10 结构与流畅的平衡——逻辑互动的实现
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.