is what I’m scared of: if I show my confusion she’ll reject me.” I realize that at the time it’s not that clear, and that only as you’re talking about it now are you getting a little clarity on what exactly happened. Still, would it be helpful to you to have that in front of you at the time? Client: I think I’d probably start bawling. Therapist: If you were more aware of your confusion? Client: Yeah, if I was that aware of it. It’s so intense. The only way I’ve dealt with it is by not dealing with it, not even seeing it. Therapist: And what are you basing that on, that you’d start bawling? Client: Um, because I feel like doing it now. Therapist: So, as you’re becoming aware of it now, some of the feelings are coming out right now? Client: Yeah, I guess. It’s hard to say, because I feel so far away… Do you know what I mean? Like, it seems really far away. Therapist: Okay, let me ask you a different question. So are you more present now? You’re crying a little bit… Client: Yeah, I guess. Therapist: Okay, you’re more present now. I mean, it’s definitely on a continuum, right? Client: Right. (Starts to cry a little bit.) Therapist: You’re more present. Client: Right. Therapist: So are some of your worries coming up right now? I mean are you worried about how I’m seeing you? Client: I’m definitely struggling with the showing-emotion thing. Therapist: So what are you worried about right now? Client: Right now? (Sighs.) I think it’s not wanting to be one down—like somehow there’s this tallying going on that gives people power. Therapist: So you feel vulnerable? Client: No, I feel kind of like a goalie. (Laughs.) I feel like I’m not just vulnerable, but… Therapist: Under attack? Client: Yeah. I feel like there’s this wall and it’s crumbling down, and I’ve got to keep people from getting in because it’s dangerous. Therapist: And you’re feeling that a little bit right now with me. Client: Yeah. And even talking about it…the calmer I can be talking about it, the more okay it is. The more analytical I can be talking about it, the more okay it is. Therapist: So is there any way right now, with me, you could not do that? Client: What do you mean? Therapist: Is there any way you could maybe ask me something—rather than avoiding, just sort of checking with me about it? I mean, if your fear is that by showing your emotions right now you’re vulnerable and a little under attack, is there any way you could stay with the feelings and talk to me about them? Client: (Laughs.) I was thinking I could ask you about what you’re thinking about me, but then I’d have to believe what you say. Therapist: Right. And you might or you might not. Client: Honestly, the safest thing feels like throwing up as many walls as I possibly can. Therapist: Well, there are a couple of options here. One is that your fears are true. That you started crying just now, that you’re showing a little more of yourself, and that now you’re potentially in more danger with me because of it. That somehow I’m going to reject you, or not understand, or do something that’s going to hurt you because of this. So if that were true, it would be best to get away from this as fast as possible. That’s one possibility. But the other option is that this may not be true. And maybe you could find out by staying with this. The big point is this: Is there anything you can do right now to check in with me? To check out your fear? To not just throw up walls but actually say, “Well, maybe my fear’s not real. Maybe he is safe and won’t hurt me.” Client: Well, the only thing that comes immediately to mind is asking what it means to you that…that… Therapist: That you’re crying? That you’re… Client: Not just that I’m crying, but that I’m sitting over here feeling so much. Therapist: Okay. I understand the question. Client: But I really don’t want to ask that. Therapist: Why not? Client: Because I don’t want to care. It shouldn’t matter. Therapist: Okay. Why shouldn’t it matter? Client: Because I should be above caring what other people think. Therapist: Why should that be the case? Client: Um, because that’s the smart way to be? And you’re stupid if you don’t? Therapist: Why? Client: I don’t know why. (Laughs.) It just is. Therapist: Caring allows you to… Client: There’s no point in it. Other people can’t do anything for you. They’re unreliable and dangerous, so you shouldn’t care. Therapist: Okay, well, you asked me what it means to me, what you were doing a few minutes ago, and then kind of took it back a little bit, but I’m going to just ignore that part of it. Client: (Laughs.) Why?! Therapist: The truth is, I can’t help you with everything. I mean, we have a limited relationship in some ways, but I still want to tell you how I feel in response to just what you’re going through. It pulls at my empathy and it warms me up to you. I feel a sense of caring for you when I see you like this, and I think—and this is the truth—I really like this person and I hope I can help her. I see that you’re struggling, and it feels a little sad for me, just because you’re sad and I like you, so it makes me a little sad. That’s just my first pass at sharing my reactions. Client: That’s very, very, very hard to hear. Therapist: Me saying this is hard for you to hear? What’s hard about it? Client: Before I get to that, when you were saying it, all I could think was, “You don’t think I’m crazy?” Therapist: (Pauses and makes prolonged, warm, consistent eye contact.) Do I think you’re crazy? No. Why would I think you’re crazy? Client: (Cries in earnest.) Because I have all this shit going on! Therapist: And that makes you crazy because…? Client: (Continues to cry.) Because I can’t handle it. Or because I have it—because I have all of this shit going on. So you don’t think I’m crazy? Therapist: (Pauses and makes prolonged, warm, consistent eye contact again.) No. Client: (Still crying.) What are you thinking? Therapist: Are you worried that I’m thinking something particular, are you just curious, or… Client: Yeah. I guess. Therapist: Well, I must admit that part of what I was thinking is that I wish this session had more time. And…um…I’m also thinking that it’s good that you’re struggling with this the way you are. I’m thinking this is good for you. Client: Is it? How so? Therapist: Let me ask you a question that might help you respond: How do you feel right now? Client: Relieved. Exhausted. (Therapist nods.) Definitely nervous, but intense. I came through that one okay, but am I going to be able to keep doing this okay? Therapist: Okay. But what if you stick with what just happened? You started out feeling emo- tional, showing that a little bit, and having some fears about it, but you stayed with it with me, and once you heard what I was really thinking, it seemed like you believed me, based on the reaction you had. It kind of opened up a lot for you, and you really expressed yourself. Now you feel relieved and a little safer, but also still have some nervousness. So you feel safer by not avoiding and by checking out what I am think- ing. I think that’s the lesson for you. Client: For me, feeling safer seems more connected to your reaction and less about not avoiding—instead checking out what you are thinking. Do you know what I mean? Therapist: Well, if I had reacted differently you wouldn’t feel safer. And if you hadn’t asked, you might not have known. Client: Right. Therapist: Right. And so the question is, how are people out in the world going to react? Right? You know how your mom and dad will react. They’re the ones who instilled this in you in the first place. (Client nods.) But the question is, what do you do with the rest of the world, with people like Angela? I mean that’s why I brought this up—to help you with Angela. So, what can you do with those feelings of confusion and how unsafe it feels to show some of this to somebody like Angela? Hopefully that’s where this will lead you. And we’re running out of time, so I think I have to just leave it as a question for you. As you might guess from this transcript, as you become more familiar with using the five rules and the logical interaction, you will develop an intuitive sense of how to pace a session based on where you are in the sequence. In turn, you will exhibit a good deal of flexibility while retaining structure in each session. Using a semistructured interaction is one useful method for practicing logical interactions— and, in connection, all of the FAP skills. You can practice this interaction with other therapists learning FAP, or with clients (use your clinical judgment about how and when to do so). Below is a sample flow of questions you might use. Don’t feel constrained to stick to this exact wording—you will need to flex and bend to make the interaction flow. What’s something important or distressing that is coming up in your life right now? What do you need to do—what is your 2—in that context? How could you practice a version of that 2 with me, right here and right now? [Continue to evoke until CRB2 occurs. Then offer a genuine rule 3 response.] What was it like to have this interaction with me? What will you take from this interaction? Here’s an example of a semistructured interaction: Therapist: What’s something important or distressing that is coming up in your life right now? Client: 198 Okay, let me see… I think what’s most important is something I’ve been struggling to deal with. My aunt has cancer. I just learned about it a couple of weeks ago. She lives on the East Coast. And I’ve been avoiding reaching out to her. We were really close when I was little, but I’ve not talked to her much since moving out here. Therapist: What is most important for you to do with her? Client: I just need to reach out to her and tell her that I’m sorry, that I’m here. That I love her. Therapist: I see how much she means to you. I hear that what you most want to do for her is reach out and speak honestly from your heart about what she means to you. Do I have that right? Client: Yes. Therapist: Would you be willing to talk to me, from your heart, right now, just as you want to talk to her? Client: Sure…but I don’t know what to say. Therapist: Tell me what our interaction right now means to you. Client: It means a lot. To be listened to. I sense your caring—that you’re listening to me and understanding what’s most important to me. Therapist: You are important to me. I want to hear what’s important to you. And for your aunt to hear that from you too. Client: Yeah. That’s what I want. Therapist: What was it like to have this interaction with me? Client: It focused me on what mattered. I can feel now what I need to say to her. Before it’s like there was a wall up. Therapist: I’m glad you can feel what you need to say. What is most important for you to remember from this interaction? Client: Just that I can say directly, honestly, what she means to me. Thank you. THERAPIST MISTAKES One crucial thing to remember about the loopiness of the therapy process is this: therapists make mistakes. It’s inevitable. For example, you might assign a useless homework assignment, miss a fun- damental aspect of the client’s history, double-book an appointment, or trigger an unexpected panic attack by asking a client to practice mindfulness of breath. In our view, because mistakes are inevitable, and because how you work through them can destroy or fuel therapy, making mistakes is a critical part of therapy—or any relationship for that matter. No one is perfect. And because each of us is in our own skin, none of us can completely know the inner world of others, including clients. To some extent, then, relating to another is always an act of reaching out into uncertainty. As we reach out to connect, the ways we fail to make contact can be just as edifying and instructive as the ways we do make contact. And if we chose not to reach out because of the risk of failure, we wouldn’t connect at all. Being committed to reaching out means trying and failing to connect at times. In turn, building lasting relationships requires becoming resilient to failures, mistakes, and mis- steps. What’s crucial is how we negotiate those mistakes. When we negotiate them well, we can actually strengthen a relationship, deepening the bond and building trust that the bond won’t be broken by mistakes. As much as we may wish to present a professional front of expertise, therapy is innately prone to missteps and failure. This is a matter of empirical fact. No one looking at the success rates of even the most robustly effective therapies can claim otherwise. If the issues for which people seek help in treatment were easily amenable to change, therapists wouldn’t be needed. Expertise, then, doesn’t lie in perfection; it lies in the ability to relate to clients in ways that allow therapist and client to collaboratively create a path to change—a path that traverses hills and valleys of mistakes and uncertainties as well as victories and clarity. And when you stick with clients through the vicissitudes of the process of change, you also gift them with the profound experience of what it means to be in a resilient relationship. You do more than teach them about it; you share the experience with them. So don’t fear mistakes in therapy. They provide an opportunity to be human and to teach something profound. In FAP terms, they provide an opportunity to evoke all sorts of CRBs: how does the client relate to your shortcomings? How does she express dissatisfaction or disappoint- ment? How does she ask for what she needs? How does she forgive, collaborate, or rebuild trust? What to Do with Mistakes Ideally, you’d notice therapeutic missteps in the moment and address them right away, perhaps saying something like “You know, what I just said made no sense. Let me try it again.” An advan- tage to this kind of statement is that it also communicates that making mistakes (and acknowledg- ing them) is acceptable. Of course, no one has the presence of mind to catch all mistakes in the moment. You can address missteps after the fact, including in the next session: “I was thinking about what I said to you last week—the way I painted a picture of why you’re seeking treatment now. As I thought about that and some of the things you’ve said, I think I’ve gotten you wrong in some ways. So I want to acknowledge and apologize for that. I think I see more clearly now why you’re here, and here’s what I think is important…” It’s okay to ask for a do over, and always give clients permission for do overs. After all, “do over” is just another name for “learning and growth.” Therapist mistakes can play a role in getting therapy stuck. It’s important to clearly acknowl- edge when this is the case in the type of evocative conversation we outlined for getting unstuck in chapter 8. For example, you might say, “I’ve played a role in how we’ve gotten stuck. I’ve backed off too easily when you pushed back or were uncertain. And I didn’t clearly get what you needed in those moments. I’m sorry about that, and I want to do better.” Apologizing can be a hard thing to do well. In our opinion, a good apology includes two ele- ments. The first is fully taking responsibility. You may rightly believe that you weren’t entirely to blame for the problem, but a good apology will still focus on your responsibility. This allows the other person to focus on his responsibility, without the added pressure of blame. The second element is promising to do better. Of course, you may make the same mistake again—you are human, after all—but you can still commit to doing better. Here’s an example that incorporates both elements: “I want to say how sorry I am. I see now that I’ve been really pushing you and not seeing how hard you’ve been trying. I’ve been interpret- ing your frustration as just more of the problem, rather than taking responsibility for how I’ve been causing it by not fully understanding what you need. I want to do better. I can’t guarantee that I’ll never make this mistake again, but I can promise to you that I will really try.” This kind of honest apology tends to not only repair a rupture in the moment, but it may also serve as a great model, helping clients learn to apologize more skillfully. If mistakes and apologies are particularly fraught territory for you, as a therapist or in your personal life, take some time to reflect on the following questions. You might consider asking col- leagues to do this exercise with you, sharing your answers with one another. What did you learn about mistakes in your family as you were growing up? How were mistakes dealt with? How does your personal history with mistakes affect the way you deal with your mistakes as a therapist? What therapeutic mistakes have you made? (Examples include empathetic failures, boundary violations, forgetting appointments, starting sessions late, or letting sessions run long.) What do you feel in general when you make mistakes? How about when you make mistakes with clients? What have clients been upset with you about or complained to you about? (Bear in mind that these things can reflect client vulnerabilities as well as mistakes on your part.) What can you do or have you done to repair your missteps with clients? What are your T1s and T2s in regard to your therapeutic mistakes? The Bony Truths About Therapy If you have trouble accepting these ins and outs of the therapy process, we find it’s helpful to rehearse and reflect upon some of the bony truths about therapy. These truths don’t fit the opti- mistic picture sometimes presented at professional meetings, but they are nevertheless the reality of our work. As you review this list, notice where your mind or heart rebels. How can you make a home in that place? Clients are doing the best they know how and yet they are often struggling. Clients are exactly as they should be, given their history. Even the most stubborn, frustrating, or senseless behavior makes sense at a certain level for the individual engaging in it. It’s more important for therapists to be helpful than to be right. You can’t force clients to do what you think they should do. The practice of therapy has many shortcomings and limitations, as do therapists. Despite your shortcomings or limitations, it’s your responsibility to be the best therapist you can be. Solving problems that stump you is the work of therapy. You may make mistakes in therapy, and a client might reasonably feel hurt or frustrated by you. Therapy has a substantial failure rate. When you try to correct an issue in a certain way and it doesn’t work, sometimes you need to stick with it. The process of therapy is often painful and uncertain before it is successful. The thing that’s most difficult for a client is often exactly what the client most needs to work on. It’s your responsibility to teach what’s most difficult, which often requires that you understand what’s needed in a very clear and experiential way. You might need to face your own scary demons to accomplish this. SUMMARY • The FAP process balances structure and flexibility. • The structure of the five FAP rules is encapsulated in the logical interaction, which flows from rule 1 to rule 5 in a single interaction. • At other times, the therapy process demands improvisation, iteration, and following a nonlinear path through trial and error. • Therapist mistakes can be a crucial part of the therapy process and the progress that is made within it. Take responsibility for your mistakes, and model for the client flexible habits of accountability, honesty, and commitment. • The flexible, challenging process of therapy can be just as evocative for therapists as it is for clients. Observe your T1s and T2s.