3 以功能分析为本

第三章

保持在功能性分析的基础上

稍加反思就会发现，确实存在一些非常重要的但未组织起来的知识，这些知识不能被称为科学意义上的普遍规则知识：即特定时间与地点的具体情况的知识。 ——F. A. 哈耶克

在会谈接近尾声时，汤姆似乎僵住了。他之前一直在很好地参与讨论，谈论了本周写作的进展。你问他，在下周继续写作和找工作时，可能会遇到哪些内心的障碍。

“我仍然在挣扎……我是否讨人喜欢？”他停顿了一下。“有时候我在想……这听起来很傻，但是——你真的怎么看待我？”

你一时语塞，想起了一位督导的老规矩：不要直接回答问题。但在那一刻，这似乎不太合适，于是你决定坦诚相告。“首先，我想让你知道，我对你的看法是诚实的。我非常尊重你在这里所做的工作。我每周都期待着我们的会谈。”

“我很感激你说这些，”汤姆说。“我想有一部分的我觉得你只是出于礼貌。”

接下来的几分钟里，你看到他变得僵硬。他回避了目光，呼吸变得急促。你不知道该说什么，所以结束了这次会谈。

几个小时后，你收到了一封电子邮件：“真的很抱歉我搞砸了。我僵住了。当我提到你觉得我只是出于礼貌时，我看到了你脸上的表情。我总是这样搞砸事情。我希望你能原谅我。”

在那次会谈中，汤姆当时发生了什么？对你来说又发生了什么？

功能性分析（FA）是指导FAP过程中的评估框架。它建立在第二章所述的基本情境行为基础上。超越CBS的一般立场意味着要对特定来访的行为及其功能建立起高度个性化和具体化的理解——包括塑造并持续影响该来访行为的“特定的时间和地点的情况”。

功能性分析可能是一个令人望而生畏的技术过程。就像学习下棋、绘画或商业谈判一样，掌握它可能需要多年的时间。这是因为使用FA来理解一个独特的情况不仅需要理解FA的原则，还需要在应用这些原则时发展出模式识别的能力（这种情况如何说得通？我以前见过这种模式吗？）。模式识别有助于理解复杂的信息，并且它是从多年的经验中产生的。我们无法保证在一章内就能让你成为FA的专家。相反，正如上一章那样，我们的目标是呈现代表FA核心临床价值的关键原则，以此开始你的精通之路。实践将取决于你自己。

进行功能性分析暗示了一个离散的过程，有明确的规则以及开始、中间和结束。在临床实践中，FA有时会采取这种形式，但更常见的是——像许多评估形式一样——过程更加分散、迭代和灵活。事实上，灵活性正是FA的一个优势。你可以根据有效性来决定使用多少。作为起点，我们建议以下重新构架：与其将FA视为一个程序，不如邀请你练习“功能性思考”。就像棋手考虑位置，画家考虑光线，谈判者考虑开场白一样，成功的FAP实践者考虑功能。

功能性思考是一种建立你对行为在其形成背景下的功能的理解的过程。它围绕三个关键问题：

• 行为是什么？
• 它在什么背景下发生或曾经发生过？
• 在这些背景下它的功能是什么？

FAP特别关注功能性思考，以处理在治疗过程中出现的来访的问题行为。FAP的目标是为每个治疗关系创建一个高度个性化的基于评估的方法。随着你参与到治疗过程中，功能性思考是一个可以反复回归的基准——提醒你要注意功能，不要让重要问题的回避在过程中扎根，并以对来访有效的方式进行治疗。过程才是关键。FA是使过程集中和具有策略性的工具，而不是过程的替代品。

在本章中，我们将从广泛的功能性思考开始，逐步聚焦于治疗过程中的思考。在接下来的部分中，我们将介绍在FAP中进行功能性思考的一些基本步骤，从上述问题开始。

第一步：关注行为和情境

以我们在第一章就开始跟踪的汤姆为例，他来到治疗室时说他的问题是“总是感到自己不值得。我需要变得更自信。”这是一个我们在治疗中经常遇到的典型问题。它集中在一种普遍的负面感受上，并且无法摆脱这种感觉。此外，他还提出了一个他认为需要改变的方向：变得自信。然而，正如你作为临床医生所经历的那样，虽然最初提出的问题通常准确描述了来访最渴望解决的问题，但这些问题有时并不能有效地指出为了产生这种转变所需要改变的内容。我们需要深入挖掘才能找到有用的理解。

这种情况类似于我们处理任何复杂系统时的情况，而行为无疑是一个复杂的系统。如果你因为下背痛去看物理治疗师，可能会发现疼痛的根源在于电脑显示器的位置或脚部的问题。同样，当一个人感到抑郁时，情绪低落的直接原因可能在于令人沮丧的工作环境、离婚、医疗状况等。长期的烦躁可能源于羞耻感。焦虑和失控的感觉可能源于过于僵化的控制努力。诸如此类。来访可能意识到了也可能没有意识到他们的问题与这些根源之间的联系。（当然，可能存在多个相互作用的“根源”。）

反过来，从根源到问题的路径可能涉及多个步骤。电脑显示器的位置导致下背痛，是因为颈部位置引起不适，这又导致姿势变化，进而导致其他区域的紧张，最终导致背部疼痛。工作环境惩罚了坚定的态度，这引起了怨恨和在家中的羞耻感，由于来访缺乏寻求支持的技能，绝望随之而来。

因此，从CBS的角度来看——就像上一章描述的“观察行为”的任务一样——我们的首要任务是看到并理解来访问题中涉及的行为。为了清晰地看到这一持续的行为流，我们会问很多问题——大量的问题——这些问题能够建立同理心和理解力，使我们能够像编剧或小说家一样描述来访的体验。我们可能会问以下问题：

• 你开始有那种感觉时发生了什么？
• 你在做什么？
• 你在想什么？
• 你有什么感觉？
• 那件事发生时你在哪儿？
• 在那之前发生了什么？
• 你觉得是什么因素导致了这种情况？
• 当你有那种感觉时，你做了什么？
• 接下来发生了什么？
• 你接下来做了什么？
• 然后你感觉怎么样？
• 别人是怎么反应的？
• 你是怎么反应的？
• 之后发生了什么？
• 还发生了什么？

这些问题都是关于理解事件的顺序：所有属于广义“行为”范畴的东西——思想、情感、冲动和行动——以及其他人对来访所回应的世界事件的反应。

请注意，这些问题中没有包含“为什么”这个词。作为一条规则，我们在这一阶段避免使用“为什么”的问题，因为这些问题可能会引导出与实际事件流程无关的原因；例如，“我不知道为什么——我想我只是太弱了。”或者，“我不知道，你告诉我吧。”

同时，请记住，你并不是为了事件本身而对事件流程感兴趣。你是在追踪与特定来访问题相关的行为和情境。你的目标是最终锁定那些似乎导致当前问题的关键行为，无论是你还是来访识别出来的。

想象一下，你有一个名叫苏珊的来访，她说她在工作中感到精疲力尽。以下是一些示例对话；它说明了这个追踪导致问题的行为并锁定关键行为的过程。

治疗师：所以你感到精疲力尽。 来访：是的，我真的不想去上班。周一早上起床简直是一种折磨。

治疗师：听起来确实很困难。告诉我更多关于你在工作中的感受。实际上，让我们回顾一下上周的情况。当你周一到达工作地点时，你在看什么？

来访：嗯，其实从那之前就开始了。我有一个项目已经迟交了。两周前我愚蠢地自愿接下了这个项目，尽管我知道我没有时间完成它。然后我在周六一整天和周日大部分时间里拖延，最后不得不在周日晚上加班六个小时。我非常痛苦。

治疗师：哎呀。你为什么会接受一个你知道自己没有时间完成的项目呢？

来访：哦，天哪。我经常这样做。

治疗师：你是先答应下来，然后再考虑后果吗？

来访：完全正确。我是个“好好先生”。

治疗师：你是否意识到，在答应的时候，说“是”可能是个坏主意？

来访：嗯……是的，最近我在接受新任务时确实会有一点恐惧感。但拒绝……这不是你应该做的事情。

治疗师：这不是你应该做的事情。我经常说“不”。

来访：哈哈！在我的工作中，很少有人说“不”。我不说“不”。如果你说“不”，你会受到评判。

治疗师：通过询问“当你周一到达工作地点时，你在看什么？”

来访描述了一系列事件，根据治疗师对职业倦怠的理解，这些事件似乎很可能导致了来访当前的问题。进一步的提问似乎证实了这一猜测。想象一下，更多的类似问题揭示了一些反复出现的关键模式：

• 她严重超负荷工作，经常牺牲晚上的时间和周末来完成她不喜欢但承诺要完成的项目。
• 她倾向于迅速同意做更多的工作，之后感到后悔。
• 在与上级交谈时，她倾向于避免说“不”或表达对任务的保留意见。
• 她倾向于与同事就她认为影响自己工作的低效率问题发生争执；她以对抗性和批判性的方式进入这些冲突。

在这个相对简单的演示中，苏珊发现自己已经知道了许多相关模式，但她还没有将整个图景拼凑起来，以便能够理解自己的经历。因此，在讨论接近尾声时，你可以退一步总结你所学到的内容：

我认为你感到精疲力尽是有充分理由的。你处于一种不断牺牲个人需求以满足工作的境况。你几乎一直在为截止日期而感到压力。你觉得无法改变这种状况，也没有多少支持。事实上，你与同事的关系往往也是另一个压力来源。

当多个可能的因素影响到当前问题时，问一个澄清性的问题以确定哪个因素最重要也是有用的。你可以问苏珊：“如果我们解决了这些问题中的哪一个，会对你的职业倦怠产生最大的影响？”例如，苏珊可能会发现，即使她与同事之间的冲突减少，她仍然会感到压力。经过一些讨论后，你可能会发现限制她接受新工作的数量会产生最大的影响；这不仅会让她有空闲的周末来照顾人际关系和做其他有意义的事情，而且如果她的整体压力减少了，她也更不容易因为同事的小缺点而感到沮丧。

第二步：明确功能

当你聚焦于那些似乎导致问题的行为时，你可能会开始理解这些行为的功能。回想第二章中提到的两种非常普遍的功能类别：

• 有些行为的功能是为了让我们接近某种令人愉悦的事物。
• 有些行为的功能是为了让我们远离某种令人不悦的事物。

更具体地理解功能通常需要深入挖掘——从更深层次的心理角度——问题行为发生的情境。这通常意味着更仔细地观察来访的体验——情绪、想法、意象、感觉等。考虑以下与苏珊的对话。

治疗师：我想更好地理解当你的主管要求志愿者参加一个项目时，你是唯一一个立即站出来的人，在那一刻你内心发生了什么？

来访：你是什么意思？我觉得我必须说“是”。

治疗师：我明白。让我们试着把那个时刻放慢来看。让我问几个问题来帮助我们聚焦。首先，在上周的会议中，在还没有人请求志愿者参加项目之前，你在会议中的感受是什么？

来访：感觉还不错。我刚刚完成了一份报告。有点因为那份报告而感到兴奋。

治疗师：还有呢？

来访：有点烦，因为我知道POS小组会把报告搁置一周，然后提出一些烦人的异议。

治疗师：好的。嗯，让我想想。如果你没有那种兴奋感，你会更有可能还是更不可能自愿参加工作？

来访：更不可能。我会犹豫。那次我只是直接跳进去了。

治疗师：对，没有考虑到时间线实际上并不实际。好的，那么接下来我们可以做的一件事是确保在说“是”之前有一个“等待期”，这样你可以更仔细地检查计划。[在这里，治疗师假设苏珊所追求的令人愉悦的事情，尤其是在她感到自信时，是贡献。但这之所以成为一个问题是因为她不顾及承诺的可行性。换句话说，苏珊的主动性在这种情况下并不奏效。她可能需要学习软性承诺的技巧**：“我愿意去做，但我可以有一个小时的时间确认一下这是否可行吗？”]

治疗师：好的，现在让我们回到POS小组。当你答应时，这对他们来说意味着什么？

来访：哦，很简单。这表明无论发生什么，我都会继续前进。我是成就者。我看起来很好。

治疗师：对你的主管来说也是同样的信息吗？

来访：是的。尽管……天哪！谁知道那是不是真的。她也知道我很疲惫。

治疗师：想象一下，如果你放慢了脚步，并且意识到这个时间线实际上对你来说并不合适，如果你没有举手自愿参加，会发生什么？

来访：哦。嗯，我会感到不舒服。我会尴尬地坐在那里等着……我会想，“还有谁会站出来？真是一群懒鬼。”

治疗师：你会考虑他们在想什么吗？

来访：当然。我总是第一个站出来，所以他们会想，“苏珊去哪儿了？”

治疗师：所以可以说，你的冲动答应部分是因为不愿意忍受那种不适感，并且担心同事认为你没有出现？同时你也想向POS小组和主管展示你很能干，即使你不知道这是否真的是他们的看法？这些小小的推动力足以让你一次又一次地做出不明智的“是”的决定？

来访：是的，这很公平。

对于苏珊来说，在她冲动地说“是”的情境中，治疗师已经确定了这种行为的几个功能：她在追求工作中表现出色并让同事和主管对她有好印象（接近令人愉悦的事物）。她也在逃避同事对她意愿的质疑（远离令人不悦的事物）。到此为止，功能性分析的三个主要问题已经得到了解答：行为是什么？它在什么情境下发生？在这些情境下的功能是什么？看看治疗师已经从苏珊最初的问题“我在工作中感到精疲力尽”走了多远。

再次强调，从一般的经验法则来看，你只需要寻找几种基本的功能模式：

• 来访的行为功能是为了避免某些不愉快的事物（真实的或想象的）。
• 来访的行为功能是为了接近某些令人愉悦的事物（真实的或想象的）。

当你感觉到有一种连贯性——就像“是的，这说得通”——并且感觉到对当前问题有了充分的解释时，你对功能的探索就已经足够深入了。让我们再来看看与明确功能相关的几个更微妙的点。

锁定功能后果

在功能性思考中，一个常见的误区是假设一种看似厌恶的反应具有惩罚问题行为的功能，然后对为什么这种行为仍然持续感到困惑。例如，假设一位女士对她丈夫冷淡对待，而他则生气并大喊大叫。她为什么会继续对他采取冷战态度呢？或者以苏珊为例：如果一直说“是”让她陷入困境，她为什么还要坚持这样做？

现实情况是，如果某种行为正在发生，那么它一定有某种形式的回报——无论是现在、过去还是间歇性的。

例如，对于那位采取冷战态度的女士来说，即使她的丈夫对她大喊大叫，关闭自己可能比在心烦意乱和受伤时尝试说话感觉更安全、更有力量。换句话说，被大喊大叫的结果并不是真正影响她的功能后果——真正影响她的是她获得的一种相对控制感。对于苏珊来说，情况类似。功能后果是立即看起来很好，并且不会显得不好。精疲力尽的负面后果实际上在那一刻并没有足够的影响力来促使她做出不同的选择。

这种反直觉的评估也适用于看似令人愉悦的后果。“我知道我应该填写我的时间卡，但就是不想做……所以我整天拖延。”有些人可能会认为提交工作时间是为了接近某种令人愉悦的事物，因为它会导致得到报酬；然而，让我们更仔细地看看这个例子中行为的实际功能。一整天避免填写时间卡可能允许她不断逃避面对本周工时不足的事实，这将使支付账单变得困难。

询问回避行为

关于回避行为需要注意的一点是，有时我们已经彻底并长期地避开了某些情境——可能是过去的痛苦经历——以至于不再清楚我们在回避什么，或者我们所害怕的事情是否真的会在当下发生。例如，苏珊的自愿行为帮助她避免了他人对她评价不佳的（想象中的）情况。然而，通过面对这种恐惧，她可能会发现实际上没有人会在她退缩时评判她。因此，让来访接触如果不回避该情境他们可能会面对的情况是有用的。试着从这个问题开始探索：如果你不做这种行为，你需要面对（或做或感受或回应）什么？

深入历史

正如上面段落所建议的，为了理解为什么某种行为在当下会发生，通常需要深入了解该行为的历史。就回避行为而言，行为所要避免的东西（对于苏珊来说，是被评判）可能并不真正存在于当前。但如果我们深入探究历史，我们会找到它。

治疗师：你记得在你生命早期经历过别人会评判你的恐惧吗——他们会认为你不会出现？ 来访：[停顿]嗯……哦，是的。我本来想说没有，但……这就是我和我妈妈的故事。特别是在她离婚后，我觉得她一直在逼迫我必须到场。我讨厌那样。

在这次对话中浮现出来的是，苏珊有一个很长的历史，人们对她“不出场”的反应是负面的——即他们认为她不在场。她学会了“不出场”会引起评判，这对她来说是痛苦的，所以她努力避免这种情况。然而，通过不断出现来避免这种不愉快的结果现在对她的生活产生了负面影响。她没有意识到，一般来说，其他人对她的评判远不如她所担心的那么多。澄清过去与现在的不同可以帮助人们变得更加灵活。

展望未来

最后，在明确行为的功能时，展望未来也是有用的。例如，我们可以通过更密切地接触问题行为的未来后果来平衡“当前后果比未来后果更重要”的问题。对于苏珊，我们可以花一些时间讨论如果她继续以目前的水平工作下去，可能会发生的后果。

治疗师：如果你继续这样生活二十年，会发生什么？ 来访：这很难去想。谁知道我的健康会怎样。我能身体上坚持这么久吗？我的儿子……他会不认识我。想到这一点真是太可怕了。

尽管审视后果通常是痛苦的，但它可以增加改变行为的动力，因为这样做会使维持问题模式的厌恶后果更加明显和痛苦。

这种痛苦的另一面是接触到放弃受限的问题行为后可能获得的东西——目的、意义、目标、自由。

第三步：寻找功能类别

一旦你收集了一组问题行为并确定了它们的功能，你将开始注意到这些有问题的行为在功能上有一些基本的模式，这些模式对个体来说是相对独特的。例如，苏珊非常在意别人对她的看法，即使代价很高（如精疲力尽、冲突等），她也会努力保持良好的形象。

然后我们可以开始寻找其他情况下苏珊同样避免“看起来不好”的情况。换句话说，我们现在有了一个关于苏珊可能在生活的其他方面遇到困难的假设。

治疗师：你的生活中还有其他地方会试图避免看起来不好吗？这种情况是否也发生在你和丈夫之间？

来访：是的。我讨厌他批评我。有时甚至是一个无辜的问题——不知为什么我会把它当作一种攻击。然后我对他就变得很刻薄。

接下来，我们可能会问她是否与朋友之间也有类似的经历。苏珊透露，由于复杂的情况，她失去了一位最好的朋友：苏珊不得不取消参加她的婚礼，让朋友失望，从那以后，由于深深的羞愧感，苏珊无法再与这位朋友建立联系。

尽管这些行为表面上看起来不同——自愿承担更多工作、对丈夫出言不逊以及疏远朋友——但它们都有一个共同的功能：帮助苏珊避免感到羞愧或不足或“看起来不好”。当行为服务于相似的核心功能时，它们在功能上是相似的：比如避免某个特定的恐惧结果或寻求某种期望的愉悦结果。

一旦你能看到这种共同的功能，就有机会更灵活地关注根本问题——在苏珊的情况下，就是面对羞愧。这样定义的一组具有核心共同功能的行为被称为功能类别。你可以清楚地看到整个类别的成本。你可以找到克服这一困境的理由。并且你可以在治疗过程中寻找功能类别出现的实例。下面第五步中将进一步讨论FAP中的这一关键元素。

第四步：定义改进

到目前为止，我们已经集中在问题行为上。功能性分析的下一步——也是极其重要的一步——是识别和测试能够帮助缓解来访问题的行为。对于苏珊冲动地说“是”导致过度承诺的问题，我们可以通过提高她拒绝的能力来改善，这可以帮助她以更有可能获得人们理解和支持的方式说“不”，而不是受到评判。

一旦你有一个关于哪种行为在关键时刻对来访更为有效的假设，你就可以帮助来访实施该行为。然后你可以评估这种行为是否有所帮助。通过足够的练习，这种行为是否有助于改变整个行为流，从而使当前问题有所缓解？

第五步：注意临床相关行为

现在我们将关注FAP中功能思维的一个非常重要的焦点：在会谈中和治疗关系中观察来访的有问题的行为（及其改进）。

在FAP中，当场注意临床相关行为是非常关键的，因为第一章中描述的机会和风险：如果我们不能清楚地看到这些行为，我们就有可能强化问题行为或惩罚向改进或改变迈出的试探性步骤。如果我们能清楚地看到这些行为并理解它们的意义——即它们对这个人是如何起作用的——那么我们可以确保我们的回应是治疗性的。这意味着什么？与其强化问题行为，我们以真实和同情的方式激发和强化所需的改进。本书的其余部分将重点讨论这一过程。

为什么功能思维对这一过程有用？首先，功能通常是不可见的，因此深入探讨行为的功能以理解它是非常有用的。此外，一旦你能从功能的角度看待来访的行为（例如作为功能类别），就更容易注意到行为出现的时刻，即使在会谈中发生的事情表面上与生活中的情况大相径庭。

这里有一个功能思维的例子：想象一下，一位来访告诉你——作为她提出的问题之一——她在与伴侣主动进行性行为方面遇到了困难。FAP不会要求你寻找来访可能希望与你进行性行为的情境，以便她可以在这个领域提高技能。

相反，你的功能性分析可能会发现，主动进行性行为的行为是更广泛的功能类别的一部分：这位来访通常发现在满足自己需求时难以敏感而直接地接触他人，其中一个表现就是在卧室里与伴侣的关系中。如果来访认为这是一个值得努力的领域，你可以在治疗关系中注意那些引发这种行为的情境，从日常情境（如需要重新安排会谈时间）到使来访感到更加脆弱的情境。例如，也许有一天她发现自己在想你是否真的关心她，并且希望适当地寻求保证。

另一个例子：苏珊对丈夫苛刻且防御性强，在工作中对上司过于顺从，在与你的会谈中过于礼貌且不提要求——即使她偶尔对你做的事情表现出不满。所有这些行为示例都是一个一般功能类别的一部分，其功能是避免她在表达需求时感到的脆弱性。

所有这些例子中的共同结构是，无论是在治疗关系内外，问题行为都属于同一个功能类别。能够看到会谈内外事件之间的功能平行性有助于在改变行为的努力中建立动力和连贯性——“在这里我们要解决你在生活中正在处理的相同问题。”

临床相关行为 (CRBS)

在功能性分析心理治疗 (FAP) 中，我们称那些在治疗过程中出现并与来访临床问题相关的行为为临床相关行为 (CRBs)。CRBs 分为两类：问题行为的例子被称为 CRB1，而相对于这种行为的改进则被称为 CRB2。与来访交流时，我们通常省略 CRB 前缀，仅使用通用缩写“1”和“2”来指代问题和改进。这些缩写成为有用的简短语言，例如，“你刚才做了一个1吗？”“那是1还是2？”等等。

这种术语的一个主要优点是其简洁性。问“这是1还是2？”将对话集中在功能性分析上。这个问题在治疗过程中容易记住，但包含了很多内容。它代表了对评估过程的持续关注，并将这种关注应用到当前时刻。

这种 CRB 术语使我们能够非常简单地陈述 FAP 的目标。临床上，我们寻求减少 CRB1 的频率并增加 CRB2 的频率。因此，使用功能性分析来定义 CRB1 和 CRB2 是 FAP 功能分析过程的关键目标。该术语也是 FAP 案例概念化的基础。

CRB1 和 CRB2 的关键特征

1. 功能相关性：

   • CRB1 和 CRB2 只有当它们在功能上与来访的当前问题相关时，才被称为 CRBs。

2. 可控性：

   • CRB1s 和 CRB2s 应始终是来访有一定控制力的行为，因此可以通过刻意的努力来改变。例如，恐惧可能是展示脆弱性时的问题反应，但很难选择去改变恐惧。一个更好的焦点——来访有更多的选择——可能是来访在害怕时所采取的行为。例如，CRB1 可能是保持沉默，避免向一个实际上值得信赖的人披露某些事情，而 CRB2 则可能是在恐惧中仍然披露信息。

3. 同理心、验证性和激励性的标签：

   • 标记 CRB1 和 CRB2 时应使用富有同情心、确认性和激励性的语言。尽可能使用来访的原话。避免使用过于临床或评判性的术语。可以使用比喻来描述 CRB 的功能类别。例如，避免自我披露的行为可以合理地称为“保持警戒”或“筑起心墙”，而过早过多披露的行为可以称为“倾诉”。通过检查你和来访是否对这些术语的使用达成一致，确保足够的精确度。

4. 接受与同情：

   • 记住，CRB1 并非本质上是坏的，CRB2 也并非本质上是好的。事实上，通常重要的是以同样多的接受和同情来对待 CRB1 和 CRB2。

区分 CRB1 和 CRB2

在这一部分中，我们将提供一些练习，帮助你在功能上思考——特别是区分 1 和 2。

这里有一个热身练习。想象一下，一位来访要求你打电话给她的医生请求处方续签。这个行为对来访的功能是什么？如果你像过去几十年培训中约50%的人一样，你会立即觉得这个行为有问题。也许你觉得来访似乎过于苛求或依赖，这确实是一个可能的评估。来访可能有过度不合理要求的习惯。相反，来访也可能有很好的理由提出这个请求。也许她正在努力变得更加自信，因为过去未能这样做给她带来了很多问题。

请注意，这些不同功能解释的不同含义会引导你的回应朝不同的方向发展。如果这个请求是 CRB1 的例子，你可能会拒绝请求，并让来访自己打电话。如果它是 CRB2 的例子，你可能会同意打电话，也许还会表达这不是你通常会同意的请求，但在这种情况下，你看到它真的可以帮助来访。

练习：探索CRB的潜在功能

阅读以下每个场景，然后在一张单独的纸上写下你对行为可能的功能的看法，以及该行为更可能是CRB1还是CRB2。鉴于我们提供的背景信息有限，每个案例中会有几种功能上的可能性。挑战在于为每个场景写出几种不同的解释，包括至少一种是CRB1的情况和另一种是CRB2的情况。在阅读我们的示例解释之前，请以这种方式完成所有四个场景。

• 情景1：一位来访来参加他的会话。当你问他这次会话想关注什么时，他说：“我不知道。”

• 情景2：你在等候室迎接一位来访，并错误地叫了她的名字。她似乎短暂地显得不悦，在你进入办公室时保持沉默。

• 情景3：在一次会话结束时，一位来访说：“我一直想问你一件事。我觉得你是个很酷的人。我想知道，治疗结束后，有没有机会我们可以一起喝一杯？”

• 情景4：你正在帮助一位来访更好地应对创伤记忆。有一天在会话中她说：“今天我们可以谈谈别的事情吗？有些事情我有点想聊一聊。”

以下是这些场景的示例功能性解释。正如以往，这样的解释只是需要通过与特定来访的评估来验证的假设。

• 情景1：一位来访来参加他的会话。当你问他这次会话想关注什么时，他说：“我不知道。”

  • 可能的解释1（CRB1）：这是来访的问题行为。他避免识别并表达自己的需求，导致生活中的许多领域出现问题。
  • 可能的解释2（CRB2）：这是来访的改进行为。他倾向于过度控制自己，完美主义，并且在不知道该怎么办时避免寻求帮助。“我不知道”代表了一种识别出需要帮助的情境，并与治疗师进行有意义对话的步骤。

• 情景2：你在等候室迎接一位来访，并错误地叫了她的名字。她似乎短暂地显得不悦，在你进入办公室时保持沉默。

  • 可能的解释1（CRB1）：这是来访的问题行为。她避免向他人表达不满或失望，并且随着怨恨的增长逐渐与他们疏远。
  • 可能的解释2（CRB2）：这是来访的改进行为。她通常会对小的冒犯反应过度，这给她的人际关系带来了困难。在这种情况下，她成功地没有反应过度。

• 情景3：在一次会话结束时，一位来访说：“我一直想问你一件事。我觉得你是个很酷的人。我想知道，治疗结束后，有没有机会我们可以一起喝一杯？”

  • 可能的解释1（CRB1）：这是来访的问题行为。他往往忽视社交界限（例如治疗关系和友谊之间的区别），这种敏感度不足给他带来了冲突和痛苦。
  • 可能的解释2（CRB2）：这是来访的改进行为。他普遍避免提出自己的要求，并且正在努力变得更加自信，无论被拒绝或排斥的可能性如何。

• 情景4：你正在帮助一位来访更好地应对创伤记忆。有一天在会话中她说：“今天我们可以谈谈别的事情吗？有些事情我有点想聊一聊。”

  • 可能的解释1（CRB1）：这是来访的问题行为。她一直试图避免她的创伤记忆，主要通过分心来应对这些记忆及其引发的情绪。
  • 可能的解释2（CRB2）：这是来访的改进行为。她往往过于专注于自己的创伤，而忽视了生活中其他重要的方面。

功能性个体化评估模板 (FIAT)

开始对来访进行功能性分析时，你可以从空白开始，创建一种完全针对她的问题描述方式。然而，有时回顾现有的常见CRB列表或更广泛地说，与FAP相关的功能性人际行为类别，对来访来说是有帮助的。与其从头开始描述，这些列表提供了你和来访可以选择的语言来描述可能发生的情况。

Glenn Callaghan（2006年）开发了功能性个体化评估模板（FIAT），这是一种用于执行FAP时识别行为功能类别的工具。Callaghan分析了他自己来访及学生来访的典型FAP治疗目标，并提出了五种关键的功能性人际行为类别。他将这些功能类别组织成一个问卷，其中每种类别都有众多具体行为。你会发现完整的FIAT在识别CRB1s和CRB2s时非常有用，特别是在你熟悉FAP方法时。可以在http://www.functionalanalyticpsychotherapy.com/fiat.pdf找到它。

为了本章的目的，我们简化了FIAT上的项目，将其作为描述而不是问题呈现。记住这五种行为类别可以帮助你留意到可能指示CRB1的具体会话行为。工作表仅列出了CRB1，但推导出相应的CRB2是直接的。这样做可以激发你在案例概念化时的思考。你也可以发现向来访展示此表格并与他们合作识别相关行为是有用的。

阅读以下各种类型CRB1的描述，并勾选那些经常出现的行为，无论是会话内还是会话外。特别注意勾选了许多项目的类别。它们可能代表了特别有问题的行为类别，或者是在这些地方进行改进最有益。

类别A—需求的表达（识别与表达）

类别A的行为包括人们想要或重视的任何事物，或者“需要”，包括表达意见、想法、信念、热情、渴望、梦想等，基本上是他们是谁。"需求的表达"也包括对社会支持或其他更实际的需求提出请求。

可能的类别A CRB1s

• 难以识别需求或希望从治疗师或他人那里获得的帮助类型
• 难以表达需求
• 难以让治疗师或他人满足需求
• 表达需求过于微妙或间接
• 用需求感将治疗师或他人推开
• 给予远多于所得到的回报
• 极度独立，在接受帮助时感到太脆弱
• 在要求满足需求时过于苛求
• 无法容忍治疗师或他人拒绝请求
• 其他：________

类别B—双向沟通（影响与反馈）

类别B的行为涉及人们如何影响他人以及他们如何给予和回应反馈。“反馈”指的是他人对个人行为的反应。反馈可以是口头的或非口头的，形式上包括面部表情、身体语言等。

可能的类别B CRB1s

• 难以接受正面反馈，如赞赏或赞美
• 难以接受负面反馈，如批评
• 难以给予正面反馈
• 难以给予负面反馈，包括建设性的批评
• 有不合理的自我期望，可能表现为完美主义或普遍的失败感
• 对治疗师或他人有不合理的期望
• 对治疗师或他人的影响过度敏感或过于在意
• 对治疗师或他人的影响缺乏意识
• 不准确地评估自己对治疗师或他人的影响
• 在对话中难以跟踪或跟随
• 说话太多或太久而不检查影响
• 目光接触过多
• 目光接触过少
• 其他：________

类别C—冲突

攻击性或敌对的类别C行为只是与冲突相关的许多潜在问题行为之一。对于分歧或不舒服的互动，不可行的应对方式也可能包括许多更为被动或回避的行为。

可能的类别C CRB1s

• 难以容忍冲突或分歧
• 难以表达负面情绪
• 回避冲突
• 间接表达愤怒，例如通过被动攻击
• 表达过多的愤怒
• 不愿意妥协
• 解决冲突无效
• 过度道歉
• 认为所有问题都是自己的错
• 将问题归咎于治疗师或他人
• 制造不必要的冲突
• 用冲突作为避免亲密的方式
• 不愿意原谅治疗师或他人
• 其他：________

类别D—披露与人际亲密

类别D的行为与“人际亲密”有关，指那些导致感觉与另一个人连接或亲近的行为。

可能的类别D CRB1s

• 难以进行对话
• 难以表达亲密和关怀
• 难以接受亲密和关怀
• 对亲密或依恋感到恐惧
• 不愿意承担情感风险
• 不愿意自我披露
• 不愿意让真实的自我被看见或听见
• 轻视自己所分享内容的重要性
• 过多地谈论自己
• 听得不够好
• 自我中心或寻求过多的支持
• 保密
• 在询问治疗师或他人的个人经历时过于侵入
• 没有意识到治疗师或他人的需求（例如，会话超时或不给治疗师发言的机会）
• 说话太多且离题
• 不信任他人
• 过于轻易或过早地信任他人
• 其他：________

类别E—情绪体验与表达

类别E的行为涉及所有类型的情绪体验与表达，从悲伤和焦虑到爱和自豪。

可能的类别E CRB1s

• 难以识别情绪
• 对正在发生的情绪没有意识
• 故意隐藏情绪
• 情绪表达平淡或疏远
• 难以哭泣
• 难以感受或表达悲伤、哀伤或悲痛
• 难以感受或表达焦虑或恐惧
• 难以感受或表达喜悦
• 难以感受或表达自豪
• 难以感受或表达幽默
• 在感受情绪时进行负面自我对话
• 以过度强烈的方式表达情绪
• 无法控制自己的情绪表达
• 过多谈论情绪
• 情绪波动过大或过于强烈
• 无法对自己的情绪保持客观；被情绪淹没而无法脱离
• 以令人烦恼或疏远的方式表达情绪
• 避免或抑制某些情绪
• 其他：________

灵活性：是1还是2？

当你思考前面的例子，或者反思你自己的来访或你自己时，你可能会注意到一些重要的事情：有时候，很难明确某个特定行为是CRB1还是CRB2。事实上，一个特定的行为可能同时包含问题行为和改进行为的元素。让我们回到那个请求你打电话给她的医生续处方的来访例子。这个请求在某些方面可能是CRB2：它代表了自信，如果她更自信，她的生活会更好。然而，她在表达自信的具体方式上（比如她可能没有足够地验证或她的语气太严厉）给她带来了一些麻烦，因此也包含了CRB1的成分。FAP如何处理这种情况？

虽然区分CRB1和CRB2是有用的，但不应该强行划分。多个功能，包括问题行为和改进行为，可以并且经常混合在同一行为中。认识到存在多种功能，使我们能够超越简单地问一个行为是CRB1还是CRB2的问题，而是问：“这种行为在哪些方面是改进，在哪些方面是问题？”从那里我们可以培养CRB2的线索，并剔除CRB1的线索，或者我们可以将CRB1塑造为更有效的行为。

接受与承诺疗法矩阵 (ACT Matrix)：一个非常有用的工具

另一个对于功能思考和区分1类行为（问题行为）和2类行为（改进行为）来说不可或缺的工具是接受与承诺疗法矩阵（ACT Matrix，Polk & Schoendorff, 2014; Polk, Schoendorff, Webster, & Olaz, 2016）。我们强烈推荐《ACT矩阵基本指南》，该书讨论了在ACT和基于FAP治疗背景下使用矩阵工具的方法。

真的很难夸大矩阵作为临床工具的实用性！

临床相关治疗师行为

到目前为止，我们主要关注的是来访的行为。但正如本书引言中所述，作为治疗师，你的行为同样是治疗过程中的重要组成部分。你在治疗过程中所做的每一件事对你自己以及你的来访都有其功能：你的行为会以某种方式影响来访，这些影响可以支持治疗进程，也可能干扰它。因此，在对会话过程和治疗关系进行功能性分析时，FAP要求你不仅要关注来访的行为，也要注意自己的行为。更广泛地说，我们邀请你发展一种跨案例的行为模式意识：作为一名治疗师，你倾向于在哪些情况下陷入困境或阻碍进展？什么时候你能发挥最佳状态？治疗师的个人历史和个人关系往往会影响这些模式。我们将在第6章更直接地讨论这个“个人”话题。

例如，面对苏珊时，你可能会对她无法清楚识别自身需求或减少那些显然（对你来说）自我挫败行为时的焦虑感到不耐烦，这种不耐烦可能导致你过度专注于行为改变，而不是建立动机、明确目标或找到情感接纳。你可能会发现这种对行为改变的不耐烦模式经常出现在焦虑且高度控制的来访身上。

与来访行为术语相对应，干扰治疗过程的治疗师行为被称为T1s，而支持治疗过程的行为则被称为T2s。就像CRBs一样，T1s和T2s的定义基于它们在治疗过程中对你和你的来访的功能：它们是否有助于促进或阻碍治疗进展？当然，你可能对不同的来访有不同的T1s和T2s。以下是一些例子：

T1s 的例子

• 过于控制或指导性强
• 避免来访表达情绪
• 过度专注于解决问题（而非验证、接纳和当下的体验）
• 允许来访以无效的方式主导会话焦点
• 没有足够精确地定义案例概念化或家庭作业活动

T2s 的例子

• 允许来访参与会话规划
• 允许或邀请来访表达情绪
• 提供验证、表达接纳并关注当下体验
• 有效引导会话焦点
• 将注意力集中在定义精确治疗计划或家庭作业所需的解决问题上

第六步：功能分析过程—假设检验

最后，让我们回到功能思考或功能分析作为一个过程的概念。我们将这一部分标记为“第六步”，但实际上它并不是一个独立的步骤。如果它是一个步骤的话，它会随着你对来访及其治疗过程中有效方法的了解而不断循环回顾之前的步骤。换句话说：功能思考是一个迭代的、假设检验的过程。这是一个提问、调查、测试、修订和澄清的过程。

判断功能分析是否成功最重要的标准可能是：

• 这个分析是否帮助我们实现了预期的治疗结果？ 如果答案是否定的，无论这个分析对你来说多么连贯、优雅或正确，都必须进行修订或放弃。

假设检验和迭代的精神也很重要，因为我们试图理解的现象本质上是复杂的。我们必须通过解谜来理解它。为了说明这一点，我们将探讨一个例子：来访请求你打电话给她的医生续处方。如果你按照本章的指导原则行事，你的第一步可能是考虑来访的临床目标。假设她一直在表达需求方面有困难。也许她有一个专横的丈夫和一个极其苛刻的老板，而她主要关注的是服从和保持安静，这让她感到疏离和痛苦。在这种情况下，你可能会注意到以这种方式表达需求对她来说是新的尝试，即使显得有些笨拙。

因此，在你的回应中认识到这一点非常重要。然而，如果你继续探索，你可能会发现行为或情境中的其他方面可能会影响你的回应。例如，当她偶尔确实表达需求时，她倾向于提出相当僵硬且不方便的要求，从而疏远他人或让他人对她不满。结果，他们通常会拒绝她的请求，或者只是勉强答应。最终，她在这些互动后认为向人提出要求并不怎么奏效。因为她没有意识到自己的请求显得僵硬且不体贴，所以她决定只有在请求极其重要时才去麻烦别人。这些考虑因素如何影响你对她的回应？

现在，让我们把这个情况变得更加现实—也更加复杂。想象一下，来访在你生活中特别忙碌的时候提出了这个请求。也许这次会话已经超时了。或许你在想着下一个来访，那是一个你遇到过的最具挑战性的来访之一。也许你正在经历健康问题，或者觉得自己没有足够的时间照顾自己。无论出于什么原因，当你听到这个额外的请求时，立刻感到身体上的紧张。所有这些因素会如何影响你对她的回应？

再想象一下，这位来访非常敏感于你的情绪反应。她准确地感知到你的反应是压力或烦躁，并将其解释为你生气了，她做错了事。如果你也敏锐地察觉到了她的这种反应—以及它如何与她的问题相吻合—那么这些情境因素又将如何塑造你的回应？相反，如果她没有注意到你对她请求的情绪反应，这又将如何影响你的回应？

理想情况下，你的功能思考应该能够响应所有的情境因素。毕竟，这些复杂且不断变化的情境正是来访行为运作并寻找出路的场所。

最后，功能思考是一个过程，因为行为是一个复杂的系统。当我们帮助来访改变其行为的一个方面时，常常会出现新的挑战，因此需要新的评估—新的分析。例如，停止饮酒的来访现在必须处理许多困难的情绪。一旦苏珊学会了更自信，她现在就必须应对对自己工作和丈夫的不满。功能思考是一个适应性过程，服务于治疗过程。

基本的功能分析“脚本”

功能分析可以采取多种形式。它可以在一个更结构化的评估中进行，也可以在多个会话中以更随意的方式进行。它可以非常技术化和详细，也可以相当宽松且看似对话式的。

多年来，我们发现一些核心的共同问题定义了许多功能分析的对话，并且这些问题通常可以组织成一种自然的流程。以下是一个版本的流程。

为了提高你的功能思考技能，你可以与一个伙伴练习这个流程。请你的伙伴选择一个现实生活中的问题情境，然后问以下问题。支持性地倾听答案。不要试图解决问题。按照问题的流程进行。可以根据你们的对话稍微修改问题，但不要偏离太多。信任这些问题。观察结果。

• 你想讨论的问题情境是什么？
• 在那种情况下会发生什么？你做了什么？对方做了什么？描述一下互动。
• 在那种情况下，你做的哪件事是导致问题的关键行为？具体说明。
• 这种行为是否在你生活的其他情境中出现过？
• 这种行为是否在你我之间出现过？
• 你做这种行为的即时回报是什么？你得到了什么？
• 这种行为在短期内的成本是什么？
• 如果这种行为长期持续下去，会发生什么？
• 如果你不做这种行为，会发生什么？会有什么困难？你需要面对或感受或接受什么？
• 你愿意为了什么目的去感受或面对或接受那些东西？
• 考虑到所有这些，对你来说最关键的是要解决什么？

完成流程后，看看你能否退一步总结你对情况、行为、对方的困境以及对方需要做什么来前进的理解。询问反馈，看看你的总结是否准确，对方是否感到被理解。

最后，交流关于过程的反馈。例如：哪些问题特别有用？哪些问题不太有用？哪些问题让你觉得不舒服但最终证明是有洞察力的？发现了哪些洞见？

总结

• 功能分析是FAP的核心评估方法，基于CBS视角的基础。
• 功能分析是一种复杂的方法。专业知识部分建立在模式识别和大量经验的基础上。通过练习功能思考开始掌握功能分析，中心问题是：“这种行为的功能是什么？”
• 功能分析涉及几个基本步骤：
  • 定位与呈现问题相关的行为。
  • 评估功能。
  • 注意功能类别（由共同核心功能定义的行为集）。
  • 定义改进。
• FAP为功能分析添加了一个独特的步骤：注意问题行为如何在治疗关系中显现。CRB1是来访在治疗过程中出现问题行为的一个例子。CRB2是在此时此地发生的改进行为的一个例子。FAP治疗的一个目标是增加CRB2的频率并减少CRB1的频率。
• 根据需要迭代上述过程，直到实现积极的治疗结果。

本章知识点阐述

知识点阐述

1. 功能性分析（FA）的重要性：

   • 功能性分析是FAP的核心评估工具，它帮助治疗师深入了解来访行为的功能及其背后的特定情境。通过FA，治疗师能够识别出维持问题行为的条件，并据此制定干预策略。

2. 个体化和具体化：

   • FA强调对每个来访的行为进行高度个性化和具体化的理解。这意味着治疗师需要关注来访的独特经历和当前情境，而不仅仅是依赖于一般性的理论或假设。

3. 模式识别：

   • 有效的FA不仅需要理解基本原则，还需要能够在实际情境中识别模式。这种能力通常来自丰富的经验和实践，它使得治疗师能够更快地理解和应对复杂的临床情况。

4. 灵活性：

   • FA是一个灵活的过程，可以根据具体情况调整。治疗师可以根据需要使用不同程度的功能性分析，而不是遵循固定的程序。这种灵活性有助于更好地适应每个来访的需求。

5. 功能性思考：

   • 功能性思考是一种思维方式，它要求治疗师始终关注行为的功能。通过这种方式，治疗师可以更好地理解来访的行为，并在治疗过程中避免忽视重要的问题。功能性思考是FAP成功的关键。

6. 过程的重要性：

   • 治疗过程本身是至关重要的。FA作为一种工具，帮助治疗师在过程中保持专注和战略性，但它不是过程的替代品。治疗师需要在过程中不断运用功能性思考，以确保治疗的有效性。

通过这些知识点，治疗师可以更好地理解和应用功能性分析，从而在治疗过程中提供更有效的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 行为和情境的重要性：

   • 功能性分析（FA）的核心是关注行为及其发生的背景。通过详细询问来访的具体经历，治疗师可以更好地理解行为的触发因素、维持因素以及后果。这有助于识别和干预问题行为。

2. 具体化和细节化：

   • 通过一系列具体的问题，治疗师能够深入了解来访的经历。这些问题不仅包括来访的行为，还包括他们的想法、感受以及周围人的反应。这种详细的了解有助于构建一个全面的情境图景。

3. 避免“为什么”的问题：

   • 在初始阶段，治疗师应避免使用“为什么”的问题，因为这些问题可能导致来访提供主观解释，而不是客观描述实际发生的事情。相反，治疗师应专注于具体的事实和事件序列。

4. 事件序列的理解：

   • 通过追问事件的前后关系，治疗师可以构建一个清晰的行为链。这有助于识别关键行为及其功能，从而为制定有效的干预策略提供依据。

5. 功能性思考的应用：

   • 功能性思考是一种思维方式，要求治疗师始终关注行为的功能。通过这种方式，治疗师可以更好地理解来访的行为模式，并在治疗过程中采取有针对性的措施。

6. 综合信息的能力：

   • 治疗师需要具备综合信息的能力，将来访提供的各种细节整合成一个连贯的故事。这不仅需要良好的倾听技巧，还需要敏锐的观察力和分析能力。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 详细询问的重要性：

   • 通过详细的询问，治疗师可以深入了解来访的实际经历和行为模式。这有助于识别导致问题的具体情境和行为，从而制定更有针对性的干预策略。

2. 行为模式的识别：

   • 通过一系列具体的问题，治疗师能够识别出来访的行为模式。这些模式包括过度承诺、快速同意、避免拒绝以及与同事的冲突等。识别这些模式有助于理解来访的行为动机和后果。

3. 自我认知的提升：

   • 来访在回答问题的过程中，可能会意识到自己的一些行为模式及其负面影响。这种自我认知的提升是治疗过程中的一个重要步骤，有助于来访在未来做出更健康的选择。

4. 多因素分析：

   • 当面临多个可能影响问题的因素时，治疗师可以通过澄清性问题帮助来访确定哪个因素最为关键。这有助于集中精力解决最紧迫的问题，提高治疗效果。

5. 综合信息的能力：

   • 治疗师需要具备综合信息的能力，将来访提供的各种细节整合成一个连贯的故事。这不仅需要良好的倾听技巧，还需要敏锐的观察力和分析能力。

6. 功能性思考的应用：

   • 功能性思考要求治疗师始终关注行为的功能。通过这种方式，治疗师可以更好地理解来访的行为模式，并在治疗过程中采取有针对性的措施。

7. 建立同理心：

   • 通过深入理解来访的具体经历和感受，治疗师能够建立更强的同理心。这种同理心有助于建立信任关系，使来访更愿意开放并接受治疗建议。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 行为功能的识别：

   • 在功能性分析中，识别行为的功能是关键步骤之一。通过深入了解来访的具体经历和心理状态，治疗师可以确定行为是为了接近令人愉悦的事物还是为了避免令人不悦的事物。

2. 详细询问的重要性：

   • 通过详细的询问，治疗师可以帮助来访逐步回忆和描述特定情境下的内心体验。这有助于揭示行为背后的心理动机和功能。

3. 情绪和认知的作用：

   • 来访的情绪状态（如兴奋或烦躁）和认知（如对他人反应的预期）在行为决策中起着重要作用。理解这些因素有助于更全面地了解行为的功能。

4. 软性承诺的技巧：

   • 治疗师建议来访学习软性承诺的技巧，即在做出承诺前先留出一段时间进行思考和评估。这有助于来访在面对压力时做出更明智的决策。

5. 多重功能的识别：

   • 一个行为可能具有多种功能。例如，苏珊的行为既是为了获得成就感和他人的认可，也是为了逃避被质疑的风险。识别这些多重功能有助于制定更有效的干预策略。

6. 功能分析的连贯性：

   • 功能分析的过程应该是连贯的，能够解释来访的行为模式及其背后的动机。当治疗师和来访都感觉到这种连贯性时，说明分析已经达到了一定的深度。

7. 行为改变的策略：

   • 一旦明确了行为的功能，治疗师可以与来访一起制定具体的策略，以改变不健康的行为模式。例如，通过设置“等待期”来减少冲动行为，或者通过角色扮演来练习如何表达保留意见。

8. 自我反思和意识提升：

   • 通过这个过程，来访可以提高自我反思的能力，更好地理解自己的行为模式和动机。这种自我意识的提升是行为改变的重要前提。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 功能后果的理解：

   • 在功能性分析中，重要的是识别行为的真实功能后果，而不是表面的反应。有时，看似厌恶的反应实际上是另一种功能的体现，如获得控制感或安全感。

2. 回避行为的复杂性：

   • 回避行为可能根植于过去的经历，即使这些经历在当前情境中不再适用。理解来访回避的具体内容有助于揭示其背后的心理动机。

3. 历史背景的重要性：

   • 了解行为的历史背景可以帮助治疗师更好地理解行为的起源和发展。通过探讨过去的经历，可以揭示出来访的行为模式是如何形成的。

4. 未来后果的考虑：

   • 讨论行为的未来后果可以增强来访改变行为的动力。通过预见长期的负面影响，来访可能会更愿意采取行动来改变现状。

5. 情感和认知的影响：

   • 来访的情感状态和认知（如对他人反应的预期）在行为决策中起着重要作用。理解这些因素有助于更全面地了解行为的功能。

6. 多维度的功能分析：

   • 行为可能具有多重功能，包括即时的奖励和长期的后果。全面分析这些功能有助于制定更有效的干预策略。

7. 自我反思和意识提升：

   • 通过深入探讨行为的历史和未来后果，来访可以提高自我反思的能力，更好地理解自己的行为模式和动机。这种自我意识的提升是行为改变的重要前提。

8. 动机增强：

   • 通过明确行为的负面后果和潜在的正面收益，治疗师可以帮助来访增强改变行为的动机。这不仅包括避免未来的痛苦，还包括实现个人目标和追求有意义的生活。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 功能类别的识别：

   • 通过识别一组行为的共同功能，可以形成功能类别。这些类别揭示了行为背后的动机和心理机制，有助于治疗师更好地理解来访的行为模式。

2. 跨情境的行为一致性：

   • 功能类别不仅限于特定情境，而是跨越多个情境。例如，苏珊在不同情境下（如家庭、工作和治疗关系）表现出的行为虽然形式不同，但功能一致，都是为了避免羞愧或不足感。

3. 行为改进的重要性：

   • 在识别问题行为之后，重要的是要识别和测试能够帮助缓解这些问题的行为。这包括提高来访在关键情境下的应对能力，从而逐步减少问题行为的发生。

4. 治疗关系中的行为观察：

   • 在治疗过程中，注意来访的行为及其变化是非常重要的。这不仅有助于评估治疗效果，还可以提供即时反馈，帮助来访调整行为。

5. 功能思维的应用：

   • 功能思维强调理解行为背后的功能，而不仅仅是表面现象。这有助于治疗师更准确地定位问题，并制定针对性的干预策略。

6. 情感和认知的影响：

   • 来访的情感状态和认知（如对他人反应的预期）在行为决策中起着重要作用。理解这些因素有助于更全面地了解行为的功能。

7. 行为改变的系统性：

   • 行为改变是一个系统的过程，需要考虑行为在不同情境中的表现。通过识别功能类别，治疗师可以系统地解决来访的问题，促进整体的行为改变。

8. 治疗关系中的真实性与同理心：

   • 在治疗过程中，治疗师的真实性和同理心对于帮助来访改变行为至关重要。通过建立信任关系，治疗师可以更有效地引导来访进行行为上的改进。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 临床相关行为 (CRBs) 的定义：

   • CRBs 是指在治疗过程中出现并与来访的临床问题相关的具体行为。分为两类：问题行为（CRB1）和改进行为（CRB2）。这种分类有助于明确治疗目标。

2. 简化术语的优势：

   • 使用“1”和“2”这样的简写术语，使得在治疗过程中讨论行为变得简单明了。这种简化的语言有助于聚焦于功能性分析，并促进即时反馈和调整。

3. 功能相关性：

   • CRB1 和 CRB2 必须与来访的当前问题在功能上相关。这意味着它们必须直接影响或反映来访的主要问题。

4. 可控性：

   • 来访必须对其行为有一定的控制能力，才能通过有意的努力进行改变。例如，恐惧本身难以直接改变，但可以在恐惧时选择如何行动。

5. 同理心和激励性标签：

   • 在标记 CRB1 和 CRB2 时，应使用富有同情心、确认性和激励性的语言。这样可以增强来访的参与感和合作意愿。

6. 接受与同情：

   • 对待 CRB1 和 CRB2 都应保持接受和同情的态度。理解来访的行为背后的原因，并以支持的方式帮助他们。

7. 区分 CRB1 和 CRB2 的重要性：

   • 正确区分 CRB1 和 CRB2 是制定有效干预策略的关键。不同的功能解释会导致不同的治疗响应。例如，一个看似过分的要求可能是一个需要改进的行为（CRB2），而不是一个问题行为（CRB1）。

8. 功能性分析的应用：

   • 通过功能性分析，治疗师可以更深入地理解来访的行为模式，并据此制定具体的治疗计划。这包括识别哪些行为是问题行为，哪些是改进行为，并根据这些信息调整治疗策略。

9. 案例概念化：

   • CRB 术语是 FAP 中案例概念化的重要基础。通过明确 CRB1 和 CRB2，治疗师可以更好地理解来访的问题，并制定针对性的干预措施。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 临床相关行为 (CRBs) 的定义与分类：

   • CRBs 是指在治疗过程中出现并与来访临床问题相关的具体行为。分为两类：问题行为（CRB1）和改进行为（CRB2）。这种分类有助于明确治疗目标，并提供具体的干预方向。

2. 行为功能的多面性：

   • 每个行为都可能有多种功能，这取决于情境和个人的动机。因此，对于同一个行为，可能有不同的解释，有的可能是问题行为（CRB1），有的则可能是改进行为（CRB2）。

3. 功能性分析的重要性：

   • 通过功能性分析，治疗师可以深入理解来访的行为模式及其背后的原因。这有助于制定更有针对性的干预策略，从而更有效地解决问题。

4. 行为功能的识别：

   • 识别行为的功能是功能性分析的关键步骤。这需要治疗师具备敏锐的观察力和同理心，能够从多个角度理解和解释来访的行为。

5. 功能性个体化评估模板 (FIAT)：

   • FIAT 是一种有用的工具，用于识别和分类行为的功能。它提供了一个结构化的框架，帮助治疗师系统地分析来访的行为，并指导治疗过程。

6. 行为功能的动态变化：

   • 行为的功能可能会随时间和情境的变化而变化。治疗师需要持续评估和调整对行为功能的理解，以确保治疗的有效性。

7. 行为功能的复杂性：

   • 即使是看似简单的行为，也可能具有复杂的背景和功能。治疗师需要综合考虑多种因素，如个人经历、情感状态和社会环境等，才能全面理解行为的功能。

8. 治疗师的角色：

   • 治疗师不仅需要识别和理解行为的功能，还需要引导来访认识到这些功能，并帮助他们发展新的、更有效的应对策略。这需要治疗师具备良好的沟通技巧和心理支持能力。

9. 行为改变的过程：

   • 通过识别和理解行为的功能，治疗师可以制定具体的干预计划，帮助来访减少问题行为（CRB1），增加改进行为（CRB2）。这是一个逐步的过程，需要治疗师和来访的共同努力。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 类别A—需求的表达（识别与表达）

   • 定义：类别A的行为包括个人希望表达的各种需求，如意见、想法、信念、情感等。这些需求可以是对社会支持的实际需求，也可以是更抽象的情感需求。
   • CRB1s：识别和表达需求的困难可能导致多种问题行为，如难以识别需求、表达需求过于微妙或间接、过度依赖他人、过度独立等。
   • 重要性：能够有效表达需求是建立健康人际关系的关键。治疗师可以通过功能性分析帮助来访识别和改进这些行为。

2. 类别B—双向沟通（影响与反馈）

   • 定义：类别B的行为涉及个体如何影响他人以及如何给予和回应反馈。这包括对正面和负面反馈的处理能力。
   • CRB1s：难以接受或给予反馈、不合理期望、过度敏感或缺乏意识等都可能是问题行为。
   • 重要性：有效的双向沟通有助于建立信任和理解。治疗师可以帮助来访提高沟通技巧，从而改善人际关系。

3. 类别C—冲突

   • 定义：类别C的行为涉及个体在面对冲突时的应对方式，包括直接或间接的攻击性行为，以及回避和妥协的能力。
   • CRB1s：难以容忍冲突、表达负面情绪、回避冲突、过度道歉等都可能是问题行为。
   • 重要性：学会有效处理冲突是维持健康关系的重要技能。治疗师可以通过功能性分析帮助来访识别和改进这些行为，从而减少冲突带来的负面影响。

4. 类别D—披露与人际亲密

   • 定义：类别D的行为涉及个体如何与他人建立亲密关系，包括分享个人信息和情感的能力。
   • 重要性：建立亲密关系有助于增强社会支持和情感联系。治疗师可以通过功能性分析帮助来访识别和改进这些行为，从而促进更深层次的人际关系。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 类别D—披露与人际亲密

   • 定义：类别D的行为涉及建立和维护亲密关系的能力，包括自我披露、接受他人的亲密和关怀等。
   • CRB1s：难以进行对话、不愿意自我披露、对亲密感恐惧、不愿意承担情感风险等都是问题行为。
   • 重要性：建立亲密关系对于心理健康和社会支持至关重要。治疗师可以通过功能性分析帮助来访识别并改善这些行为，从而促进更健康的人际关系。

2. 类别E—情绪体验与表达

   • 定义：类别E的行为涉及各种情绪体验与表达，从负面情绪如悲伤和焦虑到正面情绪如爱和自豪。
   • CRB1s：难以识别情绪、故意隐藏情绪、情绪表达平淡或疏远、难以感受或表达各种情绪等都是问题行为。
   • 重要性：有效的情绪体验与表达对于心理健康和个人成长非常重要。治疗师可以帮助来访提高情绪调节能力，从而更好地应对生活中的挑战。

3. 灵活性：是1还是2？

   • 复杂性：在实际操作中，有时一个行为既包含问题行为（CRB1）又包含改进行为（CRB2）。这需要治疗师灵活地理解和处理。
   • 多重功能：同一行为可以具有多种功能，既有积极的一面也有消极的一面。治疗师应该能够识别这些多重功能，并根据具体情况制定干预策略。
   • 综合评估：治疗师不应仅仅局限于判断一个行为是CRB1还是CRB2，而应全面评估其功能，问“这种行为在哪些方面是改进，在哪些方面是问题？”
   • 干预策略：通过综合评估，治疗师可以更有针对性地培养改进行为（CRB2），同时减少问题行为（CRB1），或将问题行为转化为更有效的行为。

通过这些知识点，治疗师可以更有效地应用功能性分析，从而在治疗过程中提供更有针对性的支持。此外，这些原则也强调了治疗师在实践中积累经验和发展技能的重要性。

知识点阐述

1. 接受与承诺疗法矩阵 (ACT Matrix)

   • 定义：ACT矩阵是一种用于功能思维和区分1类行为（问题行为）与2类行为（改进行为）的强大工具。
   • 重要性：ACT矩阵提供了一个结构化的框架，帮助治疗师和来访理解行为的功能，并制定有效的干预策略。
   • 应用：通过使用ACT矩阵，治疗师可以更清晰地识别和处理来访的问题行为，并促进改进行为的发展。

2. 临床相关治疗师行为

   • 定义：治疗师的行为同样会对治疗过程产生重要影响。治疗师的行为可以分为T1s（干扰治疗过程的行为）和T2s（支持治疗过程的行为）。
   • 重要性：治疗师的行为不仅影响来访的治疗效果，也反映了治疗师自身的心理状态和专业技能。意识到这一点有助于提高治疗质量。
   • 具体行为：
     • T1s：过于控制、避免来访表达情绪、过度专注于解决问题等行为可能干扰治疗进程。
     • T2s：允许来访参与会话规划、鼓励情绪表达、提供验证和接纳等行为有助于支持治疗进程。

3. 治疗师自我反思的重要性

   • 定义：治疗师需要定期反思自己的行为模式，识别可能影响治疗效果的个人倾向。
   • 重要性：自我反思可以帮助治疗师更好地了解自己的优势和不足，从而改进治疗方法。
   • 具体实践：治疗师可以通过记录和回顾自己的行为，识别常见的T1s和T2s，并制定相应的改进措施。

4. 治疗师与来访之间的互动

   • 定义：治疗师与来访之间的互动是治疗过程的核心。治疗师的行为直接影响来访的行为和感受。
   • 重要性：良好的互动能够建立信任和理解，促进治疗进程；不良的互动可能导致治疗效果不佳。
   • 具体实践：治疗师应该注重倾听、共情和反馈，确保与来访的互动是积极和支持性的。

通过这些知识点，治疗师可以更好地理解和应用ACT矩阵，提升治疗效果。同时，治疗师的自我反思和持续改进也是提高治疗质量的关键。

知识点阐述

1. 功能分析的过程

   • 定义：功能分析是一个迭代的、假设检验的过程，涉及提问、调查、测试、修订和澄清。
   • 重要性：功能分析的核心在于帮助实现预期的治疗结果。如果分析未能达到这一目标，则需要进行修订或放弃。
   • 应用：功能分析不仅仅是理论上的，而是需要在实际治疗过程中不断调整和验证。

2. 假设检验的重要性

   • 定义：假设检验是指在功能分析过程中，通过不断的试验和验证来确定哪些干预措施有效。
   • 重要性：由于人类行为的复杂性，假设检验有助于治疗师逐步接近最有效的治疗方法。
   • 具体实践：治疗师应持续观察和记录来访的反应，根据反馈调整假设和干预策略。

3. 情境因素的影响

   • 定义：情境因素包括来访的具体情况、治疗师的情绪状态以及治疗环境等，这些都会影响功能分析的结果。
   • 重要性：全面考虑情境因素有助于治疗师做出更合适的回应，避免因忽视某些因素而导致误解或无效的干预。
   • 具体实践：治疗师应保持高度的自我意识，注意自己的情绪反应，并灵活调整与来访的互动方式。

4. 适应性和灵活性

   • 定义：功能分析是一个动态的过程，需要根据实际情况不断调整。
   • 重要性：随着来访行为的变化，新的挑战会出现，因此需要新的评估和分析。治疗师应具备适应性和灵活性，以应对这些变化。
   • 具体实践：治疗师应定期回顾和评估治疗计划，根据来访的进展和新出现的问题进行调整。

5. 来访行为的复杂性

   • 定义：来访的行为是一个复杂的系统，改变一个方面往往会影响到其他方面。
   • 重要性：理解行为的复杂性有助于治疗师制定更全面和有效的治疗计划。
   • 具体实践：治疗师应综合考虑来访的所有相关行为和情境因素，进行全面的功能分析。

通过这些知识点，治疗师可以更好地理解和应用功能分析，提高治疗效果。同时，治疗师的自我反思和持续改进也是提高治疗质量的关键。

知识点阐述

1. 功能分析的基本流程

   • 定义：功能分析可以通过结构化评估或非正式对话来进行，旨在理解行为的功能。
   • 重要性：通过系统地提问和倾听，治疗师可以更好地理解来访的行为及其背后的原因。
   • 具体实践：治疗师应根据提供的问题流程进行练习，逐步提高功能分析的能力。

2. 功能分析的核心问题

   • 定义：功能分析的核心问题包括识别问题情境、描述行为、确定关键行为、探讨行为在不同情境中的表现等。
   • 重要性：这些问题有助于揭示行为的即时回报、短期成本、长期后果以及不采取该行为时的挑战。
   • 具体实践：治疗师应通过具体的例子和对话来应用这些问题，确保来访的理解和合作。

3. 功能分析的步骤

   • 定位行为：识别与问题相关的行为。
   • 评估功能：确定这些行为的功能。
   • 注意功能类别：识别具有共同核心功能的行为集。
   • 定义改进：明确改进的方向和目标。
   • 治疗关系中的行为：注意问题行为在治疗关系中的表现，并识别即时的改进行为（CRB2）。

4. 功能分析的迭代过程

   • 定义：功能分析是一个迭代的过程，需要不断调整和验证。
   • 重要性：通过不断的测试和反馈，治疗师可以逐步接近最有效的治疗方法。
   • 具体实践：治疗师应定期回顾和评估治疗计划，根据来访的进展和新出现的问题进行调整。

5. 功能分析的应用

   • 定义：功能分析不仅限于理论上的分析，还需要在实际治疗过程中不断调整和验证。
   • 重要性：通过功能分析，治疗师可以更有效地帮助来访识别和改变问题行为，促进治疗效果。
   • 具体实践：治疗师应结合实际情况，灵活运用功能分析的方法，确保治疗的有效性和针对性。

通过这些知识点，治疗师可以更好地理解和应用功能分析，提高治疗效果。同时，治疗师的自我反思和持续改进也是提高治疗质量的关键。

CHAPTER 3 Stay Grounded in Functional Analysis A little reflection will show that there is beyond question a body of very important but unorganized knowledge which cannot possibly be called scientific in the sense of knowledge of general rules: the knowledge of the particular circumstances of time and place. —­F. A. Hayek Toward the end of the session, Tom seems to freeze. He had been engaging well, talking about his progress with writing this week. You ask him what obstacles might come up inside of him as he continues his writing and job search next week. “I still struggle with…am I likable?” He pauses. “Sometimes I wonder… It’s silly, but—­what do you really think about me?” You stumble for a moment, remembering a supervisor’s old rule: don’t answer the question directly. But that doesn’t seem quite right in the moment, so instead you decide to offer honesty. “I want you to know, first of all, that I’m honest with you about how I feel about you. I have so much respect for the work you’re doing here. I look forward to our sessions every week.” “I appreciate you saying that,” Tom says. “I guess there’s part of me that thinks you’re just being nice.” You see him freezing up for the next few minutes. He averts his eyes, and his breathing is high in his chest. You’re not sure what else to say, so you wrap up the session. A few hours later you receive an email: “I’m so sorry I screwed up. I froze. I could see the look on your face when I said you were just being nice. I always mess up like that. I hope you will forgive me.” What was happening for Tom in that moment in session? And for you? Functional analysis (FA) is the assessment framework that guides the process in FAP. It stands on top of the basic contextual behavioral foundation described in chapter 2. Moving beyond the general stance of CBS involves building a highly individualized and specific grasp of a particu- lar client’s behaviors and their functions—­including the “particular circumstances of time and place” that have shaped and continue to shape this client’s actions. FA can be a daunting, technical process. Like building skill at chess, or painting, or business negotiation, it can take years to master. This is because using FA to understand a unique situation requires not just understanding FA principles but also developing the capacity for pattern recogni- tion when applying those principles (How does this particular situation make sense? Have I seen this pattern before?). Pattern recognition facilitates making sense of complex information, and it is born from years of experience. We cannot promise to make you an expert at FA in one chapter. Instead, as in the previous chapter, we aim to present the key principles that represent the core clinical value of FA, and in this way we aim to get you started on the road to mastery. It will be up to you to practice. Doing a functional analysis suggests a discrete procedure, with distinct rules and a beginning, middle, and end. In clinical practice, FA might take this form at times, but more often—­as with many forms of assessment—­the process is more diffuse, iterative, and flexible. In fact, flexibility is a strength of FA. You can use it as much or as little as is effective. To start, we suggest the following reframing: rather than thinking of FA as a procedure, we invite you to practice “thinking function- ally.” Just as a chess player thinks about positions, a painter about light, or a negotiator about opening statements, a successful practitioner of FAP thinks about function. Thinking functionally is a process of building your understanding of how a behavior functions in the contexts that have shaped it. It revolves around three key questions: What is the behavior? In what contexts does it or did it occur? What is or was its function in those contexts? FAP especially focuses on functional thinking to work with a client’s problem behaviors that show up in the therapy process. The aim in FAP is to create a highly individualized, assessment-­ based approach to each therapy relationship. As you participate in the therapy process, functional thinking is a touchstone to return to again and again—­a reminder to notice function, to not let avoidance of important issues take root in the process, and to work the process in a way that’s effec- tive for the client. The process is what matters. FA is a tool for being focused and strategic in the process, not a replacement for the process. In this chapter, we’ll start with a broad application of thinking functionally and gradually narrow the focus to thinking about the therapy process. In the sections that follow, we lay out some basic steps involved in thinking functionally in FAP, starting with the questions above. STEP 1: ORIENT TO BEHAVIORS AND CONTEXTS In the case of Tom, whom we’ve been following from chapter 1, Tom came to therapy stating that his problem is “feeling so unworthy all the time. I need to feel more confident.” This is a typical presenting problem that we encounter in therapy. It is focused on a pervasive negative feeling and an inability to shake that feeling. To boot, it comes with an idea about what is needed instead: to feel confident. As you have no doubt experienced as a clinician, however, while the original pre- senting problem often describes exactly what the client most longs to fix, only sometimes does the presenting problem describe in a useful way what needs to change in order to produce that shift. We have to look deeper to find that useful understanding. The situation is similar any time we’re working with a complex system, and behavior is certainly a complex system. If you go to a physical therapist because your lower back hurts, it might turn out that the source of the problem lies in the placement of your computer monitor or a problem in your feet. Similarly, when a person feels depressed, the proximal source of the low mood might lie in a frustrating work environment, a divorce, a medical condition, and so on. Chronic irritability might originate in a sense of shame. Anxiety and a feeling of being out of control might arise out of rigid efforts to control. And so on. Clients may or may not be aware of the links between their problems and the sources of these problems. (And of course there may be multiple “sources” interacting in complex ways.) In turn, the pathway that leads from source to problem might involve a number of steps. The placement of the computer monitor causes lower back pain because neck position causes discom- fort, which causes postural changes that cause tension in other areas and, down the line, the result is back pain. The work situation punishes assertiveness, which gives rise to resentment and a sense of shame at home, and because the client lacks the skill for seeking support, hopelessness sets in. From a CBS perspective, then—­mirroring the task of “seeing behavior” described in the previ- ous chapter—­our initial task is to see and understand the behaviors involved in the client’s issues. To see that ongoing stream of behavior clearly, we ask questions—­lots of questions—­that build empathy and understanding and allow us to describe the client’s experience like a screenwriter or novelist. We might ask the following questions: What was happening when you started to feel that way? What were you doing? What were you thinking? What were you feeling? Where were you when that happened? What happened before that? What factors do you think contributed to that? When you felt that way, what did you do? What happened next? What did you do next? Then how did you feel? How did others respond? How did you respond? What happened after that? What else happened? These questions are all about understanding the sequence of events: everything that falls under the umbrella term “behavior”—­thoughts, feelings, urges, and actions—­as well as the responses of other people and the events in the world to which the client was responding. Notice that none of these questions include the word “why.” As a rule, we avoid why questions at this stage because why questions lead to reasons that may not be connected to the actual flow of events; for example, “I don’t know why—­I guess I’m just weak.” Or, “I don’t know, you tell me.” At the same time, bear in mind that you aren’t interested in the flow of events for its own sake. You are tracking the flow of behaviors and contexts relevant to a given client’s presenting problem. You are aiming to eventually zero in on what seem to be the key behaviors that lead to the present- ing problem, as identified by either you or the client. Imagine you have a client, Susan, who says she feels burned-­out at work. Here is some sample dialogue; it illustrates this process of tracking behaviors that lead to the presenting problem and zeroing in on the key behaviors that seem relevant. Therapist: So you feel burned-­out. Client: Yeah, I just really don’t want to be there. It’s agony to get out of bed on Monday morning. Therapist: Sounds really challenging. Tell me more about what it’s like to be at work. Actually, let’s review last week. When you arrived at work on Monday, what were you looking at? Client: Well, it starts even before that. I was already late on a project. I volunteered for it, stupidly, two weeks ago, even though I knew I wouldn’t have time for it. Then I pro- crastinated all day Saturday and most of Sunday, and then finally had to put in about six hours on Sunday evening. I was miserable. Therapist: Ugh. What was going on that you accepted a project even though you didn’t have time? Client: Oh, man. I do that a lot. Therapist: Do you say yes first and then think through the costs later? Client: Exactly. I’m a yes person. Therapist: Are you aware that saying yes might be a bad idea when you say it? Client: Well…yes, recently I have been having a little sense of dread when I sign up for new work. But the thought of saying no…that’s just not what you do. Therapist: That’s not what you do. I say no all the time. Client: Ha! At my work, not many people say no. I don’t say no. You get judged if you say no. Immediately with the inquiry—­“When you arrived at work on Monday, what were you looking at?”—­the client described a series of events that, based on the therapist’s understanding of burnout, seem likely to have contributed to the client’s presenting problem. Further questioning seemed to confirm this hunch. Imagine that more similar questions reveal a few key patterns that recur again and again: • She’s severely overcommitted, often sacrificing her evenings and weekends to work on projects that she doesn’t enjoy but has promised to complete. • She tends to quickly agree to doing more work and feels regret afterward. • She tends to avoid saying no or otherwise expressing her reservations about a task when speaking with supervisors. • She tends to get into arguments with coworkers about what she perceives as their inef- ficiencies that negatively impact her own work; she enters these conflicts in a confron- tational, judgmental way. In this relatively simple demonstration, Susan discovered that she already knew what many of the relevant patterns were but had not yet put together the whole picture in such a way that she could understand her experience. Toward the end of the discussion, then, you might step back and summarize what you have learned: I think you’re feeling burned-out for good reasons. You’re in a situation where your needs are constantly sacrificed in favor of work. You’re carrying a near-­constant state of stress about deadlines. You don’t feel able or hopeful about changing this situation. And you don’t have much support at work. In fact, your relationships with coworkers are often another source of stress. When there are multiple possible factors bearing upon a presenting problem, it can also be useful to ask a clarifying question to get at which factor is most important. You might ask Susan, “Which of these issues, if we fixed it, would have the biggest effect on your burnout?” Susan, for instance, might discover that even if she had less conflict with coworkers, she would still be stressed-­ out. After some discussion, you might discover that limiting her acceptance of new work will have the biggest impact; not only will it free up her weekends so she can take care of her relationships and do other rewarding things, but if she is less stressed overall she will be less likely to become upset with her coworkers’ foibles. STEP 2: CLARIFY FUNCTIONS As you zero in on the behaviors that seem to create the problem, you may begin to get a sense of how the behaviors function. Recall from chapter 2 that there are two very general classes of function: • Some behaviors function to move us toward something appetitive. • Some behaviors function to move us away from something aversive. Grasping the function more specifically usually involves digging into—­with more psychologi- cal depth—­the situations in which the problem behavior happens. This often means looking at the client’s experience—­emotions, thoughts, images, sensations, and so forth—­more closely. Consider the following exchange with Susan. Therapist: I’d like us to understand better what was going on for you in that moment when your supervisor asked for volunteers for a project, and out of everyone in the room, you were the one who immediately stepped forward. What was going on inside of you in that moment? Client: What do you mean? I think I just ha ve to say yes. Therapist: I get it. Let’s see if we can put that moment in slow motion. Let me ask a few ques- tions to help focus the lens. First, in the meeting last week, before there was a request for volunteers for the project, what were you feeling as you sat in the meeting? Client: Pretty good. I had just finished a report. Was kind of riding the high from that. Therapist: And what else? Client: Slightly annoyed, because I knew the POS group was going to sit on the report for a week and then make some annoying objections. Therapist: Okay. Hmm. Let me think. If you hadn’t been riding high, would you have been more or less likely to volunteer for the work? Client: Less likely. I would hesitate. That time I just dove right in. Therapist: Right, without connecting that the timelines were really not workable. Okay. So moving forward, one thing we might work on is ensuring there is a “waiting period” before any yes; that way you can check out the plan more carefully. [Here the thera- pist hypothesizes that the appetitive thing Susan moves toward, especially when feeling confident, is contribution. This is only a problem because she does it without regard of the workability of the commitment. In other words, Susan’s initiative does not work well in this context. She might need to learn the skill of the soft commit- ment: “I would be willing to do it, but can I have an hour to just confirm that this will be workable?”] Therapist: Okay, now let’s go back to the POS group. When you say yes, what does it get you with respect to them? Client: Oh, simple. It shows them that I am going to keep moving no matter what. I’m the achiever. I look good. Therapist: Does it say the same thing to your supervisor? Client: Yes. Though…good lord! Who knows if that’s really true. She knows I’m burned-­out as well. Therapist: And…imagine this. If you had slowed down and considered that this timeline was actually not a good fit for you, what would have happened if you didn’t raise your hand to volunteer? Client: Oh. Well, it would have felt uncomfortable. I’d sit there awkwardly waiting… I’d think, “Is anyone else going to step up? What a bunch of slackers.” Therapist: Would you think about what they’re thinking of you? Client: Of course. I always step up, so they’d be thinking, “Where’s Susan?” Therapist: So is it fair to say your impulsive volunteering is partially about an unwillingness to sit in that discomfort and risk your coworkers thinking you’re not showing up? And you are also wanting to show the POS group and the supervisors that you are on the ball, even though you don’t know if that’s really the effect you are having on them? And those little nudges are enough to propel you to unwise yes after unwise yes? Client: Yes, that’s fair. For Susan, in the situation where she impulsively says yes, the therapist has identified a couple of functions of that behavior: She is moving toward the appetitive stimuli of being accomplished at work and looking good to her colleagues and supervisor. She is also moving away from the aversive stimulus of their questioning her willingness. At this point, the three main questions of functional analysis have been addressed: What is the behavior? In what contexts does it or did it occur? What is or was its function in those contexts? And look how far the therapist has come from Susan’s presenting problem of “I feel burned-­out at work.” Again, in terms of general heuristics, you are looking for only a few basic functional patterns: • The client’s behavior functions to avoid something unpleasant (real or imagined). • The client’s behavior functions to approach something appetitive (real or imagined). Your search for function has gone far enough when there is a sense of coherence—­as in yes, that makes sense—­and a sense that there is an adequate explanation of the presenting problem. Let’s look at a couple of more subtle points related to this process of clarifying function. Zeroing In on the Functional Consequence A common pitfall in functional thinking is making the assumption that a seemingly aversive response has the function of punishing a problem behavior, and then being puzzled at why the behavior persists. For example, let’s say a woman gives her husband the cold shoulder and he gets angry and yells at her. Why would she persist then in stonewalling him? Or consider Susan: If saying yes consistently lands her in hot water, why does she persist? The reality is, if the behavior is happening, there is some form of payoff—­either now, in the past, or intermittently. For example, for the woman who is stonewalling, it’s possible that shutting down—­even though her husband yells at her—­feels safer and more powerful than trying to speak when she is upset and hurt. In other words, the consequence of getting yelled at is not the functional consequence—­the consequence that actually influences her. The consequence that influences her is the relative sense of control she gets. For Susan, the situation is similar. The functional consequence is the immediate sense of looking good and not looking bad. The negative consequence of burnout doesn’t actually have enough influence over her in that moment to lead to a different choice. This counterintuitive assessment also applies to seemingly appetitive consequences. “I know I should just fill out my time card, but I just don’t want to do it…so I procrastinate all day.” Some people might think of turning in their work hours as moving toward something appetitive because it leads to being paid; however, let’s look more closely at the actual function of the behavior in this example. It’s possible that avoiding the time card all day allows a continuous escape from the aver- sive experience of facing the fact that hours are short this week, so it will be difficult to pay the bills. Inquiring About Avoidance One important thing to note about avoidance is that sometimes we’ve avoided some situation—­ perhaps a painful experience from the past—­so thoroughly and for so long that it is no longer clear what we are avoiding or whether the thing we fear would actually occur in the present. Susan’s volunteering, for example, helps her avoid the (imaginary) situation in which others think poorly of her. However, by facing that fear, she might discover that in fact nobody judges her when she hangs back. For this reason, it can be useful to put the client in touch with what he or she might contact by no longer avoiding a situation. Try starting the exploration with this question: What would you have to face (or do or feel or respond to) if you didn’t do this behavior? Going into History As suggested in the passage above, to understand why a behavior happens in the present, it’s often useful to get into the history of the behavior. In relation to avoidance, the thing that a behav- ior functions to avoid (for Susan, being judged) might not actually be present in the present. But if we look into the history, we will find it. Therapist: Do you remember experiencing the fear that others would judge you—­that they’ll think you’re not going to show up—­earlier in your life? Client: [pauses] Well… Oh, yeah. I was going to say no, but…that’s the whole story of me and my mom. Especially after her divorce, it felt like she was constantly hounding me to be there. I hated that. What emerges in this conversation is that Susan has a long history of people reacting negatively to her “not showing up”—­that is, their perception of her not being there. She learned that “not showing up” incurs judgment, which is painful to her, and so she works to avoid that aversive situ- ation. However, working to avoid that aversive outcome by constantly showing up is now having a nega- tive effect on her life. What she doesn’t realize is that, in general, others are much less likely to judge her than she fears. Getting clarity about how the past is different from the present can help people become more flexible. Going into the Future Finally, when clarifying the function of a behavior, it can be useful to go into the future. For example, we might balance out the “consequences now matter more than consequences later” problem by getting in closer contact with the future consequences of a problem behavior. With Susan, we might spend some time discussing the likely consequences if she continues to work at her current level of burnout. Therapist: What will happen if you keep living this way—­say, for another twenty years? Client: 48 That’s hard to think about. Who knows what would happen to my health. Could I physically keep going that long? My son…he wouldn’t know me. That’s horrible to think about. Even though examining consequences is often painful, it can help increase the motivation to change the behavior because doing so makes the aversive consequences of maintaining the problem pattern more salient and more painful. The flip side of this pain is to get in contact with what might be gained—­what purpose, what meaning, what goals, what freedom—­if one were to let go of the constricted problem behavior. STEP 3: LOOK FOR FUNCTIONAL CLASSES Once you have collected a set of problem behaviors and identified their functions, you will start to notice basic patterns in the function of the problematic behaviors that are somewhat unique to the individual. For instance, Susan is very sensitive to looking bad to others, and she will work hard to look good even when the costs are high (burnout, conflict, and so on). We can then start looking for other situations in which Susan similarly avoids (something like) “looking bad.” In other words, we now have a hypothesis about how Susan might struggle in other parts of her life. Therapist: Are there other places in your life where you try to avoid looking bad? Does it ever happen with your husband? Client: Yeah. I hate it when he is critical of me. Or sometimes even an innocent question— for some reason I take it as an attack. Then I can be really bitchy with him. We might then ask if she has experienced a related dynamic with friends. Susan discloses that she lost one of her best friends due to complex circumstances: Susan had to cancel attending her wedding, letting her friend down, and since then Susan has been unable to feel connected to her friend due to feelings of deep shame. As different as these behaviors may appear on the surface—­volunteering for more work, speak- ing crossly to her husband, and withdrawing from her friend—­they all have a common function: helping Susan avoid feeling ashamed or deficient or “not looking good.” Behaviors are functionally similar when they serve similar core functions: for instance, avoiding some specific feared outcome or seeking some desired appetitive outcome. In turn, once you can see the common function, there is an opportunity to focus more flexibly on the root problem—­facing shame, in Susan’s case. Sets of behaviors defined by a core common function in this way are known as functional classes. You can look clearly at the cost of the whole class. You can muster reasons to overcome this struggle. And you can look for instances of the functional class occurring in the therapy process. More on this key element of FAP in step 5 below. STEP 4: DEFINE IMPROVEMENTS Up to this point, we’ve focused on problem behaviors. The next step in functional analysis—­and an extremely important one—­is identifying and testing behaviors that will help alleviate a client’s problems. With Susan’s problem of overcommitting by saying yes impulsively, we might improve her skill at saying no, which could help her say no in ways that are more likely to garner people’s understanding and support rather than their judgment. Once you have a hypothesis about which behavior would be more effective at a crucial moment for the client, you can help the client put that behavior in place. Then you can evaluate whether or not the behavior helps. With enough practice, does the behavior help change the whole stream of behavior such that the presenting problem is somewhat ameliorated? STEP 5: NOTICING CLINICALLY RELEVANT BEHAVIOR Now we’ll look at a very important focus of functional thinking in FAP: seeing the client’s problem behaviors (and improvements) when they occur in the session and in the therapy relationship. Noticing clinically relevant behavior in the moment is key in FAP because of the opportunity and the liability described in chapter 1: if we don’t see these behaviors clearly, we risk reinforcing problem behaviors or punishing the tentative steps toward improvement or change. If we see the behaviors clearly and understand what they mean—­that is, how they function for this person—­ then we can make sure we respond therapeutically. What do we mean? Instead of reinforcing problem behavior, we evoke and reinforce needed improvements in a way that is authentic and compassionate. This process is the focus of the remainder of the book. Why is functional thinking useful for this process? For starters, function is not typically visible, so delving deeper into the function of a behavior in order to understand it is very useful. Also, once you can see a client’s behavior in functional terms (as functional classes, for instance), it becomes easier to notice moments in which the behavior arises, even if what happens in session is, on the surface, quite different from what happens outside—­in the client’s life. Here’s an example of functional thinking: Imagine a client tells you—­as one of her presenting problems—­that she’s having trouble initiating sex with her partner. FAP would not call for you to look for situations in which the client might want to initiate sex with you so she can improve her skills in this area. Instead, your functional analysis might lead to the discovery that the behavior of initiating sex is part of a broader functional class of behaviors: this client generally finds it difficult to reach out sensitively but directly to someone else to get her needs met, and one place this deficit shows up is with her partner in the bedroom. If the client buys that this is a valuable area to work on, you can attend to situations in the therapy relationship that invoke this behavior, from mundane situations, such as needing to reschedule a session, to those that make the client feel more vulnerable. For example, perhaps she finds herself wondering one day if you really care about her, and she wishes to appropriately seek reassurance about that. Here’s another example: Susan is critical and defensive with her husband, overly compliant with her supervisors at work, and overly polite and nondemanding in session with you—­even though she occasionally appears irritated by something you’ve done. All of these behavioral exam- ples are instances of a general functional class of behaviors that function to avoid the vulnerability she feels when she is assertive about her needs. The common structure in all of these examples is that the problem behaviors both inside and outside of the therapy relationship are part of the same functional class. Being able to see the func- tion parallels between in-­session and out-­of-­session events helps build a momentum and coherence in the effort to change behavior—­“In here we’re going to work on the same things you’re working on in your life.” CRBS: CLINICALLY RELEVANT BEHAVIORS In FAP, we refer to behaviors that show up in the therapy room that are related to the client’s clini- cal problems as clinically relevant behaviors (CRBs). CRBs are divided into two categories: an example of problematic behavior is referred to as CRB1, and an example of improvement relative to this behavior is referred to as CRB2. With clients, we commonly drop the CRB prefix and just use the generic abbreviations “1” and “2” to refer to problems and improvements. These abbreviations become useful shorthand language, as in, “Did you just do a 1?” “Was that a 1 or a 2?” And so forth. A major strength of this terminology is its simplicity. Asking “Is this a 1 or a 2?” focuses the conversation on functional analysis. The question is easy to remember in the moment during therapy, yet it encapsulates a great deal. It represents the ongoing focus on the process of assess- ment and brings that focus to bear on the present moment. This CRB terminology allows us to state the aims of FAP quite simply. Clinically, we seek to reduce the frequency of CRB1 and increase the frequency of CRB2. Using functional analysis to define CRB1 and CRB2 is, therefore, the key aim of the functional analytic process in FAP. The terminology is also the foundation for case conceptualization in FAP. Key Features of CRB1 and CRB2

1. CRB1 and CRB2 are only CRBs because they are functionally related to the client’s presenting problems.
2. CRB1s and CRB2s should always be behaviors that clients have some control over and therefore can work on changing with deliberate effort. For instance, fear may be a prob- lematic response to showing vulnerability, but it’s hard to choose to change fear. A better focus—­one in which the client would have more choice—­might be the behav- iors the client engages in when afraid. For example, the CRB1 might be to hold back and avoid disclosing something to someone who is in fact trustworthy, and the CRB2 might be to disclose despite the fear.
3. Label CRB1 and CRB2 in ways that are empathic, validating, and motivating. Use the client’s own language when possible. Steer away from terminology that’s overly clinical or judgmental. It’s fine to use metaphors to describe functional classes of CRB. For instance, the behavior of avoiding self-­disclosure could quite reasonably be called “keeping your guard up” or “having your wall up,” and the behavior of disclosing too much too soon might be called “spilling.” Ensure sufficient precision by checking that you and your client are on the same page regarding how you use these terms.
4. Remember that CRB1 isn’t inherently bad, and CRB2 isn’t inherently good. In fact, it’s often important to relate to CRB1 with as much acceptance and compassion as you would to CRB2. Discriminating CRB1 and CRB2 In this section we offer some practice in thinking functionally—­specifically in discriminating 1s and 2s. Here’s a warm-­up. Imagine a client asks you to call her physician to request a prescription refill. What’s the function of this behavior for the client? If you’re like about 50 percent of people we’ve asked during trainings over the past couple of decades, you have an immediate sense that the behavior is problematic. Perhaps you think the client seems overly demanding or dependent, which is definitely a possible assessment. The client may have a habit of making excessive, unreasonable demands. In contrast, the client may also have a very good reason for asking you. Perhaps she is working hard to be more assertive because failing to do so in the past has caused her a lot of problems. Notice that the implications of these different functional interpretations of the request would steer your response in different directions. If the request is an example of CRB1, you might decline the request and ask the client to make the phone call herself. If it’s an example of CRB2, you might agree to make the call, perhaps also expressing that it’s not typical for you to agree to such requests, but in this situation you see how it could really help. EXERCISE: EXPLORING POTENTIAL FUNCTIONS OF CRB Read each scenario below, and then, on a separate piece of paper, write your ideas about what the functions of the behavior might be and whether the behavior is likely to be CRB1 or CRB2. Given the scant context we’re providing, there will be several functional possibilities in each case. The challenge is to write a few different interpretations for each scenario, including at least one in which the behavior is CRB1 and another in which it’s CRB2. Go through all four scenarios in this way before reading our sample interpretations. •Scenario 1: A client arrives for his session. When you ask him what he’d like to focus on in this session, he says, “I don’t know.” •Scenario 2: You greet a client in the waiting room and mistakenly call her by the wrong name. She appears irritated for a brief moment and is silent as you enter your office. •Scenario 3: At the end of a session, a client says, “I’ve been meaning to ask you something. I think you’re a pretty cool person. I wonder, when therapy is over, is there any chance you’d like to get a beer sometime?” •Scenario 4: You’re helping a client cope better with memories of trauma. One day in session she says, “Is it okay if we talk about something else today? There’s something I’d kind of like to talk about.” Here are our sample functional interpretations for these scenarios. As always, such interpretations are only hypotheses to be evaluated through assessment with a given client. • Scenario 1: A client arrives for his session. When you ask him what he’d like to focus on in this session, he says, “I don’t know.” Possible interpretation 1: This is CRB1 for the client. His avoidance of identifying and express- ing his needs leads to problems in many areas of his life. Possible interpretation 2: This is CRB2 for the client. He tends to excessively control himself, is perfectionistic, and avoids asking for help when he doesn’t know what to do. Saying “I don’t know” represents a step toward identifying a situation in which he needs help and engaging in a meaningful dialogue about that situation with the therapist. • Scenario 2: You greet a client in the waiting room and mistakenly call her by the wrong name. She appears irritated for a brief moment and is silent as you enter your office. Possible interpretation 1: This is CRB1. The client avoids expressing her irritation or disap- pointment with others and tends to gradually disconnect from them as her resentment grows. Possible interpretation 2: This is CRB2. The client usually overreacts to minor slights, which causes difficulties in her relationships. In this instance she’s been successful in not overreacting. • Scenario 3: At the end of a session, a client says, “I’ve been meaning to ask you something. I think you’re a pretty cool person. I wonder, when therapy is over, is there any chance you’d like to get a beer sometime?” Possible interpretation 1: This is CRB1. The client tends to be oblivious to social limits (such as the difference between a therapeutic relationship and a friendship), and this insensitivity creates conflict and suffering for him. Possible interpretation 2: This is CRB2. The client pervasively avoids asking for what he wants, and he’s working on being more assertive, regardless of the possibility of being declined or rejected. • Scenario 4: You’re helping a client cope better with memories of trauma. One day in session, she says, “Is it okay if we talk about something else today? There’s something I’d kind of like to talk about.” Possible interpretation 1: This is CRB1. The client consistently tries to avoid her trauma memories and primarily uses distraction to cope with those memories and the emotions they bring up. Possible interpretation 2: This is CRB2. The client tends to be so preoccupied with her trauma that she neglects other important aspects of her life. The Functional Idiographic Assessment Template When starting functional analysis with a client, you can begin with a blank slate, creating a way of talking about the client’s problems that is completely tailored to her. That said, sometimes it’s helpful to review existing lists of common CRBs or, more broadly, functional classes of interper- sonal behavior relevant to FAP with your client. Rather than making a description from scratch, these lists provide language you and the client can choose from to describe what might be happening. Glenn Callaghan (2006) developed the functional idiographic assessment template (FIAT), a tool for identifying functional classes of behavior when performing FAP. Callaghan analyzed the typical FAP treatment targets among his own clients and his students’ clients and came up with a set of five key functional classes of interpersonal behavior. He organized these functional classes into a questionnaire with numerous specific behaviors set forth for each class. You may find the full FIAT useful in identifying CRB1s and CRB2s, especially as you’re getting familiar with the FAP approach. It can be found at http://www.functionalanalyticpsychotherapy.com/fiat.pdf. For the purposes of this chapter, we’ve streamlined the items on the FIAT, presenting them as descriptions rather than questions. Keeping in mind the five classes of behavior can help you be alert to specific in-­session behaviors that may indicate a possible CRB1. The worksheet only lists CRB1s, but deriving corresponding CRB2s is straightforward. And doing so can stimulate your thinking when you work on case conceptualization. You may also find it useful to show the form to clients and to work together collaboratively to identify the behaviors that are relevant for the client. Read through the following descriptions of various types of CRB1 and check off any that arise frequently, either in session or outside of session. Take special note of any categories for which many items are checked. They could represent classes of behavior that are particularly problematic or where improvements would be most useful. CLASS A—­ASSERTION OF NEEDS (IDENTIFICATION AND EXPRESSION) Class A behaviors include anything people want or value or “need,” including the need to state opinions, ideas, convictions, passions, longings, desires, dreams, and—­basically—­who they are. “Assertion of needs” also includes making requests for social support or other needs that are more practical. Possible Class A CRB1s    Difficulty identifying needs or the type of help or support wished for from the therapist or others    Difficulty expressing needs    Difficulty getting needs met by the therapist or others    Expressing needs too subtly or indirectly    Pushing the therapist or others away with neediness    Giving much more than is received in return    Being extremely independent and feeling too vulnerable when receiving help    Being too demanding when asking for needs to be met    Being unable to tolerate the therapist or others saying no to requests    Other: CLASS B—­BIDIRECTIONAL COMMUNICATION (IMPACTS AND FEEDBACK) Class B behaviors involve how people affect others and how they give and respond to feedback. The term “feedback” refers to how others respond and react to the person’s behavior. Feedback can be verbal or nonverbal and in the form of facial expressions, body language, and so on. Possible Class B CRB1s    Difficulty receiving positive feedback, such as appreciation or compliments    Difficulty receiving negative feedback, such as criticism    Difficulty giving positive feedback    Difficulty giving negative feedback, including constructive criticism    Having unreasonable self-­expectations, which may show up as perfectionism or a pervasive sense of failure    Having unreasonable expectations of the therapist or others    Being hypersensitive to or overly aware of his or her impact on the therapist or others    Not having much awareness of his or her impact on the therapist or others    Inaccurately assessing his or her impact on the therapist or others    Being hard to track or follow in conversation    Talking too much or for too long without checking impact    Making too much eye contact    Making too little eye contact    Other: CLASS C—­CONFLICT Aggressive or hostile class C behavior is just one of many potentially problematic behaviors that can come up with conflict. Unworkable responses to disagreement or uncomfortable interac- tions can also include many behaviors that are more passive or avoidant. Possible Class C CRB1s    Difficulty tolerating conflict or disagreement    Difficulty expressing negative feelings    Avoiding conflict    Expressing anger indirectly, such as by being passive-­aggressive    Expressing too much anger    Not being willing to compromise    Being ineffective at resolving conflict    Apologizing too much    Assuming everything is his or her fault    Blaming the therapist or others for problems    Creating unnecessary conflict    Using conflict as way to avoid closeness    Being unwilling to forgive the therapist or others    Other: CLASS D—­DISCLOSURE AND INTERPERSONAL CLOSENESS Class D behaviors relate to “interpersonal closeness,” which refers to behaviors that lead to feeling connected to or close with another person. Possible Class D CRB1s    Difficulty conversing    Difficulty expressing closeness and caring    Difficulty receiving closeness and caring    Being fearful of closeness or attachment    Being reluctant to take emotional risks    Being reluctant to self-­disclose    Being reluctant to let his or her true self be seen or heard    Downplaying the importance of what he or she shares    Talking about himself or herself too much    Not listening well    Being self-­absorbed or asking for too much support    Being secretive    Being too intrusive when asking about the personal experiences of the therapist or others    Not being aware of the needs of the therapist or others (for example, going overtime in session or not giving the therapist openings to talk)    Talking too much and too tangentially    Not trusting others    Trusting others too easily or too soon    Other: CLASS E—­EMOTIONAL EXPERIENCE AND EXPRESSION Class E behaviors, related to emotional experience and expression, refer to all types of emo- tions, from sadness and anxiety to love and pride. Possible Class E CRB1s    Difficulty identifying emotions    Being unaware of emotions as they’re happening    Intentionally hiding emotions    Being flat or distant in emotional expression    Difficulty with crying    Difficulty feeling or expressing sorrow, sadness, or grief    Difficulty feeling or expressing anxiety or fear    Difficulty feeling or expressing joy    Difficulty feeling or expressing pride    Difficulty feeling or expressing humor    Engaging in negative self-­talk when feeling emotions    Expressing emotions in an overly intense manner    Unable to control his or her expression of emotions    Talking about emotions too much    Having overly labile or intense emotions    Unable to have perspective on his or her emotions; feeling overwhelmed by emotions and unable to detach from them    Expressing emotions in a way that annoys or alienates the therapist or others    Avoiding or suppressing certain emotions    Other: Flexibility: A 1 or a 2? As you think about the preceding examples or reflect on your own clients or yourself, you might notice something important: sometimes it isn’t at all clear whether a particular behavior is CRB1 or CRB2. In fact, a particular behavior may seem to include both problematic aspects and improvement. Let’s return to the example of the client who asks you to call her physician for a prescription refill. The request itself might in some ways be CRB2: it represents assertiveness, and the client’s life will be better if she’s more assertive. At the same time, the particular way in which she’s assertive (perhaps she doesn’t validate enough or her tone of voice is too harsh) causes her some trouble, so there’s an element of CRB1, as well. How does FAP deal with such situations? Although it can be useful to cleanly discriminate between CRB1 and CRB2, doing so shouldn’t be forced. Multiple functions, including problematic behavior and improvement, can and often do mingle in the same behavior. Recognizing that multiple functions are present allows us to move beyond the simpler question of whether a given behavior is CRB1 or CRB2 and instead ask, “How is this behavior an improvement, and how is it a problem?” From there we can nurture the threads of CRB2 and weed out the threads of CRB1, or we can shape CRB1 into more effective behavior. The ACT Matrix: A Very Useful Tool Another invaluable tool for functional thinking and discriminating 1s and 2s is the ACT matrix (Polk & Schoendorff, 2014; Polk, Schoendorff, Webster, & Olaz, 2016). We highly recommend The Essential Guide to the ACT Matrix, which discusses the use of the matrix tool in the context of ACT and FAP-­based treatment. Seriously, it is hard to overstate how useful the matrix is as a clinical tool! Clinically Relevant Therapist Behavior So far we’ve focused on client behaviors. But, as we stated in the introduction of this book, your behaviors as the therapist are an equally important part of the process of therapy. Anything and everything you do in therapy has a function for you and will have a function for your clients: your behavior will affect the clients in some way, and the effects can either support the therapeutic process or interfere with it. As part of your functional analysis of the in-­session process and the therapy relationship, therefore, FAP asks you to pay attention to your own behaviors as well as those of clients. More broadly, we invite you to develop a broader awareness of your patterns of behavior across cases: How do you tend to get into trouble or undermine progress as a therapist? When are you at your best? A therapist’s personal history and personal relationships are often involved in these patterns. We’ll address this topic of “personal” more directly in chapter 6. For example, with Susan you might grow impatient with her confusion about identifying her own needs more clearly or her anxiety about reducing behaviors that are clearly (to you) self-­ defeating, and your impatience might lead you to focus excessively on behavior change rather than building motivation, clarifying purpose, or finding emotional acceptance. You might see this pattern of impatience about behavior change show up commonly with anxious, highly controlled clients. Paralleling the terminology for client behaviors, therapist behaviors that interfere with the therapy process are known as T1s, and those that support therapy process are T2s. Like CRBs, T1s and T2s are defined based on how they function for you and your clients in therapy: Do they serve to facilitate or detract from therapy progress? You may, of course, have different T1s and T2s with different clients. Here are some examples: Examples of T1 • Being too controlling or directive • Avoiding clients’ expressions of emotion • Focusing excessively on problem solving (as opposed to validation, acceptance, and present-­moment experience) • Allowing clients to direct the focus of sessions in ineffective ways • Failing to define case conceptualizations or homework activities precisely enough Examples of T2 • Allowing clients to collaborate in planning sessions • Allowing or inviting clients’ expressions of emotion • Providing validation, expressing acceptance, and attending to present-­ moment experience • Directing the focus of the session effectively • Focusing attention on the problem solving needed to define precise treatment plans or homework assignments STEP 6: THE PROCESS OF FUNCTIONAL ANALYSIS—­ HYPOTHESIS TESTING Finally, let’s return to the notion of functional thinking—­or functional analysis—­as a process. We labeled this section “step 6,” but it’s not really a discrete step. If it were a step, it would be looping back through all the previous steps as you learn more about the client and what works in therapy to help him move forward. In other words: functional thinking is an iterative, hypothesis-­testing process. It is a process of questioning, investigating, testing, revising, and clarifying. The most important—­possibly the only—­criterion by which a functional analysis is judged is this: Has this analysis helped us achieve the desired therapy outcomes? If not, no matter how coherent or elegant or right the analysis feels to you, it must be revised or discarded. A spirit of hypothesis testing and iteration is important, as well, because the phenomenon we are seeking to understand is inherently complex. We have to puzzle our way through it. To illus- trate, we’ll explore the example of the client who asks you to call her physician for a prescription refill. If you follow our guidelines in this chapter, your first step would probably be to consider the client’s stated clinical goals. Let’s say she has ongoing difficulty expressing her needs. Perhaps she has an overbearing husband and an extremely demanding boss, and she’s mostly focused on being obedient and staying quiet, at the cost of feeling disconnected and miserable. In this context, you might notice that asserting her needs in this way is something new, even if it seems clumsy. Therefore, it would be extremely important to recognize this in your response. If you continue to explore, however, you might discover other aspects of the behavior or context that might temper your response. For example, perhaps when she does, on rare occasion, assert her needs, she tends to make rather rigid and inconvenient requests, alienating others or leaving them unhappy with her. As a result, they typically refuse her requests or comply only begrudgingly. Ultimately, she walks away from these interactions thinking that requesting things of people doesn’t work very well. And because she’s blind to the way her requests come across as rigid and inconsiderate, she’s decided that it’s only worthwhile to inconvenience others if a request is extremely important. How might these considerations shape how you respond to her? Now we’ll make this situation even more realistic—­and realistically complex. Imagine that the client makes her request at a time when you’re feeling especially harried in life. Perhaps the session is already running overtime. Maybe you’re thinking about your next client, who’s one of the most challenging clients you’ve ever had. Perhaps you’re experiencing health problems or feel you don’t have enough time for yourself. For whatever reason, when you hear this request to do yet another thing, you immediately feel tension in your body. How would all of this impact how you respond to her? Now imagine that this client is very attuned to your emotional response. She accurately per- ceives your response as stress or irritation, and she interprets your response to mean “My therapist is angry at me and I made a mistake.” If you’re attuned to her as well and sense this reaction—­and how it fits in with her presenting problem—­how would those aspects of context shape your response? In contrast, if she doesn’t tune in to your emotional response to her request, how would this shape your response? Ideally, your functional thinking becomes responsive to all aspects of context. After all, these kinds of complex, evolving contexts are the arena in which clients’ behaviors are functioning and in which they must find their way. Finally, thinking functionally is a process because behavior is a complex system. As we help clients change one aspect of their behavior, often new challenges emerge, and thus new assessment—­ new analysis—­is needed. The client who stops drinking alcohol, for instance, now has to deal with lots of difficult emotions. Once Susan has learned to be more assertive, she now has to contend with her dissatisfaction with her job and her husband. Functional thinking is an adaptive process that serves the process of therapy. A Basic Functional Analysis “Script” Functional analysis can take a variety of forms. It can happen in a more structured assessment, or it can happen more casually, spread out over many sessions. It can be incredibly technical and detailed, or it can be quite loose and seemingly conversational. Over the years we have found that a few core common questions define many functional analy- sis conversations, and these questions can often be organized into a kind of natural flow. Here is a version of that flow. To build your skill with functional thinking, you might practice this flow with a partner. Ask your partner to pick a real-­life problem situation, and then ask the following questions. Listen sup- portively to the answers. Don’t attempt to problem solve. Follow the flow of questions. Feel free to modify the questions slightly to fit the conversation you are having, but don’t deviate too much. Trust the questions. Observe the results. What is the problem situation that you want to talk about? What happens in that situation? What do you do? What does the other person do? Describe the interaction. What is the key thing you do in that situation that contributes to the problem? Be specific. Does that behavior ever show up in other situations in your life? Does that behavior ever show up between you and me? What is the immediate payoff for you doing that behavior? What do you “get”? What is the cost of that behavior in the short term? What will happen if this behavior continues long term? If you didn’t do that behavior, what would happen? What would be difficult? What would you have to face or feel or accept? For what purpose would you be willing to feel or face or accept that? Considering all of this, what is the key thing for you to work on? Once you have completed the flow, see if you can step back and summarize what you learned about the situation, the behavior, how the other person is stuck, and what that person needs to do to move forward. Ask for feedback about whether your summary is on track and whether the other person feels understood by you. Finally, exchange feedback about the process. For example: Which questions were especially useful? Which questions were less useful? Which questions were you uncomfortable asking but actually proved insightful? What insights were discovered? SUMMARY • Functional analysis is the central assessment method of FAP, standing upon the founda- tion of the CBS perspective. • Functional analysis is a complex method. Expertise is built, in part, on pattern recogni- tion and lots of experience. Start to master functional analysis by practicing functional thinking, which is centered on this question: “What is the function of this behavior?” • Functional analysis involves a few basic steps: • Orient to the behaviors involved in the presenting problems. • Assess function. • Notice functional classes (sets of behavior defined by a common core function). • Define improvements. • FAP adds a unique step to functional analysis: to notice how the problem behavior may show up in the therapy relationship. A CRB1 is an example of a client behavior related to problems occurring in the therapy session. A CRB2 is an example of an improvement occurring here and now. One aim of FAP therapy is to increase the frequency of CRB2 and decrease the frequency of CRB1. • Iterate the above process as needed until positive therapy results are achieved.