11 动态理解——利用FAP进行案例概念化

第十一章

理解在行动中——FAP案例概念化

知识的任务是说话，而智慧的特权是倾听。 —奥利弗·温德尔·霍姆斯

列出你接下来要见的五位来访。在空白页上键入或写下他们的名字。现在就做。选择一个进展特别缓慢或不确定的来访。然后针对该来访考虑以下问题：

• 这个人目前生活中最需要做什么？（尽可能具体地描述行为。记住，行为包括看似不重要的事情，如接受、相信、设想等。）
• 为了从下一次会谈中获得最大收益，这个人在这次治疗过程中最需要练习什么？
• 来访需要接受和体验什么？
• 来访需要思考什么？请求什么？感受什么？关注什么？
• 来访需要做什么？
• 这个人做了什么最妨碍或阻碍了治疗的进展？
• 这种特定行为的功能是什么？（从来访的角度描述。）
• 鉴于来访的经历，这种行为如何完全合理？
• 在这次治疗会谈中，你最重要的事情是什么？
• 为了做到这些事情，你必须愿意经历和接受什么？

这些问题可能并不适用于所有来访。也许你已经与几位来访取得了很好的进展。也许对于某些来访来说，这些问题正是他们所需要的焦点，你也清楚这一点。也许你在回答其他来访的问题时感到困惑。

这些问题在很多方面都是FAP的核心案例概念化问题。我们发现这些问题——或其变体——通常是有帮助的，尤其是在治疗陷入僵局或缺乏焦点时。它们与其他治疗方法的原则和案例概念化策略相契合，并将你的注意力集中在具体的行为上，以及这些行为如何在治疗过程中表现出来。当然，最终你会成为判断何时或如何使用这些问题的最佳裁判（尽管你可能会从咨询提供外部视角的人那里受益）。

我们想提供以下关于FAP案例概念化的定义，因为它可能与你学习的其他类型治疗的定义不同： FAP使理解处于动态之中。你如何在当下与来访工作是由你对他们作为个体及其当前情境的理解所引导的：他们需要你做什么，他们在生活中需要什么，什么对他们有效。这种理解通过治疗关系不断发展。本质上，案例概念化是一个不断发展的、持续的过程，它帮助你为与来访的即时互动做好准备并指导你。案例概念化不是治疗师藏在心里或隐藏在秘密文件夹中的东西，也不是用术语包裹起来的。在FAP中，案例概念化是一种透明的、关怀的对话，讨论治疗中的相关行为。

正如你所知，在FAP中，这一过程以功能分析为中心。在第三章中，我们概述了从FAP视角来看的功能分析的一般原则（这些原则是上述问题的另一种版本）：

• 确定与来访提出问题相关的关键行为和情境。
• 明确这些行为的功能。
• 寻找涉及的功能类别。
• 定义改进。
• 注意到临床相关行为的即时出现。定义问题行为（CRB1）和改进（CRB2）如何在治疗关系中体现。
• 理解你自己那些干扰（T1）或支持（T2）来访变化过程的关键行为。
• 随时间推移塑造和完善你对上述内容的理解。

在本章中，我们将扩展这些基本思想，描述它们如何在整个治疗过程中影响案例概念化的过程。

扩展功能性分析到案例概念化

正如FAP中的几乎所有内容一样，案例概念化可以根据来访、情境以及你的个人风格采取多种形式。案例概念化可能涉及大量的功能性分析，也可能进展迅速。有效的概念化可以是高度精确和复杂的，也可以是高度概括和简单的。最终，案例概念化的质量取决于其功能——即它在实现治疗目标方面的工作效果，而不是它的形式。换句话说，通过其工作效果来评估你的案例概念化。

在这个框架下，有一个案例概念化的结果通常是FAP中的关键绩效指标：概念化允许来访和治疗师在行为发生时识别出CRB（临床相关行为）的实例。（也许这仅是FAP中的一个关键指标，因为没有识别CRB就无法进行FAP。当然，除了FAP之外，还有其他方法可以实现治疗成果。）更广泛地说，当FAP中的案例概念化走上正轨时，通常会出现以下情况：

• 治疗师和来访同意某些有问题的人际行为与当前问题有关。
• 治疗师和来访在会谈中共同识别出CRB1的实例。
• 治疗师和来访同意在会谈中识别出的CRB（包括CRB1和CRB2）与会话外的问题行为在功能上相关。
• 治疗师努力有效地管理治疗过程，更多地进行T2（支持性行为），减少T1（干扰性行为）。
• 治疗师对CRB1和CRB2的关注是平衡的，使来访既感到进步被认可，又受到适当的挑战以继续前进。
• 在会谈中处理CRB的过程（通过家庭作业支持）产生洞察，并激励来访改变日常生活中功能相关的有问题行为，从而验证案例概念化在集中治疗过程方面的有效性。

有许多方法可以达到这些目的。为了以另一种方式展示FAP的灵活性，请考虑以下案例概念化的摘要。（FAP中的案例概念化摘要列出了问题、CRB、T1和T2，并作为治疗师和来访的快速参考指南。记住，摘要是案例概念化过程的结果，而不是过程本身。）这些摘要在使用的语言类型和所采用的精确度水平上各不相同，但它们都可能充分起到在治疗过程中集中治疗师和来访注意力的作用。

示例1：相对隐喻性的语言

• 来访在会话外的问题：避免风险、退缩、筑起心墙
• CRB1：避免风险、退缩、筑起心墙
• CRB2：承担风险、走出舒适区开放自己、探索心墙并愿意降低它
• 一般化的CRB2：有策略地承担风险、开放自己、稍微降低心墙（尤其是在与男性交谈时）
• T1：退缩、允许心墙保持原状
• T2：探讨连接的感觉、探索为什么来访觉得需要心墙、温和地邀请来访打开一扇窗

示例2：较少隐喻性的语言

• 来访在会话外的问题：在工作中和伴侣面前避免表达需求、过度承诺帮助他人
• CRB1：专注于治疗师认为他应该做的事情、避免表达自己的需求、过度承诺于不符合他需求的治疗任务
• CRB2：根据对他有效或无效的情况调整并表达他的需求、为符合他需求的治疗任务做出实际承诺
• 一般化的CRB2：清楚而主动地表达他的需求、在请求不可行时说“不”
• T1：迎合并强化“好来访”的常规
• T2：放慢过程以帮助来访接触他的需求、探索他对表达需求的恐惧、确定实际承诺

示例3：使用ACL模型——详尽的概念化

• 来访在会话外的问题：缺乏对他人的需求及其影响的认识，尤其是对家庭成员；过于批评；倾向于在家庭成员表达脆弱时用惩罚回应；无法用爱回应家庭成员；无法在家庭成员脆弱时让他们感到安全
• CRB1：缺乏对她对治疗师的影响的认识、专注于解决问题、倾向于避免讨论情感或对情感讨论作出敌意反应
• CRB2：增强对治疗师感受及其影响的认识、能够在讨论情感时不变得敌对或讽刺、在接受治疗师反馈时即使感到敌意也能接受、发展在治疗师挑战她时传递安全和接纳的能力
• 一般化的CRB2：更加意识到家庭成员的情感需求；在家庭成员表达脆弱时能够耐心、充满爱心和安全感地回应
• T1：让来访解决问题、在她变得敌对和讽刺时避免挑战她留在情感上、评判来访
• T2：当她以敌意回应时直接向来访表达悲伤和恐惧、即使面对惩罚也坚持同情的方法、记住来访在那一刻总是尽其所能

示例4：使用ACL模型——简化的概念化

• 来访在会话外的问题：没有注意到自己的需求（意识）、没有要求自己的需求（勇气）
• CRB1：没有注意到自己的需求（意识）、没有要求自己的需求（勇气）
• CRB2：调入自己、注意自己的需求、和/或要求（意识/勇气）自己的需求
• 一般化的CRB2：调入自己、注意自己的需求、和/或要求（意识/勇气）自己的需求
• T1：不停下来创造空间、忽视来访的需求
• T2：创造空间、邀请请求

请注意，这些案例概念化摘要中并未明确涵盖功能性分析的所有方面。例如，特定的情境，特别是该情境中的特定强化物或学习历史，并未包含在内。这类摘要的主要目的是简单地提示治疗师和来访记住并关注关键行为。

案例概念化的完整过程

无论案例概念化的过程是简短的还是扩展的，线性的还是非线性的（以及描述问题行为和CRB的摘要是否详尽或简单），它通常涉及三个关键步骤，我们将在以下部分简要回顾：

1. 形成初步的工作假设。
2. 测试工作假设。
3. 精炼假设。

第一步：形成初步的工作假设

案例概念化的第一步是提出关于来访的关键问题行为及其相应的临床相关行为（CRB）的初步最佳猜测——即，与来访当前问题相关的那些行为是如何在治疗关系中即时发生的。

达到这一初步CRB假设包括三个子步骤： A. 识别问题行为及其功能。 B. 定义问题行为的功能类别。 C. 识别CRB1和CRB2作为这些有问题的功能类别的实例。

子步骤A：识别问题行为及其功能

想象你有一个名叫克里斯的来访，她希望改善自己的情绪。她报告说人际关系是她的主要压力源，并且她透露大多数当前的人际互动都是冲突的或疏远的，通常会导致她的情绪低落，而更积极的互动则会改善她的情绪。

为了更好地理解“情绪低落”所涉及的具体行为，接下来你需要详细定义来访在经历“情绪低落”之前、期间和之后的行为。例如，你确定她在情绪低落时做了什么。她是否会从所有社交互动中撤退？她是否会喝更多的酒并看更多的电视？她是否会拖延工作？

假设你发现当克里斯情绪低落时，她倾向于孤立自己。她不回电话，不再打扫房子，也不再准备食物。她更有可能打电话请病假。反过来，这些行为导致了一种日益增长的被压倒感——所有未完成的事情，所有她失败的方式。

询问这些痛苦的问题行为的功能时，你假设——与行为激活框架一致（Martell, Addis, & Jacobson, 2001）——它们的主要功能是避免某些令人不悦的事物。所以你问克里斯：“如果你不逃避，你会面对什么可能更不舒服或痛苦的事情？”随后的对话揭示了克里斯对自己情绪低落以及未能回应朋友感到强烈的羞耻，以至于如果她打电话给别人，她担心会感到极度脆弱。她描述说喝酒和看电视是她暂时逃避痛苦羞耻感的唯一方式。

在这个阶段，在治疗初期，你正在使用各种工具和信息流来塑造对问题行为及其功能的初步分析。你考虑克里斯口头向你报告的内容。你也可能会使用心理测量工具或访谈。短信、电子邮件和其他虚拟通信的记录可以提供一个非常有用的自然记录，显示来访如何与他人互动。（你还可能会注意到来访自我报告与其在这些人际互动中的表现之间的差异。）

无疑，你也会注意到，对于任何给定的呈现问题，都有许多行为涉及其中。例如，除了为克里斯检测到的简单的回避模式外，你可能还会了解到她

• 对自己的价值观或目标认识有限，导致面对困难情况的动力减少；
• 倾向于对他人的反应做出错误归因（例如，她认为他们在评判她）；
• 难以识别和理解自己的痛苦情绪（例如，区分悲伤、羞耻和焦虑）；并且
• 缺乏建设性地向能够提供支持的人表达需求的社交技能。

鉴于这种复杂性，正确的焦点是什么？在这个早期阶段，“正确”的焦点总是一个移动的目标。你在观察行为的流动，还不知道哪些改变最有效地带来最好的结果。你拥有的只是你的最佳猜测。

因此，正确的焦点往往由当下可行的东西定义。一个可行的焦点通常具有几个特征：首先，有良好的实证或评估基础的理由认为该目标是有成效的——换句话说，改变这个目标将导致临床进展。其次，来访有动机并有能力处理这个目标。一个有用的问题是问来访：“如果我们现在改变了某种情况或某些情况，会对您的福祉产生最大的影响是什么？”这个问题的答案可以帮助你判断是否有可行的焦点。（记住，陷入困境的来访可能有一些关于他们需要做什么的想法，而这实际上可能是问题的一部分。例如，克里斯可能会告诉你她“只需要有足够的意志力来做一些事情”，尽管她每次努力鼓起意志力都导致了更大的自我批评和羞耻感。）

子步骤B：定义问题行为的功能类别

当你开始理解与呈现问题相关的各种行为流动时，常见的功能往往就会显现出来。例如，在克里斯的案例中，你会发现她所有行为的一个共同点是避免在自己或他人眼中被评判为不足的情境。看到这种功能模式可以帮助来访获得洞察，因为他们通常没有意识到某些行为在不同情境下具有相似的功能。来访也可能没有意识到，表面上看起来非常不同的行为实际上可能具有相同的功能。例如，经过反思，克里斯发现她避免他人评判的一种方式是在工作中承担过多的责任（她认为如果总是说“是”，别人会更尊重她）。她还发现，她之所以不向长期伴侣提出更深层次的承诺（如结婚），是因为害怕伴侣会认为她过于依赖，尽管并没有证据表明这一点。虽然她在这些情境中的行为形式非常不同，但两种情况都涉及僵化的行为，其功能是为了避免他人的评判。

另一个例子是一个人在一个他知道从长远来看不会让他满意的职业上花费大量时间。他可能没有意识到这种行为与他作为阿片类药物成瘾者时的生活方式有何相似之处。然而，在这两种情况下，他都在避免追求更有意义的生活所带来的痛苦和不确定性，以及面对永远无法实现这一目标的绝望感。

子步骤C：识别CRB1和CRB2作为那些有问题的功能类别的实例

在子步骤A和B的评估过程中，你将与来访互动。正如我们在第七章中描述的那样，在整个互动过程中，你会观察来访当下的行为、这些行为对你产生的影响以及你对来访的影响。你在当下的观察帮助你对来访的与呈现问题相关的行为做出假设；例如，“我感觉你现在X。这是否与你在日常生活中的困扰有关？”随着功能性分析变得越来越清晰，你也将开始看到CRB——即在此时此地发生的、与来访问题在功能上相关的行为。

想象一下，克里斯描述了一次与伴侣进行得不顺利的对话，其中她就他们年初同意的一次度假计划质问了伴侣拖延的态度。在她描述这次对话时，你注意到她的语气有些恼火，并且她以一种评判的方式谈论她的伴侣。这让你感到惊讶，因为你一直认为克里斯比较被动和回避。你也对她的叙述感到有些困惑，当你要求澄清时，她显得有些生气。这时你可以问：“我想知道……我们现在对话的感觉，是不是就像你和伴侣说话时的感觉？当你告诉我这个故事时，你的语气当时也是这样的吗？”

如果克里斯承认她的语气可能相当负面，那么你就获得了关于相关互动中发生的关键信息：当克里斯觉得自己的需求没有得到满足时，她无效地表达了自己的挫败感，并且没有意识到自己语气的负面影响。这延续了一个模式，即他人对她产生抵触或回避，进而导致克里斯感到羞耻、自我批评，并回避与他人的这类互动。然后你可以问自己，还有哪些行为符合这种模式。现在你也清楚了与此模式相关的CRB。

在探索可能的CRB，或者连接你当下注意到的内容与来访呈现的问题时，尤其是在治疗初期，通常有助于关注来访显得更加情绪化、更加回避、社交技能较低或与你脱节的时刻。请记住，治疗的情境充满了人际挑战，这些挑战可能与来访在日常生活中面临的挑战相似，因此治疗可能会引发这些问题。考虑一些治疗可能涉及的来访挑战：

• 对另一个人有义务或承诺
• 与被认为社会地位较高的人互动
• 脆弱地分享情感、经历或事实
• 有机会信任或依赖某人
• 与他们付费服务的人建立关系
• 与期望能解决他们问题的专家建立关系
• 表达需求或请求
• 应对失望或未满足的期望
• 在困难且不确定的任务上合作
• 想更多了解对方
• 感觉被看见、认可或关心
• 希望比对方能给予的时间更多
• 感到感激或赞赏
• 怀疑对方是否诚实或真实
• 希望比其他人更特别（例如，不仅仅是一个普通来访）
• 面对有时限的关系

在某些情况下，CRB1和相关的CRB2会迅速显现。而在其他情况下，你可能能够清楚地看到CRB1，但对于一个更可行的CRB2则不太确定。在这种情况下，你将进入一个设计或发现过程，由这个关键问题引导：在这个来访挣扎的情境中，哪些行为将更有效和更具功能性？你可能需要花时间来充分理解来访的困境及其生活状况，才能明确路径。

反过来，理解来访的CRB1和CRB2将帮助你确定为了成为该来访的有效治疗师必须采取的关键行为。你必须做什么来激发CRB2？你需要注意哪些模式和行为，因为它们会破坏治疗进展？例如，对于克里斯，你可能需要在邀请她在会谈中表达需求时保持坚定而冷静。你也可能需要耐心，帮助克里斯找到合适的语言来表达她的需求，并在她过于模糊或严厉时宽容对待她。这种态度可能是具有挑战性的，特别是如果你在生活中和治疗实践中都非常注重目标导向。为了保持开放和邀请的态度，你可能需要接受治疗过程中的一些不确定性和缺乏焦点，因为克里斯正在寻找自己的方向。

第二步：测试工作假设

记住，正确的案例概念化是有效果的。你只能通过测试来知道某些东西是否有效。因此，在形成初步的工作假设后，下一步就是对其进行测试。这种测试的一种简单形式是在当下引发和强化CRB2，然后根据在其他情境中练习相同行为来布置家庭作业。然后观察结果：来访是否能够实现改变？这种改变是否产生了预期的效果？如果有看似负面的结果（例如，来访感觉不好），这实际上是不是负面结果？

当然，测试过程并不总是如此集中和简单，因此重要的是要记住，更广泛地说，这个过程是在进行治疗的过程中，询问假设是否导致了治疗进展。你可能会遇到挫折。或者你可能取得了一些进展，但这些进展反过来可能导致新的焦点。

例如，对于克里斯，你可能会选择专注于提高她尽管害怕他人负面评判，但仍能同情且有效地表达自己的能力——因为有几个痛苦的情境中她的需求被践踏了。为了实现这一目标，你同情地挑战她（规则2，引发CRB）对你直接说明她需要什么样的指导（CRB2），以最有效地建立自信技能，并愿意实践它们。接下来的几周里，她与伴侣和上司进行了几次对话，效果良好。她在这些关系中感到一种解脱。然而，她立即透露，她一直在挣扎的更深层次的问题涉及是否应该继续与伴侣在一起以及留在目前的工作中。虽然她的自信增强可能促进了她对这些疑虑的坦诚，但现在焦点从自信的CRB转移到了讨论她对更深层次变化的渴望时愿意表现出脆弱性。

第三步：精炼假设

问题的初步工作假设让你开始了治疗。它促进了来访的认同感，创造了合作和理解的感觉。然而，随着治疗的进行，测试过程可能会揭示出初步假设不够准确或不够有用。这时你需要通过持续的评估和对话来精炼、发展和重新制定你的假设。

这种情况尤其可能发生在来访对外界发生的事情及其原因报告不准确或不可靠时。对于这样的来访，可能需要时间来获得概念化的清晰度。反过来，精炼概念化的过程有助于聚焦治疗并提升来访的自我意识。

在治疗过程中，由于你可以清楚地看到和体验来访当下的行为，这特别有助于精炼假设。随着你对个别来访及其问题和生活情境的理解不断深入，你对会谈中所观察到的行为的意义也可能有所改变。有时行为会显得独特或奇怪，但你可能需要一段时间才能确定其临床意义。只有随着时间的推移，谜题的各个部分才会开始拼合在一起。这是随着你逐渐了解来访而自然演变的治疗过程的一部分，也是FAP中案例概念化的一个关键方面。例如，对于克里斯来说，可能需要一段时间才能理解她在第一次见面时就表现出的轻微防御性和对他人的评判与她的临床问题有关。（这也可能需要一段时间来建立足够的信任，使你有信心克里斯会接受你的反馈。）

接受过程不是线性的

有效的概念化可能需要时间才能显现出来。在寻找清晰度的过程中，你和来访都可能在治疗关系中经历挑战。例如，来访可能怀疑治疗是否能帮助她。她可能想知道她是否“无法修复”。她可能会因你无法找到更直接的路径而感到沮丧。反过来，你也可能会质疑自己是否有能力帮助这位来访。

这些体验对于案例概念化是有用的，因为你可以观察来访如何应对这些挑战。事实上，难以忍受必要的试错过程可能是让来访陷入困境的一部分模式。处理来访如何应对变化、变化的障碍以及失败努力带来的挫败感可以非常有疗效。在某些情况下，直接关注过程对于治疗的进步至关重要。

想象一下，克里斯向你透露她一直在考虑离开伴侣和工作之后，一股绝望的情绪涌上心头。她告诉你她担心治疗无法帮助她做出重大决定，而且对她来说，这样的决定是无解的。你可能会花几周时间摸索，试图找到一种似乎支持克里斯克服恐惧的方法。然而，通过这个斗争，你最终可能会发现关于克里斯如何处理重大决定的关键点：她期望有一个完美的答案，这样就不会有任何不确定或冲突。一旦你认识到这个关键信念，就可以致力于一个更加灵活和接受的方法来处理她的决定。（当然，你也可以更快地识别这个问题。我们的意思是，有时候清晰的认识确实需要时间。）

治疗师与来访的对话

治疗师：那么，当你和父母在一起时，会出现什么样的情况呢？ 来访： 嗯，我担心他们一定在评判我，因为我整天都躺在床上，什么都不做。 治疗师：你说过你爸爸在你小时候非常挑剔。这种情况现在还持续吗？ 来访： 不，他现在其实好多了。以前他会非常生气。他总是批评我。我还记得他对妈妈大喊大叫的样子。 治疗师：你还记得些什么？ 来访： 有一次，在我十几岁的时候，我们去度夏假，我试图晒得特别黑。他说如果我们是在南方，我这么黑的话，就得坐在公共汽车的后面。 治疗师：哇，这在很多层面上都是有问题的。 来访： 我有很多类似的故事。 治疗师：当他这么说的时候，你会怎么做？ 来访： 我觉得很糟糕……感到羞愧。 治疗师：那你还是想和他亲近吗？想要得到他的认可？ 来访： 当然想。我一直都想得到他的认可。 治疗师：你是怎么应对这种感觉的？那一定非常痛苦。 来访： 我会退缩。我隐藏了很多东西。我尽我所能去取悦他。我不知道…… 治疗师：看来你学会了在与人亲近时可能会被评判——而你的焦虑似乎特别敏感于这种威胁。你对父亲关系中的那种威胁已经习以为常了。但现在，焦虑似乎有了自己的生命。你想建立联系。你一再告诉我这就是你想要的。但围绕着这一点，尤其是对你在意的人表现出脆弱性，会有许多焦虑。所以，退缩并保持距离就变得更容易了。当你真的接近某个人时，你的恐惧可能会加剧，所以你可能会感觉更糟。你觉得我说的有道理吗？ 来访： 嗯，我知道这很有道理。但我并不完全相信其他人就没有威胁。 治疗师：哦，确实可能有。他们可能会评判你，也可能不会。这种不确定性似乎才是让你真正害怕的。我是说，想象一下如果有人评判你，而你能反应说“无所谓”——那会是一个巨大的改变，对吧？但现在的情况是，所有的警报都响起来了。就像是一场灾难。当你感觉到某种灾难正在发生时，很难与人建立联系。 来访： 即使我真的建立了联系，我也会对自己说，“如果这个人对我好，那是因为他们觉得我很丑。他们在可怜我。” 治疗师：是的。如果他们不好，解释也差不多。只不过不是怜悯，而是厌恶。 来访： 是的。 治疗师：你看，这样你又回到了同样的境地。当你退缩，当一切都井然有序时，你会感到解脱。正如你所说，认为人们觉得你丑会让你感觉更好一些。但这样一来，就没有新的信息或体验进入。这是一个封闭的系统。 来访： 我想是这样的。 治疗师：你能再说多一点吗？ 来访： 我明白你的意思。我只是还不完全信任它。 治疗师：我能理解你不完全信任。我也不完全信任。我们正在一起探索这个问题。 来访： 即使我们现在在谈话，我也感到有点恐惧，并且会被它困住。有一部分我在分心。我想躲起来。 治疗师：是的。你注意到了什么？ 来访： 我只是想让你知道那里有恐惧。我总是觉得有什么不对劲。 治疗师：你说过在这里和我交谈会让你感到不舒服。有时这些恐惧会出现。恐惧还会说什么？ 来访： 嗯，我不希望有什么问题我没有发现。我不希望你在我不知道的情况下评判我。就像刚才，我还在想你是否能看出来我的头发有什么问题。 治疗师：通常情况下，你会告诉别人你的恐惧吗？ 来访： 不会。 治疗师：在这种情境下，我很高兴你能告诉我。这有助于我理解你。考虑到我们正在讨论的内容，这是合理的。在我们的工作中，我希望帮助你愿意以一种不退缩、不隐藏的方式向我开放。

总结

这段对话从描述来访与其父亲之间的一个旧动态开始：她不向父亲透露脆弱的信息，因为她害怕他的反应。然后，来访披露了当下也有同样的逃避倾向（“我想躲起来”）。基于这次对话，功能性思维使治疗师假设来访通过避免暴露脆弱来应对被评判的恐惧。反过来，来访对外貌的关注很可能也是为了帮助她避免或应对这种脆弱性和被评判的恐惧（类似于强迫症中强迫行为与强迫思维的关系）。这种思考让治疗师注意到，披露恐惧以及潜在地面对评判的行为是一种变化——可能是CRB2的一种可能性。

注意到仍有许多不确定性

请注意，仍然存在许多不确定性。例如，来访是否在回避脆弱性的同时也存在寻求安慰的问题？她提到想知道治疗师是否注意到她的头发有什么问题，这是否是一种寻求安慰的表现？在日常生活中增加哪种类型的脆弱性披露有助于她朝着更好的人际关系目标迈进？朝这个方向前进需要什么样的意愿或接受度？所有这些问题可能都需要时间来解决。上面的对话仅仅展示了案例概念化过程中的一个瞬间。

FAP 实践：短期治疗中的持续案例概念化

托尼是一位38岁的已婚银行家，在第一次会谈中，他表示自己在工作中感到精疲力尽。他表达了对上司（“他们有时真的无能”）和同事（“他们就像小孩子一样”）的不满。以下描述了托尼相对较短的治疗过程中案例概念化的演变。

基于愤怒常常反映的是未满足的需求这一观点，治疗师首先询问托尼他在工作中需求得到满足的程度以及他表达需求的有效性，无论是主动还是在需求未被满足时。托尼报告说，他倾向于避免发声，直到达到爆发点，之后他会带着极大的愤怒进行沟通。

治疗师还发现，托尼维持了许多对他来说并不满意的友谊，而这些友谊对另一方来说似乎也不满意，许多这样的友谊在几个月后就逐渐消散了，而那些持续下来的友谊则充满了持续的冲突。这也与他如何表达（或不表达）需求有关，因为他在朋友关系中的大部分困难都围绕着他们（在他看来）没有考虑到他的需求。最终，托尼似乎投入了大量的精力在那些提供相反于他所需的关系中：压力而不是支持，冲突而不是理解。根据工作和友谊中的情况，在第一次会谈中，治疗师决定最初将治疗重点放在托尼如何表达他的需求上。

在最初的几次会谈中，托尼以一种友好但缺乏焦点的方式参与。他对治疗师很友好，即使在长时间谈论会话之外的人际挫折时也是如此。当治疗师指出这种差异（“为什么我们相处得很好，而你在生活中却对其他人有这么多的不满？”）时，托尼说：“嗯，你还没有让我失望。”治疗师还注意到，即使是在提示下，托尼也不清楚每次治疗会话中他想要关注什么。他倾向于花很多时间讲述他一周内发生的详细故事。经过几次会谈后，治疗师指出了这一点：“我觉得很奇怪，你说我没有让你失望，但你也评价我们的会话帮助程度为一般。似乎你聘请我是有很好的理由的，我的工作是帮助你。我想帮助你。但我注意到，当你在这里时，你的需求对我来说常常显得非常模糊。我发现自己难以跟踪你需要什么，我们在做什么。我感觉如果你愿意的话，你会在整个会话中讲故事，然后感谢我，然后把会话的帮助程度评为一般。我感觉你会满意地这样继续一段时间。但我们实际上并没有取得任何进展。这是正确的吗？”

托尼微笑着回答：“是的，差不多就是这样。这就是我对上一位治疗师所做的。”这引发了一场关于托尼——至少在他达到爆发点之前——通过将自己的需求放在一边，使社交互动变得顺畅轻松的讨论。他说直接要求东西让他感到尴尬，短期内对他来说更容易随波逐流而不表明自己的需求。在治疗师的邀请下，托尼承诺将在治疗关系和其他情境中更清晰地表达自己的需求。治疗师反过来提供了具体的自信技能框架。

在这次讨论后的几周内，托尼在与同事的几次关键对话中练习了表达自己的需求。这些对话还算顺利，因为他得到了当时需要的东西，但他仍然对上司怀有持续的怨恨，他的职业倦怠也没有明显减少。随着治疗师的进一步探索，托尼提到了几个工作承诺——他自愿承担的额外任务——这些任务每周都在给他带来压力。这进而引出了关于托尼总体工作量的讨论。结果发现，托尼在几个他并不喜欢但觉得必须完成的项目上过度承诺且分散精力。直到治疗师直接问及这种可能性，托尼才意识到这些承诺可能在他的职业倦怠中起到了关键作用。托尼回应道：“难道不是每个人都有太多的工作要做吗？”

根据这些新信息，治疗师帮助托尼为相关主管重新协商这些承诺制定了请求

基于这些新信息，治疗师帮助托尼为相关主管重新协商这些承诺制定了请求。尽管托尼在开始这些对话时感到相当焦虑，但他还是承诺会去做。他也在向治疗师寻求支持以准备这些对话方面更加直接了当，治疗师认为这是CRB2（功能性行为改变）的表现。由于所有这些努力，在接下来的几周里，托尼从根本上重新安排了他在工作中的时间分配，他的职业倦怠迅速且显著地得到了改善。

在治疗的下一个阶段，托尼表达了更深层次的需求，坦诚地谈到了与最亲近的人之间的持续不满和冲突，包括他的婚姻。托尼和他的治疗师共同发现，他对身边的人抱有很高的期望，并且像在专业关系和友谊中一样，他通常不会非常清楚地表达与这些期望相关的需要；当他所爱的人未能满足他未表达的需求时，他倾向于要么愤怒爆发，要么退缩。所有这些行为在功能上与其他情境中的行为相似。但在与亲人相处时，还表现出了一种不同类型的行径：托尼非常担心他们的福祉和成功，因此他会试图施压，让他们按照他认为应该的方式改变行为。不出所料，这通常会导致关系中的冲突或疏远。

随着治疗师探索这一动态，她发现托尼是家中几个孩子中的长子，童年时期他经常觉得必须照顾弟妹，因为父母相对忽视。作为一个孩子，他对自己承担的责任感到自豪，但他渴望却未能得到对他所扮演的家长角色的认可和赞赏。同时，他对弟妹的责任感也让他感到相当焦虑，他主要是通过唠叨和威胁来管理他们。

这种行为模式在托尼童年的背景下是可以理解的。然而，在成年后，这种模式并不具有功能性。在这次让这种模式完全显现的对话中，它起到了一个巨大的CRB2作用，托尼深刻地表达了他希望从根本上改变与最亲近的人的关系的愿望。就在几天后，托尼与妻子进行了一次对话，打破了长期以来避免谈论“房间里的大象”——他们的关系。他承认，要求她按自己的意愿行事并没有帮助，他为不够同情而道歉。他还清晰地表达了自己需求和脆弱性。结果是他立刻感觉到比以往任何时候都更接近妻子。

FAP 实践：长期案例概念化

托尼的案例是一个相对简单、短暂的治疗过程，案例概念化在几个月内逐步发展。现在我们将提供一个历时近三年的案例概念化示例。尼克正在与更为严重的问题作斗争——慢性抑郁、焦虑、人际困难以及对酒精的依赖——并且在自杀住院后被推荐接受治疗。

早期治疗（持续时间：两个月）

最初，尼克对治疗持怀疑态度，几乎不透露任何情感体验的细节。在治疗的前两个月里，他逐渐打开心扉，描述了即使有频繁的社会交往，他仍然感到强烈的孤独。治疗师尝试使用活动安排的方法失败了。在这个阶段，尼克的CRB1（维持问题的行为）包括通过跳过会谈和在干预无效时不提供反馈来逃避治疗师。他的CRB2（功能性行为改变）包括诚实披露并向治疗师表达自己的需求。

第二阶段（持续时间：四个月）

随着尼克更多的披露，很明显他符合边缘型人格障碍的标准。这对尼克来说是一个重要的认识。治疗师识别出他在情绪调节、社会视角转换和社会技能方面的缺陷，并随后深入评估了尼克的历史，重点放在他的人际关系和目标追求上。这揭示了尼克的许多行为是基于对他人和一种非常严格的关于人们应该如何行为的准则的感知义务，这种准则是从他很小的时候起由父母强加给他的。这个准则的一个功能是帮助他决定如何与他人相处以避免羞耻和失礼。但同时也变得明显的是，他在理解他人视角方面非常困难；因此，当别人的行为违反了这个准则时，他无法理解，常常感到愤怒、焦虑和困惑。

这种缺乏理解和对他人的失望——以及基本的视角转换能力不足——意味着他的关系令人沮丧且缺乏深度。他因他人在他看来的肤浅和不遵守准则而感到怨恨（并嫉妒）。这些感受在会谈中以发泄的形式表现出来，虽然有时会让治疗师感到不舒服，但这也是重要的，因为治疗师认识到发泄可能是塑造与诚实情感表达和需求表达相关的CRB2的起点。这种挫败感也激励尼克与治疗师合作，开发基本的行为策略来解决痛苦的冲突，包括结束几个功能失调的关系，并开始以更自信或灵活的方式与家庭成员互动。

在这个阶段，尼克的CRB1包括要求治疗师提供过于简单的解决方案（“你需要告诉我怎么解决这个问题！”），并在会谈中坚持自己的准则，而不是超越它。他的CRB2包括公开表达情感和需求，专注于他想要解决的问题和情况（而不是抱怨），即使过程中涉及挑战或不确定性也能坚持下去，并询问和接受治疗师关于可能有帮助的观点。

第三阶段（持续时间：八个月）

治疗六个月后，尼克的痛苦有所缓解，冲突也显著减少。然而，他仍然没有在生活中实现任何实质性的改变，并且感到极度孤独，这导致了更深的绝望感、增加的自杀念头以及与治疗师之间的冲突加剧，主要围绕着要求她提供更有效的解决方案。在这些高度痛苦的时期，尽管不太情愿且效果有限，他还是进行了一些基于辩证行为疗法（DBT）的技能练习。

他的治疗似乎通过一系列非常坦诚的讨论达到了一个转折点，这些讨论集中在变化的过程上。在这些讨论中，治疗师带着强烈的情感说：“除非你从根本上改变你的生活方式，否则变化不会发生。这涉及到接受一种让你感到害怕的生活方式——面对放弃准则成为真正想要成为的人时的焦虑。如果你不这样做，你可能会继续感到同样的感觉。”这听起来可能很严厉，但在这种情况下，正是这种直接性激励尼克放下了那些不起作用的东西，放弃了以前的生活方式，并朝着接受更深层次变化的需求迈进——以及随之而来的所有焦虑和悲伤。

在处理了治疗过程中的这一冲突后，他们讨论了尼克在冲突中的模式，这种模式通常让他感到与对方完全疏远——包括治疗师。他们承诺无论彼此之间出现什么冲突，都要努力保持对彼此的理解和联系。这项工作让尼克体验到了一些前所未有的东西：即使在愤怒和高冲突水平下，他也感受到了被理解和关心，并且能够通过冲突重新建立联系。

在会谈中这种新的人际互动过程，在非常高层次上反映了尼克在生活其他方面需要达到的目标：克服不适和恐惧，找到一种更真实的生活方式并与他人建立联系。

为了巩固案例概念化，治疗师和尼克定义了两种不同的存在方式：一种是基于准则的，另一种是基于真实愿望和需求的。他们将基于准则的生活方式命名为“汉斯”，因为这个名字象征着责任和义务；将基于真实愿望和需求的生活方式命名为“鲍伊”，因为这个名字捕捉了尼克内心秘密希望的生活方式：像一位摇滚明星一样，充满创造力、社交活跃且不受传统束缚。在这个阶段，尼克的CRB1包括通过增加要求、焦虑和自杀念头来吸引治疗师的注意；避免或抑制他对如何生活的真正愿望；攻击或评判他人。他的CRB2包括脆弱而直接地表达需求，考虑对治疗师的影响；接受不确定性；接受来自治疗师的关怀；并披露他关于如何生活的真正愿望。

第四阶段（持续时间：十三个月）

治疗十四个月后，尼克承诺彻底改变自己的生活方式。这种改变集中在如何向他人展示自己（字面上来说，如何穿衣和说话）、参与他感兴趣但汉斯禁止的社会活动，以及学习以鲍伊而不是汉斯的方式说话和交往。第一次，尼克开始自发地报告感到有希望。在强烈的愿望驱使下，像鲍伊那样生活，尼克变得更加积极地练习各种DBT情绪调节技巧，特别是主动管理他的焦虑。

随着尼克实施这些改变，治疗关系变得越来越深入和稳固，基于相互尊重、理解、关怀以及对这一重要但困难任务的承诺——即按照鲍伊的价值观生活。尼克的CRB1包括“像汉斯一样”，寻求安慰或黑白分明的答案，以及压抑他的需求。他的CRB2包括冒险表达并体现他想成为的人和事物；接受不确定性；考虑治疗师的观点；分享他对治疗师的感激之情。

第五阶段（持续时间：六个月）

到第五阶段，经过大量的努力（这里省略了许多细节），并在进行了二十七个月的治疗后，尼克实现了他认为不可能实现的几个生活目标。他在与家人互动时不再感到恐惧或愤怒。他处于一段稳定而投入的浪漫关系中。除了伴侣之外，他还拥有一个强大的本地朋友社区。他大部分时间都在做他重视的活动。为了准备结束治疗，在这个阶段，治疗师专注于处理所谓的正常生活挑战，例如当工作与浪漫关系冲突时该怎么办，或者如何与伴侣谈论未来。

总结

• FAP中的案例概念化基于在治疗关系中展开的持续功能性分析。
• 案例概念化，就像FAP中的治疗过程一样，是迭代和协作的。它只需要足够的精确度来高效地实现积极的治疗结果。
• 案例概念化可能会识别出会谈外的问题、CRB1s、CRB2s、会谈外的目标、T1s和T2s。

知识点阐述

1. 案例概念化的重要性

   • 定义：案例概念化是指治疗师基于对来访的全面了解，形成一个综合性的理解和框架，以指导治疗过程。
   • 重要性：案例概念化有助于治疗师更好地理解来访的需求、行为模式和心理机制，从而制定更有效的治疗计划。
   • 具体实践：
     • 收集信息：通过访谈、评估工具等方式收集来访的信息。
     • 整合信息：将收集到的信息整合成一个连贯的故事，解释来访的问题和行为。
     • 制定计划：根据概念化结果制定具体的治疗目标和干预措施。

2. 功能分析在FAP中的应用

   • 定义：功能分析是FAP的核心方法，旨在识别和理解行为的功能，即行为背后的原因和目的。
   • 重要性：通过功能分析，治疗师可以更准确地识别问题行为和改善行为，从而更有针对性地进行干预。
   • 具体实践：
     • 确定关键行为：识别来访的主要问题行为及其发生的情境。
     • 明确功能：理解这些行为的功能，即它们满足了来访的哪些需求。
     • 寻找功能类别：识别行为所属的功能类别，如逃避、寻求注意等。
     • 定义改进：设定具体的目标，定义希望看到的行为改变。

3. 即时互动中的理解

   • 定义：FAP强调在治疗过程中即时理解来访的行为和需求，并据此调整治疗策略。
   • 重要性：即时理解可以帮助治疗师更灵活地应对来访的变化，提高治疗的有效性。
   • 具体实践：
     • 观察行为：在治疗过程中密切观察来访的行为。
     • 反思反馈：及时反思来访的反馈，调整自己的行为。
     • 灵活调整：根据来访的反应灵活调整治疗计划和策略。

4. 治疗师的自我反思

   • 定义：治疗师需要对自己的行为和态度进行反思，以确保自己能够有效地支持来访。
   • 重要性：自我反思有助于治疗师识别自身的行为是否在促进或阻碍来访的进步。
   • 具体实践：
     • 定期反思：定期反思自己的行为和态度，识别潜在的问题。
     • 寻求督导：寻求专业督导，获取外部视角和建议。
     • 持续学习：不断学习新的理论和技术，提升自己的专业能力。

5. 透明和关怀的对话

   • 定义：FAP强调治疗师与来访之间的透明和关怀的对话，共同探讨和理解行为。
   • 重要性：透明和关怀的对话有助于建立信任关系，促进来访的情感表达和行为改变。
   • 具体实践：
     • 开放沟通：保持开放的态度，鼓励来访表达自己的感受和想法。
     • 共情理解：设身处地地理解来访的情感和需求。
     • 共同探索：与来访一起探讨行为背后的原因和解决方案。

通过这些知识点，我们可以更好地理解FAP案例概念化的过程及其在治疗中的应用。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

1. 案例概念化的多样性

   • 定义：案例概念化可以根据来访的具体情况、治疗师的风格和治疗环境的不同而采取多种形式。
   • 重要性：多样化的案例概念化方法可以帮助治疗师更好地适应不同的来访和情境，提高治疗的有效性。
   • 具体实践：
     • 个性化：根据每个来访的具体需求和背景制定个性化的概念化方案。
     • 灵活调整：根据治疗过程中的变化灵活调整概念化方案。
     • 持续评估：定期评估概念化的效果，确保其始终符合治疗目标。

2. 功能性分析在案例概念化中的作用

   • 定义：功能性分析是FAP的核心方法，旨在识别和理解行为的功能，即行为背后的原因和目的。
   • 重要性：通过功能性分析，治疗师可以更准确地识别问题行为和改善行为，从而更有针对性地进行干预。
   • 具体实践：
     • 识别关键行为：确定来访的主要问题行为及其发生的情境。
     • 明确功能：理解这些行为的功能，即它们满足了来访的哪些需求。
     • 寻找功能类别：识别行为所属的功能类别，如逃避、寻求注意等。
     • 定义改进：设定具体的目标，定义希望看到的行为改变。

3. 即时识别CRB的重要性

   • 定义：CRB（临床相关行为）是指在治疗过程中出现的、与来访问题相关的具体行为。
   • 重要性：即时识别CRB有助于治疗师及时干预，促进来访的行为改变。
   • 具体实践：
     • 观察行为：在治疗过程中密切观察来访的行为。
     • 共同识别：与来访一起识别CRB，确保双方对行为的理解一致。
     • 即时反馈：对识别出的CRB提供即时反馈，帮助来访理解和调整行为。

4. 治疗师的角色和行为

   • 定义：治疗师在FAP中扮演着重要的角色，其行为（T1和T2）直接影响治疗过程。
   • 重要性：治疗师的行为应当支持来访的行为改变，而不是阻碍。
   • 具体实践：
     • 增加T2：更多地进行支持性行为，如鼓励、倾听和支持。
     • 减少T1：减少干扰性行为，如批评、指责或忽略来访的需求。
     • 平衡关注：平衡对问题行为和改善行为的关注，确保来访感受到进步和挑战。

5. 案例概念化摘要的作用

   • 定义：案例概念化摘要是对来访问题、CRB、T1和T2的简要总结，用于指导治疗过程。
   • 重要性：摘要提供了一个快速参考指南，帮助治疗师和来访聚焦于关键行为。
   • 具体实践：
     • 简洁明了：使用简洁明了的语言编写摘要，便于快速查阅。
     • 实用性强：确保摘要具有实用性，能够指导实际的治疗操作。
     • 定期更新：根据治疗进展定期更新摘要，确保其始终反映最新的治疗状况。

通过这些知识点，我们可以更好地理解如何在FAP中扩展功能性分析到案例概念化，并在治疗过程中有效地应用这些概念。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

1. 初步工作假设的形成

   • 定义：初步工作假设是指治疗师基于现有信息对来访问题行为及其功能的初步理解和猜测。
   • 重要性：初步假设为后续的测试和精炼提供了基础，帮助治疗师聚焦于关键问题。
   • 具体实践：
     • 收集信息：通过访谈、问卷调查、观察等多种手段收集来访的信息。
     • 识别行为：明确来访在特定情境下的具体行为，包括问题行为及其功能。
     • 初步分析：根据收集到的信息，形成初步的工作假设。

2. 问题行为及其功能的识别

   • 定义：问题行为是指来访在特定情境下表现出的、与问题相关的具体行为，其功能是指这些行为背后的原因和目的。
   • 重要性：识别问题行为及其功能有助于治疗师理解来访的行为模式，从而制定有效的干预策略。
   • 具体实践：
     • 详细定义：详细描述来访在不同情境下的行为，特别是在问题发生前后的具体行为。
     • 功能分析：探讨这些行为的功能，了解它们满足了来访的哪些需求或避免了哪些不适。
     • 综合信息：结合来访自述、观察记录和其他评估工具的信息，形成全面的理解。

3. 功能类别的定义

   • 定义：功能类别是指将问题行为按照其功能进行分类，以便更好地理解和干预。
   • 重要性：通过定义功能类别，治疗师可以更有针对性地处理特定类型的行为，提高治疗的有效性。
   • 具体实践：
     • 分类行为：将问题行为按照其功能（如逃避、寻求注意等）进行分类。
     • 识别模式：寻找来访行为中的模式，确定哪些行为属于同一功能类别。
     • 制定策略：针对每个功能类别制定具体的干预策略。

4. CRB1和CRB2的识别

   • 定义：CRB1指问题行为，CRB2指改进行为，两者都是在治疗过程中出现的具体行为实例。
   • 重要性：识别CRB1和CRB2有助于治疗师在治疗过程中及时干预，促进来访的行为改变。
   • 具体实践：
     • 观察行为：在治疗过程中密切观察来访的行为，识别出CRB1和CRB2。
     • 共同识别：与来访一起识别这些行为，确保双方对行为的理解一致。
     • 即时反馈：对识别出的CRB提供即时反馈，帮助来访理解和调整行为。

5. 可行焦点的选择

   • 定义：可行焦点是指在治疗过程中选择的、能够有效推动治疗进展的目标。
   • 重要性：选择合适的焦点有助于集中资源，提高治疗效果。
   • 具体实践：
     • 实证基础：选择有实证或评估基础的目标，确保其有效性。
     • 来访动机：选择来访有动机并有能力处理的目标。
     • 灵活调整：根据治疗进展灵活调整焦点，确保始终符合来访的实际情况。

通过这些知识点，我们可以更好地理解案例概念化的完整过程及其在FAP中的应用。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

1. 定义问题行为的功能类别

   • 定义：通过识别来访行为背后的功能，将其分类为不同的功能类别，以便更好地理解和干预。
   • 重要性：帮助来访认识到他们在不同情境下表现出的行为可能具有相同的功能，从而增加自我意识并促进改变。
   • 具体实践：
     • 识别共同点：找出来访行为背后的共同功能，如逃避、寻求注意等。
     • 提高意识：帮助来访认识到行为的功能，使他们能够更好地理解自己的行为模式。
     • 跨情境应用：指出不同情境下行为的相似功能，帮助来访在多种情境中应用相同的策略。

2. 识别CRB1和CRB2作为功能类别的实例

   • 定义：CRB1是指问题行为，CRB2是指改进行为，两者都是在治疗过程中出现的具体行为实例。
   • 重要性：识别CRB1和CRB2有助于治疗师及时干预，促进来访的行为改变。
   • 具体实践：
     • 观察行为：在治疗过程中密切观察来访的行为，识别出CRB1和CRB2。
     • 共同识别：与来访一起识别这些行为，确保双方对行为的理解一致。
     • 即时反馈：对识别出的CRB提供即时反馈，帮助来访理解和调整行为。
     • 设计改进：根据CRB1制定具体的改进策略，帮助来访发展CRB2。

3. 治疗过程中的关键行为

   • 定义：治疗师在治疗过程中需要采取的关键行为，以支持来访的发展和改变。
   • 重要性：治疗师的行为直接影响治疗效果，恰当的行为可以促进来访的进步。
   • 具体实践：
     • 激发CRB2：通过特定的干预措施激发来访的改进行为。
     • 避免阻碍：识别并避免那些可能阻碍治疗进展的行为。
     • 灵活应对：根据来访的反应和进展情况灵活调整治疗策略。
     • 建立信任：通过开放和邀请的态度建立与来访的信任关系。

4. 治疗中的挑战与应对

   • 定义：治疗过程中来访可能面临的各种挑战，包括人际关系、信任、表达需求等方面的挑战。
   • 重要性：理解这些挑战有助于治疗师更好地支持来访，促进他们的成长和发展。
   • 具体实践：
     • 识别挑战：识别来访在治疗过程中可能遇到的具体挑战。
     • 针对性支持：根据挑战提供有针对性的支持和干预。
     • 鼓励表达：鼓励来访表达自己的感受和需求，增强他们的自我意识。
     • 建立安全感：创造一个安全和支持的环境，让来访感到被接纳和理解。

通过这些知识点，我们可以更好地理解如何在FAP中定义问题行为的功能类别，并识别CRB1和CRB2。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

1. 测试工作假设

   • 定义：在形成初步的工作假设后，通过实际操作来验证假设的有效性。
   • 重要性：确保假设不仅理论上合理，而且在实践中有效，从而为来访提供真正有用的干预。
   • 具体实践：
     • 即时测试：在治疗过程中立即尝试引发和强化CRB2，并观察其效果。
     • 家庭作业：布置相关家庭作业，让来访在不同情境中练习相同行为。
     • 观察结果：评估来访是否能够实现改变，以及改变是否产生了预期效果。

2. 精炼假设

   • 定义：根据治疗过程中的新信息和反馈，不断调整和完善初步的工作假设。
   • 重要性：确保假设始终符合来访的实际情况，从而提供更有效的治疗。
   • 具体实践：
     • 持续评估：通过持续的评估和对话，不断更新对来访及其问题的理解。
     • 灵活调整：根据新的信息和来访的反应，灵活调整假设。
     • 深化理解：随着治疗的深入，逐步深化对来访行为和问题的理解。

3. 接受过程的非线性

   • 定义：理解治疗过程并非总是直线前进，而是可能充满曲折和反复。
   • 重要性：保持耐心和灵活性，允许治疗过程自然发展，而不是强求快速解决方案。
   • 具体实践：
     • 观察应对：观察来访如何应对治疗中的挑战和不确定性。
     • 处理挫败感：帮助来访处理变化过程中的挫败感和失望。
     • 灵活调整：根据治疗过程中的新发现，灵活调整治疗方向和策略。

4. 案例概念化的实例

   • 定义：通过不同时间段的案例示例，展示案例概念化在实际治疗中的应用。
   • 重要性：提供具体的案例，帮助理解和应用案例概念化的理论和方法。
   • 具体实践：
     • 单次对话：通过一次对话展示功能性分析的应用。
     • 短期案例：展示较短期治疗中的案例概念化。
     • 长期复杂案例：描述多阶段、复杂的长期治疗过程中的案例概念化。

通过这些知识点，我们可以更好地理解如何在FAP中测试和精炼工作假设，以及如何接受治疗过程的非线性。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

1. 功能分析的应用

   • 定义：功能分析是一种方法，用于理解行为背后的功能，即行为如何帮助个体满足其需求或解决其问题。
   • 重要性：通过识别行为的功能，治疗师可以更好地理解来访的行为模式，并设计有效的干预措施。
   • 具体实践：
     • 识别行为：观察和记录来访的具体行为。
     • 探索动机：询问来访为什么会有这些行为，以及这些行为是如何帮助他们的。
     • 形成假设：根据收集到的信息，形成关于行为功能的假设。
     • 验证假设：通过进一步的提问和观察来验证假设的有效性。

2. 暴露脆弱性与回避行为

   • 定义：暴露脆弱性是指个体在人际交往中展示真实自我，包括情感、需求和弱点；回避行为则是指个体为了避免潜在的负面评价或伤害而采取的退缩行为。
   • 重要性：暴露脆弱性有助于建立真诚的人际关系，而回避行为则可能导致孤立和社交障碍。
   • 具体实践：
     • 识别回避模式：观察来访在面对亲密关系时的回避行为。
     • 探讨原因：了解来访为何选择回避，以及这种行为如何影响他们的生活。
     • 鼓励暴露：通过逐步引导和支持，帮助来访逐渐暴露脆弱性，从而建立更健康的人际关系。

3. 焦虑与认知偏差

   • 定义：焦虑是一种情绪状态，表现为对未来不确定性的担忧和恐惧；认知偏差是指个体在处理信息时出现的系统性错误，导致误解或扭曲现实。
   • 重要性：焦虑和认知偏差往往相互作用，共同维持个体的不良心理状态。
   • 具体实践：
     • 识别焦虑源：确定引发来访焦虑的具体情境或事件。
     • 挑战认知偏差：通过认知重构技术，帮助来访识别并纠正其认知偏差。
     • 应对策略：教授来访应对焦虑的技巧，如放松训练、正念冥想等。

4. 治疗过程中的信任与开放

   • 定义：治疗过程中，建立信任和开放的关系是治疗成功的关键因素之一。
   • 重要性：信任和开放有助于来访更真实地表达自己，促进治疗师对来访问题的理解和干预。
   • 具体实践：
     • 建立信任：通过倾听、共情和支持，建立与来访的信任关系。
     • 鼓励开放：鼓励来访分享内心的感受和想法，即使这些内容可能让他们感到不安。
     • 反馈与调整：根据来访的反馈不断调整治疗计划，确保治疗方向符合来访的需求。

通过这些知识点，我们可以更好地理解如何在FAP中应用功能分析，识别和处理暴露脆弱性与回避行为，以及管理焦虑和认知偏差。同时，强调了在治疗过程中建立信任和开放关系的重要性。这些内容不仅有助于治疗师更有效地开展工作，也能帮助来访在治疗过程中获得更好的体验和支持。

知识点阐述

1. 不确定性与案例概念化

   • 定义：在案例概念化过程中，治疗师可能会遇到多种不确定性和未知因素，这些因素需要随着时间的推移逐步澄清。
   • 重要性：识别并处理这些不确定性有助于治疗师更准确地理解来访的情况，并制定有效的干预措施。
   • 具体实践：
     • 识别不确定性：明确当前存在的不确定性和待解决的问题。
     • 逐步澄清：通过持续的对话和观察，逐步澄清这些不确定性和问题。
     • 调整假设：根据新的信息不断调整和完善初步的假设。

2. 来访需求表达与职业倦怠

   • 定义：来访需求表达是指个体在人际交往中有效地表达自己的需求；职业倦怠是一种长期的工作压力导致的情感、心理和生理上的疲惫状态。
   • 重要性：有效的需求表达可以减少误解和冲突，提高工作效率和满意度；而职业倦怠则可能导致工作表现下降和个人健康问题。
   • 具体实践：
     • 评估需求表达：了解来访在不同情境下的需求表达方式及其效果。
     • 增强需求表达：教授来访有效的需求表达技巧，如自信训练。
     • 应对职业倦怠：识别职业倦怠的原因，制定应对策略，如时间管理、放松技巧等。

3. 治疗过程中的自我反思

   • 定义：自我反思是指治疗师和来访在治疗过程中对自己的行为、感受和思维进行深入思考的过程。
   • 重要性：自我反思有助于双方更好地理解自己的模式和动机，促进治疗的有效性。
   • 具体实践：
     • 鼓励自我反思：通过提问和反馈，引导来访进行自我反思。
     • 治疗师的自我反思：治疗师也需要对自己的行为和反应进行反思，确保治疗的方向正确。
     • 共同探讨：治疗师和来访共同探讨自我反思的结果，制定下一步的行动计划。

4. 治疗关系中的信任与开放

   • 定义：在治疗关系中建立信任和开放的氛围，有助于来访更真实地表达自己，促进治疗的进展。
   • 重要性：信任和开放是治疗成功的关键因素之一，有助于治疗师更深入地理解来访的问题。
   • 具体实践：
     • 建立信任：通过倾听、共情和支持，建立与来访的信任关系。
     • 鼓励开放：鼓励来访分享内心的感受和想法，即使这些内容可能让他们感到不安。
     • 反馈与调整：根据来访的反馈不断调整治疗计划，确保治疗方向符合来访的需求。

通过这些知识点，我们可以更好地理解如何在FAP中处理案例概念化过程中的不确定性，识别和处理来访需求表达与职业倦怠，以及在治疗过程中促进自我反思和建立信任与开放的关系。这些内容不仅有助于治疗师更有效地开展工作，也能帮助来访在治疗过程中获得更好的体验和支持。

知识点阐述

1. 功能性行为改变（CRB2）

   • 定义：CRB2是指那些有助于解决问题或改善个体生活质量的行为变化。
   • 重要性：CRB2是FAP（功能性分析心理治疗）的核心，通过促进这些行为，可以有效提升个体的心理健康和人际关系质量。
   • 具体实践：
     • 识别CRB2：观察并记录来访在治疗过程中出现的积极行为变化。
     • 强化CRB2：通过正向反馈和支持，鼓励来访继续这些行为。
     • 扩展CRB2：将这些行为扩展到日常生活中，以实现更广泛的功能性改变。

2. 情绪调节与社会视角转换

   • 定义：情绪调节是指个体管理和调整自己情绪的能力；社会视角转换是指能够理解并考虑他人观点的能力。
   • 重要性：良好的情绪调节和社会视角转换能力对于建立健康的人际关系至关重要。
   • 具体实践：
     • 情绪调节技巧：教授来访情绪识别、接纳和管理的技巧。
     • 社会视角转换训练：通过角色扮演和情景模拟，帮助来访更好地理解他人的情感和动机。

3. 治疗关系中的信任与开放

   • 定义：在治疗关系中建立信任和开放的氛围，有助于来访更真实地表达自己，促进治疗的进展。
   • 重要性：信任和开放是治疗成功的关键因素之一，有助于治疗师更深入地理解来访的问题。
   • 具体实践：
     • 建立信任：通过倾听、共情和支持，建立与来访的信任关系。
     • 鼓励开放：鼓励来访分享内心的感受和想法，即使这些内容可能让他们感到不安。
     • 反馈与调整：根据来访的反馈不断调整治疗计划，确保治疗方向符合来访的需求。

4. 长期治疗中的案例概念化

   • 定义：长期治疗中的案例概念化是指在较长的时间跨度内，通过持续的评估和干预，逐步深化对来访问题的理解。
   • 重要性：长期治疗中的案例概念化有助于治疗师更全面地了解来访的情况，制定更有效的治疗计划。
   • 具体实践：
     • 持续评估：定期评估来访的状态和治疗进展。
     • 多维度分析：从多个角度（如情绪、认知、行为、社会关系等）分析来访的问题。
     • 动态调整：根据新的信息和来访的反馈，动态调整治疗策略。

通过这些知识点，我们可以更好地理解如何在FAP中促进功能性行为改变，增强情绪调节和社会视角转换能力，以及在治疗过程中建立信任与开放的关系。此外，我们还了解到在长期治疗中如何通过持续的案例概念化，逐步深化对来访问题的理解，从而制定更有效的治疗计划。这些内容不仅有助于治疗师更有效地开展工作，也能帮助来访在治疗过程中获得更好的体验和支持。

知识点阐述

1. 功能性行为改变（CRB2）

   • 定义：CRB2是指那些有助于解决问题或改善个体生活质量的行为变化。
   • 重要性：CRB2是FAP（功能性分析心理治疗）的核心，通过促进这些行为，可以有效提升个体的心理健康和人际关系质量。
   • 具体实践：
     • 识别CRB2：观察并记录来访在治疗过程中出现的积极行为变化。
     • 强化CRB2：通过正向反馈和支持，鼓励来访继续这些行为。
     • 扩展CRB2：将这些行为扩展到日常生活中，以实现更广泛的功能性改变。

2. 情绪调节与社会视角转换

   • 定义：情绪调节是指个体管理和调整自己情绪的能力；社会视角转换是指能够理解并考虑他人观点的能力。
   • 重要性：良好的情绪调节和社会视角转换能力对于建立健康的人际关系至关重要。
   • 具体实践：
     • 情绪调节技巧：教授来访情绪识别、接纳和管理的技巧。
     • 社会视角转换训练：通过角色扮演和情景模拟，帮助来访更好地理解他人的情感和动机。

3. 长期治疗中的案例概念化

   • 定义：长期治疗中的案例概念化是指在较长的时间跨度内，通过持续的评估和干预，逐步深化对来访问题的理解。
   • 重要性：长期治疗中的案例概念化有助于治疗师更全面地了解来访的情况，制定更有效的治疗计划。
   • 具体实践：
     • 持续评估：定期评估来访的状态和治疗进展。
     • 多维度分析：从多个角度（如情绪、认知、行为、社会关系等）分析来访的问题。
     • 动态调整：根据新的信息和来访的反馈，动态调整治疗策略。

4. 治疗关系中的信任与开放

   • 定义：在治疗关系中建立信任和开放的氛围，有助于来访更真实地表达自己，促进治疗的进展。
   • 重要性：信任和开放是治疗成功的关键因素之一，有助于治疗师更深入地理解来访的问题。
   • 具体实践：
     • 建立信任：通过倾听、共情和支持，建立与来访的信任关系。
     • 鼓励开放：鼓励来访分享内心的感受和想法，即使这些内容可能让他们感到不安。
     • 反馈与调整：根据来访的反馈不断调整治疗计划，确保治疗方向符合来访的需求。

5. 治疗过程中的自我反思

   • 定义：自我反思是指治疗师和来访在治疗过程中对自己的行为、感受和思维进行深入思考的过程。
   • 重要性：自我反思有助于双方更好地理解自己的模式和动机，促进治疗的有效性。
   • 具体实践：
     • 鼓励自我反思：通过提问和反馈，引导来访进行自我反思。
     • 治疗师的自我反思：治疗师也需要对自己的行为和反应进行反思，确保治疗的方向正确。
     • 共同探讨：治疗师和来访共同探讨自我反思的结果，制定下一步的行动计划。

通过这些知识点，我们可以更好地理解如何在FAP中促进功能性行为改变，增强情绪调节和社会视角转换能力，以及在治疗过程中建立信任与开放的关系。此外，我们还了解到在长期治疗中如何通过持续的案例概念化，逐步深化对来访问题的理解，从而制定更有效的治疗计划。这些内容不仅有助于治疗师更有效地开展工作，也能帮助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 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 Make 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.