11 动态理解——利用FAP进行案例概念化

C H A P T E R 11 Understanding in Motion— Case Conceptualization with FAP It is the province of knowledge to speak, and it is the privilege of wisdom to listen. —­Oliver Wendell Holmes M ake a list of the next five clients you will see. Type or write their names on a blank page. Do it right now. Pick one client with whom progress seems particularly slow or uncertain. Then consider these questions for that client: • What does this person most need to do in life right now? (Be as behaviorally specific as possible. Remember that behavior includes seemingly insubstantial things such as accepting, believing, envisioning, and so on.) • What is most important for this person to practice doing, in the moment in therapy, to get the most out of the next session? • What does the client need to accept and experience? • What does the client need to think about? Ask for? Feel? Attend to? • What does the client need to do? • What does this person do that most undermines or impedes progress in therapy? • What is the function of this particular behavior? (Describe from the client’s perspective.) • How does that behavior make complete sense, given the client’s history? • What are the most important things for you to do in this therapy session with the client? • What must you be willing to experience and accept in order to do those things? These questions might not prove useful or insightful for all clients. Perhaps you are already making terrific progress with several clients. Perhaps there are other clients with whom these are exactly the right questions—­exactly the right focus—­and you know it. Perhaps you are stumped about how to answer these questions for other clients. These questions are, in many ways, the core case conceptualization questions of FAP. We have found that these questions—­or variants of them—­are often helpful, especially when therapy is stuck or unfocused. They fit nicely with the principles and case-­conceptualization strategies of other treatment models, and they focus your attention on concrete behaviors and on how those behaviors will show up in the therapy process. Ultimately, of course, you will be the best judge of when or how these questions will be useful (though you might benefit from consulting with someone who can offer a perspective outside your own). We want to offer the following definition of case conceptualization in terms of FAP because it might differ from the definitions you’ve learned for other types of therapy: FAP puts understanding in motion. How you work with clients in the moment is guided by your understanding of them as individuals within their present-­moment context: what they need from you, what they need in life, what works for them. That understanding evolves through the therapy relationship. Case conceptualization is, in essence, an evolving, ongoing process of understanding clients that prepares you for and steers you during in-­ the-­moment interactions with them. The process of case conceptualization isn’t something a therapist keeps close to his or her chest or hidden in a secret folder, and it isn’t shrouded in jargon. In FAP, case conceptualization is a transparent, caring conversation about the behaviors at issue in therapy. As you know, in FAP this process centers on functional analysis. In chapter 3 we outlined the general principles of functional analysis from the FAP perspective (these principles are another version of the questions above): • Orient to the key behaviors and contexts that are related to the client’s presenting problems. • Clarify the function of those behaviors. • Look for the functional classes involved. • Define improvements. • Notice clinically relevant behavior in the moment. Define how problem behaviors (CRB1) and improvements (CRB2) might show up in the therapy relationship. • Understand your own key behaviors that either interfere with (T1) or support (T2) the client’s process of change. • Shape and refine your understanding of the above over time. In this chapter, we expand on these fundamental ideas to describe how they inform the process of case conceptualization across therapy. EXPANDING FUNCTIONAL ANALYSIS TO CASE CONCEPTUALIZATION As with just about everything in FAP, case conceptualization can take many different forms depending on the client, the context, and your personal style. Case conceptualization may involve spending a great deal of time on functional analysis, or it may proceed rapidly. An effective con- ceptualization can vary from highly precise and complex to highly generalized and simple. Ultimately, the quality of the case conceptualization depends on its function—­how well it works to achieve the aims of therapy—­rather than its form. In other words, evaluate your case conceptu- alization by how well it’s working. Under that umbrella, there is one outcome of case conceptualization that tends to be a key performance indicator in FAP: the conceptualization allows both client and therapist to identify instances of CRB as they happen. (Perhaps this is only a key indicator in FAP because you can’t do FAP without being able to see CRBs. There are, of course, other ways to achieve therapy outcomes besides FAP.) More generally, when case conceptualization is on track in FAP, the following condi- tions tend to arise: Therapist and client agree that certain problematic interpersonal behaviors are related to the presenting problem. Therapist and client mutually recognize instances of CRB1 as they occur in session. Therapist and client agree that CRBs identified in session (both CRB1 and CRB2) are functionally related to problem behavior outside of session. The therapist works to manage the therapy process effectively, engaging in more T2s and fewer T1s. The therapist’s attention to CRB1 and CRB2 is balanced, such that the client feels both recognized for progress and appropriately challenged to keep moving forward. The process of addressing CRBs in session (supported by homework assignments) yields insight and motivates the client to change functionally related problem behaviors in daily life, thus validating that the case conceptualization is useful in focusing the therapeutic process. There are many ways to achieve these ends. To illustrate FAP’s flexibility in another way, con- sider these summaries of case conceptualization. (A summary of a case conceptualization in FAP lists problems, CRBs, T1s, and T2s and serves as a quick reference guide for therapist and client. Remember, the summary is not the process of case conceptualization; it’s an outcome of that process.) The summaries are diverse in the type of language they use and the level of precision they employ, but they may all adequately function to focus therapist and client attention in the process of therapy. Example 1: Relatively Metaphorical Language Client’s out-­of-­session problems: Avoiding risk, holding back, putting her wall up CRB1: Avoiding risk, holding back, putting her wall up CRB2: Taking risks, moving beyond her comfort zone in opening up, exploring the wall and being willing to lower it Generalized CRB2: Taking strategic risks, opening up, dropping the wall a little bit (especially when talking with men) T1: Holding back, allowing the wall to stay up T2: Addressing how the connection feels, exploring why the client feels she needs the wall, gently inviting the client to put up a window instead Example 2: Less Metaphorical Language Client’s out-­of-­session problems: Avoiding expression of needs at work and with his partner, overcommitting to helping others CRB1: Focusing on what the therapist thinks he should do, avoiding expression of his needs, overcommitting to therapy tasks that don’t serve his needs CRB2: Tuning in to and expressing what he needs based on what works or doesn’t work for him, making realistic commitments to therapy tasks that serve his needs Generalized CRB2: Expressing clearly and proactively what he needs, saying no when meeting a request isn’t workable T1: Playing into and reinforcing the “good client” routine T2: Slowing the process down to help the client contact his needs, exploring his fear of expressing his needs, and identifying realistic commitments Example 3: Using the ACL Model—­Elaborate Conceptualization Client’s out-­of-­session problems: Lacking awareness of others’ needs and her impact on others, especially family members; being excessively critical; tending to respond with punishment when family members express vulnerability; being unable to respond to family members with love; being unable to help family members feel safe when they’re vulnerable CRB1: Lacking awareness of her impact on the therapist, focusing on problem solving, tending to avoid discussions of emotion or reacting to discussions of emotions with hostility CRB2: Having an increased awareness of the therapist’s feelings and her impact on the therapist, being able to stay focused on emotional topics without becoming hostile or sarcastic, accepting feedback from the therapist when she feels hostile, developing the ability to signal safety and acceptance when the therapist challenges her Generalized CRB2: Becoming more aware of the emotional needs of family members; being able to respond with patience, love, and safety when family members express vulnerability T1: Letting the client problem solve, avoiding challenging the client to stay with emotions when she becomes hostile and sarcastic, judging the client T2: Directly expressing sadness and fear to the client when she reacts with hostility, persisting with a compassionate approach even in the face of punishment, remembering that the client is always doing the best she can in the moment Example 4: Using the ACL Model—­Simple Conceptualization Client’s out-­of-­session problems: Not noticing what he needs (awareness), not asking for what he needs (courage) CRB1: Not noticing what he needs (awareness), not asking for what he needs (courage) CRB2: Tuning into himself, noticing his needs, and/or asking (awareness/courage) for what he needs Generalized CRB2: Tuning into himself, noticing his needs, and/or asking (awareness/courage) for what he needs T1: Not pausing to create space, bowling over the client’s needs T2: Creating space, inviting requests Notice that not all aspects of the functional analysis are addressed explicitly in these case con- ceptualization summaries. For instance, the specific context, and especially the particular reinforc- ers in that context or learning history, aren’t included. The main purpose of such summaries is simply to cue both therapist and client to remember and attend to key behaviors. THE FULL PROCESS OF CASE CONCEPTUALIZATION Whether the process of case conceptualization is brief or extended, linear or nonlinear (and whether the summary describing problem behavior and CRB is elaborate or simple), it typically involves three key steps, which we’ll briefly review in the following sections:

1. Arrive at an initial working formulation.
2. Test the working formulation.
3. Refine the formulation. Step 1: Arrive at an Initial Working Formulation The first step of case conceptualization is to come up with an initial best guess about what the client’s key problem behaviors are and what the corresponding CRBs are—­that is, how do behav- iors related to the client’s presenting problems occur here and now in the therapy relationship. Arriving at this initial formulation of CRB involves three substeps: A.Identify problem behaviors and their functions. B.Define functional classes of problem behavior. C.Identify CRB1 and CRB2 as instances of those problematic functional classes. SUBSTEP A: IDENTIFY PROBLEM BEHAVIORS AND THEIR FUNCTIONS Imagine you have a client named Chris who wants help improving her mood. She reports that relationships are a major stressor for her, and she reveals that most of her current interactions are conflictual or distant and generally precede her episodes of low mood, whereas more positive interactions tend to improve her mood. In order to orient yourself to the specific behaviors involved in “low mood,” you next define in greater detail what the client is doing before, during, and after she experiences “low mood.” For instance, you determine what she does when she has a low mood. Does she withdraw from all social interaction? Does she drink more alcohol and watch more television? Does she procrastinate work? Imagine you discover that Chris tends to isolate when her mood is low. She doesn’t return phone calls. She stops cleaning the house. She stops preparing food. She is much more likely to call in sick at work. In turn, these behaviors result in a mounting sense of being overwhelmed about all the things she hasn’t done—­all the ways she is failing. Inquiring about the function of these painful problem behaviors, you assume—­consistent with the framework of behavioral activation (Martell, Addis, & Jacobson, 2001)—­that their key function is avoidance of something aversive. So you ask Chris, “If you weren’t avoiding, what would you have to face that might be even more uncomfortable or painful?” The conversation that follows reveals that Chris feels intense shame about her low mood and her failure to respond to friends, such that if she were to talk to someone on the phone, she fears she would feel intense vulnerability. She describes that drinking alcohol and watching television are the only ways she can temporarily escape her painful feelings of shame. At this stage, early in treatment, you are using a variety of tools and streams of information to shape your initial analysis of the problem behaviors and their functions. You consider what Chris reports to you verbally. You might also use psychometric instruments or interviews. Transcripts of text messages, e-­mails, and other virtual communications can provide an amazingly useful natural record of how the client interacts with others. (You might also see discrepancies between the cli- ent’s self-­reporting and what you observe in these interpersonal interactions.) No doubt you will also notice that, for any given presenting problem, there are numerous behaviors involved. For instance, in addition to the simple pattern of avoidance detected for Chris, you might learn that she has a limited sense of her values or goals, leading to reduced motivation to face difficult situations; tends to make critical misattributions about the reactions of others (she thinks they are judging her, for instance); has difficulty recognizing and making sense of her painful emotions (for example, differentiating sadness from shame from anxiety); and lacks the social skills to constructively express her needs to others who could offer support. Given this complexity, what is the right focus? At this early stage, the “right” focus will always be a moving target. You are observing the flow of behavior, and you don’t know yet what changes will lead most effectively to the best outcome. All you have is your best guess. The right focus, then, is often defined by what seems workable in the moment. A workable focus tends to have a few features: First, there’s a good empirical or assessment-­based reason for thinking the target will be fruitful—­in other words, moving that target will result in clinical prog- ress. Second, the client is motivated and able to work on that target. A useful question to ask clients is “What situation or situations, if we changed them now, would have the biggest impact on your well-­being?” The answer can help you get at whether or not you have a workable focus. (Keep in mind that clients who are stuck might have ideas about what they need to do that are in fact part of the problem. For instance, Chris might tell you that she “just needs to get up enough willpower to get some things done,” even though every effort she has made to drum up willpower has resulted in greater self-­criticism and shame.) SUBSTEP B: DEFINE FUNCTIONAL CLASSES OF PROBLEM BEHAVIOR As you get a sense of the flow of behavior related to presenting problems, common functions tend to come into view. For instance, with Chris you notice that the common thread across all of her behaviors is avoiding situations in which she will be judged as deficient, either by herself or by others. In turn, seeing a functional pattern can help clients gain insight, as they often aren’t aware that a behavior has a similar function in different situations. Clients also may not realize that behaviors that outwardly appear quite different often serve the same function. For example, upon reflection Chris discovers that one way she avoids the judgment of others is by committing to too much at work (she thinks that if she always says yes, others will respect her more). She also discovers that she avoids asking her long-­term partner to make a deeper commitment in the form of marriage because she fears her partner will judge her as needy, even though there is no evidence of that. Though the form of her behavior in these two contexts is quite different, both situations involve rigid behavior that functions to avoid incurring the judgment of others. As another example, consider a man who spends long hours toiling away in a career that he knows won’t satisfy him in the long run. He may not see how this behavior resembles how he approached life as an opiate addict. However, in both cases he’s avoiding the pain and uncertainty of striving for a more meaningful life and facing his hopelessness about ever achieving that. SUBSTEP C: IDENTIFY CRB1 AND CRB2 AS INSTANCES OF THOSE PROBLEMATIC FUNCTIONAL CLASSES The assessment process in substeps A and B unfolds while you interact with the client. As we described in chapter 7, on beginning therapy, throughout that interaction you observe the client’s behaviors in the moment, the effects those behaviors have on you, and the effect you have on the client. What you observe in the moment helps you make hypotheses about the client’s behavior as it relates to his or her presenting problems; for example, “You seem X to me. Is that related to your struggle in daily life?” As the functional analysis becomes clearer, you will also start to see CRB—­ behaviors occurring here and now that are functionally related to the client’s problems. Imagine Chris describes a conversation with her partner that didn’t go well, in which she con- fronted her partner’s procrastination regarding the planning of a vacation they had agreed to earlier in the year. As she describes the conversation, you notice that her tone of voice is slightly exasper- ated and she talks about her partner in judgmental ways. This is surprising to you, because you’ve tended to think of Chris as more passive and avoidant. You’re also slightly confused by her narra- tive, and when you ask for clarification, she seems irritated. You might then ask, “I wonder…the way our conversation feels right now, is this what it felt like when you were talking to your partner? As you tell me the story, is that how your tone of voice sounded then, as well?” If Chris admits that her tone was probably quite negative, you have crucial information about what happens in relevant interactions: When Chris feels that her needs aren’t met, she communi- cates her frustration ineffectively, and she isn’t aware of the negative impact of her tone of voice. This perpetuates a pattern in which others resist or avoid her, which, in turn, leads to Chris feeling ashamed and self-­critical and avoidant of these sorts of interactions with others. You can then ask yourself what other behaviors fit this pattern. You also now have a clear sense of the CRB related to this pattern. In exploring possible CRB, or the links between what you notice in the moment and the client’s presenting problems, it’s often helpful—­especially early in therapy—­to focus on moments when the client seems more emotional, more avoidant, less socially skilled, or disconnected from you. Keep in mind that the context of therapy is filled with interpersonal challenges that may parallel the challenges the client faces in daily life, and because of this, therapy may evoke these difficulties. Consider some of these challenges that therapy may involve for clients: Having obligations or commitments to another person oasis-ebl|Rsalles|1490374261 Interacting with someone who’s more educated or higher on a perceived social ladder Vulnerably sharing emotions, experiences, or facts Having an opportunity to trust or depend on someone Relating to someone whom they pay to serve them Relating to an expert whom they expect to have answers to their problems Making needs or requests known Coping with disappointments or unmet expectations Collaborating on a difficult, uncertain task Wanting to know more about the other person Feeling seen, validated, or cared about Wanting more time than the other person can give Feeling gratitude or appreciation Wondering if the other person is being honest or authentic Wanting to be more special than others (for example, not just one of many clients) Facing a time-­limited relationship In some cases, both CRB1 and the related CRB2 will rapidly become evident. In other cases, you’ll be able to see the CRB1 clearly but be uncertain about a more workable CRB2. In the latter situation, you’ll enter into a design or discovery process guided by this key question: What behav- iors will be more effective and functional in the contexts in which this client is struggling? It might take time for you to understand the struggle and the client’s life situations well enough to see the path clearly. In turn, understanding the client’s CRB1 and CRB2 will help you identify the key behaviors you must engage in to be an effective therapist for this client. What must you do to evoke CRB2? What patterns and behaviors must you watch out for because they will undermine therapy prog- ress? For example, with Chris you might need to be firm but calm when inviting her to express her needs in session. You might also need to be patient, helping Chris find the language to articulate her needs and forgiving her when she is overly vague or harsh. This stance might be challenging, especially if you are very goal directed in your own life and in how you conduct therapy. To main- tain an open, inviting stance, you may need to accept some uncertainty and lack of focus in the therapy process as Chris finds her way. oasis-ebl|Rsalles|1490488837 Step 2: Test the Working Formulation Remember, the right case conceptualization is the one that works. You can only know if some- thing works by testing it. Therefore, after arriving at an initial working formulation, the next step is to test it. One simple form this testing takes is to formulate CRB2 that can be evoked and rein- forced in the moment, then assign homework based on practicing that same behavior in other contexts. Then, observe the results: Is the client able to achieve the change? Does the change produce the desired effect? And if there seems to be a negative outcome (for example, the client feels bad), is it actually a negative outcome? Of course, the testing process is not always so focused and simple, so it’s important to keep in mind that the process, more broadly speaking, is to proceed with therapy, inquiring whether the formulation leads to progress in therapy as you go along. You might swing a strike. Or you might get a hit, but the hit, in turn, may lead to a new focus. For example, with Chris you might choose to focus on increasing her ability to compassionately and effectively assert herself with others—­despite her fear of their negative judgment—­because there are several painful situations in which her own needs are being trampled. In service of that focus, you compassionately challenge her (rule 2, evoke CRB) to be more direct with you about what kind of guidance she needs (CRB2) to most effectively build assertiveness skills and be willing to practice them. In the following weeks, she has several conversations—­with her partner, with her supervisor—­that go well. She feels a sense of relief in those relationships. She immediately dis- closes, however, that the much deeper issues she has been struggling with involve whether to even stay with her partner and in her current job. While it’s perhaps true that her increased assertiveness facilitated her honesty about those doubts, the focus now shifts from the CRB of assertiveness to willingness to be vulnerable in discussing her longing for deeper changes. Step 3. Refine the Formulation The initial working formulation of the problem gets you started. It facilitates client buy-­in and creates a sense of collaboration and understanding. However, as therapy proceeds, the testing process may reveal that the initial formulation is less than accurate or less than useful. You will then need to refine and evolve and reformulate your formulation through ongoing assessment and dialogue. This is especially likely when clients are inaccurate or unreliable reporters of what happens to them outside of session and why. With such clients, it can take time to gain the needed clarity in conceptualization. In turn, the process of sharpening the conceptualization helps to focus therapy and hone the client’s self-­awareness. In-­session work can be especially fruitful for refining the formulation because of the clarity with which you can see and experience client behavior in the here and now. And as your understanding of individual clients and their problems and life situations evolves, so might your understanding of the significance of what you observe in session. Sometimes the behavior will strike you as unique or odd, but you won’t know for a while whether it is clinically significant. Only with time do the pieces of the puzzle start to fall together. This is a natural evolution of the therapy process as you get to know a client over time, and it’s a key aspect of case conceptualization in FAP. With Chris, for instance, perhaps it takes a while to understand that her slight edge of defensiveness and judg- ment of others—­visible even in your first meeting—­is related to her clinical issues. (It may also take a while to build enough rapport that you feel confident Chris will accept your feedback.) ACCEPTING THAT THE PROCESS ISN’T LINEAR It may take time for an effective conceptualization to come into focus. While you’re searching for clarity, both you and the client may experience challenges within the therapy relationship. For example, the client may doubt whether therapy can help her. She may wonder if she is “unfixable.” She may be frustrated by your inability to find a more direct path. You in turn may wonder about your competence to help this client. These experiences can be useful for case conceptualization because you can observe how the client responds to such challenges. In fact, difficulty tolerating the necessary trial and error of change could be part of the pattern that keeps a client stuck. Addressing how clients cope with change, with obstacles to change, and with the frustration of failed efforts can be extremely thera- peutic. In some cases, this direct focus on process is crucial for progress in therapy. Imagine that a wave of hopelessness arises for Chris after she discloses to you that she has been contemplating leaving her partner and her job. She tells you that she fears therapy can’t help her with big decisions and, in fact, such decisions are no-­win situations for her. You may spend several weeks floundering, trying to find a way that seems to support Chris with her fear. Through that struggle, however, you might eventually discover something critical about how Chris approaches big decisions: she expects there to be a perfect answer that entails her not feeling any uncertainty or conflict. Once you recognize that key belief, you can work on a more flexible and accepting approach to her decisions. (Of course you are welcome to identify that hang-­up more quickly. Our point is that it’s helpful to accept the fact that sometimes clarity takes time.) EXAMPLES OF CASE CONCEPTUALIZATION OVER THREE DIFFERENT TIME FRAMES In the final sections of this chapter, we provide several extended examples of case conceptualiza- tion to illustrate the range of settings in which it occurs. We start with a single conversation focused on functional analysis. We’ll then present case conceptualization from a relatively short-­term case, closing with a description of a complex, multiyear course of therapy. FAP in Action: Functional Analysis in the Moment When clinicians first learn functional analysis, they sometimes have difficulty putting the prin- ciples into practice in session. Even if the goal outcome of functional analysis is fairly targeted (for instance, identifying CRB), it’s important to know that the process itself can be quite flexible, conversational, and completely jargon-­free, as the following dialogue illustrates. In this example, the client is a woman struggling with a severe anxiety disorder. She has just described how this anxiety worsens when her parents come to visit. Therapist: So, when you’re with your parents, what sorts of things come up? Client: Well, I’m worried that they must be judging me because I just stay in bed all day and don’t really do anything. Therapist: You’ve said your dad was pretty critical when you were young, too. Does that still continue? Client: No, he’s actually better now. He used to get really angry. He was critical of me all the time. I remember him yelling at my mom. Therapist: What else do you remember? Client: One time we were on a summer vacation when I was a teenager, and I was trying to get a really dark tan. He said that if we were in the South and I was that tan, I’d have to sit in the back of the bus. Therapist: Wow. That’s problematic on so many levels. Client: I have lots of stories like that. Therapist: What would you do when he said things like that? Client: I felt terrible…ashamed. Therapist: And did you still want to be close to him? To have his approval? Client: Of course I did. I always wanted his approval. Therapist: How did you cope with that? It must have been really painful. Client: I pulled back. I hid a lot. I did my best to please him. I don’t know… Therapist: It seems you learned that you’re likely to be judged when you’re close to other people—­and it’s as though your anxiety is really tuned in to that threat. You’re cali- brated for the relationship with your dad, where there actually was a lot of threat. But now the anxiety has a life of its own. You want connection. Over and over you’ve told me that’s what you want. But there’s so much anxiety around that, around being vulnerable with people, especially those who matter to you. So it’s easier to pull back and stay separate. And when you do get closer to someone, there’s a good chance your fear will spike, so you very well may feel worse. What do you think about what I’m saying? Client: Well, I know it makes sense. But I’m not convinced that there aren’t really threats with other people too. Therapist: Oh, there might be. They might judge you. They might not. That uncertainty seems to be what’s really scary for you. I mean, imagine if someone judged you and you could just react like, meh…whatever. That would be a huge change, right? But what happens now is that all your alarms go off. It’s like a catastrophe. It’s hard to connect when you’re having the feeling that some kind of catastrophe is happening. Client: Even when I do connect, I say to myself, “If this person is nice to me, it’s because they think I’m ugly. They’re taking pity on me.” Therapist: Yes. And if they weren’t nice, the explanation would be similar. But instead of pity, they’re disgusted by you. Client: Yes. Therapist: See how you end up back in the same spot? You get relief when you withdraw, when everything is coherent. Like you said, it feels better to think people find you ugly. But then no new information or experience gets in. It’s a closed system. Client: I guess so. Therapist: Can you say more? Client: I get what you’re saying. I just don’t trust it all yet. Therapist: It makes sense that you don’t. I don’t either yet. We’re figuring it out together. Client: Even as we’re talking now, it’s like I feel that fear a bit, and I get stuck on it. Part of me is distracted with it. I want to hide. Therapist: Yes. And what do you notice? Client: I just want you to know that fear is there. I always think something is going wrong with me. Therapist: You’ve said it’s uncomfortable to be here, talking to me. And sometimes these fears come up. What else does the fear say? Client: Well, I wouldn’t want there to be something wrong without me catching it. I wouldn’t want you to judge me without me knowing about it. Like even a minute ago, I was wondering if you could see what’s wrong with my hair. Therapist: So, normally, would you tell someone about your fear? Client: No. Therapist: In this context, I’m glad you’re telling me. It helps me understand you. It makes sense given what we’re talking about. In our work, I want to help you feel willing to be open with me in a way that doesn’t involve pulling back and hiding. To summarize, this dialogue starts with a description of an old dynamic between the client and her dad: she doesn’t disclose vulnerable information to him because she fears his reaction. Then the client discloses the same urge to avoid showing up in the moment (“I want to hide.”). Based on this conversation, functional thinking leads the therapist to hypothesize that the client reacts to fear of judgment by avoiding vulnerable disclosure. In turn, the client’s preoccupation with her appear- ance likely also functions to help her avoid or cope with that vulnerability and fear of judgment (similar to the way a compulsion functions in relation to an obsession in obsessive-­compulsive dis- order). This thinking allows the therapist to notice that the behavior of disclosing fear, and poten- tially meeting judgment, is a change—­a possible CRB2. Notice that there are still many uncertainties. For example, does the client struggle with reas- surance seeking (in addition to her avoidance of vulnerability)? Is she seeking reassurance by men- tioning that she wonders if the therapist noticed anything about her hair? What kind of vulnerable disclosure would it be effective to increase in her daily life to move her toward the goal of better relationships? What kind of willingness or acceptance will be needed to move in that direction? All of these issues might be addressed with time. The conversation above simply illustrates one moment in the process of case conceptualization. FAP in Action: Ongoing Case Conceptualization Over a Short-­Term Treatment Tony is a thirty-­eight-­year-­old married banker who, in his first session, said he felt burned-­out in his work. He expressed frustration about his supervisors (“They’re so incompetent sometimes”) and his colleagues (“They’re like children”). Below we describe the evolution of the case concep- tualization across Tony’s relatively short-­term treatment. Based on the idea that anger often reflects frustrated or unmet needs, the therapist first asked Tony about how well his needs were met at work and how effectively he expressed his needs, both proactively and when they weren’t met. Tony reported that he tended to avoid speaking up until he reached his boiling point, after which he communicated with a lot of anger. The therapist also discovered that Tony persevered in a lot of friendships that weren’t very satisfying to him or apparently to the other person, and that many of these friendships fizzled out after a few months, while those that lasted involved ongoing conflict. This also related to how he expressed (or didn’t express) his needs, as most of his difficulties with friends revolved around their failure (in his view) to be considerate of him. Ultimately, it seemed that Tony invested a lot of energy in relationships that arguably provided the opposite of what he needed: stress instead of support, and conflict instead of understanding. Based on what was happening at work and in his friendships, in the first session, the therapist decided to initially focus treatment on how Tony expressed his needs. For the first several sessions, Tony participated in an agreeable but unfocused way. He was pleasant to the therapist, even while talking at length about his frustrations with people outside of session. When the therapist pointed out this discrepancy (“How is it that we get along so well, yet you have so many frustrations with others in your life?”), Tony said, “Well, you haven’t done any- thing to disappoint me.” The therapist also noticed that Tony wasn’t very clear about what he wanted to focus on in each therapy session, even when prompted. He tended to spend a lot of time telling detailed stories about events in his week. After several sessions, the therapist pointed this out: “It’s curious to me that you say I haven’t disappointed you, yet you’ve also rated the helpfulness of our sessions as moderate. It seems like you hired me for a good reason, and my job is to help you. I want to help you. Yet I notice that your needs often seem quite vague to me when you’re here. I find myself losing track of what you need and what we’re working on. I have the sense that if I let you, you’d tell stories for the entire session, then thank me, and then rate the helpfulness of the session as moderate. And I sense that you’d be satisfied to go on that way for a while. But we wouldn’t really get anywhere. Is that right?” Tony smiled and replied, “Yep, that’s pretty much right. That’s what I did with my last thera- pist.” This led to a conversation about how Tony—­at least until he reached his boiling point—­ made his social interactions smooth and easy by putting his own needs aside. He said it felt awkward for him to ask for things directly, and that in the short term it was easier for him to cruise along without making his needs known. At the therapist’s invitation, Tony committed to work toward expressing his needs more clearly, both in the therapeutic relationship and in other contexts. The therapist in turn provided a concrete framework for assertiveness skills. In the first few weeks after this discussion, Tony practiced expressing what he needed in several crucial conversations with colleagues. The conversations worked well enough, in that he got what he needed in the moment, but he still felt ongoing resentment toward his supervisors, and his burnout didn’t decrease markedly. As the therapist explored this, Tony mentioned a couple of work commitments—­extra assignments he had volunteered for—­that were stressing him out on a weekly basis. This in turn led to a discussion about Tony’s overall workload. It emerged that Tony was dramatically overcommitted and spread thin over several projects he was not enjoying but felt obligated to complete. Tony hadn’t realized that these commitments likely played a key role in his burnout until the therapist asked about this possibility directly. Tony responded, “Doesn’t every- one have too much work to do?” Based on this new information, the therapist helped Tony craft requests for the relevant super- visors to renegotiate these commitments, and although Tony felt considerable anxiety about initiat- ing these conversations, he committed to doing so. He was also more direct with his therapist in asking for her support in preparing for these conversations, which she recognized as CRB2. As a result of all of this work, over the next few weeks Tony fundamentally restructured how his time was allocated at work, and his burnout improved rapidly and substantially. In the next phase of therapy, Tony expressed deeper needs, opening up about ongoing frustra- tions and conflicts in his closest relationships, including his marriage. Together, Tony and his thera- pist discovered that he had a pattern of holding high expectations of those closest to him and that, as in professional relationships and friendships, he typically didn’t express his needs with respect to these expectations very clearly; then when his loved ones failed to meet his unexpressed needs, he tended to either blow up with anger or withdraw. All of this was functionally similar to his behavior in other contexts. But with loved ones, a different type of behavior also manifested: Tony worried a lot about their well-­being and success, and in response to this worry, he tended to pressure them to change their behavior in ways he thought they should. Not surprisingly, this usually resulted in conflict or distance in the relationship. As the therapist explored this dynamic, she discovered that Tony was the oldest of several children, and that during his childhood he often felt compelled to take care of his siblings because his parents were fairly neglectful. As a child, he felt proud of the responsibility he carried, and he wanted—­but didn’t receive—­recognition and appreciation for the parental role he played. At the same time, he had considerable anxiety about his responsibility for his siblings, and he mainly managed them through nagging and threatening. This pattern of behavior was understandable in the context of Tony’s childhood situation. However, in his adult life, it wasn’t functional. The conversation in which this pattern came fully to light functioned as a huge CRB2, with Tony deeply expressing his wish to fundamentally change how he related to those closest to him. Just a few days afterward, Tony had a conversation with his wife in which he broke a long-­standing avoidance of talking about the elephant in the room: their relationship. He acknowledged that putting pressure on her to behave how he wanted wasn’t helpful, and he apologized for not being more sympathetic. He also clearly expressed his own needs and vulnerability. The result was that he immediately felt closer to his wife than he had in a long time. FAP in Action: Case Conceptualization Over the Long Term Tony’s case is a relatively straightforward, brief treatment, with the case conceptualization evolving over a couple of months. Now we’ll offer an example of case conceptualization that evolved over almost three years. Nick was struggling with more severe problems—­chronic depres- sion, anxiety, interpersonal difficulties, and dependence on alcohol—­and had been referred to treatment after hospitalization for being suicidal. EARLY TREATMENT (DURATION: TWO MONTHS) Initially Nick was suspicious of therapy and withheld most of the details of his emotional expe- rience. During the first two months of treatment, he gradually opened up and described intense loneliness, despite having fairly frequent social contact. The therapist’s attempts to use activity scheduling failed. During this phase, Nick’s CRB1s included avoiding the therapist by skipping ses- sions and withholding feedback when interventions weren’t helpful. His CRB2s included honest disclosure and making his needs known to the therapist. PHASE 2 (DURATION: FOUR MONTHS) As Nick disclosed more, it became clear that he met criteria for borderline personality disorder. This was a significant realization for him. The therapist identified deficits in emotion regulation, social perspective-­taking, and social skills more generally, and then she intensively assessed Nick’s history, focusing on his interpersonal relationships and pursuit of goals. This revealed that many of Nick’s actions were based on perceived obligations to others and to a very rigid code of how people should behave, which his parents had imposed upon him from an early age. One function of this code was to help him decide how he should relate to others in order to avoid shame and faux pas. Yet it also became clear that he had a very difficult time taking others’ perspectives; as a result, he couldn’t make sense of other people’s behavior when it broke the code, and he felt angry, anxious, and puzzled much of the time. This lack of understanding and disappointment with others—­and basic lack of perspective taking—­meant his relationships were frustrating and lacked depth. He resented (and envied) others for what he perceived as their superficiality and failure to adhere to the code. These feelings emerged in the form of ranting in session, and although this was uncomfortable for the therapist at times, it was also important, as the therapist recognized the ranting as a likely starting point for shaping CRB2s related to honest emotional expression and expression of needs. This frustration also motivated Nick to work with the therapist to develop basic behavioral strategies to address painful conflicts, including ending several dysfunctional relationships and starting to engage with his family members differently—­in more assertive or flexible ways. In this phase, Nick’s CRB1s included demanding overly simplistic solutions from the therapist (“You need to tell me how to fix this!”) and sticking rigidly to his code in session, rather than think- ing beyond it. His CRB2s included expressing feelings and needs openly, orienting toward prob- lems and situations he wanted to solve (instead of complaining), sticking with the process even when it involved challenges or uncertainty, and inquiring about and accepting the therapist’s per- spective on what might be helpful. PHASE 3 (DURATION: EIGHT MONTHS) Six months into therapy, Nick’s suffering had eased somewhat, and he was experiencing signifi- cantly less conflict. However, he still hadn’t achieved any substantial changes in his life, and he was painfully lonely, which led to a deeper feeling of hopelessness, increased suicidal thinking, and increased conflict with his therapist centered around the demand that she provide more effective solutions. During these times of high distress, he engaged in some skills practice based on dialecti- cal behavior therapy (DBT), albeit reluctantly and without much benefit. His therapy seemed to reach a turning point through a series of very raw discussions focused on the process of change. In these discussions, his therapist said, with considerable emotion, “Change won’t happen unless you change how you’re living more fundamentally. It involves opening up to a way of living that’s scary to you—­facing the anxiety of letting go of the code to become who you really want to be. If you don’t do this, you’ll probably keep feeling the same way.” This may sound harsh. But in the context, it was exactly this directness that motivated Nick to let go of what was not workable, to let go of how he had been living previously, and to move toward accept- ing the need for deeper change—­and all the anxiety and grief that came with these changes. After working through that conflict in the therapy process, they discussed Nick’s pattern in conflicts, which usually left him feeling completely alienated from the other person—­including the therapist. They committed to work on maintaining an understanding of and connection to each other through any conflict that arose between them. This work led to Nick experiencing things with the therapist that he had never experienced before: being understood and cared for despite his anger and high levels of conflict, and persevering through conflict to reestablish a connection. This new interpersonal process in session functionally mirrored, at a very high level, what Nick needed to achieve in his life outside of session: pushing through discomfort and fear to find a more authentic way of living and connecting with others. To consolidate the case conceptualization, the therapist and Nick defined two different ways of being: one based on the code versus one based on genuine desires and needs. They named living by the code Hans because the name signified duty and obligation, and they named living based on genuine desires and needs Bowie because the name captured how Nick secretly wished to live: as a rock star who is creative, gregarious, and free of conventions. During this phase, Nick’s CRB1s included escalating his demands, anxiety, and suicidal thinking in order to get his therapist’s atten- tion; avoiding or suppressing his genuine desires and wishes about how to live; and attacking or judging others. His CRB2s included expressing his needs vulnerably and directly, taking into account his impact on the therapist; accepting uncertainty; accepting care from the therapist; and disclosing his genuine wishes about how he wanted to live. PHASE 4 (DURATION: THIRTEEN MONTHS) Fourteen months into treatment, Nick committed to radically changing how he was living life. This change centered on altering how he presented himself to others (literally, how he dressed and spoke), participating in social activities he was interested in but Hans forbade, and learning to speak and relate as Bowie rather than as Hans. For the first time, Nick started to spontaneously report feeling hopeful. In the context of his compelling desire to live like Bowie would, Nick became much more motivated to practice a variety of DBT emotion regulation skills, with a par- ticular focus on actively managing his anxiety. As Nick implemented these changes, the therapeutic relationship became progressively deeper and more solid based on mutual respect, understanding, caring, and commitment to this crucial but difficult task of living in line with his values as Bowie. Nick’s CRB1s included “being like Hans,” seeking reassurance or black-­and-­white answers, and suppressing his needs. His CRB2s included taking risks to express and embody who and what he wanted to be; accepting uncertainty; taking the therapist’s perspective; and sharing his appreciation for the therapist. PHASE 5 (DURATION: SIX MONTHS) By phase 5, through a lot of hard work (much is left out of the condensed story we offer here) and after twenty-­seven months of therapy, Nick had achieved several life goals he had believed were impossible. He no longer felt terrified or enraged during interactions with his family. He was in a committed and stable romantic relationship. And beyond his partner, he had a strong, local community of friends. He was also spending most of his time doing activities he valued. To prepare Nick for the end of treatment, during this phase the therapist focused on dealing with the so-­called normal challenges of living, such as what to do when work conflicts with romantic relationships or how to talk about the future with your partner.

SUMMARY • Case conceptualization in FAP is based on ongoing functional analysis that unfolds in the therapeutic relationship. • Case conceptualization, like the therapy process in FAP, is iterative and collaborative. It only needs as much precision as is required to efficiently achieve a positive therapy outcome. • The case conceptualization might identify out-­of-­session problems, CRB1s, CRB2s, out-­of-­session goals, T1s, and T2s.