5 依据FAP五原则塑造过程

CHAPTER 5 Shape Process with the Five Rules of FAP It’s easy to think it’s about them, about him or her, but it’s about you. And me. Connecting. Right now, in this conversation. Not that one. This one. —­Susan Scott “Every time my wife criticizes my behavior, of course, I get defensive.” You pause as the dots connect. “Is it possible that this—­criticism, getting defensive—­occurred between us earlier in session?” There’s a flickering frown. “No, it’s pretty different here. Why would you ask that?” “Well, I asked because it seemed like you were a little defensive then. And…you seem a little defensive now. Do you see what I mean?” She shrugs, irritated. “Okay, well now that you point it out, yes.” “What could you try right now that would appear less defensive?” “I guess…” She stops and appears to stare off into the distance. “I feel like when I receive criticism, my mood changes very quickly and I feel as though my self-­esteem has deflated. And my guard goes up.” Suddenly, she seems on the verge of being tearful. You are surprised at the change in her tone. “You know. It’s amazing how different that sounds. How different it feels. What is it like for you?” “Vulnerable. I’m anxious.” She purses her lips and looks away. “Anyway…” “Is it okay if we just pause in this?” You pause a few beats. “I know we’ve talked about it before…it just strikes me how that bit of pause, that bit of vulnerability—­even about the fact that you feel guarded, it makes all the difference. I know she wants you to give her this as well. And give it to yourself. It means so much.” “It’s so hard for me…” She is tearful this time. “I know. What does it mean for you?” “Just that I could relax and be…trust her. I’m like a feral cat so much of the time.” She weeps softly. “I want that for you too. To be able to take that pause and be seen…to let yourself be. Let her see you. What if you could do this with her?” When a client brings her interpersonal struggle—­bound up with her psychological strug- gle—­to the therapy relationship, when you see the very issue that is causing strife in her relationships occurring here and now, in therapy, you have a liability and an opportunity. Your relationship, here and now, will leave a mark. The liability rests in replicating what experience has shown her: that vulnerability is dangerous; that it’s better to remain distanced and defended. If, however, you have done the work to know her interpersonally—­to see, for instance, how resistance to asking for what she needs, in part, maintains her depression and leaves her feeling voiceless—­then you may see the behavior for what it is: something learned and once adaptive but now maladaptive; a costly and avoidant behavior that is both comfortable and uncomfortable at the same time. If you have done the work to know her empathically, so you can know what this moment feels like for her on the inside, you will be able to pause sensitively. You will be able to disrupt what normally happens in order to create something different. This is your opportunity, in which you will be able to walk with her into the novelty and anxiety of change. FAP is about these moments in the therapy relationship, when a compassionate (and functional) understanding of the other person allows you to see and evoke and reinforce a different way of relating. In the first half of this book, we have mainly focused on the first part of this formula: seeing behavior from a contextual behavioral science, or functional, perspective. While this seeing is foundational to FAP, the heart of the FAP process lies in how you use that seeing to create change. The process of change in FAP is essentially the process of influencing CRBs, as they happen in the therapy process, in such a way that you decrease the frequency of CRB1 and increase the fre- quency of CRB2. In this chapter, we present five rules (originally published in Kohlenberg & Tsai, 1991) to guide you in the process. Note that we use the term “rule” in a specific sense, meaning “Try it; you’ll probably like it because good things will happen.” This is in opposition to a more rigid prescription: “The rules are something you must do or something bad will happen.” The five rules are a learning tool to help you get your head around the FAP process. This chapter is primarily devoted to discussing each rule. For each, we’ve included questions for self-­ reflection or consultation. In part 2 of the book, we’ll detail how to practice with these rules. Here, then, are the rules: Rule 1: Notice CRB. Rule 2: Evoke CRB. Rule 3: Reinforce CRB2. Rule 4: Notice your effect. Rule 5: Support generalization. RULE 1: NOTICE CRB Over the years, Bob Kohlenberg has often said that rule 1 is the most important rule in FAP. The reason is captured somewhat in our discussion of Carl Rogers in chapter 2: when you understand which behaviors serve a client and represent growth and flexibility and which represent being stuck and don’t serve the client, you’ll naturally tend to respond in ways that nurture and support the more effective behaviors. Broadly, then, rule 1 is about awareness: understanding what is evoked in the client during the work of therapy and how that behavior relates to the clinical problem. It also involves empathy, as what’s needed in the moment is an exquisite sensitivity to the client’s experi- ence, who she ideally wants to be, and how close she is to that ideal in each moment. Because this awareness is structured by functional analysis, rule 1 encompasses much of FAP and is the foundation for all the other rules. More technically, noticing CRB is about discriminating which behaviors are CRB1 and which are CRB2, as well as how these are being evoked and shaped in the moment. As discussed in chapter 3, on functional analysis, this requires appreciating the larger context in which the client lives and understanding the emotions and other internal experi- ences she may be experiencing. This process of seeing various contexts and functions in the stream of behavior—­and all of the associated judgments about what’s effective and what isn’t—­is ongoing, collaborative, and complex. We’ll address the specifics of how to put this rule into practice in part 2 of the book. For now, we’ll offer a few examples of noticing CRB in the moment. As you’ll see, these observations only take on a definite meaning in the context of a broader functional analysis: • A client seems overly accommodating when it comes to scheduling, and despite this being convenient for you, you also know that she struggles with asserting her needs. • A client seems to close up in a big way, with body language indicating shame, when you touch upon a particular topic. • A client whose relationships are characterized by a lot of avoidance and conflict seems underengaged in session, and it seems the therapy isn’t meeting his needs. • A client who struggles to express emotion in her daily life cries in one session, and at the next she seems withdrawn. • Despite appearing to be quite honest and direct in his disclosures, a client confuses you by seeming to shift between radically different views of himself and the world, and he also complains that nobody understands him or wants to get close to him. Questions for Self-­Reflection or Consultation: Rule 1 •What are the client’s patterns in interpersonal relationships in daily life? Which patterns are problematic? •What are the patterns in the client’s process with you? •Are there any points of functional similarity between outside-­of-­session relationships and in-­ session processes? •What are the client’s specific behaviors related to these patterns? •Which of your behaviors contribute to these patterns? •Are there any noteworthy patterns in the therapy relationship that are difficult to conceptual- ize, such as the client being confusing, annoying, or unsettling? •Do you have any blind spots, areas of confusion, or vulnerabilities, perhaps related to your life history, that affect your ability to see the client’s CRBs clearly? RULE 2: EVOKE CRB Once you attune with exquisite sensitivity to the client in the moment and can see the functions of what’s happening in the here and now, you can be more strategic and explicit about creating a context in which CRBs are evoked. In other words, you can talk directly about what’s happening in the therapy relationship, how it relates to clinical problems, and how different, more effective responses can be practiced. Rule 2 is about being strategically and deliberately evocative in this way. Said another way, once you clearly see the contexts in which a client struggles most and there- fore has the most to gain by improving her behavior, you have an opportunity. Beyond passively noticing CRBs when they happen naturally, in keeping with rule 1, you can invite the client to notice these moments as they happen and directly encourage a different response. This is where becoming a positive disruptive force for clients becomes a more deliberate, strategic, and collab- orative act of courage and compassion. It’s crucial that creating this kind of deliberate, evocative context doesn’t result in a more arti- ficial, manipulative-­feeling interaction, as this would undermine the foundation of social connec- tion on which everything else stands. The spirit of rule 2 is to attend to what happens naturally in the therapeutic process and approach what’s happening boldly, flexibly, and compassionately. In this way, rule 2 often requires courage from the therapist because evoking in order to prompt something new, outside the comfort zone, can disrupt behaviors that are the status quo path of least resistance for client and therapist alike. Yet if you avoid being evocative, you risk allowing dysfunctional patterns to continue and may even reinforce those patterns. Evoking has functions beyond prompting CRB. An evocative interaction also elicits a range of emotions, thoughts, and other reactions from both client and therapist. Often these reactions play a large role in why the desired CRB2 is so difficult. For instance, the prospect of asking for what one needs can be bundled with intense shame or anxiety, or sharing the experience of sadness with someone may be accompanied by a deep fear of humiliation. When you evoke CRB and begin to shape CRB2 (rule 3), you aren’t just asking clients to respond to what you’re presenting in the moment; you’re also inviting them to respond with acceptance and compassion to whatever they’re feeling in that moment. Therefore, when you evoke CRB, your responsibility is to be attuned and responsive to the entire moment and to support clients as much as you’re challenging them. Here are a few examples of evoking CRB in the moment: • If you know a client who struggles with asserting her needs, you can invite her to begin each session with a clear statement of her needs. • If a client fears intimacy, you could courageously ask him to practice sharing what he wants to avoid discussing and encourage him to ask personal questions of you that could build connection in the therapy relationship. • If you know a client has difficulty accepting love from others, you might ask her to notice your warm expression as she enters the room. • If a client has asked you for help in being more responsive to the emotions of his family members about a death in the family, you could spend a few minutes talking to him about your own mother’s death, providing him the opportunity to respond to your emo- tions (taking care to ensure that the interaction remains focused on the client’s goals). Questions for Self-­Reflection or Consultation: Rule 2 86 •Which situations in therapy or behaviors from you evoke CRB from the client? •What do you avoid doing because the client’s CRB is aversive to you? Are there any topics you’re avoiding, in regard to either the therapy relationship or the therapeutic process? Is that avoidance effective in therapy? •Have you brought up the issues you’ve identified in session? And have you owned your part in the cycles unfolding between you and the client? •When evoking CRB2, are you sensitive to the balance of courage and love the client needs? Are you courageous enough when evoking CRB? Are you loving enough? •If you were to describe the client’s struggle in the most clear, bold, and compassionate way, what would you say? Would it work to present this statement to the client? If yes, why? If not, why not? •How does your history affect the way you challenge the client or evoke CRB? RULE 3: REINFORCE CRB2 After noticing and evoking CRB, the next step in FAP is to shape CRB2 so it persists. From the contextual behavioral viewpoint, what matters most in accomplishing this is consequences: how you respond to CRB in the moment as it happens. Once you observe a more effective behavior (via rule 1) or directly evoke it (via rule 2), provide attention and respond in a way that will hopefully be reinforcing. FAP focuses on reinforcing CRB2 because aligning with the positive function of supportive social connection is a more potent and effective way to shape behavior than punishing CRB1. After all, think about how it feels to be in a relationship in which your steps toward growth are invited, praised, and supported, versus one in which your missteps are scrutinized and criticized. The former creates a more nurturing context for growth and well-­being. In this way, responsiveness to CRB2 (corresponding to love) is functionally equivalent to rule 3. In many ways, rule 3 lies at the heart of FAP because it instantiates a specific mechanism of change: reinforcement of CRB2. One could argue that the other rules only provide a supportive context for applying rule 3. The big challenge with rule 3 lies in determining which of your responses will actually function as reinforcing for a particular client in a particular context. The following sections provide some general guidelines in this regard. Respond in a way that’s socially natural but intense. Your responses need to make sense to the client and come across as relevant to the world outside of therapy, so it’s important to be socially natural. This is different from being socially typical or appropriate, as these kinds of responses often aren’t strong enough. Therefore, you would ideally identify your natural response and then amplify it beyond what social norms would dictate. This way, your response will be explicit and command attention and reflection. The most influential responses are likely to break the bounds of convention or propriety in this way, which is part of what makes them memorable and beneficially disruptive. To be clear, these responses break social conventions because they’re unusually strong or loud, not because they’re weird or hard to make sense of. They typically channel and express what other people might feel but not say. Emphasize safety and acceptance. When seen from an eagle’s-­eye view, high above and with good perspective, therapy is centered around working with a client who’s experiencing vulnerability and emotion in the context of a social interaction. What that client needs from you at a very basic level is safety and acceptance. It’s all too easy for therapists to get caught up in problem solving or wanting to “fix” clients and forget this basic vulnerability. Express to clients that they’re fully safe and accepted by you. Do this explicitly, with authenticity. Speak with conviction. Like everyone, clients have doubts, especially in the moments of vulnera- bility surrounding their CRB2s. So when you respond to CRB2, your voice should be clear, strong, and authentic. The best responses are bold and crystal clear, especially in terms of being 100 percent accepting of clients, no matter how emotional they get. This is especially important when clients are very emotional, because at these times they may latch onto ambiguities or silences and view them as indicators of judgments or lack of safety. Find a way to clearly and compassionately state your acceptance: “I want you to know that as you’re sharing this with me, I’m feeling 100 percent accepting and loving toward you, and I feel really confident that you’re safe with me.” Learn what works for a given client. For some people, intense, emotional outbursts of appreciation can be aversive, causing shame or raising fears that the person must now reciprocate or live up to a new standard. For others, highly emotional appreciation is extremely validating. As always, the function of the response is what matters—­not the form. This makes it important to attend to indi- vidual clients and discover what works for each. Be authentic. Most of all, don’t be phony. Humans are very skilled bullshit detectors, especially those who have been harmed by others in the past. Inauthenticity prevents or destroys connection and influence. Responsiveness is most effective when you bring your unique voice and emotion to it, rather than following a script, talking like a professional, or offering typical therapist responses such as “I’m so proud of you” or “You’re so courageous.” Conveying genuineness through tone of voice, eye contact, and facial expressions is also extremely important—­sometimes more important than your words. Here are few examples of reinforcing CRB2 in the moment: • Acknowledging a request for more session time by granting it. • Sharing a heartfelt response to the client’s life history, such as expressing how inspired and moved you are by her courage and persistence, and why you feel that way. • Saying something like “This is an awesome 2 for you!” while offering your hand for a high five. • Telling a client that his CRB2 has renewed your enthusiasm for your work. • Joining a client in her vulnerability after she describes something she feels ashamed about by sharing that you’ve had a similar experience. Questions for Self-­Reflection or Consultation: Rule 3 88 •Can you see the client’s moments of improvement? Do you feel engaged in the client’s process of change? •Is the client aware of your responses to her vulnerability, improvements, and growth? •Do you respond to the client in openhearted ways that feel genuine to you? •Do you hold back your authentic emotional responses or conceal them within a lot of other information, such as disclaimers, psychoeducation, or case formulation? •What do you value and cherish about the client? How has this client affected you? Have you let the client know these things?

RULE 4: NOTICE YOUR EFFECT Remember that reinforcement doesn’t exert its effects immediately. Rather, it’s a process in which behavior increases in frequency as a result of its consequences over time. Therefore, to ensure that you’re effectively reinforcing your clients’ CRB2s and helping them move toward their therapy goals, you need to attend not only to how you respond in the moment but also to how their behav- ior evolves over time. In fact, what happens over time is much more important than the events comprising any single moment. (And given that mistakes are inevitable in therapy, thank goodness for this fact.) The only way we can know the impact of any single moment of interaction is by noticing how the process of therapy unfolds over time. When CRB2s are increasing in strength and frequency and CRB1s are decreasing, then therapy is working. Of course, if this isn’t happening, you want to know that too. Therapy is always a work in progress. Here are a few examples of ways in which you can determine the effect of your actions in the therapeutic interaction: • After an intense exchange in which a client expressed a lot of emotion and you recipro- cated in a heartfelt way, you might inquire about how she experienced the interaction. • If you and the client seem to keep repeating a similar pattern, such as a session that’s more intensely emotional followed by a session that’s more withdrawn, you could ask the client whether he has the same impression and what that pattern might represent. • After you’ve tried to provide safety in response to a client’s vulnerability, you can directly ask whether she feels safer. • When a client is going through a stuck period in therapy, you could ask him whether he thinks anything you’re doing isn’t helpful. • At the end of each session, you might ask the client, “How was I in responding to you today?” • You can also use various monitoring tools or standardized measures, such as asking clients to use a diary card to record the frequency of their CRB1s and CRB2s in daily life. Questions for Self-­Reflection or Consultation: Rule 4 •Is the client changing within the therapeutic relationship over time? Are you seeing more CRB2 and less CRB1? •Are the two of you repeating the same cycles and patterns? •Are you talking with the client about how things are evolving in the therapeutic relationship and in the therapy? •Do you and the client discuss the effects you have on each other? •Do you acknowledge and discuss the changes you’re seeing in the moment? •Are you working with any issues or limitations of your own that could impede the client’s progress? RULE 5: SUPPORT GENERALIZATION Of course, the point of therapy is not just to change client behaviors in the therapy room; the goal is behavior change outside of therapy that’s sufficiently sustained and durable so that therapy can eventually end. Generalization is a behavioral term for the process by which behavior in one context transfers to other contexts. Thus, rule 5 calls for attending to and supporting the transfer of improvements from the context of therapy to all of the relevant contexts outside of therapy. In FAP, this generalization is achieved in two ways: by discussing functional analyses and case formu- lations, and by assigning home practice of CRB2. Discussing Functional Analyses and Case Formulations with Clients In FAP, therapists discuss their functional analyses and case formulation with clients and include them in developing the formulation as much as possible. This helps clients to start seeing how various functions show up in life outside of session. When clients are aware of the parallels between their in-­session and outside-­of-­session behaviors and can notice their CRBs in the moment, they can see the progress they’re making in therapy and how it can be meaningful and useful in other contexts. To this end, we recommend that you reflect on chapters 2 and 3, about seeing function and doing functional analysis, and think about how you can share those principles with clients: How can they collaborate with you in developing a functional analysis? Then take this approach whenever it makes sense, especially after you’ve reinforced CRB2. That’s the key moment when verbal learning will promote generalization of the new behavior to other contexts. Talk about what just happened so the client can see the connections between what she did as CRB2 and what you did in response, and how all of this matters and applies to her life. We have a term for this kind of debriefing: in-­to-­out parallels. This refers to taking what just hap- pened in session and making a parallel with a situation the client cares about outside of session. Here are a few examples of in-­to-­out parallels: • When you show vulnerability to me in here, you see how I can be really open and safe for you. It actually gives me space and motivates me to be there for you. I think your partner wants this from you too. What do you think? • When you ask me for what you need, I’ll always try to give it to you—­like right now. So guess what? I think this is true for your friends too. Maybe not every one of them, but from what I’ve heard from you, Mary really wants to support you, no? • I bet your mom would have the exact same look on her face as I do right now if you tried this with her. Assigning Home Practice of CRB2 The second way to implement rule 5 is by assigning homework—­typically working to practice new CRB2s, developed in session, with others. Take another look at those examples of in-­to-­out parallels we just provided. Can you see how each could lead to a specific homework assignment? The best assignments flow directly and immediately from powerful in-­session interactions. For example, consider a client who has difficulty forming close relationships and makes minimal eye contact with you when she’s struggling with expressing feelings. After identifying minimal eye contact as CRB1, you can establish increased eye contact as the relevant CRB2 and make this an explicit in-­session target. After an instance of reinforcing this CRB2 in the here and now, you could then ask the client to try to increase eye contact with others. All of this might be stated in the fol- lowing way: “When we first started therapy, you tended to avoid expressing your feelings and to reduce our connection by diverting your eyes. That created distance between us. After you became aware of this issue and were more willing to have eye contact with me and express your feelings, our relationship became closer. I’m going to suggest that you try to do the same thing with your friend Carol and see what happens to the closeness in your relationship with her.” You could then schedule a very specific homework assignment for the client to do this with Carol in a certain context. You might also discuss how this might feel risky, given that we can’t guarantee how others will respond, and why it might be important for the client to take the risk anyway. Here are a few examples of how you can promote generalization of new CRB2s: • Collaborate with the client in functional analysis and the identification of CRB1 and CRB2. • Get the client’s feedback about how in-­session moments are similar to or different from important out-­of-­session contexts. • Point out how what the client did in session with you is relevant to relating to others, and offer some guidance on how to practice the CRB2 with others. • For a client who has difficulty identifying her needs, after she’s successfully done so in session, assign homework that involves getting in touch with her needs each day. • Help the client schedule particular activities that offer opportunities to practice a new CRB2 immediately after that CRB2 shows up in session. Questions for Self-­Reflection or Consultation: Rule 5 •Does the client agree with your conceptualization of how his in-­session CRBs are functionally similar to relevant out-­of-­session behaviors? •If not, have you discussed where the two of you disagree? •Are you discussing the ways in which the client is taking what he’s experiencing with you out into his life? •How well is this transfer of CRB2 into daily life working? What might improve the process of generalization? EXPERIENCING THE FIVE RULES OF FAP IN CONTEXT We’ll close this chapter, and part 1 of the book, with the same dialogue that opened this chapter, but this time annotated to show the five rules of FAP in action and the CRB the therapist is responding to. Although it’s brief, the transcript also conveys the kind of relational focus, flexibil- ity, and individualization that’s characteristic of FAP. Note, however, that this is just one example of FAP as it plays out between one particular therapist and one particular client. FAP isn’t about a particular style; it’s about process. We’ll reinforce this important point in part 2 of the book, where we provide numerous dialogues illustrating FAP skills in action—­examples that demonstrate a range of therapeutic styles. “Every time my wife criticizes my behavior, of course, I get defensive.” [Description of an out-­of-­session problem.] You pause as the dots connect. “Is it possible that this—­criticism, getting defensive—­ occurred between us earlier in session?” [Noticing a potential CRB earlier in session (rule

1. and drawing a parallel.] There’s a flickering frown. “No, it’s pretty different here. Why would you ask that?” [CRB1.] “Well, I asked because it seemed like you were a little defensive then. And…you seem a little defensive now. Do you see what I mean?” [Rules 1 and 2: Noticing and evoking CRB.] She shrugs, irritated. “Okay, well now that you point it out, yes.” [Emerging CRB2.] “What could you try right now that would appear less defensive?” [Rule 2: Evoking CRB.] “I guess…” She stops and appears to stare off into the distance. “I feel like when I receive criticism, my mood changes very quickly and I feel as though my self-­esteem has deflated. And my guard goes up.” Suddenly she is on the verge of being tearful. [CRB2: Vulnerable self-­disclosure.] You are surprised at the change in her tone. “You know. It’s amazing how different that sounds. How different it feels. [Rule 3: Reinforcing CRB2.] What is it like for you?” [Rule 4: Checking on the effect of the therapist’s response to the client’s CRB2.] “Vulnerable. I’m anxious.” [CRB2.] She purses her lips and looks away. “Anyway…” [CRB1.] “Is it okay if we just pause in this?” You pause a few beats. [Rule 2: Evoking CRB.] “I know we’ve talked about it before… It just strikes me how that bit of pause, that bit of vulnerability—­even about the fact that you feel guarded, it makes all the difference. [Rule 3: Reinforcing CRB2.] I know she wants you to give her this as well. And give it to yourself. It means so much.” [Rule 5: Supporting generalization, in this case by describing the func- tion of in-­session behavior—­that her vulnerability leads to connection.] “It’s so hard for me…” She is tearful this time. [CRB2.] “I know. [Rule 3: Reinforcing CRB2.] What does it mean for you?” [Rule 2: Evoking CRB.] “Just that I could relax and be…trust her. I’m like a feral cat so much of the time.” She weeps softly. [CRB2.] “I want that for you too. To be able to take that pause and be seen…let yourself be. [Rule 3: Reinforcing CRB2.] Let her see you. What if you could do this with her?” [Rule 5: Supporting generalization by suggesting homework.] SUMMARY • The moment-­by-­moment process of FAP is guided by functional thinking and proceeds through the five rules of FAP. • Rule 1: Notice CRB. • Rule 2: Evoke CRB. oasis-ebl|Rsalles|1490374125 • Rule 3: Reinforce CRB2. • Rule 4: Notice your effect. • Rule 5: Support generalization. 93PA R T 2 The Practice I am rooted, but I flow. —­Virginia Woolf oasis-ebl|Rsalles|1490374121 When Nick came to therapy he was down a miserable, bitter hole. His voice on the answering machine was clipped: “I’ve been referred to you for treatment by the inpatient unit. How does this work? Call me back please.” Arriving at the first session, he sat tensely in a heavy peacoat and well-­worn Brooks Brothers shirt. His hair and beard were neatly trimmed. His body was tense and heavy, jaw set. His eyes, darting around, betrayed his anxiety but also a quickness of mind. He often seemed on the verge of rolling his eyes, anticipating the next annoying or mundane thing that might be said. Given the vagueness of the referral and the previous treatment notes, the first few sessions centered on diagnostic assessment and rapport building. What stood out to the therapist was the depth of Nick’s despair and the emptiness he felt. He also felt a lot of rage. Hatred, even. They talked about whether there was anything he liked. Sometimes he liked opera or classical music, but these also seemed to make him miserable, just slightly more exalted in his misery. Then in the third week, Nick took a big risk. He described what it felt like to go to a department event and perceive waves of little slights and insults coming at him from faculty and fellow graduate students; to feel a rising sense of fear, then terror, and then paranoia—­they must all be thinking that I’m a fool. Such interactions left him with a burning pain inside of his chest. “Is this normal?” he gasped. “I need to know if this is normal. I don’t have anywhere else to turn. It’s either work with you or I’m done. I will kill myself.” This moment—­when he was willing to share an experience that was deeply disturbing, that undermined his willingness to trust everyone—­was when the real therapeutic relationship started. He asked a genuine, vulnerable question and relied on the therapist’s responsiveness. Together the therapist and Nick eventually decided that the valid diagnosis was borderline personality disorder. The treatment that followed incorporated elements of dialectical behavior therapy, acceptance and commitment therapy, and FAP. The treatment took several years, and it was successful. Afterward, recalling what worked, Nick said it had helped that he and the therapist were the same age, that they shared a worldview, and that “he felt like me.” They developed a framework for thinking about what had happened to him, and how he was changing in the here and now. The core of what he experienced as being helpful was simple: deep empathy. This took many forms, including seeing the experience together, understanding it, naming it, and then asking for change—­inviting change even when it was difficult to change. They responded to victories and hashed out lots of disagreements. They looked at how Nick hid in the moment and how the therapist hid. They put a whole range of emotions onto the table. The therapist had to apologize numerous times, take feedback, and even share longings and aspirations to help paint the picture of what it means to be human.