12 通过家庭作业和体验活动巩固成果

C H A P T E R 12 Solidify Change with Homework and Experiential Exercises This is the real secret of life—­to be completely engaged with what you are doing in the here and now. And instead of calling it work, realize it is play. —­Alan Watts “What you did with me in session today was so powerful. The way you ‘dropped the wall’—­and yet I could see you staying in contact with me, even with your anxiety, through your eye contact. I have the sense it took a lot of courage and trust to take that leap.” “Yes. I feel really proud about it. I feel like I’m doing something I’ve not let myself do for so long.” “I’m glad to be here with you. And I’m curious, as we come into our last ten minutes today, are there places in your life this week, with other people, where it could be useful, or powerful, to drop the wall in a similar way? Maybe not 100 percent like you did with me. But maybe 10 percent? Or 30 percent? Do you know what I mean?” “Yes, absolutely. What comes to mind is, I have a volunteer group meeting on Wednesday. There’s a new member, a guy who I’ve only met briefly before, but I’ve heard so many good things about him. I’ve already been anticipating feeling really insecure and closed up. I’d like to try dropping the wall some more with him. Just being real.” In this vignette, the therapist reinforces the progress the client makes in the session, but, rather than stop there, she suggests the client take this behavior to the outside world. This is a form of homework, one of the topics of this short chapter. Homework in FAP is a tool for rule 5 (support generalization). We also present a small set of experiential exercises in this chapter that might be useful in FAP. We’ve combined these two topics in one chapter for a few reasons. First, many expe- riential exercises are suitable as homework assignments. Second, good, functionally attuned home- work assignments and experiential exercises are defined by a common quality: they provide an effective context for evoking CRB2 and for receiving reinforcing consequences for that behavior. We encourage you to think about them in this similar way, as further practice in developing func- tional thinking. HOMEWORK Homework is often a crucial therapy tool. In FAP, it’s a tool for following rule 5, support generaliza- tion. Rule 5 is about providing a means for transferring in-­session behavior change to other con- texts in the client’s life. In that sense, homework is simply a cue or framework for doing certain things in certain situations. As a general rule, homework is assigned every session. This guideline is rooted in FAP’s founda- tion in behavior therapy. The goal of therapy is to change how clients are functioning in their lives. Homework is about making the process of change deliberate, active, and strategic. At the same time, homework need not be overtly focused on action. It can target a broad range of behaviors: noticing, reflecting, thinking, feeling, as well as taking action. Individualizing Homework Homework should be individualized to the client’s behavioral goals and contexts. This might mean adapting one of the exercises we offer, or it might mean designing homework assignments from scratch. You can let go of rigid formats for homework activities (as in, “You’ve got to do it this way because that’s what the manual says”) and instead flexibly attend to the functional question “What will work for this client this week?” The simplest homework is to practice CRB2 outside of session. As an example, for the client in the opening vignette of this chapter, the homework is simply practicing the behavior of courageous self-­disclosure, first undertaken in session, when opportunities to do so naturally arise. The client identifies a natural setting where she wants to practice CRB2 (and based on contextual under- standing, the therapist and client together are confident that the client can be successful in that context), but she also has freedom to improvise. Alternatively, the homework could entail having very specific conversations and conducting them in a very particular way, perhaps even starting with a prepared script. It’s important to strike the right balance between structure and flexibility. Homework is often most effective when clients own the process of creating it and are encouraged to adapt it to the situations they face and in ways that seem to work. Keep in mind that sometimes it takes time to build the confidence and skills to make such adaptations. In contrast, when clients take on rote assignments in a rote way, they’re more likely to give up when the assignments don’t seem to achieve the desired change or it’s not clear how to adapt the assignment to reality. A structured assignment should be targeted to a very specific context in which the client needs structure; or it should be able to be completed independently of context (for example, simply filling out a work- sheet). A flexible assignment should be given when the client will succeed with that flexibility (even if it is somewhat challenging; for example, if the client is working on the behavior of making deci- sions under conditions of uncertainty, she might be slightly uncomfortable but perfectly capable of enduring the discomfort). Finally, remember that assigning homework is another aspect of the therapy process, in which a range of CRB (or T1s and T2s) might be evoked. This applies not just to assigning homework, but also to whether and how clients complete it. Throughout the therapy process it’s important to debrief about homework assignments and revise them to be more focused and effective. Integrating these considerations, here are some questions that can keep you and your clients on track in regard to homework. Is the homework feasible and realistic? As a general rule, an intense, important assignment that clients don’t complete isn’t as useful as a more modest assignment that they will actually do. Does the homework address important behavioral targets? Homework that doesn’t challenge clients to try something new isn’t particularly useful either. Homework should be feasible but should also target the most important behaviors and push clients to try new things. The outcome of homework should be something new. Is the client’s commitment (or lack of commitment) to the homework CRB? For some clients, compliance with homework is CRB1—­part of a pattern of overcommitment and underexpression of needs that tends to create frustration and burnout. For them, assigning homework can provide a context in which they are invited to practice the CRB2 of making realistic commitments and being direct about their needs. For other clients, failure to follow through on homework assignments is an important CRB1, though this may, of course, reflect similar deficits in expressing their needs prior to agreeing to an unrealistic commitment. Are you collaborating on homework in a way that builds the client’s mastery? Clients should actively keep track of what does and doesn’t work in regard to homework, not just whether they did it or not. Similarly, ideally they will become increasingly autonomous in designing and debriefing their homework, reflecting increased skill at self-­management. Keep in mind that homework that doesn’t turn out the way you or the client thought it would isn’t necessarily “failed” homework. It can still provide invaluable learning. Among other things, “failed homework” provides an opportunity to see and engage with how the client responds to setbacks and learns from them. Three Common Types of FAP Homework In this section we present three standard types of FAP homework: keeping a behavior log, engaging in specific conversations, and connecting with the therapist outside of session. KEEPING A BEHAVIOR LOG The concept of a behavior log is simple: in a diary, clients track behaviors relevant to therapy goals between sessions. Use any format that works for a given client: a journal, a structured form, a spreadsheet, and so on. Many potentially useful target behaviors can be tracked in this way, including engaging in vul- nerable self-­disclosure, expressing emotions, offering or requesting feedback, making requests or expressing needs, or approaching significant conflicts or disagreements. Of course, you can also target more specific contexts or actions in keeping with the case conceptualization. One common focus for behavior logs is risk; in fact, we often ask clients to keep a “risk log” in which they keep track of interpersonal risks. In FAP, taking risks means approaching interpersonal situations that clients might otherwise avoid; it doesn’t mean engaging in reckless or destructive actions. Risks are strategic. That said, engaging in a deliberate practice of risk-­taking will involve occasional “failures” in the sense of not getting the desired results. Therefore, encouraging clients to engage in this kind of risk-­taking typically involves both experiencing the benefits of risks, as well as learning to cope with and respond to failure or disappointment in new ways. In the bigger picture, the function of risk-­taking extends beyond immediate results as clients engage in an overarching practice of pursuing goals or values despite the chance they might encounter obstacles or failure. For some clients, tracking risk is exactly the wrong homework. For example, clients who are too impulsive, tend to lack awareness of the appropriateness of their behavior, or are unlikely to experience a positive response should not track risks. For these kinds of clients, it might be better to keep an “impact log” (What impact do I think I have on others?) to build skill with seeing other perspectives. Behavior logs can be used to track any behavior that fits the case conceptualization and CRB2, from a “loving others log” to a “self-­care log” to a “proud-­moments log.” We tend to favor tracking CRB2 (improvements) over CRB1 (problem behavior) because it is generally more appetitive to track improvements. Besides making behavior change visible and providing you the opportunity to respond to prog- ress, the log provides a window into the client’s daily life, potentially revealing features of his or her behavior you might not otherwise notice: absence of emotion, an excessive focus on negative events, avoidance of important relationships or issues, and so on. The way the client writes the log can also reveal CRB. ENGAGING IN SPECIFIC CONVERSATIONS Success in a single important conversation can have a massive positive impact on the trajectory of a relationship. For example, talking about a long-­avoided issue with a friend, discussing the idea of having children with a partner, making plans for the holidays with a difficult family member, giving feedback to a partner about the impact of his drinking, or asking for a raise or change of focus at work can dramatically alter a client’s life. As therapists, we are perfectly situated to help clients craft and engage in these conversations. The first step of this multilayered homework assignment is to identify a crucial conversation. Then work with the client toward the goal of making the conversation happen in a successful way. Preparation is key. Sometimes the words or tone that the client needs to bring to the conversation will already have happened in the therapy relationship as CRB2. In that case, the instruction is to “do what you did with me in that conversation.” Sometimes it takes a while to shape up the CRB before you and the client are confident he will be successful. You may also need to prepare the client in more direct ways to create a bridge between in-­ session work and the conversation itself. For instance, you might collaboratively create a thirty-­to-­ sixty-­second script for an opening statement to begin the conversation. You may want to coach the client in important aspects of the conversation in a more didactic way, such as remembering to vali- date or not casting blame. Remember that tone and body language are sometimes more important than what is said. It can also be useful to attend to the setting of the conversation; for example, depending on what will work best, you may want to suggest e-­mail or written form for some con- versations rather than face-­to-­face, or vice versa. (E-­mail is often solid ground for learning because it provides the opportunity to really craft a message.) Some therapists are hesitant to provide such highly directive guidance about how to engage in conversations. However, when clients lack the skills to converse effectively and yet a conversation needs to happen, teaching the needed skills directly can be extremely helpful and more efficient than waiting for clients to discover the skill for themselves. There are, of course, many different resources available for training in social skills and communication, including books related to psy- chology, self-­help, and business. You can use these resources to train yourself. You can also recom- mend that clients use them as appropriate. (Susan Scott’s 2002 book Fierce Conversations is a favorite of the authors.) oasis-ebl|Rsalles|1490488867 CONNECTING WITH THE THERAPIST OUTSIDE OF SESSION Although FAP homework often focuses on client interactions with significant people, in some contexts it may be helpful to choose homework that involves interacting with the therapist outside of session. Technology has made this kind of connection immensely easier. However, two impor- tant caveats are in order: First, and obviously, any technology used for therapy purposes should comply with relevant laws and your professional and organizational guidelines. Second, it’s impor- tant that this kind of contact not exceed the therapist’s limits, and that any CRB1 or T1 be addressed. (This practice mirrors the skill coaching elements of dialectical behavior therapy.) Caveats aside, out-­of-­session contact with the therapist can be a strategic way to provide the client an additional bridge between therapy and daily life. It gives the therapist an opportunity to respond in reinforcing ways to behaviors when and where they happen. For instance, consider a client who’s working on noticing and approaching moments of happiness; his homework assign- ment might be to notice and take pictures of things that make him happy and then send the pic- tures to his therapist in the moment via text message. The therapist can then respond as befits the case conceptualization or her guidelines. As another example, the homework for a client struggling with disconnection might be noticing her disconnection in the moment and then reaching out to her therapist with a short e-­mail (“I’m feeling disconnected now.”), thereby creating connection in moments of disconnection. EXPERIENTIAL EXERCISES The remainder of this chapter offers a small sample of experiential exercises that can be useful vehicles for implementing the five rules of FAP in session; or they can be used as homework assign- ments that set the stage for in-­session work. We recommend viewing them as templates for adapta- tion or as inspiration for creating client-­specific exercises or homework. Before we turn to the specific exercises, there are a few things to consider prior to using them. Keeping Exercises Relevant There has been some debate in the FAP community about experiential exercises—­specifically, whether they’re clinically useful. The main concern of detractors is that exercises are a weird or artificial context detached from normal interpersonal interactions, and because of that, behavior shaped by exercises can’t really transfer to other settings. In other word, they’re irrelevant. And, even worse, they argue that exercises may actually do harm; for instance, an exercise might encour- age intense emotional disclosure that would be disastrous if replicated in a professional meeting. There’s also a more general concern that using structured exercises could insidiously lead thera- pists away from functional attunement—­that is, being aware of what clients are experiencing and need in the moment. In other words, the therapist might become more concerned about the goal of the exercise than about the client. Although these are valid concerns, at its core FAP is about using any therapeutic tool, including exercises, in a way that’s functionally attuned, embedded in a working functional analysis, and ori- ented toward transferring behavior shaped in the here and now to relevant settings in the client’s life. If therapists keep that orientation in mind, the “unnatural” nature of experiential exercises (or any other aspect of therapy, for that matter) can in fact serve several useful functions. One is that exercises sometimes offer an expedient way to evoke a behavior that might not otherwise occur naturally but would function well in a given situation. For instance, consider a client who would benefit from practicing giving and receiving appreciation. In this case, you might introduce the exercise “sharing appreciations” (which we present shortly): “In the service of practicing positive connections, let’s end each session by exchanging appreciations. This is also a good way to let me know in the moment what’s most important or effective about what we did today. How about if we take turns and share one or two appreciations each. Would you like to go first?” In this case, the exercise is essentially a directive and evocative (in the sense of rule 2) interven- tion. The method of evoking, and the exercise itself, can be somewhat unnatural; for example, it’s unlikely that clients will receive direct requests to exchange appreciations in other contexts (although this is actually a very useful interpersonal strategy). However, the behavior that’s shaped in the exercise (giving and receiving appreciation) can function well in a variety of real-­life contexts. Selecting Useful Exercises The same functional analysis that guides the selection of any intervention in FAP should be used to choose exercises. The primary question to ask yourself is, how can this exercise evoke CRB2 for a given client? Different exercises tend to evoke different CRB2s for different clients. In turn, once the target CRB2 is evoked, ensure that it’s reinforced, whether it be within the exercise itself or while debriefing the exercise afterward. Sometimes it’s useful to discuss with the client in advance what the exercise will evoke and what the client should focus on in the exercise. For example, depending on a given client’s case conceptualization, you might ask one of the following questions: How can you engage in this exercise in a way that’s meaningful to you? How can you remain connected with yourself and others if the exercise elicits strong emotion? How can you be more aware and accepting of whatever feelings come up for you during the exercise? What do you want to do in the presence of any emotions that come up during the exercise? How do you want to explore emotional topics and share about them in the context of this exercise? Then, when you debrief exercises, help clients assess what they experienced, whether the target CRB2 was evoked, and what they experienced as a result. Specific Exercises The following sections briefly describe specific exercises, or general types of exercises, com- monly used by FAP therapists. The last three exercises invite deeper reflection, so they are more often assigned as homework. A critical part of each one, however, is sharing and processing the work in session. INTENTIONAL SHARING Clients often begin sessions by describing (or venting about) events that happened since the last session. The intentional sharing exercise offers a way to structure and contain such sharing and to encourage CRB2 during the process. To put this exercise into action, invite clients to begin ses- sions with a mindful, succinct (one-­to-­five-­minute) update about what they experienced over the previous one to two days, with a focus on describing specific emotions they experienced. For example, “I woke up feeling anxious about my presentation. It went really well, though, and after- wards I felt proud—­excited. Then I got a message that a dear friend is really sick. I felt stunned. Then really sad…” If it seems helpful for increasing reciprocity and connection, you can offer a brief personal update as well. Common CRB1s evoked by this exercise include sharing too much; not sharing enough; offer- ing descriptions of emotion that are thin, confusing, minimal, and so on; avoiding the discussion of more emotional situations; skimming over significant experiences; or failing to remember or attend to significant events. Sometimes it is useful to cue the client to stay focused on emotions as he’s talking. At other times it’s more effective to wait until the client is finished before offering your feedback (for example, “I noticed that you tended to drift away from emotions and toward story- telling. Did you notice that?”). The intentional sharing exercise can be practiced in other relationships as well, though clients don’t need to signal that they’re doing an exercise and can instead talk in a more natural way; however, they should remain mindful of their emotions. Clients are often surprised by the amount of change they experience regarding the level of connection to others they feel when they adopt this focus. SHARING APPRECIATIONS In the sharing appreciations exercise, set aside time—­for example, at the end of each session—­ for the deliberate exchange of appreciation. This may be particularly valuable for clients with CRB1s related to difficulty accepting compassion or appreciation from others or asking for appreciation. You can invite the client to go first or second. For your part, share something the client said or did in the session that you appreciate, or something you appreciate about the client in general: I appreciate the way you slowed me down, listened to me, and helped me see more clearly what I need to do. I appreciate how open you were in sharing things you felt uncertain or vulnerable about. I appreciate that you let me see you clearly. I appreciate how hard you are working in your life at this point. Of course, appreciation is just one type of feedback that can be shared. If relevant to the cli- ent’s CRB, it may be useful to target constructive criticism or asking for a need to be met; for example, instead of exchanging appreciation you could ask, “How could we have made the session better today?”

TIMED WRITING EXERCISES Timed writing can be used in session or assigned as homework. In this exercise, clients are given a set amount of time, such as three minutes, to write whatever comes to mind without cen- soring. Choose the topic based on the client’s CRB. You can ask her to write about a specific topic that the two of you are addressing in therapy (for example, what she feels shame about, the fear of closeness, or feelings toward a parent). Alternatively, you can ask the client to write about whatever is on her mind. Other than a time limit and the task being written rather than oral, the exercise is a lot like free association, with the aim being to express feelings and thoughts that may be more difficult to contact and express under typical social conditions. In other words, the timed writing task is often about evoking vulnerable disclosure. It can be helpful to provide stem phrases for clients to work with. Here are a few suggestions, though of course you can use others: I’m sad that… (or I’m hurt that…) I’m angry that… I miss… I’m relieved that… I’m grateful that… I’m sorry about… (or I regret…) I wish I had… I wish [someone significant] had… I forgive [someone significant] for… Please forgive me for… I never told [someone significant] that… [Someone significant] never told me that… What I learned from my relationship with this person is… I will always remember… (or I will never forget…) I want [someone significant] to know… If only I could…

LIFE HISTORY You may assign the life history exercise—­the same one we gave you in chapter 6—­as home- work for your clients. (Many FAP therapists assign this exercise as standard homework in prepara- tion for or immediately following the first session of therapy.) By sharing their stories, clients reveal a lot about their history as well as potential CRB related to vulnerable disclosure. It’s important to be sensitive to the demands of this exercise; it may be incredibly intense—­even unthinkable—­for some clients. Adjust the level of disclosure or detail you ask for based on the client’s needs and current tolerance for vulnerability. COMPILING AN INVENTORY Compiling an inventory about a particular type of experience is similar to writing a life history. For example, you might invite a client who seems to be carrying a lot of avoided grief to write a history focused on experiences of loss. This can be a useful way to evoke vulnerable disclosure alongside the processing of sadness and the experiences of loss. You might ask clients to consider one of these examples: From your earliest memories to the present, what are the losses (big and small) that you’ve endured in life that stand out to you? What has made you sad, broken your heart, or left a gap in your life? What has been missing in your life? What losses do you think should or could evoke a response in you now but don’t? What do good-­byes bring up for you? Other useful inventories include accomplishments, close relationships, appreciation, and shame- ful experiences. NURTURING CONNECTION For some clients, nurturing connection with an important person can be a useful homework assignment. First, the client needs to identify a specific person he’d like to be closer to; then he asks that person if she’d be willing to have a conversation (or perhaps a conversation that repeats weekly or monthly) to share and connect on an emotional level. Here are some potential questions the client might pose: What was the best thing that happened to you this past week? When did you feel closest to me this past week? Why? When did you feel most distant from me this past week? Why? What are you excited about or looking forward to doing in the near future? What are you concerned or worried about? What have you recently felt grateful for? Why? Is there anything you’re avoiding saying or communicating to me? If so, what is it? What have you appreciated about me this past week? What have you appreciated about yourself this past week? Is there anything else you want to tell me? Initially, you might ask clients to answer these questions with you reciprocally before doing the assignment with others. SUMMARY • Homework in FAP supports the generalization of CRB2 in the client’s daily life outside of session. • Homework design is based on functional thinking. Homework creates a context that evokes target behavior in target contexts. • Common types of homework assignments include behavior logs, engaging in specific conversations, and connecting with the therapist outside of session. • Experiential exercises in FAP, like homework, are designed to evoke and provide an opportunity for reinforcing CRB2.