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7 治疗初期打下基础

第七章

在治疗开始时奠定基础 超越是非对错的观念，有一片田野。 我会在那里与你相遇。 ——鲁米

亨利迟到了。三分钟……六分钟。你正准备给他打电话时，听到走廊里传来自信的脚步声，与上周电话中听到的声音相符。

他走进房间，不紧不慢地问道：“我迟到了吗？”

“是的，几分钟。”你回答道。

“这正是我喜欢的方式。”他似乎在研究墙上的艺术品，有些心不在焉，但感觉上他在展示自己的自信。轻松承认的背后有一丝歉意，但这很容易被忽略。

“你经常迟到吗？”

“是的，不幸的是，这是我常有的事。”他停顿了一下。“也许比我愿意承认的还要多。”

考虑到他面无表情的脸，他的坦诚让你有些惊讶。你进一步追问：“你总是避免为此道歉吗？”你的语气中没有责备，只有好奇。

他对你的直接感到惊讶。“哈！我不知道。我想是吧。”

随着会谈的进行，你对亨利有了更多的了解。他是一名刚毕业的大学生。他的父母和继父母都是高成就者。他小时候也惹了不少麻烦。

他表现得非常自信，甚至有些强硬。他的目光常常专注地看向窗外或地板。偶尔他会直视你的眼睛，似乎在向你展示他的自信。然而，你并不相信他的外表下的真正自信。

“你想从治疗中得到什么？”

“我不知道。只是想找个人聊聊。把事情说清楚。”

“嗯。我不太明白具体是什么意思。这样如何：我想理解你，帮助你理解自己，并帮助你朝着生活中重要的事情前进。你愿意这样做吗？”

“是的。”长时间的停顿。“其实，这正是我想要的。”

“我注意到你的一点是，你看起来很硬朗，但我看不清你内心的感受。我喜欢你的魅力和自信，但说实话，你表达方式有点让人不舒服。你是否意识到这一点？”

“是的。”又是一次停顿。“实际上，我经常觉得自己像个混蛋。”他说这话时并没有表现出脆弱。

你担心自己可能有点过于直接了，但他的诚实让你松了一口气。

“刚才我对你说得很直接。如果我有让你感到不舒服的地方，请告诉我好吗？”

“当然可以，但我希望你能这样。”

“实际上……我能看出你的自信或冷漠会吸引别人的直接反应。我也能理解这可能会让你保持不易受伤的状态，以某种方式保护自己。我想知道这是你学会的一种方式，还是你在追求某种标准。我说的这些对你来说有什么共鸣吗？”

“我不确定。我觉得我很开放。我们继续下去你会明白的。”

会谈后期，你意识到亨利对于他想要的东西仍然含糊其辞——不仅仅是关于治疗，还有他目前生活中的目标。他在谈论看似情感话题时隐藏了自己的情绪，或者根本没有接触到它们。他的自信有时会让人反感，但他也非常能够直接和真诚。这可能在某些情境下对他很有用，但在他的表面之下，有着痛苦和脆弱，或许他的自信和强硬是为了避免脆弱。你了解到他有很多需要达到的标准，并且他有相当长的历史因为自己的行为而受到负面评价。

在会谈接近尾声时，当他完成例行评估时，你问他是否曾经想过自杀。他停顿了一会儿。当他开口说话时，带着感情。

“我每天都在想。我不会真的去做，但我确实会想。”

“你还不太了解我。但对我来说最重要的是，我的工作基于现实——来访的实际经历。我不想在半真半假的基础上做治疗。所以我很感激你分享了这部分真实。这将使我们的合作更加顺利。反过来，我也会努力赢得你的信任。我会真诚待你，也希望你能同样对待我。这样我才能看清你——我看不见的东西就无法帮助。通过清晰地看到你，我可以更好地提供帮助。”

上述故事在很多方面都相当极端。这不是一个理想的治疗开端，但治疗师和亨利最终发展出了牢固的关系。事情的发展基于亨利是谁、治疗师是谁以及他们互动的性质。例如，治疗师确信亨利功能良好且受过良好教育（这些信息是在最初的电话交谈中收集到的）。治疗师还迅速判断出，FAP风格的当下评估会被亨利很好地接受，并且当下的情况很可能与他的临床问题相关。例如，亨利在电话中透露他正在找工作，而迟到显然在这个领域是个问题。

尽管这个故事具有其独特性，但它展示了在治疗开始时可以发生很多事情。它代表了FAP的一种（当然不是唯一一种）实施方式。正如你所见，FAP的两个核心原则都得到了体现：

  • 处理当下的互动，包括通过脆弱的自我披露和对对方披露的响应来建立连接（例如亨利承认他考虑过自杀）。向来访展示工作将如何进行，并让他了解这一点（如治疗师最后说的话）。
  • 通过整合你在当下观察到的内容与来访关于临床问题的描述，开始构建对来访问题的功能性理解。

在本章中，我们将讨论如何在治疗开始时将FAP原则付诸实践。在关系的早期阶段整合这些原则比在规范性的回避已经形成之后要容易得多。如果能够巧妙地运用，我们相信处理当下的互动和构建功能性理解的原则有助于在早期建立牢固的关系，并增加来访愿意再次来看你的可能性。为什么？因为他们体验到了你对他们及其问题的理解，以及你愿意与他们合作以取得进展。

当治疗师感到与来访脱节或沮丧时（反之亦然），原因很可能是未能注意到这种连接的过程。例如，如果与亨利工作的治疗师没有解决亨利的迟到问题，或者没有深入探究他的表现以发现背后的脆弱性，治疗师可能会感到恼怒或困惑。FAP中的假设是，导致联盟问题的原因并不是来访和治疗师之间的任何特定差异，而是这些差异如何被处理的问题。亨利的治疗师使用直接而富有同情心的沟通来处理他的迟到和看似无懈可击的自信。

再举一个例子：一位来访可能更喜欢非常具体、线性的解释，而治疗师则倾向于抽象。如果治疗师和来访公开讨论这种差异并同意检查治疗师是否满足了来访的需求，那么他们成功的机会就会更大（事实上，来访可能会从应对这种差异的经验中学到有价值的东西）。如果治疗师和来访避而不谈这个问题，来访可能会因为治疗师的模糊不清而感到沮丧，而治疗师可能会因为反复要求澄清而感到烦躁。

本章围绕在治疗开始时将FAP付诸实践的四个主要相互关联的任务组织：

  • 觉察：注意当下的潜在CRB（临床相关行为）。
  • 询问：以好奇、非评判性和勇敢的态度询问当下的行为及其与呈现问题或最佳治疗过程的关系。
  • FAP原理说明：向来访介绍FAP干预措施，并寻求知情同意。
  • 反馈：设置正式和非正式的反馈机制，以指导治疗过程。

觉察

当你遇到新来访时，你会看到什么？例如，在本书的第一部分中提到的汤姆显得非常渴望取悦他人且过于礼貌。尼克则显得紧张而正式。亨利则显得戒备心强且过度自信。从来访出现在门口或候诊室的那一刻起，我们就开始收集信息并对其进行评估。评估行为——记住，来访在治疗过程中的所有表现都是行为——是功能性分析的重点。当来访坐在你面前时，你可以接触到一个高分辨率、响应迅速且互动的行为实例。通常来说，我们在第一次会话中所看到和体验到的内容往往会与来访的临床问题相关。

功能性的思考方式引导我们发现这种行为是如何相关的。换句话说，情境行为科学（CBS）的观点要求你在即时判断、感知和观察之外迈出关键一步。超越表面现象，你必须问自己：这种行为对来访有什么功能？换句话说，它在生活中对她“起什么作用”？它是否与呈现的问题有关？同样，我们必须问自己的反应是否仅仅是个人特质的表现。例如，我对亨利迟到感到恼火，这是否仅仅反映了我对准时的严格标准？还是我的反应也表明了其他人可能对亨利的反应？这种区分需要自我认知。记住，我们不是在寻找关于“来访是什么样的人”的道德判断；我们是在寻找关于来访的行为如何在人际交往中发挥作用以及可能导致痛苦问题的假设。

当来访在房间里的表现与其描述的临床问题明显不同时，会出现一个有趣的挑战。考虑一个异常温和、体贴的来访，她寻求帮助是因为她在早上送孩子出门时情绪会升级。有可能她是过于礼貌和内敛，以至于她的孩子（及其他人？）常常忽视她的需求，从而只有通过剧烈改变语气才能有效地获得他们的顺从。在这种分析的核心是一个一般性功能问题：我现在在这里看到和体验到的这种显著行为，如何可能与来访描述的临床问题相关？功能性分析就像一个连点成线的谜题，需要通过评估和调查来解答。在这个过程中，如果某些聪明的假设看起来并不成立，就要准备好放弃它们。

在治疗开始时注意潜在的1s和2s

以下是治疗初期常见行为（1s和2s）的列表。这些行为被大致分为觉察、勇气和爱三个类别，尽管许多行为具有多重功能。这些列表旨在帮助你生成关于来访和你自己可能表现出的行为类型的想法。它们并不是详尽无遗的。当然，治疗师可能与他们的来访有许多相同的问题，但我们把只与治疗师相关的特定行为列在单独的清单中。

觉察

  • 来访（及治疗师）行为
    • 没有注意到治疗过程中的重要细节（如作业、同意书、地址、预约时间等）
    • 没有意识到行为的影响（如不尊重个人空间、忽略问题、打断治疗师等）
    • 不使用情感词汇（例如焦虑、羞愧、烦躁、不安、满足等）
    • 过度谈论无关细节
    • 提供简略、模糊的回答
  • 治疗师行为
    • 过于专注于治疗协议或方法，而牺牲了与来访的同理心接触或自我联系
    • 未能深刻理解或同情来访
    • 忽视来访表现中的重要细节
    • 直到督导或咨询时才注意到来访的CRBs

勇气

  • 来访（及治疗师）行为
    • 隐瞒脆弱的细节
    • 抑制或避免情绪
    • 展现非常积极但不一致的形象
    • 对治疗的愿望和需求有所保留
    • 以一种导致回避或感觉不知所措的方式快速披露大量信息
    • 过于强势、要求过高或批评过多
    • 保持戒备
  • 治疗师行为
    • 不询问更脆弱的话题，如亲密关系、性、自伤或自杀
    • 以过于直接或临床的方式提问
    • 不讨论治疗过程或不请求反馈
    • 不披露更多个人反应

爱（包括自爱）

  • 来访（及治疗师）行为
    • 很少提供正面反馈或鼓励的话语
    • 对温暖或认可感到不适或回避
    • 过于关注提供感激或安慰，并以一种看似不真诚或过分的方式进行
    • 对请求或自我照顾过于道歉
  • 治疗师行为
    • 不表达对来访的关心或赞赏
    • 不接受来访的赞美或感激
    • 过度承诺给来访，例如提供额外的治疗时间或非治疗时段的支持

练习

选择上述列表中的一个行为，生成关于该行为如何持续临床问题的假设。例如，对温暖或认可感到不适或回避可能会导致来访在他人提供支持时微妙地惩罚他们；这种行为反过来可能会使他人的支持减少，从而导致来访的社会支持减少，孤立感增加。

询问

在本章开头与亨利的对话中，治疗师根据他所注意到的情况做出了一些可能引起共鸣的陈述；例如，他指出亨利没有为迟到道歉，并询问这是否是一种模式，还提到亨利似乎有所戒备。这类陈述在FAP中起着关键作用。它们与其他元素一起构成了治疗关系中的基本FAP立场。为了理解这一立场，让我们首先回顾一下从FAP的角度来看，在治疗开始时应设定的目标。

治疗开始时一个非常基本的目标是了解来访；例如，她为什么来接受治疗，她在治疗师身上寻找什么，等等。因此，询问是FAP立场的基本原则。当然，积极的询问构成了功能性思维的基础。

在FAP中，我们还希望关注我们的询问所引发的披露过程。也就是说，披露行为是如何展开并回应治疗互动中发生的事情的。关注这一过程有几个原因。首先，如果来访没有公开披露，治疗可能会受到阻碍。其次，治疗中的披露邀请可能与在其他社交场合中的情况大不相同，因此当邀请他们披露时，来访可能会经历自然的脆弱、羞愧或犹豫反应。关注这些反应并确保我们以符合来访需求的方式进行，是治疗联盟的关键部分。第三，来访的披露过程可能是CRB（临床相关行为）——即它与她的临床问题功能相关。CRB可能涉及愿意披露或不愿意披露。它们还可能涉及各种其他行为：例如，避免情感表达、无益地沉思、绕弯子说话或以黑白分明的方式看待事物。当我们关注披露过程时，我们的目标是用心和同情地塑造一种信任和安全的关系体验；我们也希望这种体验能清晰地展示来访心理如何运作。

除了这些目标之外，重要的是要记住，在治疗开始时你还不了解来访或她的人际脆弱性所在。如果你在询问过程中过于大胆——提出侵入性的问题——你可能会损害联盟或压倒来访。如果你过于谨慎，你可能会让互动保持表面化，而无法进入更深层次的披露（以及提供响应的机会），而这正是建立牢固治疗联盟所需要的。因此，以敏感和灵活的方式进行是非常重要的。

考虑到这些目标和我们对来访的不了解，FAP的关系立场平衡了非评判的好奇心和验证性的同情心，以及试探性和灵活地向更大程度的直接性和勇气迈进。普遍的好奇心和同情心确保整个治疗互动是吸引人的；来访应该因为参加治疗并与你交谈而得到丰富的强化。你不应对来访的披露产生任何负面的社会后果。

通过直接性和勇气，你可以邀请来访稍微更多地披露脆弱的信息。这可能会逐渐加深来访在关系中体验到的亲密感和脆弱性（从而增加信任）。FAP的关系立场为日后直接处理CRB奠定了基础，并允许你观察来访对鼓励更大程度的脆弱性的反应。

在接下来的对话中，治疗师展示了这种平衡立场的一些关键特征。

治疗师：听起来你父母的离婚发生在一个非常困难的时期——就在你开始在大学里探索自己想要成为什么样的人的时候。我能看到你在谈论这件事时的痛苦。

来访：这种事情，我想每个人都会以某种形式经历吧。这就是成年的滋味。

治疗师：是的，我能看出你也在告诉自己要坚强起来。比如，要坚强，没有时间去情绪化。

来访：那么情绪化的意义是什么呢？感觉糟糕只是为了……感觉糟糕？

治疗师：嗯，我看到你有些困惑。为什么要感觉糟糕？这似乎毫无用处……无休无止。我在想，我看到的你是不是有一种矛盾。因为我注意到你似乎在努力对抗负面情绪的同时，实际上仍然感到不好。几乎像是你在试图说服自己不要感觉糟糕，但事实是**：你确实感觉很糟糕。我这样理解对吗？

来访：是的，当然。但是……然后这就显得毫无希望了。

治疗师：嗯，我还在逐渐了解你，所以我可能在这里理解错了。但我注意到你是一个很有力量的人。尽管生活中充满了混乱，你还是努力完成了大学学业。你只是埋头苦干。而且你不怕问那些艰难的问题，并且直截了当地说**：“感觉糟糕有什么意义？” 但是我在想，如果这种力量——你的力量——对于生活中的某些挣扎并不适用怎么办？如果你的坚韧实际上并不适用于这种情感上的挣扎呢？

来访：那我该怎么改变？

治疗师：你的坚韧又出现了。你立刻想知道如何改变。该怎么做。我能听到你要求改变时的那种强硬和急躁。你感觉到这些了吗？

来访：是的……啊！我太累了。

治疗师：我知道我现在有点逼你了。你愿意继续下去吗？

来访：是的。当然愿意。

治疗师：你愿意告诉我更多关于这种疲惫的情况吗？那种隐藏在你急躁和坚强背后的疲惫？

来访：感觉很虚弱。就像，当我感到疲惫时，我只想躺在床上，用枕头盖住自己哭泣。我觉得自己像个孩子在开自怜派对。

治疗师：你说这话的方式让我对你感到一种温柔。我在想，你是否从某个对你很重要的人那里学到了——或者你自己悟出来的——“软弱”是不被允许的，或者躺在床哭是不行的。也许你学到的是，如果你这样做，人们就不会尊重你。那么，一直强迫自己坚强是多么累啊。但同时，变得坚强并取悦他人，克服困难并取得成功，又是多么令人满足。我说得对吗？

来访：嗯，是的。“坚强起来”，这是我爸爸——100%会说的话。还有我的体操教练也是。“我们不容许软弱。”

治疗师：我在想，我们的工作之一可能是放慢脚步。注意你在哪里陷入了这种矛盾**：试图不去感受糟糕却仍然感到糟糕，并找到一种不同的方式来对待自己？事实上，这可能是一种不同的挑战——尝试轻松而不是总是努力。

来访：嗯，你说得有道理。

治疗师：我问这些问题让你感觉怎么样？

来访：有帮助。有很多东西需要思考。它们让我以不同的方式思考问题，我想。

治疗师：而我反过来也尊重你的力量，因为这让我们能够坦诚和直接。我尊重你在这里的努力，处理那些感觉不确定和绝望的事情。处理那些你内心认为自己软弱的时候。

治疗师在这里是从接纳与承诺疗法的角度进行工作的，但整个互动中贯穿了FAP关系立场的关键要素：

  1. 自我披露：治疗师在对话中偶然地披露了自己的内心过程：“我还在逐渐了解你，所以我可能在这里理解错了”以及“这让我对你感到一种温柔。”这些披露有助于建立脆弱披露的规范。
  2. 合作精神：治疗师请求继续询问的许可，承认自己对来访可能产生的影响。他还问来访是否愿意接受他建议共同探讨的问题，尤其是在她体验了一部分治疗过程之后。他没有强加自己的观点，而是请她尝试一下。他的自我披露也传达了合作的精神，表明他可能有偏差，并且愿意接受反馈以调整方向。这不是一个“我的方式或走开”的情况。
  3. 接纳和验证：治疗师反映了来访力量的价值。毕竟，这种力量在很多情境下都被强烈强化，并被视为一种美德。治疗师在肯定这一点的同时，也验证了始终坚强的代价：疲惫。力量和疲惫之间有着非常自然的关系。最后，治疗师认识到——并希望加强——来访参与治疗过程的行为，暗示探索脆弱性是一种不同类型的坚强。
  4. 直接性和勇气：对于来访的提问“那我该怎么改变？”治疗师做出了尖锐的观察：“你的坚韧又出现了。”这是一个勇气的例子：为了提高更大的觉察而说一些稍微具有挑战性的话。他也意识到这个挑战可能会引发来访的自我批评。她可能会对自己说，我什么都做不对吗？他决定不在这次会话中探索这种可能性，而是选择放慢速度，探索来访对他挑战的反应。对于来访来说，一种疲惫感浮现了出来。他怀疑来访在分享这一部分时会感到更加脆弱，所以他征求她的同意去探讨。反过来，她关于疲惫的披露自然让治疗师对她产生了一种温柔的感觉，他表达了这种温柔，因为这是对她脆弱性的自然、温暖的回应。当然，他会继续观察并在一段时间内询问她实际上如何回应这样的陈述。总体而言，这种逐步、调谐地向更深层次的自我披露迈进也反映了勇气的另一个方面。

有时很明显，来访是有所戒备的——不愿意敞开心扉。而在其他时候，她是否披露脆弱的事情并不是意愿问题；她实际上无法在当下表达自己的内在体验。在这种情况下，你不会强行推进，因为强行推进是适得其反的。

询问治疗过程

来访带着他们的问题来到咨询中，但他们也会对治疗过程作出反应——填写同意书、参加第一次预约、回应初步问题。他们的反应可以成为了解他们在生活中如何运作的宝贵窗口；探索这些反应可以作为建立关系的一种途径。因此，FAP治疗师可能会以开放式的方式询问来访来接受治疗的感受。

治疗师： 我很好奇，在我们第一次见面之前，你感觉怎么样？

来访： 我很期待。

治疗师： 关于来这里，你有什么想法或感受吗？今天你在想什么？

来访： 其实没怎么想。今天非常忙乱。我们的预约在我的脑海里有点模糊。我觉得自己像是在打开一扇门，有些不安全感，但我是一个很好的演员。自从我抑郁以来，为了生活下去，我不得不这样做。

治疗师： 我想听听更多关于这一点的情况。

你也可以询问来访对本次会谈的期望，他们对已经阅读过的材料（例如你的网站、同意书、任何传单或小册子）的反应，他们在以前治疗中的经历，以及他们想要更多了解你的愿望。所有这些询问领域都提供了机会，使你能与来访建立合作关系，并开始理解她的行为模式。在下面的例子中，治疗师将几个线索编织在一起，形成了对潜在临床相关行为（CRB）的初步理解，并将治疗互动推向更深层次的脆弱性。

治疗师： 你觉得今天我们最重要的是要讨论什么？你想谈些什么？当你进来时，有没有想过怎样才能让这次会谈变得特别好？

来访： 没有。

治疗师： 那么你是打算让我来决定。

来访： 我可以帮助你弄清楚。我想第一次会谈总是很难，因为你还不太了解我。试着去了解别人总是很难。

治疗师： 第一次会谈确实很难。我从来不知道会遇到什么。我有一个今天要讨论的清单，但其中一件事是你认为重要的事情，因为对我来说非常重要的是根据你的需要来定制这个治疗。所以，你读过我对这个治疗的描述，对吧？

来访： 是的。我非常喜欢你写的内容。

治疗师： 我想再和你一起回顾一下，并回答你可能有的任何问题。你可以告诉我你喜欢什么，不喜欢什么。我还想回答你对我个人的任何疑问。你对我不太了解。

来访： 如果你是私人执业的话，我想知道你是如何与大学联系起来的。

治疗师： 我也与大学有关联。我是临床讲师，还在这里教一门课。你对我的培训或背景感兴趣吗？

来访： 是的。

治疗师： 我在1982年在这里获得了博士学位。我在UCLA完成了本科教育，1976年来这里攻读研究生。我本以为我会回到南加州，但最终没有回去。

来访： 这很有趣。

治疗师： 你喜欢你的治疗师是什么样的？看起来你很喜欢你的精神科医生L博士。你希望我是指导性的还是非指导性的？

来访： 我真的很喜欢人们对我进行指导，但同时我也非常敏感。我一直都是这样。所以我总是要求与我合作的人小心一些——不是说他们意图不好，只是我会有点敏感。

治疗师： 你能给我举个例子吗？

来访： 当然。有一次和L博士，我离开时感觉更糟——生气和沮丧。我有很多债务，我觉得她在这方面对我有点严厉，这让我很惊讶。我只是想谈谈这件事，把它说出来。因为我欠她钱，我感到非常不舒服。我欠所有医疗专业人员的钱。当我离开时，我感觉糟透了。

治疗师： 哇，好的，那么我非常想对你谈论事情的困难程度保持敏感，并确保我能正确处理。

来访： 我会很感激的。

治疗师： 你知道吗，这是一个很好的时刻，因为在你读到的关于我们共同治疗的描述中，我们的一个重点将是我们的关系，以及它如何连接到你所有的其他关系。我注意到你有一些其他良好的关系。

来访： 我很幸运。

治疗师：这不仅仅是你幸运。我认为你的社交技巧很好。你说你知道如何表现得很好，尽管这样做很累，但这也是一种技能。但在这里，我想我们来看看在与我互动时什么是有用的，以及我们如何能够更擅长真实地表达自己。例如，如果我没有做对，你可以告诉我。你有没有告诉L博士你的感受？ 来访：没有。

治疗师：是的，我理解这有多难。看起来一方面你有很好的人际关系，但另一方面你感到孤独。也许不说话是其中的一部分。这是你想解决的一个领域吗？

来访：我还没有想出如何减少孤独感。一个原因是，我一个人住。而且我注意到，在过去的一年半里，我越来越远离社交活动。

治疗师：感到孤独是什么感觉？你现在感到孤独吗？

来访：有一点……可能是一种空虚感。

治疗师：你在哪儿感觉到这种空虚？

来访：在我的心里……我的胸口。我注意到的不是缺少了什么东西，而是一种空虚的感觉。

治疗师：你最后一次感到充实是什么时候？

来访：我不太记得了。可能是我上一段长期关系的时候。

治疗师：那是多久以前的事了？

来访：三年半前。

治疗师：所以当你谈到你的关系时，似乎你仍然有一种渴望。你是渴望那段特定的关系，还是只是渴望一种关系？

来访：一种关系。（停顿）我觉得有些情绪化。

治疗师：你在谈论孤独时感到情绪化？

来访：我想是的。（哭泣）整个事情都很困难。我可以要一些纸巾吗？我在纸上可以否认我的痛苦，但如果我必须和别人谈论它，就会很难受。

治疗师：嗯，你现在正在和我说话，这对我来说真的很有帮助。你对这次治疗能帮助你有多少希望？你的希望和恐惧是什么？

来访：实际上我有很多希望。

治疗师：告诉我你觉得积极的事情。

来访：我的生活。我和L博士在一起时没有专注于任何事情。我也没有在做什么，或者感觉我没有在做。我觉得自己一直在原地踏步，而这次治疗感觉像是我需要的东西。我需要一个方向。

治疗师：我很擅长给出方向——并且提供支持。

来访：你看起来确实如此。你的眼睛非常善良。我充满希望。

治疗师：我很高兴你充满希望。我也很高兴你注意到了我眼中的善意——我已经对你感到善意。对我来说很重要的一点是，这里对你来说是一个神圣的空间。当我在这里时，我不会想其他的事情；这个空间是受到保护的。我非常认真地对待这一点。我希望尊重你来到这里的努力和风险。

来访：这让我想起了某件事。你知道在药店经常能看到那些戒烟的小册子吗？它们通常会有一句格言。有一次我看到一本上面写着类似这样的话**：“为了在生活中有所进展，你必须决定不再停留在原地。”这提醒我，第一步仅仅是决定你要移动。

治疗师：而这正是你在做的。你来这里就是在冒险。所以，鉴于你之前所说的话，我想知道，假装冒险和真正冒险之间有什么区别？我们在这里可以做的一件事就是帮助你真正去冒险，并且采取正确的风险。

来访：这会很难——但很好。

治疗师：我知道。我会感激这对你是多么艰难。

通过即时功能性分析询问CRB

正如我们之前提到的，功能性分析过程的一部分是将你在治疗过程中观察到的行为与来访描述的日常生活中出现的问题联系起来。建立这些联系最终为你提供了识别并在当下改变临床相关行为（CRB）的机会。即使在第一次会谈中，这种会话内和会话外行为之间的联系也有助于你更好地理解来访所面临的问题及其相关行为。

例如，假设一位来访描述了他的妻子经常打断他或对他失去耐心。你注意到他倾向于长时间讲话，以至于不清楚他什么时候会停下来让你说话。你可以委婉地与他分享这一观察，并询问他是否也以这种方式与妻子交谈。

治疗师： 如果我可以分享一个微妙的观察：我注意到你确实倾向于长篇大论。所以我想知道，这是否可能是导致你妻子打断你的一个因素？她对你说话的方式感到不耐烦？

来访： 嗯，也许吧。我一直都是这样说话，我的一生都在为此受到批评。我厌倦了人们想要我变得不同。当我上四年级时，他们叫我“话匣子”。有一位老师总是在我在全班面前回答问题时故意打断我……

在这里，治疗师利用她在会谈中的观察来推测会话外可能发生的情况。反过来，探索你在会谈中观察到的行为与来访报告的会话外行为之间的差异也是有用的。

治疗师： 我意识到指出你话多可能会让你感到不舒服。但我很感激你的坦诚，我希望我们可以有一种“把所有事实都摆在桌面上”的精神。我注意到你似乎愿意接受我的反馈，并考虑你的说话方式的影响。但我也听到你说，如果你的妻子试图给你反馈，你的反应会非常不同。

来访： 是的，我会非常防御。我们偶尔会因此争吵，然后又回到一种怨恨的回避状态。

治疗师： 那么这里有什么不同——你愿意听我的反馈？

来访： 在这里我相信你是想理解我，并且希望对我好。

通过对比会话内和会话外的情境，治疗师发现来访与其妻子关系中的一个重要错位：他不相信她能够同情地理解他。

你也可以使用以下问题来比较会话内和会话外的情境：

  • [某种在日常生活中发生的临床相关行为]会不会在这里发生在我身上？
  • 如果[那种行为]发生了，你会告诉我吗？

这些问题尤其有用，当来访的日常行为涉及不对其他人透露正在发生的事情时。例如，如果一位来访逐渐对自然强势的人感到更加怨恨，因为这些人无意中踩到了他未表达的需求，直到他最终爆发，你可以明确地问这样的怨恨是否会出现在治疗关系中。如果你知道自己是一个自然强势的人，这个问题尤为重要。同样，这类问题为开放、披露的治疗关系设定了基调。

对可能的CRB2作出回应

有时来访会在治疗的早期阶段进行重要且有风险的脆弱披露，因为他们认为这是他们“应该做的”，或者因为他们独自承受痛苦已经疲惫不堪，于是冒险与一个同情的倾听者分享他们的负担。例如，在本章开头的对话中，亨利披露了自杀的想法，这是他承认从未告诉过任何人的事情。随后，治疗师采取了一种非常直接和个人的方式来回应。虽然这种转变在对话中没有明确表示，但治疗师的回应不仅体现在他的言语上，还体现在声音语调和姿势的变化上，反映了他对亨利痛苦的真实情感反应。治疗师希望他的回应能强化亨利的披露，并促使更多的脆弱披露随之而来。

然而，在治疗的早期阶段，治疗师不能确定亨利的披露是否真的是CRB2（关于他痛苦的诚实披露），也不能确定他真诚的回应是否会强化这种披露。亨利实际上可能会觉得这种回应令人反感。尽管如此，作为治疗师，我们有时必须猜测，尤其是在涉及脆弱披露的问题上。值得做出这些猜测，因为在早期未能积极回应重要的披露可能会造成有意义的伤害；真诚的回应设定了真诚的先例，同时也设定了直接处理当前情况的先例。确保以自然的方式回应脆弱的披露。（更多内容请参见第9章，该章专注于如何回应CRB2。）

提供FAP治疗原理

在治疗开始时，明确告知来访你将如何在你们共同的工作中使用治疗关系也是很有用的。换句话说，提供一个功能分析心理治疗（FAP）的治疗原理（简称“FAP rap”）。通常在你知道FAP干预很可能会成为你的治疗计划的一部分时，就应传达FAP rap。FAP rap的核心很简单，可以按照以下方式呈现：

治疗师： 当你在治疗过程中遇到的问题此时此刻出现时，注意到它们是有用的，这给你一个机会在此时此地改变你正在努力的行为，并给我——你的治疗师——一个机会以一种支持和有用的方式回应你，反馈你正在做的事情。

一个不太正式的版本可能看起来像这样：

治疗师： 我发现，在这项工作中，有时能够放慢脚步，仔细观察当下发生的事情是很有用的。例如，我们之间的一些互动对你来说可能是有用的时刻，让你了解自己。你可以从我这里得到即时反馈，了解你是如何表现的，或者别人在那些时刻是如何看待你的。如果觉得有帮助的话，你还可以练习不同的回应方式。你觉得这样怎么样？

如果你的风格允许，或者来访要求知道你所实践的疗法类型，你也可以更明确地介绍FAP：

治疗师： 我做的一种治疗叫做功能分析心理治疗，简称FAP。是的，这是一个有点傻气的缩写。FAP的一个关键部分是利用我们在治疗中的互动来理解你是谁以及你想如何改变。比如，你告诉我你想学会更加意识到自己、你对他人产生的影响，以及你在与他人的互动中是如何陷入困境或自我限制的。我们可以一起关注当你与我进行这些具体行为时的时刻，并看看我们如何在这些时刻改变发生的事情。你觉得这样怎么样？

最后，一些FAP治疗师会用更具启发性的语言来阐述他们的理由，并寻求更明确的人际深度承诺和总体FAP工作：

治疗师： 我感到荣幸能与你一起踏上探索和成长的旅程。我想让你知道的第一件也是最重要的事情是，FAP强调我们之间建立联系。这将是这次旅程的主要工具。我希望与你建立真正的关系。我承诺在这个房间里，我会是一个真实的人；我不会假装或隐藏任何东西。我知道脆弱和谈论困难的事情有多难，但我也知道它有多么重要。因此，我承诺让治疗对你来说感觉像是一个神圣的空间，一个充满异常程度的安全感、理解、关怀和支持的地方。我会这样做，以便你能加入我，真正地工作、探索和成长。我希望在我们之间创造一种感觉，让你知道你拥有我100%的注意力；我能深刻地看到、接受并尊重你内在的本质，无论是缺点还是优点；并且我会怀着敬意和关怀对待你分享的一切。

我将在我们的共同努力中投入大量的关怀和努力，也期望你同样如此。基于你的治疗目标，并征得你的同意，我会挑战你变得更加自觉、在场、开放、脆弱和富有爱心。我会询问你对我们关系中哪些方面做得好，哪些需要改变。如果我们之间的互动出现了你在生活中与其他人的互动中也遇到的困难，无论积极还是消极，我们都会专注于这些互动，看看发生了什么，我们可以从中学习什么。这些都是我们的关键时刻，我会一直寻找这些时刻。还有一些练习可以直接将这些问题带入我们的治疗室。我们的治疗关系将是你练习如何在与我、与他人以及在生活中真正成为你想成为的人的理想场所。从这里开始，我们将促进改变和成长，使你能过上真正想要的生活。你觉得这一切听起来怎么样？

你应该根据自己的价值观、说话方式、文化背景和临床环境开发适合自己的FAP rap。

将FAP与来访问题联系起来

前面的FAP rap例子是比较通用的——即使是最后一个非常诚恳的例子。通过将其与你对来访的理解和她的问题联系起来，你可以使FAP rap更有意义和说服力。下面是一个例子：

治疗师： 你提到你在与人相处时感到轻松有困难，特别是在不清楚你的角色时。例如，在鸡尾酒会上，你往往会感到非常尴尬，而在工作中，你却很清楚该做什么。在我们的工作中，可能会有一些时刻，你对你的角色也会有类似的困惑。就像你在今天会议开始时所说的，你对自己应该告诉我什么感到有些焦虑。所以这就是你所挣扎的情境之一，现在就在这个时刻。在我们之间发生的这种体验中直接处理这个问题，而不是仅仅从远处谈论它，这可能会非常有用。你觉得这样怎么样？

对于那些与社交脱节相关的问题，强调治疗关系中自然发生的连接——如脆弱披露等——可能会有所帮助：

治疗师： 你说过对他人的信任和脆弱对你来说真的很可怕，我知道治疗过程本身也可能是一个非常脆弱的过程。你来到这里告诉我一些非常私人的事情，而这些事情你是不会告诉其他人的，这可能会让人感到害怕。我想让你知道这种诚实的重要性。当我了解你的情况时，我可以最有效地帮助你。我希望随着你向我敞开心扉，我会以有助于你信任我的方式回应。相信我，对我来说，作为治疗师最重要的是值得信赖。反过来，你也可能会学会更加自信地向生活中其他值得信赖的人敞开心扉。

治疗师自我披露

FAP rap的另一个关键元素是治疗师的自我披露。在本书中，你已经多次看到治疗师在当下向来访披露她的反应以及对过程的看法，在FAP中扮演了重要角色。有些来访期望治疗师是一个“空白屏幕”；他们可能不愿意直接问治疗师问题，或者对于听到治疗师分享个人反应感到惊讶。因此，明确说明你的自我披露可以为关系带来的价值，以及你的全身心投入和可及性是有用的。以下是一个例子：

治疗师： 正如我所说，治疗是一个脆弱的过程，所以我希望做一些事情来帮助你在我们的关系中更容易感到信任和尊重。为了建立这种信任和相互理解，如果你对我有任何疑问，或者你任何时候想知道我在想什么，比如我对发生在你身上的事情或你说的话的反应，我邀请你问我。现在刚开始时，你有什么想知道的关于我的吗？

你也可以表明你会提供诚实的回应，并描述你将如何做到这一点：

治疗师： 治疗有帮助的一个方式是，我在我们的会谈中不仅仅作为一个治疗师出现，而是作为一个完整的人。因此，有时我可能会对你有一些反应，这些反应对你来说可能是有用的。例如，我可能会被你说的话所感动。或者——这可能更难讨论——我可能会对你所说的某些内容感到挑战，或者不同意你的观点。我希望得到你的许可，以一种敏感且我认为对你有益的方式来与你分享我的真实反应。这样可以吗？

再次强调，这些理由不应作为模板使用。它们应该根据具体情况、个别来访以及功能分析揭示的来访情况来进行调整。例如，如果向治疗师提出大量问题是一种CRB1（即避免更脆弱但有用的治疗话题的方式），那么理由应进行相应调整。

练习：FAP Rap强化练习

通过密集练习，尤其是小组形式的练习，你可以从他人的示范和反馈中受益，从而迅速提高交付FAP rap的技能。因此，我们建议进行一些刻意练习：

  1. 想一个可能适合FAP的来访。
  2. 写出（或思考或讨论）一个对你来说感觉真诚且与该来访相关联的FAP rap。
  3. 大声朗读或说出你的rap，可以是对自己、录音机，或者最好是给一个同事听，让他们给你反馈哪些地方做得好，哪些地方可以改进。
  4. 根据需要改进你的rap。
  5. 将rap提供给你的来访，并注意哪些地方做得好，哪些地方可以改进。记下你学到的东西。
  6. 重复！

反馈

在治疗早期要建立的一个最终且重要的FAP元素是开放和相互的反馈。而且，不仅仅是谈论它，真正启动这种反馈交流至关重要。广义上讲，反馈是改变治疗过程的信息。你会发现，反馈贯穿于本章前面的例子中。例如，治疗师提供了各种形式的反馈，关于来访的表现。治疗师也询问来访对他问题的感受。前一节中的FAP rap也提到了反馈的重要性，以保持治疗的正确方向，并应对治疗中的关键时刻，比如当来访的问题出现在会谈中时。随着治疗工作的展开，FAP要求你持续关注治疗对来访的影响（如规则4所规定；更多内容见第9章）。在所有这些方面，FAP要求你参与多种形式的反馈交流。

会谈总结与诚实邀请

在本章前面描述的询问过程中，每次会谈结束时，以一种邀请脆弱性和诚实的方式进行总结和回顾是很有用的。例如，你可以表达对来访选择参与治疗所迈出的重要步伐的感激之情。以下是一个例子：

治疗师： 我们第一次会谈就要结束了，你对这次会谈有什么感想？

来访：很好。我感到受到了鼓舞。

治疗师： 我注意到的是你的毅力。从十三岁起你就一直抑郁，但你身上有一种坚持不懈的东西，一种不可思议的力量，让你不断成长并保持希望。还有一点是你喜欢那首冒险诗。我很兴奋，因为如果你喜欢冒险，我们俩会相处得很好。你觉得什么特别突出？

来访：我能哭出来。我不常一个人哭泣。我觉得稍微好了一些。

治疗师： 在你哭过之后？

来访： 是的。我感到惊讶和受到鼓励。

治疗师： 你对自己能够哭泣感到惊讶？

来访： 我通常会把它压下去。

治疗师： 知道你能哭泣并且感到受到鼓励，这对我来说是很好的信息。

另一个反馈机制是会谈衔接表（Tsai等人，2009）。该表的第一部分（A）在会谈后不久填写，要求来访反思会谈的各个方面。第二部分（B）则在下一次会谈前填写，简要概述两次会谈之间的事件，并表达来访对下次会谈议程的愿望。有些治疗师更喜欢在会谈前收到表格；另一些则是在下一次会谈开始时阅读。可以用简单的方式介绍这个表格： 治疗师： 关于作业，这里有一份工作表，可以帮助我们在每次会谈中集中注意力并充分利用时间。它被称为FAP会谈衔接表。它有两个部分。请在我们的会谈结束后立即填写第一部分。在来参加下一次会谈之前填写第二部分。如果在这期间有任何问题，请随时给我发邮件。

随着你对CRB评估的发展，你可以个性化地使用这个表格；例如，你可以调整它以关注脆弱披露、直接请求或分享感激之情。或者，你可以在治疗开始时以一种更直接关联到你对来访潜在CRB理解的方式来引入这个表格。

这个表格提供了几个独特的价值。它为处理会谈中的事件提供了一个替代媒介。有时来访会在表格上写下他们不会当面说的话，这种开放性非常有成效。表格还为每次会谈提供了书面记录，从而减少了遗忘，并增强了会谈之间的连续性（这就是为什么它被称为“衔接”表）。对于治疗师来说，如果来访投入了努力填写表格，假设这种努力是2级行为，一定要通过留出时间阅读并回应表格来强化这种努力！换句话说，完成表格提供了强化2级行为的机会。

再次强调，围绕会谈衔接表可能会出现各种CRB（以及T1s和T2s）。一些来访非常注重正确地完成表格，而另一些则漫不经心。所有这些都是你功能分析的素材。

会谈衔接表

姓名：
日期：

A部分（在治疗会谈后不久完成）

  1. 你对我们上次会谈的印象是什么？想法、感受、见解？

  2. 在10分制的评分中，你会如何评价以下各项，a到d？ 完全不A一点点中等显著 1357 a) 2 4 6 8 非常显著 9 10 会谈的帮助/有效性：
    什么是有帮助的？
    什么是没有帮助的？
    b) 你感觉到与治疗师的连接程度：
    c) 你对讨论的话题的参与/投入程度：
    d) 你在会谈中的存在感：

  3. 什么会使会谈更有帮助或体验更好？有没有你不愿意说或要求的事情？

  4. 会谈中或与治疗师互动时出现了哪些与你日常生活问题相似的问题？

  5. 你在会谈中或与治疗师互动时采取了哪些风险，或者取得了哪些可以转化为生活中的进步？

B部分（在下次治疗会谈前完成） 6. 你这一周的高潮和低谷是什么？ 7. 你希望在我们的下次会谈中讨论哪些项目、问题、挑战或积极变化？ 8. 你在回答上述1至7题时的坦诚程度是多少（0-100%）？
9. 你还想添加什么吗？

总结

  • FAP过程可以从第一次会谈的最初时刻就融入治疗中。
  • 注意来访在参与治疗过程中可能表现出来的CRB。
  • 询问你注意到的当下情况、来访对其问题的描述，以及与这些问题相关的行为之间的关系。
  • 提供关于治疗关系和FAP干预的重点解释。
  • 设置非正式和正式的治疗过程反馈交流。利用会谈衔接表在会谈之间收集书面反馈。

本章知识点阐述

知识点阐述

  1. 建立治疗关系的基础

    • 定义：在治疗开始时建立良好的关系是确保后续治疗成功的关键。这包括建立信任、透明度和共同的目标。
    • 重要性：治疗关系的质量直接影响治疗效果。一个稳固的基础有助于来访感到安全和支持，从而更愿意开放和参与治疗过程。
    • 具体实践：
      • 建立信任：通过真诚、一致性和尊重来建立信任。让来访感受到你是可靠和可信赖的。
      • 透明沟通：明确说明治疗的目的、方法和期望，确保来访理解并同意治疗计划。
      • 共同目标：与来访一起设定明确的治疗目标，确保双方对治疗的方向有共同的理解和承诺。

  2. 处理来访的防御机制

    • 定义：来访的防御机制是指他们在面对压力、痛苦或不安时采取的自我保护策略。这些机制可能表现为回避、否认或过度自信等。
    • 重要性：识别和处理来访的防御机制是治疗的重要部分。这有助于揭示来访的真实感受和需求，从而更有效地解决问题。
    • 具体实践：
      • 观察和倾听：仔细观察来访的言语和非言语行为，倾听他们的言外之意。
      • 温和挑战：在适当的时候温和地挑战来访的防御机制，引导他们更深入地探索自己的感受。
      • 提供支持：在挑战防御机制的同时，提供情感支持和理解，确保来访感到安全和被接纳。

  3. 直接性和真诚性的重要性

    • 定义：直接性和真诚性是指治疗师在与来访交流时坦率和真实的态度。这包括直接表达观察、感受和反馈。
    • 重要性：直接性和真诚性有助于建立真实的治疗关系，促进来访的自我认识和成长。它还能帮助治疗师更好地理解来访的需求和动机。
    • 具体实践：
      • 直接表达：在适当的时候直接表达观察和感受，避免模糊或误导性的语言。
      • 邀请反馈：鼓励来访提供反馈，了解他们对治疗过程的感受和看法。
      • 保持一致性：在所有互动中保持一致性和真实性，确保来访感到被尊重和理解。

  4. 处理来访的脆弱性

    • 定义：来访的脆弱性是指他们在面对困难和挑战时的情感敏感性和易受伤性。这可能表现为焦虑、抑郁或其他情绪问题。
    • 重要性：理解和处理来访的脆弱性是治疗的核心。这有助于来访感到被理解和接纳，从而更愿意开放和寻求帮助。
    • 具体实践：
      • 共情：通过共情来理解来访的感受和经历，表达对他们情感的支持。
      • 提供安全感：创造一个安全和支持的环境，让来访感到可以自由表达自己的感受。
      • 逐步暴露：逐步引导来访面对和处理他们的脆弱性，帮助他们建立应对策略和韧性。

  5. 治疗中的评估和反馈

    • 定义：治疗中的评估和反馈是指定期回顾和评估治疗进展的过程。这包括收集来访反馈、调整治疗计划和设定新的目标。
    • 重要性：持续的评估和反馈有助于确保治疗的有效性和适应性。它可以帮助治疗师及时调整方法，以满足来访不断变化的需求。
    • 具体实践：
      • 定期评估：定期进行评估，了解治疗进展和来访满意度。
      • 调整计划：根据评估结果调整治疗计划，确保治疗目标的实现。
      • 邀请来访参与：鼓励来访参与评估过程，让他们感到自己是治疗过程中的积极参与者。

通过这些知识点，我们可以更好地理解如何在治疗开始时建立坚实的基础，处理来访的防御机制，保持直接性和真诚性，处理来访的脆弱性，并通过评估和反馈来确保治疗的有效性。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 处理当下的互动

    • 定义：处理当下的互动是指在治疗过程中关注当前发生的事件、情感和行为，并利用这些信息来促进治疗关系和治疗效果。
    • 重要性：通过处理当下的互动，治疗师可以更好地理解来访的即时感受和需求，从而提供更有效的支持和干预。这有助于建立信任和连接，使来访感到被理解和接纳。
    • 具体实践：
      • 观察和倾听：仔细观察来访的行为和言语，倾听他们的言外之意。
      • 回应和反馈：及时回应来访的情感和行为，提供具体的反馈。
      • 自我披露：适当地进行自我披露，以建立更加真实的治疗关系。

  2. 构建功能性理解

    • 定义：构建功能性理解是指通过整合来访的描述和治疗师的观察，来理解来访问题背后的功能和意义。
    • 重要性：这种理解有助于治疗师更全面地把握来访的问题，制定更有效的治疗计划。它还可以帮助来访更好地认识自己，促进自我成长。
    • 具体实践：
      • 综合信息：结合来访提供的信息和治疗师的观察，形成对问题的综合理解。
      • 探讨动机：探讨来访行为背后的动机和功能，帮助他们认识到自己的模式。
      • 制定计划：根据功能性理解制定具体的治疗计划，确保目标明确且可行。

  3. FAP原理说明与知情同意

    • 定义：FAP原理说明是指向来访介绍FAP的基本理念和方法，并获得他们的知情同意。这包括解释FAP的目标、过程和预期结果。
    • 重要性：通过清晰地说明FAP原理，治疗师可以帮助来访更好地理解治疗过程，提高他们的参与度和满意度。同时，知情同意是伦理和法律的要求，确保治疗的透明性和合法性。
    • 具体实践：
      • 详细解释：详细解释FAP的核心原则和方法，确保来访充分理解。
      • 征求同意：明确征求来访的同意，确保他们在知情的情况下参与治疗。
      • 持续沟通：在治疗过程中持续沟通，确保来访始终了解治疗的进展和方向。

  4. 反馈机制

    • 定义：反馈机制是指在治疗过程中设立的正式和非正式的反馈渠道，用于收集来访的意见和建议，以指导治疗过程。
    • 重要性：反馈机制有助于治疗师了解来访的真实感受和需求，及时调整治疗策略，提高治疗效果。它还可以增强来访的参与感和满意度。
    • 具体实践：
      • 定期评估：定期进行评估，收集来访的反馈，了解治疗进展。
      • 开放式沟通：鼓励来访开放地表达他们的感受和意见，确保沟通畅通。
      • 调整计划：根据反馈结果调整治疗计划，确保治疗目标的实现。

通过这些知识点，我们可以更好地理解如何在治疗开始时应用FAP原则，处理当下的互动，构建功能性理解，解释FAP原理并获得知情同意，以及设置有效的反馈机制。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 觉察的重要性

    • 定义：觉察是指在治疗过程中，治疗师对来访的行为、情感和言语进行细致观察和评估的能力。这包括注意来访的非言语行为、言语内容以及行为模式。
    • 重要性：觉察能力是治疗师有效开展工作的基础。通过觉察，治疗师可以更好地理解来访的真实感受和需求，从而制定更有效的治疗计划。觉察还有助于建立信任和连接，使来访感到被理解和接纳。
    • 具体实践：
      • 细致观察：仔细观察来访的行为和言语，倾听他们的言外之意。
      • 记录和反思：记录观察结果，并进行反思，以形成对来访行为的综合理解。
      • 持续学习：不断学习和提高觉察能力，了解不同行为背后的功能和意义。

  2. 功能性分析

    • 定义：功能性分析是一种评估和理解来访行为的方法，它关注行为在特定情境中的功能和目的。这包括识别行为如何影响来访的生活及其人际关系。
    • 重要性：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，从而制定更有针对性的干预措施。这种方法有助于揭示行为背后的动机和功能，促进来访的自我认识和成长。
    • 具体实践：
      • 识别行为：识别来访的具体行为，包括言语和非言语行为。
      • 探讨功能：探讨这些行为在来访生活中的功能，了解它们如何影响来访的情感和人际关系。
      • 制定干预计划：根据功能性分析的结果，制定具体的干预计划，帮助来访改变不利的行为模式。

  3. 处理来访与治疗师的行为

    • 定义：处理来访与治疗师的行为是指在治疗过程中，识别和应对双方的行为模式，以促进治疗的有效性和关系的建立。
    • 重要性：良好的治疗关系是治疗成功的关键。通过处理来访与治疗师的行为，可以增强双方的信任和合作，提高治疗效果。
    • 具体实践：
      • 自我觉察：治疗师需要对自己的行为和反应进行觉察，确保自己的行为不会妨碍治疗关系。
      • 沟通和反馈：与来访进行开放和诚实的沟通，提供和接受反馈，以改善双方的行为。
      • 调整治疗策略：根据来访和治疗师的行为调整治疗策略，确保治疗目标的实现。

  4. 觉察、勇气和爱的行为分类

    • 定义：觉察、勇气和爱是治疗过程中常见的行为分类。觉察涉及对细节和行为影响的注意；勇气涉及面对困难和脆弱的行为；爱涉及表达关怀和支持的行为。
    • 重要性：这些行为分类有助于治疗师全面理解来访的行为模式，并制定相应的干预措施。通过培养这些行为，可以增强治疗关系，促进来访的自我成长。
    • 具体实践：
      • 觉察：注意治疗过程中的细节，理解行为的影响。
      • 勇气：鼓励来访和治疗师面对困难和脆弱，表达真实情感。
      • 爱：表达对来访的关心和支持，建立温暖和接纳的治疗环境。

通过这些知识点，我们可以更好地理解如何在治疗开始时应用觉察、功能性分析和处理来访与治疗师的行为，从而建立稳固的治疗关系，促进来访的自我成长和治疗效果。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 询问的重要性

    • 定义：询问是指治疗师通过提问来了解来访的需求、感受和行为模式的过程。这是FAP（功能性分析疗法）的核心原则之一。
    • 重要性：询问有助于治疗师收集信息，理解来访的背景和动机，从而制定有效的治疗计划。此外，它还能促进治疗关系的建立，使来访感到被理解和接纳。
    • 具体实践：
      • 开放式提问：使用开放式问题，鼓励来访提供详细的信息。
      • 倾听和反馈：认真倾听来访的回答，并给予适当的反馈，表明你在关注他们的感受。
      • 逐步深入：根据来访的反应逐步深入提问，避免一开始就提出过于侵入性的问题。

  2. 披露过程的关注

    • 定义：披露过程是指来访在治疗过程中分享个人信息和感受的过程。治疗师需要关注这个过程，以确保它是有益且安全的。
    • 重要性：有效的披露过程可以促进治疗的进展，帮助来访打开心扉。治疗师需要注意来访的反应，确保他们在披露时感到舒适和支持。
    • 具体实践：
      • 创建安全环境：通过表现出同情和理解，创造一个安全的环境，让来访感到可以自由地表达自己。
      • 注意非言语信号：观察来访的非言语行为，如肢体语言和面部表情，以更好地理解他们的感受。
      • 逐步引导：逐步引导来访进行更深层次的披露，同时确保他们感到被支持和尊重。

  3. 平衡非评判的好奇心和验证性的同情心

    • 定义：非评判的好奇心是指治疗师对来访的行为和感受保持好奇，但不进行道德或价值判断。验证性的同情心是指治疗师通过同理心来确认来访的感受，让他们感到被理解和接纳。
    • 重要性：这种平衡的态度有助于建立信任和安全感，使来访更愿意开放和参与治疗过程。
    • 具体实践：
      • 保持好奇心：对来访的行为和感受保持好奇，避免过早下结论。
      • 表达同情：通过语言和行为表达对来访的同情，让他们感到被理解和支持。
      • 灵活调整：根据来访的反应灵活调整自己的态度和方法，确保治疗过程顺利进行。

  4. 试探性和灵活地向更大程度的直接性和勇气迈进

    • 定义：试探性和灵活性是指治疗师在询问过程中逐步增加直接性和勇气，同时保持对来访反应的敏感度。
    • 重要性：这种试探性和灵活性有助于治疗师在深入了解来访的同时，避免过度侵入或疏远来访。
    • 具体实践：
      • 逐步深入：根据来访的反应逐步提出更深入的问题，避免一开始就过于直接。
      • 观察反应：密切观察来访的反应，确保他们在披露过程中感到舒适。
      • 适时调整：根据来访的反应适时调整提问方式和内容，确保治疗过程的有效性。

通过这些知识点，我们可以更好地理解如何在治疗开始时应用询问的原则，关注披露过程，平衡非评判的好奇心和验证性的同情心，以及试探性和灵活地向更大程度的直接性和勇气迈进。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 共情与理解

    • 定义：共情是指治疗师能够理解和感受来访的情感状态，从而建立信任和支持的关系。理解则是指治疗师通过倾听和观察来准确把握来访的需求和动机。
    • 重要性：共情和理解有助于建立治疗关系，使来访感到被接纳和支持。这可以促进来访的开放性和参与度，为治疗过程打下良好的基础。
    • 具体实践：
      • 倾听：认真倾听来访的言语和非言语信息，理解他们的感受和需求。
      • 反馈：通过语言和肢体语言表达对来访的理解，让他们感到被听见和重视。
      • 验证感受：确认来访的感受，让他们知道他们的感受是合理的。

  2. 识别矛盾与悖论

    • 定义：矛盾与悖论是指来访在行为或情感上表现出的不一致。例如，来访可能在努力避免负面情绪的同时，仍然感到痛苦。
    • 重要性：识别这些矛盾可以帮助治疗师深入了解来访的内在冲突，并提供有针对性的支持。这有助于来访更好地理解自己的情感模式，找到新的应对策略。
    • 具体实践：
      • 观察：仔细观察来访的行为和言语，寻找不一致之处。
      • 提问：通过开放式问题引导来访探讨这些矛盾，帮助他们意识到内在的冲突。
      • 反思：与来访一起反思这些矛盾，探讨其背后的原因和影响。

  3. 探索力量与脆弱性的平衡

    • 定义：探索力量与脆弱性的平衡是指帮助来访认识到他们在面对困难时所展现的力量，同时也接受自己的脆弱性。
    • 重要性：这种平衡有助于来访更全面地认识自己，学会在适当的时候展示力量，在需要的时候允许自己脆弱。这可以提高他们的适应能力和心理健康。
    • 具体实践：
      • 认可力量：肯定来访在面对困难时所展现的力量和韧性。
      • 讨论脆弱性：鼓励来访分享他们的脆弱时刻，探讨这些时刻对他们的影响。
      • 寻找平衡：帮助来访找到在力量和脆弱性之间的平衡点，学习如何在不同情境下灵活应对。

  4. 逐步深入与试探性推进

    • 定义：逐步深入与试探性推进是指治疗师在询问过程中逐步增加深度，同时保持对来访反应的敏感度。
    • 重要性：这种渐进式的方法有助于治疗师在深入了解来访的同时，避免过度侵入或疏远来访。它还能确保治疗过程的安全性和有效性。
    • 具体实践：
      • 逐步提问：根据来访的反应逐步提出更深入的问题，避免一开始就过于直接。
      • 观察反应：密切观察来访的反应，确保他们在披露过程中感到舒适。
      • 适时调整：根据来访的反应适时调整提问方式和内容，确保治疗过程的有效性。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用共情与理解、识别矛盾与悖论、探索力量与脆弱性的平衡，以及逐步深入与试探性推进的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 自我披露

    • 定义：自我披露是指治疗师在适当的时候分享自己的感受、想法或经历，以促进治疗关系的建立。
    • 重要性：自我披露可以帮助建立信任和亲密感，使来访感到被理解和接纳。它还能为来访提供一个榜样，鼓励他们开放和分享自己的脆弱性。
    • 具体实践：
      • 适度披露：治疗师应适度披露，避免过度暴露个人隐私。
      • 相关性：确保自我披露与治疗目标相关，有助于来访更好地理解自己的情感和行为。
      • 适时性：选择适当的时机进行自我披露，以便增强治疗效果。

  2. 合作精神

    • 定义：合作精神是指治疗师与来访之间的平等合作关系，双方共同制定治疗目标和计划。
    • 重要性：合作精神可以增强来访的参与度和主动性，使他们感到自己是治疗过程中的积极参与者，而不是被动接受者。
    • 具体实践：
      • 征求同意：在提出新的治疗方向或方法时，征求来访的同意和反馈。
      • 共同决策：与来访一起讨论和制定治疗计划，确保他们的需求和意见得到尊重。
      • 开放沟通：保持开放的沟通渠道，鼓励来访表达自己的想法和感受。

  3. 接纳和验证

    • 定义：接纳是指治疗师无条件地接受来访的所有感受和行为，而不进行评判。验证则是指治疗师确认来访的情感和经历，让他们感到被理解和认可。
    • 重要性：接纳和验证有助于建立安全和支持的环境，使来访感到被接纳和理解。这可以促进来访的自我探索和成长。
    • 具体实践：
      • 倾听和反馈：认真倾听来访的言语和非言语信息，并通过语言和肢体语言表达对他们的理解。
      • 确认感受：明确表示来访的情感和经历是合理的，并给予正面的反馈。
      • 平衡视角：在肯定来访的优势和成就的同时，也要关注他们的困难和挑战。

  4. 直接性和勇气

    • 定义：直接性是指治疗师在适当的时候直接指出来访的行为模式或情感状态。勇气则是在面对挑战时，治疗师能够坦诚地表达自己的观察和见解。
    • 重要性：直接性和勇气可以帮助来访更深入地认识自己，发现潜在的问题和模式。这有助于推动治疗进程，促进来访的自我觉察和成长。
    • 具体实践：
      • 适时直接：在适当的时候直接指出来访的行为模式或情感状态，但要注意语气和方式，避免造成伤害。
      • 勇于表达：勇敢地表达自己的观察和见解，但要保持同理心和尊重。
      • 灵活调整：根据来访的反应灵活调整自己的态度和方法，确保治疗过程的有效性和安全性。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用自我披露、合作精神、接纳和验证，以及直接性和勇气的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 询问治疗过程

    • 定义：询问治疗过程是指治疗师通过开放性的问题来了解来访对治疗过程的感受和反应。
    • 重要性：这种询问可以帮助治疗师更好地理解来访的内心状态和行为模式，从而建立起信任和支持的关系。它还能揭示来访在日常生活中的应对方式，为治疗提供有价值的线索。
    • 具体实践：
      • 开放式提问：使用开放式问题，鼓励来访提供详细的回答。
      • 倾听和反馈：认真倾听来访的回答，并给予适当的反馈，表明你在关注他们的感受。
      • 逐步深入：根据来访的反应逐步深入提问，避免一开始就提出过于侵入性的问题。

  2. 探索来访的期望和反应

    • 定义：探索来访的期望和反应是指治疗师询问来访对治疗的具体期望，以及他们对已提供的材料（如网站、同意书等）的反应。
    • 重要性：这有助于治疗师更好地了解来访的期望和需求，从而制定更符合来访需求的治疗计划。同时，它也能帮助治疗师识别来访的行为模式和情感状态。
    • 具体实践：
      • 询问期望：明确询问来访对治疗的期望，包括他们希望达到的目标和希望讨论的主题。
      • 探讨材料反应：询问来访对已提供材料的反应，了解他们对治疗过程的理解和感受。
      • 倾听体验：倾听来访在以往治疗中的经历，了解他们的感受和效果。

  3. 建立合作关系

    • 定义：建立合作关系是指治疗师与来访之间建立平等、互信的合作关系，共同参与治疗过程。
    • 重要性：合作关系可以增强来访的参与度和主动性，使他们感到自己是治疗过程中的积极参与者，而不是被动接受者。这有助于提高治疗的效果。
    • 具体实践：
      • 征求同意：在提出新的治疗方向或方法时，征求来访的同意和反馈。
      • 共同决策：与来访一起讨论和制定治疗计划，确保他们的需求和意见得到尊重。
      • 开放沟通：保持开放的沟通渠道，鼓励来访表达自己的想法和感受。

  4. 探索临床相关行为（CRB）

    • 定义：临床相关行为（CRB）是指在治疗过程中观察到的，与来访当前问题相关的特定行为模式。
    • 重要性：通过探索CRB，治疗师可以更深入地了解来访的内在冲突和行为模式，从而更有针对性地制定治疗策略。这有助于推动治疗进程，促进来访的自我觉察和成长。
    • 具体实践：
      • 观察行为：仔细观察来访在治疗过程中的行为，寻找与其问题相关的模式。
      • 提问和反思：通过提问和反思，引导来访探索这些行为背后的原因和影响。
      • 验证感受：确认来访的情感和经历，让他们感到被理解和认可。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用询问治疗过程、探索来访的期望和反应、建立合作关系，以及探索临床相关行为的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 真实表达

    • 定义：真实表达是指在治疗过程中，鼓励来访诚实地表达自己的感受、想法和经历，而不是隐藏或伪装。
    • 重要性：真实表达有助于建立信任和支持的关系，使来访能够在安全的环境中探索自己的情感和行为模式。这也有助于治疗师更好地了解来访的需求和挑战。
    • 具体实践：
      • 鼓励开放：治疗师应通过语言和态度鼓励来访开放地表达自己。
      • 倾听反馈：认真倾听来访的表达，并给予适当的反馈，确认他们的感受。
      • 逐步引导：根据来访的反应逐步引导他们深入探讨内心的真实感受。

  2. 处理孤独感

    • 定义：处理孤独感是指帮助来访识别和表达他们在生活中感到孤独的原因，并寻找应对策略。
    • 重要性：孤独感会影响来访的心理健康和生活质量。通过探索孤独感的根源，治疗师可以帮助来访找到缓解孤独的方法，提高他们的幸福感。
    • 具体实践：
      • 识别根源：询问来访感到孤独的具体情境和原因。
      • 探索感受：深入了解来访在孤独时的感受和身体体验。
      • 制定策略：与来访一起探讨和制定应对孤独的策略，如增加社交活动、寻求支持等。

  3. 建立信任和支持

    • 定义：建立信任和支持是指治疗师通过言行一致、真诚关怀等方式，让来访感到被接纳和支持。
    • 重要性：信任和支持是治疗成功的关键因素。当来访感到被理解和接纳时，他们更愿意开放自己，积极参与治疗过程。
    • 具体实践：
      • 言行一致：保持一致的行为和言语，确保来访感到可靠。
      • 真诚关怀：通过肢体语言和言语表达对来访的关心和理解。
      • 保护隐私：确保治疗过程中的隐私和保密性，增强来访的信任感。

  4. 鼓励冒险与改变

    • 定义：鼓励冒险与改变是指治疗师支持来访面对并克服内心的恐惧和障碍，尝试新的行为和思维方式。
    • 重要性：冒险与改变是个人成长的重要部分。通过鼓励来访走出舒适区，治疗师可以帮助他们克服心理障碍，实现自我提升。
    • 具体实践：
      • 识别恐惧：帮助来访识别和表达他们内心的恐惧和障碍。
      • 设定目标：与来访一起设定具体、可实现的目标。
      • 逐步推进：通过小步骤逐步引导来访尝试新的行为和思维方式，逐步克服恐惧。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用真实表达、处理孤独感、建立信任和支持，以及鼓励冒险与改变的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 即时功能性分析

    • 定义：即时功能性分析是指在治疗过程中，通过观察来访的行为并与他们在日常生活中的问题相联系，来识别和改变临床相关行为（CRB）。
    • 重要性：这种分析有助于治疗师更好地理解来访的行为模式及其背后的原因，从而制定更有效的干预策略。
    • 具体实践：
      • 观察行为：注意来访在会谈中的行为模式。
      • 连接问题：将观察到的行为与来访描述的日常生活中的问题联系起来。
      • 提出假设：基于观察提出假设，并与来访讨论这些假设的有效性。
      • 探索差异：探讨会话内和会话外行为之间的差异，以深入了解来访的行为模式。

  2. 建立信任和支持的关系

    • 定义：建立信任和支持的关系是指通过开放、真诚的沟通，使来访感到被理解和接纳。
    • 重要性：信任和支持是治疗成功的关键。当来访感到安全和被支持时，他们更有可能开放自己，积极参与治疗过程。
    • 具体实践：
      • 开放沟通：鼓励来访坦诚地表达自己的感受和经历。
      • 真诚反馈：给予来访真诚而建设性的反馈。
      • 共情理解：展示对来访感受的理解和同情。

  3. 处理脆弱披露

    • 定义：处理脆弱披露是指在治疗过程中，来访分享敏感或痛苦的经历，治疗师需要以适当的方式回应。
    • 重要性：脆弱披露是治疗过程中的关键环节，有助于深化治疗关系并促进来访的自我探索。
    • 具体实践：
      • 真诚回应：用真诚的态度回应来访的披露，展现同情和理解。
      • 保持自然：以自然的方式回应，避免过度夸张或冷漠。
      • 设定先例：通过真诚的回应，为未来的治疗互动设定正面的先例。
      • 评估效果：观察来访的反应，评估回应的效果，并根据需要调整方法。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用即时功能性分析、建立信任和支持的关系，以及处理脆弱披露的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. FAP治疗原理

    • 定义：FAP治疗原理是指在治疗开始时，向来访解释如何在治疗过程中利用治疗关系来促进个人成长和行为改变。
    • 重要性：提供FAP治疗原理有助于来访理解治疗的目标和方法，增强他们对治疗的信任和参与度。
    • 具体实践：
      • 明确说明：清晰地向来访解释FAP的核心理念和操作方法。
      • 个性化调整：根据来访的特定情况和需求，调整FAP的解释内容。
      • 建立信任：通过真诚的态度和具体的例子，增强来访对治疗的信任。

  2. 建立真实的治疗关系

    • 定义：建立真实的治疗关系是指治疗师与来访之间建立一种基于真诚、开放和支持的关系。
    • 重要性：真实的关系有助于来访感到安全和被接纳，从而更愿意开放自己，积极参与治疗过程。
    • 具体实践：
      • 真诚表达：治疗师展示真实的自我，避免伪装或隐藏。
      • 共情理解：展示对来访感受的理解和同情。
      • 提供支持：给予来访情感上的支持和建设性的反馈。

  3. 处理脆弱性和信任

    • 定义：处理脆弱性和信任是指在治疗过程中，鼓励来访面对和表达自己的脆弱性，并建立对治疗师的信任。
    • 重要性：脆弱性和信任是治疗成功的关键因素。当来访感到安全和被支持时，他们更有可能深入探讨自己的问题。
    • 具体实践：
      • 创造安全空间：确保治疗环境是一个安全、无评判的空间。
      • 鼓励开放：鼓励来访坦诚地表达自己的感受和经历。
      • 逐步引导：逐步引导来访面对和处理脆弱性，逐渐建立信任。

  4. 将FAP与来访问题联系起来

    • 定义：将FAP与来访问题联系起来是指在解释FAP时，结合来访的具体问题和经历，使其更具针对性和说服力。
    • 重要性：通过将FAP与来访的具体问题联系起来，可以使治疗更加个性化和有效，增强来访的参与度和认同感。
    • 具体实践：
      • 了解来访：深入了解来访的问题和经历。
      • 具体示例：使用具体的例子来说明FAP如何应用于来访的情况。
      • 定制化解释：根据来访的具体需求和背景，定制化地解释FAP。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用FAP治疗原理、建立真实的治疗关系、处理脆弱性和信任，以及将FAP与来访问题联系起来的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 治疗师自我披露

    • 定义：治疗师自我披露是指治疗师在治疗过程中分享自己的感受、想法和反应，以促进来访的理解和信任。
    • 重要性：自我披露有助于建立真实的治疗关系，增强来访的信任感，使来访感到治疗师是一个真实的人，而不仅仅是职业角色。
    • 具体实践：
      • 鼓励提问：主动邀请来访提问，表达对他们的好奇心和关心。
      • 真诚分享：分享自己对来访行为的真实反应，无论是正面还是负面的。
      • 适度调整：根据来访的具体情况和需求，调整自我披露的内容和程度。

  2. FAP Rap强化练习

    • 定义：FAP Rap强化练习是指通过密集练习来提高治疗师在FAP框架下进行解释和沟通的能力。
    • 重要性：这种练习有助于治疗师更好地掌握FAP的核心理念，提高其在实际治疗中的应用能力。
    • 具体实践：
      • 选择案例：选择一个适合FAP的来访案例。
      • 编写Rap：编写一个符合实际情况的FAP rap。
      • 模拟练习：通过自言自语、录音或与同事合作，进行模拟练习。
      • 获取反馈：从他人那里获取反馈，了解哪些地方做得好，哪些地方需要改进。
      • 不断改进：根据反馈不断改进FAP rap，并将其应用于实际治疗中。

  3. 开放和相互的反馈

    • 定义：开放和相互的反馈是指在治疗过程中，治疗师和来访之间持续进行的双向信息交流，以改善治疗效果。
    • 重要性：反馈是治疗过程的重要组成部分，有助于治疗师及时调整方法，确保治疗的有效性和针对性。
    • 具体实践：
      • 定期反馈：定期与来访进行反馈交流，了解他们的感受和进展。
      • 多形式反馈：采用多种方式收集反馈，包括口头、书面或其他形式。
      • 即时响应：对来访的反馈做出即时响应，调整治疗策略。
      • 持续关注：持续关注治疗对来访的影响，确保治疗始终符合来访的需求。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用治疗师自我披露、FAP Rap强化练习以及开放和相互的反馈原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

知识点阐述

  1. 会谈总结与诚实邀请

    • 定义：在每次会谈结束时，通过回顾和总结的方式邀请来访表达他们的感受和想法，特别是那些可能涉及脆弱性和诚实的内容。
    • 重要性：这样的总结有助于增强来访的自我意识，同时促进治疗师和来访之间的信任和理解。
    • 具体实践：
      • 表达感激：对来访在会谈中的积极参与表示感谢。
      • 鼓励表达：鼓励来访分享他们在会谈中的感受、想法和进展。
      • 倾听和反馈：认真倾听来访的反馈，并给予适当的肯定和建议。

  2. 会谈衔接表的作用

    • 定义：会谈衔接表是一种工具，用于在两次会谈之间收集来访的反馈和信息，帮助治疗师更好地了解来访的情况和需求。
    • 重要性：通过这种方式，治疗师可以更好地跟踪来访的进展，及时调整治疗计划，并确保治疗的连续性和有效性。
    • 具体实践：
      • 定制化：根据来访的具体情况和需求，个性化设计表格内容。
      • 反馈循环：定期查看并回应来访的填写内容，形成一个持续的反馈循环。
      • 强化行为：通过认可来访填写表格的努力，强化他们的积极参与行为。

  3. 识别和处理CRB

    • 定义：CRB（临床相关行为）是指在治疗过程中观察到的、与来访问题相关的特定行为。
    • 重要性：识别和处理CRB有助于治疗师更好地理解来访的问题，并针对性地制定治疗策略。
    • 具体实践：
      • 观察和记录：在会谈中密切观察来访的行为，并记录重要的发现。
      • 询问和探讨：询问来访对这些行为的看法，探讨它们与来访问题之间的联系。
      • 制定计划：根据观察结果和来访反馈，制定具体的治疗计划。

  4. 建立反馈机制

    • 定义：建立一个有效的反馈机制，包括非正式和正式的反馈交流，以确保治疗过程的透明度和有效性。
    • 重要性：良好的反馈机制有助于治疗师及时了解来访的需求和感受，调整治疗策略，提高治疗效果。
    • 具体实践：
      • 定期检查：定期与来访进行反馈交流，了解他们的感受和进展。
      • 多种方式：采用口头、书面或其他形式收集反馈。
      • 即时响应：对来访的反馈做出即时响应，调整治疗策略。

通过这些知识点，我们可以更好地理解如何在治疗过程中应用会谈总结与诚实邀请、会谈衔接表、识别和处理CRB以及建立反馈机制的原则。这些内容不仅有助于治疗师更好地开展工作，也有助于来访在治疗过程中获得更好的体验和支持。

CHAPTER 7 Lay a Foundation at the Beginning of Therapy Out beyond ideas of wrongdoing and rightdoing, there is a field. I’ll meet you there. —­Rumi Henry is late. Three minutes…six minutes. You’re about to call him when you hear a confident stride coming down the hall, matching the voice you spoke with on the phone last week. He enters the room and asks, without urgency, “Am I late?” “Yes, a few minutes,” you reply. “Just how I like it.” He seems to be studying the art on your walls, vaguely distracted, but something says he’s making a show of being confident. There’s a slight hint of apology behind the breezy acknowledgement, but it would be easy to miss. “Are you often late?” “Yeah, unfortunately it’s a thing for me.” He pauses. “Maybe more than I’d like to admit.” You are slightly surprised by his honesty, given his impassive face. You press further. “Do you always avoid apologizing for it?” There is no disapproval in your voice, just curiosity. He in turn is surprised by your directness. “Ha! I don’t know. I guess.” As the meeting unfolds, you learn more about Henry. He is a recent college graduate. His parents and step-­parents are high achieving. He was also in trouble a fair amount as a kid. He remains confident, even steely, in his presentation. His eyes are often focused, looking out the window or at the floor. Occasionally he looks at your eyes in a way that seems intent on showing you that he’s confident. And yet you don’t believe he’s confident beneath his exterior. “What do you want to get from therapy?” “I don’t know. Just someone to talk with. Talk things out.” “Hmm. I don’t know what that means exactly. How about this: I want to understand you, help you understand yourself, and help you move toward what matters in your life. Are you up for that?” “Yes.” A long pause. “Well, that’s actually what I want.” “One thing I notice about you right off is that you seem hard on the outside, and I can’t tell what you’re feeling on the inside. I like your charisma and confidence, but how you express it can be slightly off-­putting, to tell you the truth. Are you aware of any of this about yourself?” “Yes.” Another pause. “Actually I often feel like an asshole.” He says this without vulnerability. You worry that you might have been a bit too forceful, but the honesty is a relief. “I was very direct with you just now. Would you mind telling me if I am ever off-­ putting to you?” “Sure, but I want that.” “Actually… I can see how your confidence or aloofness would invite directness from others. I can also see how that could lead you to stay invulnerable, guarded in a way. I wonder if that’s how you learned to be, or if you’re living up to something. Any of what I’m saying resonating for you?” “I’m not sure. I feel like I’m open. You’ll have to figure that out as we go along.” Later in the session, you realize that Henry remains vague about what he wants—­ not just about therapy, but about what he wants in his life at the moment. He hides his emotions or isn’t in contact with them when talking about what would seem to be emotional topics. He can be off-­putting with his confidence, but he is also very capable of directness and truth telling. This probably works well for him in some contexts, but there’s pain and vulnerability behind his front, and perhaps his confidence and hardness are about avoiding vulnerability. You’ve learned that he has a lot to live up to after all, and he has a considerable history of being negatively judged for his actions. He validates this intuition toward the end of the session when, while completing a routine assessment, you ask if he ever thinks about killing himself. He pauses for a moment. And when he speaks, it is with feeling. “I think about it every day. I wouldn’t act on it, but I think about it.” “You don’t know me well yet. But what matters most to me is that the work I do is based on reality—­the real experiences of my clients. I don’t want to do therapy on half-­truths. So I’m grateful to you for sharing that part of your truth with me. That’s what will make this work well between us. In turn I aim to earn your trust. I will be genuine, and I invite you to be the same. That will allow me to see you—­I can’t help with what I can’t see. And by seeing you clearly I can help more.” T he previous story is in many ways quite extreme. It’s not a perfect start to therapy, but the therapist and Henry went on to develop a strong relationship. Things unfolded the way they did based on who Henry is, who the therapist is, and the nature of their engagement. For instance, the therapist felt confident that Henry was reasonably well functioning and well educated (infor- mation he gathered in the initial phone call with Henry). The therapist also made quick judgments that FAP-­style assessment of the present moment would be well tolerated by Henry, and that what was happening in the moment was likely relevant to his clinical issues. For instance, Henry dis- closed on the phone that he was looking for work, and showing up late to appointments is definitely a problem in that realm. Despite its unique qualities, the story illustrates how much can happen at the beginning of therapy. It represents one (certainly not the only) way of doing FAP. As you can see, both of the core principles of FAP are present: • Addressing the present-­moment interaction, including building connection through vulnerable disclosure and responsiveness to the other’s disclosure (such as when Henry admits to considering suicide). Showing the client how the work will go, as well as ori- enting him to it (as in the last sentences the therapist spoke). • Beginning to build a functional understanding of the client’s issues by integrating what you see in the moment with what the client is telling you about his clinical issues. In this chapter, we’ll discuss how to put FAP principles into action at the beginning of therapy. It’s much easier to integrate them at the beginning of a relationship rather than later on, when norms of avoidance are already in place. In turn, if pursued skillfully, we believe the FAP principles of addressing the present-­moment interaction and building functional understanding contribute to a strong rapport early on and increase the likelihood that clients will want to return to see you again. Why? Because they experience your understanding of them and their issues and your will- ingness to work collaboratively with them to make progress. When therapists feel disconnected or frustrated with a client (or vice versa), the cause is likely found in a failure to attend to this process of connecting. For instance, if the therapist working with Henry had not addressed Henry’s tardiness or delved deeper into his presentation to discover the vulnerability underneath, he or she might have been left feeling annoyed or confused. Our ­assumption in FAP is that it’s not any particular differences between client and therapist that cause problems for the alliance; instead it’s how these differences are handled that matters. Henry’s therapist used direct and compassionate communication to handle his tardiness and invulnerable confidence. Consider another example: A client might prefer very concrete, linear explanations, whereas a therapist leans toward the abstract. If therapist and client openly discuss this difference and agree to check in on whether the therapist is meeting the client’s needs, then they stand a better chance of doing well (in fact, the client might learn something valuable from the experience of navigating this difference). If therapist and client instead skirt the issue, the client may become frustrated by the vagueness of the therapist, and the therapist may be irritated by the repeated requests for clarity. This chapter is organized around the four main interrelated tasks involved in putting FAP into action at the beginning of treatment: • Awareness: Noticing potential CRB in the moment. • Inquiry: Inquiring, from a curious, nonjudgmental, courageous stance, about in-­the-­ moment behavior and how it relates to the presenting problems or the optimal process of therapy. • FAP rationale: Orienting the client to and seeking informed consent for FAP interventions. • Feedback: Setting up formal and informal feedback mechanisms to guide the therapy process. AWARENESS When you meet a new client, what do you see? Tom, for instance, from part 1 of this book, seemed eager to please and overly polite. Nick was tense and formal. Henry was guarded and overconfi- dent. From the first moments a client appears in the doorway or the waiting room, we are gathering information and making assessments about her. Assessing behavior—­and remember, all of what a client does in session is behavior—­is the focus of functional analysis. When a client is in front of you, you have access to a high-­resolution, responsive, interactive instance of behavior. As a rule, what we see and experience in the first session tends to become relevant to a client’s clinical problem. Functional thinking, in turn, leads us to discover how this behavior is relevant. In other words, the contextual behavioral science (CBS) standpoint asks you to take a critical next step beyond your immediate judgments and perceptions and observations. Going beyond surface appearance, you must ask this: How does this behavior function for the client? In other words, how does it “work” for her in life? Is it related to a presenting problem? Similarly, we must ask if our reaction to our clients is us simply being idiosyncratic. For example, is my annoyance at Henry’s lateness merely reflective of my tight standards about punctuality? Or does my reaction indicate how others likely respond to Henry as well? This discrimination requires self-­knowledge. Remember, we are not looking for moral judgments about “the type of person the client is”; we’re looking for hypotheses about how the client’s behaviors function interpersonally and may create problems that lead to suffering. An interesting challenge occurs when a client’s appearance and behavior in the room differ markedly from the presenting problem she describes. Consider an unusually mild-­mannered, thoughtful client who seeks help for anger that escalates when she’s getting her children out the door in the mornings. Is it possible that she is overly polite and reserved, such that her kids (and others?) tend to walk over her needs and, in turn, she only effectively gains their obedience through a dramatic change of tone? The general functional question at the center of the analysis is this: How does this striking behavior that I see and experience here and now possibly relate to the clini- cal problem the client describes? Functional analysis is like a connect-­the-­dots puzzle, something to be pursued through assessment and investigation. In that process, be prepared to let go of clever hypotheses if they do not appear valid. Noticing Potential 1s and 2s at the Outset of Therapy Below are lists of behaviors (1s and 2s) that commonly arise at the beginning of therapy. The behaviors are divided somewhat arbitrarily in the categories of awareness, courage, and love even though many behaviors have multiple functions. These lists are intended to help you generate ideas about the kinds of behavior to look for in your clients and yourself. They are not exhaustive. Of course therapists may have many of the same issues as their clients, but we included behaviors that are only relevant for therapists in a separate list. Awareness Client (and Therapist) Behaviors Not noticing important details about the therapy process (assignments, consent, address, appointment time, and so on) Not being aware of the impacts of behaviors (not respecting personal space, ignoring questions, talking over the therapist, and so on) Not using emotion words (for example, anxious, ashamed, irritated, uneasy, content) Talking excessively about irrelevant details Offering thin, vague responses Therapist Behaviors Being overly focused on a protocol or method of therapy at the expense of empathetic contact with the client or self Failing to deeply understand or empathize with the client Overlooking important details in the client’s presentation Not noticing client CRBs until later, in supervision or consultation Courage Client (and Therapist) Behaviors Withholding vulnerable details Suppressing or avoiding emotion Presenting a very positive, incongruent picture Holding back on wishes and needs for therapy Disclosing a lot very quickly in a way that leads to avoidance or feeling overwhelmed Being overly assertive, demanding, or critical Being guarded Therapist Behaviors Not asking about more vulnerable topics, such as intimacy, sex, self-­harm, or suicide Asking questions in overly blunt or clinical ways Not discussing the therapy process or not requesting feedback Not disclosing more personal reactions Love (Including Self-­Love) Client (and Therapist) Behaviors Seldom providing positive feedback or saying encouraging things Being uncomfortable with or avoidant of warmth or validation Being overly concerned with offering appreciation or reassurance and doing so in a way that appears inauthentic or excessive Being overly apologetic about requests or self-­care Therapist Behaviors Not expressing care for or appreciation of the client Not accepting praise or appreciation from the client Overcommitting to the client; for example, by offering extra therapy time or out-­of-­session support EXERCISE Using one of the behaviors listed above, generate hypotheses about how the behavior could function in a way that perpetuates a clinical issue. For example, being uncomfortable with or avoidant of warmth or validation might lead a client to subtly punish others when they offer support; and this behavior, in turn, may make offers of support less likely, leading to a decrease in the client’s social support and an increase in feelings of isolation. INQUIRY In the dialogue with Henry that opened the chapter, the therapist made a number of potentially evocative statements in response to what he was noticing; for example, he pointed out that Henry was not apologizing for his lateness, asking whether that was a pattern, and he also noted that Henry seemed guarded. These kinds of statements play a crucial role in FAP. Together with other elements, they make up the basic FAP stance in the therapeutic relationship. To understand this stance, let’s first review the goals, from a FAP perspective, that should be in place at the outset of treatment. A very basic goal at the beginning of therapy is to learn about the client; for example, what brings her to therapy, what she is looking for in a therapist, and so forth. Therefore, inquiry is a basic principle of the FAP stance. Active inquiry, of course, forms the basis of functional thinking. In FAP we also want to pay attention to the process of disclosure that our inquiry invites. That is, how the behavior of disclosure unfolds and responds to what is happening in the therapy interac- tion. There are several reasons to pay attention to this process. First, if the client is not disclosing openly, therapy is likely to be impeded. Second, the invitation to disclose in therapy may be quite different from what happens in other social settings, so the client may experience quite natural reactions of vulnerability or shame or hesitation as we invite them to disclose. Attending to these reactions and ensuring that we proceed in a way that is attuned to the client’s needs is a key part of the therapeutic alliance. Third, it is possible that the client’s process of disclosure is CRB—­that is, it’s functionally related to her presenting clinical issues. The CRBs may involve willingness to dis- close or not. They might also involve a variety of other behaviors: for example, a tendency to avoid emotional expression, to ruminate unproductively, to beat around the bush, or to look at things in black-­and-­white terms. When we attune to the process of disclosure, then, we aim to mindfully and compassionately shape the relationship as an experience of trust and safety; we also want it to be an experience that offers a clear view of how the client’s psychology works. In addition to these goals, it’s important to keep in mind that at the beginning of therapy you don’t yet know the client or where her interpersonal vulnerabilities lie. If you proceed too boldly in your inquiry—­asking invasive questions—­you risk damaging the alliance or overpowering the client. If you proceed too tentatively, you risk allowing the interaction to remain superficial rather than proceeding toward the more intimate type of disclosure (and the opportunity to provide responsiveness) that forms a strong therapeutic alliance. Therefore, it’s important to proceed in a sensitive, flexible way. With these goals and our lack of knowledge about the client in mind, the FAP relational stance balances nonjudgmental curiosity and validating compassion with tentative, flexible ventures toward greater directness or courage. Pervasive curiosity and compassion ensure that the thera- peutic interaction, as a whole, is appetitive; the client should be richly reinforced for attending therapy and talking with you. There should be no aversive social consequences coming from you related to disclosure of what the client is experiencing. With directness and courage you can invite slightly more vulnerable disclosures from the client. This may gradually deepen the intimacy and vulnerability (and therefore trust) the client experiences in the relationship. The FAP relational stance sets the scene for addressing CRB directly later on and allows you to observe how the client responds to encouragement for greater vulnerability. In the following dialogue, the therapist demonstrates some key features of this balanced stance. Therapist: It sounds like your parents’ divorce came at a really difficult time—­just when you’re figuring out who you wanted to be at college. I can see your pain as you talk about it. Client: It’s the sort of thing everyone has to deal with, I guess, in some form or another. Welcome to being an adult. Therapist: Yes, I can see you sort of telling yourself to buck up as well. Like, be tough, there’s no time to be emotional. Client: Well what’s the point of being emotional? Feeling bad just to…feel bad? Therapist: Yeah, I see puzzlement there. Why feel bad? It seems so useless…endless. I wonder if what I see in you is a kind of paradox. Because I notice you seem to me to be feeling bad as you struggle against feeling bad. Almost as if you’re trying to talk your way out of feeling bad, but the fact remains: you are feeling bad. Am I seeing you right? Client: Yes, sure. But…then it just seems hopeless. Therapist: Well, again, I’m just getting to know you, so I might be wrong here. But I notice you are a person with lots of strength. You worked hard through college, despite the chaos happening. You just put your head down and worked. And you’re not afraid to ask the hard questions and call it like it is, like “What’s the point of feeling bad?” But then I wonder, what if strength—­your strength—­doesn’t work well for all types of struggles in life? What if your tenacity actually doesn’t work for this type of emo- tional struggle? Client: But how do I change? Therapist: And there goes your tenacity again. You immediately want to know how to change. What to do. I can hear a kind of hardness in how you’re demanding that. Impatience. Do you feel that? Client: Yes…argh! I’m so exhausted. Therapist: I know I’m pushing you a bit here. Would you be willing to keep going? Client: Yes. Of course. Therapist: Would you be willing to tell me more about that exhaustion? That exhaustion that’s behind your impatience, behind your strength? Client: It feels so weak. Like, I want to just get in bed and cover myself with pillows and cry when I feel exhausted. I feel like a child throwing a pity party. Therapist: The way you say that makes me feel tender toward you. I wonder if you learned—­ maybe from someone very important to you, or maybe you sort of figured it out yourself—­that it’s just not okay to be “weak” or to want to lay in bed and cry. Maybe you learned that people don’t respect you if you do that. And then how exhausting to have to just buck up all the time. But how rewarding it must have felt to be strong and to please others, to overcome and be successful. Do I have this somewhat right? Client: Well, yes. Buck up, that’s my dad—­100 percent. And my gymnastics coach as well. “We do not entertain weakness.” Therapist: I wonder if part of our work together could be about slowing down. Noticing where you are getting caught in the paradox of feeling bad while trying not to feel bad and instead finding a different way of relating to yourself? In fact, it might be a different kind of challenge—­a challenge to try easy instead of trying hard all the time. Client: Yeah, what you say makes sense. Therapist: What’s it like that I’m asking all these questions? Client: It helps. It’s a lot to think about. They make me think about things in a different way, I guess. Therapist: And I, in turn, respect your strength because it lets us be honest, and direct. I respect your strength in being here, working on what feels so uncertain and hopeless. Working on when your mind says you’re weak. The therapist here is working from an acceptance and commitment therapy standpoint, yet woven throughout the interaction are key elements of the FAP relational stance:

  1. Self-­disclosure: The therapist makes incidental self-­ disclosures about his internal process: “I’m just getting to know you, so I might be wrong here” and “makes me feel tender toward you.” These disclosures help set the norm of vulnerable disclosure.
  2. Collaborative spirit: The therapist asks for permission to continue the inquiry, acknowl- edging his potential impact on the client. He also asks if the client would like to buy into what he’s suggesting they work on together, once she’s experienced a bit of the therapy process. He doesn’t impose his view, rather he asks her to try it on. His self-­ disclosures also communicate collaboration, that he might be off the mark and is open to feedback in order to adjust course. This is not a “my way or the highway” situation.
  3. Accepting and validating: The therapist reflects the value of the client’s strengths. After all, this strength has been strongly reinforced and is in many contexts regarded as a virtue. The therapist balances this reflection with a validation of the cost of being strong all the time: exhaustion. Strength and exhaustion have a very natural relation- ship. Finally, the therapist recognizes—­and hopefully reinforces—­the client’s partici- pation in the therapy process, suggesting that exploring vulnerability is a different type of strength.
  4. Directness and courage: In response to the client’s question “But how do I change?” the therapist makes a pointed observation: “And there goes your tenacity again.” This is an example of courage: saying something slightly challenging in service of building greater awareness. He also recognizes that this challenge may evoke the client’s self-­criticism. She might say to herself, Can’t I do anything right? He decides not to explore that possibility in this session, instead opting to slow down and explore the client’s response to his chal- lenging. For the client a sense of exhaustion comes up. He suspects that the client will feel more vulnerable sharing that part of herself, so he asks for her permission to go there. In turn, her disclosure of exhaustion naturally makes the therapist feel tender toward her, and he expresses that tenderness, because it is a natural, warm response to her vulnerability. He will, of course, continue to observe and inquire over time about how she actually responds to such statements. Overall, this gradual, attuned movement toward greater vulnerability in self-­disclosure also reflects another aspect of courage. Sometimes it is obvious that a client is guarded—­unwilling to open up. At other times, whether or not she discloses vulnerable things about herself is not a matter of willingness; she is actually unable to articulate her internal experience in the moment. At these times, you will not push as hard, because pushing is counterproductive. Inquiring About the Therapy Process Clients bring their presenting problems to sessions, but they also react to the process of therapy—­ filling out consent forms, coming to the first appointment, responding to initial questions. Their reactions can be a valuable window into how they function in life; exploring these reactions can serve as a road to rapport. Accordingly, a FAP therapist might ask in open-­ended ways what it is like to come to therapy. Therapist: I’m curious how it’s been for you, leading up to our first appointment. Client: I was looking forward to it. Therapist: Any thoughts or feelings about coming here? What were you thinking today? Client: Not very much at all. It was a crazy day. Our appointment was kind of stuck in the back of my mind. I feel like I’m opening a door and I’m kind of insecure, but I’m a really good actress. I’ve had to be since I got depressed—­to get through life. Therapist: I want to hear more about that. You might also inquire about clients’ wishes for the session, their reactions to any materials they’ve already read (for example, your website, your consent form, any flyers or brochures you circulate), their experiences in previous treatments, and their desires to know more about you. All of these areas of inquiry provide opportunities to engage the client in a collaborative relationship and to begin to understand her patterns of behavior. In the following sample, the therapist weaves several of these threads together, shaping an initial understanding of a potential CRB and moving the therapy interaction toward greater vulnerability. Therapist: What feels important to you for us to get to today? What do you want to talk about? When you came in, did you have certain ideas about what would make this a really good session? Client: No. Therapist: So you’re going to leave it up to me. Client: I can help you figure it out. I bet the first session is always hard because there’s so much of me that you don’t know about. It’s always hard to try to get to know people. Therapist: The first session is hard. I never quite know what to expect. I have a list of things to get to today, but one of the things is what’s important to you, because it’s very important to me to tailor this treatment to you. So, you read my description of this treatment, right? Client: Yeah. I really like what you wrote. Therapist: I want to go over that and answer any questions you have. You can let me know what you like and don’t like. I want to answer any questions you have about me. You don’t know that much about me. Client: If you’re in private practice, I want to know how you got involved with the university. Therapist: I’m also affiliated with the university. I’m a clinical instructor, and I also teach a class here. Are you curious about my training or background? Client: Yeah. Therapist: I got my doctorate here in 1982. I did my undergraduate training at UCLA, and in 1976 I came here for graduate school. I thought I’d go back to southern California, but I never did. Client: That’s interesting. Therapist: How do you like your therapists to be? It seems that you like your psychiatrist, Dr. L., a lot. Do you want me to be directive or nondirective? Client: I really like people to be directive with me, but at the same time I’m ultrasensitive. I always have been. And so I always ask the people I work with to be careful—­not that anything isn’t well-­intentioned, but I get a bit sensitive. Therapist: Can you give me an example of something that’s happened? Client: Sure. Once with Dr. L., I left feeling worse—­angry and upset. I have all this debt, and I felt like she was kind of hard on me about it, which surprised me. I just wanted to talk about it and get it out. I felt really uncomfortable because I owed her money. I owe all of my health professionals money. When I left I felt awful. Therapist: Wow. Okay, well I want to be really sensitive to how hard it is for you to talk about things and make sure I get that right for you. Client: I’d appreciate that. Therapist: You know, this is a good moment, because as you read in that description of our therapy together, one focus of our treatment is going to be our relationship and how it connects to all your other relationships. I notice that you’ve got some other good relationships going. Client: I’m lucky. Therapist: It’s not just that you’re lucky. I think you’re pretty socially skilled. You’re saying you know how to put on a good act and doing so is exhausting, but it’s also a skill that you have. But in here I want us to look at what’s effective in terms of how you relate to me and how I relate to you, and maybe we can look at getting more skilled at being authentic. For example, if I don’t get something right, you can tell me. Did you tell Dr. L. how you felt? Client: No. Therapist: Yeah, I understand how hard that is. It seems that on the one hand you have really good relationships, but on the other hand you feel lonely. Maybe not speaking up is part of it. Is that an area you want to work on? Client: I haven’t figured out how to feel less lonely. One thing is that I live alone. And I’ve noticed a trend that over the past year and a half I’ve pulled back more and more from socializing. Therapist: What does it feel like to feel lonely? Do you feel lonely right now? Client: A little bit…maybe empty. Therapist: Where do you feel empty? Client: My heart…my chest. I notice not so much something missing but more of an emptiness. Therapist: When did you last feel more full? Client: I’m not sure I can remember. I think probably during my last long-­ term relationship. Therapist: How long ago was that? Client: Three and a half years ago. Therapist: So when you talk about your relationship, it seems you still have a sense of longing. Do you long for that relationship, or just a relationship in general? Client: A relationship. (Pauses.) I feel emotional. Therapist: You feel emotional talking about your loneliness? Client: I think so. (Cries.) The whole thing is difficult. May I bother you for some tissues? I can kind of deny my miserableness on paper, but if I to have to talk to somebody about it, it’s painful. Therapist: Well, you’re talking right now, to me, and it’s really helpful to me. How much hope do you have that this treatment will help you? What are your hopes and fears? Client: I have a lot of hope actually. Therapist: Tell me what you feel positively about. Client: My life. I didn’t focus on anything with Dr. L. I haven’t been working on anything, or don’t feel like I have. I feel like I’ve been treading water for a long time, and this therapy feels like something I need. I need a direction. Therapist: I’m good at giving direction—­and at hand-­holding. Client: You seem like you are. You have very kind eyes. I am hopeful. Therapist: I’m really glad that you’re hopeful. And I’m glad you notice the kindness in my eyes—­the kindness I’m feeling for you already. One of the things that’s important to me is that this is a sacred space for you. When I’m here, I’m not thinking about any- thing else; this space is protected. I take it really seriously. I want to respect the effort and risk you put into being here. Client: It reminds me of something that happened. You know how at a drugstore you often see those pamphlets on quitting smoking? They usually have a little saying. One time I saw one that said something like, “In order to get anywhere in life, you have to decide you’re not going to stay where you are.” This reminded me that the first step is simply deciding you’re going to move. Therapist: And that’s what you’re doing. You’re taking a risk by being here. So, given what you said before, I wonder, what’s the difference between acting like you’re taking a risk and actually taking a risk? One of the things we can do in here is help you really take risks, and take the right kind of risks. Client: That’s going to be hard—­good, but hard. Therapist: I know. I’ll appreciate how hard it is for you. Inquiring About CRB with In-­the-­Moment Functional Analysis As we mentioned earlier, part of the functional analysis process is linking the behaviors you see here and now with the presenting problems the client describes as happening in daily life. Making these connections eventually gives you the opportunity to identify and work on changing CRB in the moment. In the interim—­even in a first session—­this linking of in-­session and out-­of-­session behavior can help you better understand the client’s presenting problems and related behaviors. For example, let’s say a client describes how his wife often interrupts him or grows impatient with him. You notice that he tends to talk at length, to the point that it’s not clear when he will stop to let you talk. You might delicately share this observation with him and ask whether he tends to talk in this lengthy way with his wife. Therapist: If I might share something delicate: I notice that you do tend to talk at length. So, I wonder if that might be one factor that contributes to your wife interrupting? That she gets impatient with how you are talking? Client: Well, I suppose. I always talk like this and I’ve been given crap for it my whole life. I get tired of people wanting me to be different. When I was in the fourth grade they used to call me motormouth. There was this one teacher who used to interrupt me on purpose whenever I was giving answers in front of the class… Here, the therapist uses what she observes in session to make a hypothesis about what might be going on outside of session. In turn, it can be useful to explore differences between what you observe in session and what is reported about out of session. Therapist: Well, I recognize my pointing out that you do talk a lot might put you on edge. But I appreciate that openness, and I hope we can have a spirit of “let’s put all the facts on the table.” I notice you do seem willing to take that feedback from me, and to consider the effect of your talking. But I heard you say that with your wife, if she tries to give you feedback, you respond quite differently. Client: Yes, I’m very defensive. We argue about it every once in a while, then we go back to a resentful avoidance. Therapist: So what is different here—­that you are willing to hear my feedback? Client: Here I trust that you want to understand me and you want what’s good for me. By contrasting the in-­session and out-­of-­session contexts, the therapist discovers an important misalignment in the client’s relationship with his wife: he doesn’t trust that she wants to understand him compassionately. You can also compare in-­session and out-­of-­session context using the following questions: Would [some clinically relevant behavior that happens in daily life] ever happen in here with me? If [that behavior] happens, would you tell me? These questions are especially useful when the client’s daily behavior involves not disclosing what is happening to the other people involved. For example, if a client gradually feels more resent- ful toward naturally assertive people because of the way they unknowingly step on his unvoiced needs, until he eventually blows up at them, you might explicitly ask whether such resentment might conceivably show up in the therapy relationship. This could be an especially important inquiry if you know yourself to be a naturally assertive person. Again, such questions set the tone for an open, disclosing therapeutic relationship. Responding to Possible CRB2 Sometimes clients engage in significant and risky vulnerable disclosure in the early stage of therapy because they think that is what they’re “supposed to do,” or because they’re so under- standably exhausted from suffering in isolation that they take a chance and share their burden with a sympathetic listener. For example, in the dialogue that opens this chapter, Henry discloses sui- cidal ideation, something he admits that he has not told anyone else. The therapist then takes a risk by responding in a very direct and personal way. While this shift is not explicitly indicated in the dialogue, the therapist’s response is marked not just by his words, but also by a change in voice tone and posture that reflect a genuine emotional response to Henry’s distress. The therapist hopes that his response reinforces Henry’s disclosure and that more vulnerable disclosure will follow. At an early stage in therapy, however, the therapist cannot be certain that the disclosure from Henry really is CRB2 (honest disclosure about his suffering) nor whether his heartfelt response will reinforce the disclosure. Henry might actually find the response off-­putting. Nevertheless, as therapists we sometimes have to guess, especially with issues of vulnerable disclosure. It’s worth making these guesses, because the harm of failing to respond receptively to a significant disclosure early on can be meaningful; responding genuinely sets the precedent of genuineness and also the precedent of addressing directly what is happening in the here and now. Be sure to respond to vulnerable disclosures in ways that are natural. (More on that in chapter 9, which focuses on responding to CRB2.) OFFER A FAP RATIONALE At the beginning of treatment, it’s also useful to orient clients explicitly to how you will use the therapy relationship in your work together. In other words, provide a FAP treatment rationale (“FAP rap” for short). The FAP rap is typically delivered as soon as you know that FAP interven- tions will likely be part of your treatment plan. The core of the FAP rap is simple and can be pre- sented along these lines: Therapist: When the issues you’re working on show up here and now in therapy, it’s useful to notice them, giving you an opportunity to change the behavior you’re working on right here and now in the moment, and giving me—­your therapist—­an opportunity to respond to you in a way that gives you support and useful feedback about what you’re doing. A less formal variant looks something like this: Therapist: I find it’s useful in this work to be able to slow down at certain points so we can look closely at what’s happening in the moment. For example, certain interactions between us can be useful moments for you to learn about yourself. You can get feedback from me in the moment about how you’re coming across, or how others might see you in those moments. You can also then practice responding differently, if that seems useful. How does all this sound to you? You can also be more explicit about FAP if doing so fits your style or if a client has requested to know what type of therapy you practice: Therapist: I do a type of therapy called functional analytic psychotherapy, or FAP. Yes, it’s a silly acronym. A key part of FAP is using our interactions, here in therapy, as a way to understand who you are and how you want to change. For instance, you’ve told me you want to learn to be more aware of yourself, how you impact others, and how you get stuck or hold yourself back in interactions with others. Together we can watch for moments when you do these exact things with me, and we’ll see how we can shift what happens in those moments. How does that sound to you? Finally, some FAP therapists phrase their rationale with more evocative language and seek a more explicit commitment to interpersonal depth and FAP work in general: Therapist: I feel privileged to be embarking on a journey of exploration and growth with you. One of the first and most important things I want you to know about our work together is that FAP emphasizes that we form a bond. It will be a major vehicle in this journey. I’d like to have a real relationship with you. I commit to you that I will be a genuine person in this room with you; I will not be fake or hide behind anything. I know how hard it is to be vulnerable and to talk about difficult things. I also know how important it is. So I commit to make therapy feel like a sacred space for you, a place with unusual levels of safety, understanding, caring, and support. I will do this so you can join me in really working, exploring, and growing. I want to create a feeling between us that lets you know you have 100 percent of my attention; I’m able to deeply see, accept, and respect who you are at your core, both flaws and strengths; and I’ll hold with reverence and care all that you share. I’ll be investing a great deal of care and effort into our work together, and I expect you to do the same. Based on your goals for therapy, and with your permis- sion, I’ll challenge you to be more aware, present, open, vulnerable, and loving. I’ll check with you about what’s working well for you in our relationship and what needs to be changed. And if difficulties come up with me that also come up with other people in your life, we’ll zero in on our interaction, either positive or negative, and look at what’s going on and what we can learn from it. These will be key moments for us, and I’ll always be looking for them. There are also exercises we can do to get these issues directly in the room with us. Our therapeutic relationship will be an ideal place for you to practice how to navigate these moments in a way that feels like you’re really being who you want to be, with me, with others, and in life. From here, we begin to foster change and growth so you can live the life you really want. How does all of this sound to you? You should develop a FAP rap that fits your values, way of speaking, cultural context, and clini- cal context. Linking to Client Problems The preceding examples of the FAP rap were fairly generic—­even the final, very heartfelt one. You can often make the FAP rap more meaningful and persuasive by linking it to what you under- stand about the client and her presenting problems. Here’s an example: Therapist: You mentioned that you struggle with feeling at ease around people, especially when it’s not clear what your role is. For example, at cocktail parties you tend to feel very awkward, whereas at your job you know exactly what to do. In our work, there might be moments when there is similar confusion about what your role is. It’s like what you said at the beginning of our meeting today, that you were a little anxious about what you were supposed to tell me about yourself. So here is a version of that very situation you struggle with, here in the moment. It can be quite useful to work with that experience here in the moment, as it happens between us, rather than just talking about it from a distance. How does that sound to you? For clients with presenting problems related to social disconnection, it might be useful to high- light the aspects of connection—­vulnerable disclosure, and so on—­that naturally occur in the therapy relationship: Therapist: You’ve said that trusting and being vulnerable with others is really scary for you, and I know that therapy can be a really vulnerable process. You come in here and tell me things that are very personal that you don’t tell anyone else, and that can be scary. I want you to know how important that honesty is. I can help you most effectively when I know what’s happening for you. What I hope is that, as you open up to me, I’ll respond in ways that help you come to trust me. And believe me, nothing is more important to me than being trustworthy as a therapist. And in turn, you might learn to become more confident in opening up to other people in your life who are also trustworthy. Therapist Self-­Disclosure Another key element of the FAP rap is therapist self-­disclosure. At this point in the book, you’ve seen again and again how a therapist disclosing her reactions to the client and the process in the moment plays an important role in FAP. Some clients expect the therapist to be a “blank screen”; they may be reticent to ask the therapist direct questions, or they may be surprised to hear the therapist sharing personal reactions. It can be useful, therefore, to orient explicitly to the value your own self-­disclosure can bring to the relationship, as well as your full presence and availability. Here’s an example: Therapist: As I said, therapy is a vulnerable process, so I want to do things that make it easier for you to feel trust and respect in our relationship. In the service of building that trust and understanding of each other, if there’s anything you’re wondering about me, or if you’re ever wondering what I’m thinking, such as my reaction to something that happened to you or what you said, I invite you to ask me. Is there anything you want to know about me right now, as we get started? You might also establish that you’ll offer honest responses and describe how you’ll do so: Therapist: A way that therapy can be helpful is if I show up to our sessions not as merely a thera- pist but as a full human being. As such, I might sometimes have responses to you that could be useful for you to hear. For instance, I might be moved by something you say. Or—­and this could be more difficult to talk about—­I may be challenged by something you say or might disagree with you. I’d like to have your permission to share my honest reactions with you, in a way that’s sensitive and that I think will serve you. Is that okay? Again, none of these rationales should be offered as boilerplate. They should be adapted to the context, the individual client, and what the functional analysis reveals about the client. For example, if asking lots of questions of the therapist appears to be a CRB1—­a way of avoiding more vulner- able but useful therapeutic topics—­then the rationale should be adjusted. EXERCISE: FAP R AP INTENSIVE PR ACTICE Your skill at delivering FAP raps can rapidly improve with intensive practice, especially in a group format in which you can benefit from the modeling and feedback of others. Therefore, we recommend some deliberate practice:
  5. Think of a client with whom FAP might be productive.
  6. Write (or think or talk through) a FAP rap that feels genuine to you and relevant to this client.
  7. Read or speak your rap out loud, either to yourself, an audio recorder, or, better yet, a colleague who can give you feedback about what works well and what can be improved.
  8. Improve the rap as needed.
  9. Offer the rap to your client and notice what went well and what you could improve. Capture what you learn by writing it down.
  10. Repeat! FEEDBACK A final, important FAP element to establish early in therapy is open and mutual feedback. And, beyond merely talking about it, it’s vital to put this exchange of feedback in motion. Broadly speak- ing, feedback is information that changes the process of therapy. You’ll notice that feedback is woven into the earlier examples presented in this chapter. For instance, the therapist offers various forms of feedback about how the client is coming across. The therapist also asks for feedback from the client about how his questions affect her. The FAP raps in the previous section also mention the importance of feedback for keeping therapy on track and for responding to key moments in therapy, such as when a client’s issues show up in the room. And as the work of therapy unfolds, FAP asks you to keep in touch with how the work is going for the client (as prescribed by rule 4; more on that in chapter 9). In all these ways, FAP asks you to engage in various forms of feedback exchange. Building on the process of inquiry described earlier in this chapter, at the end of each session it can be useful to recap and summarize in ways that invite vulnerability and honesty. For instance, you might express appreciation for the important steps forward the client is making by choosing to participate in therapy. Here’s an example: Therapist: What are your thoughts about our first session as we are coming to the end of it? Client: Good. I feel encouraged. Therapist: What stands out to me is your perseverance. You’ve been depressed since you were thirteen, and there’s something about you that perseveres, some incredible strength inside you that keeps you growing and keeps you hopeful. Something else that stands out is that you like the risk-­taking poem. I’m excited about that, because if you like to take risks you and I are going to get along really well. What stands out to you? Client: I was able to cry. I don’t spend a lot of time crying alone. I feel a little better. Therapist: After you cried? Client: Yeah. I’m surprised and encouraged. Therapist: You’re surprised that you were able to cry? Client: I push it away and push it down. Therapist: It’s good for me to know that you feel encouraged that you could cry. One additional feedback mechanism is the session bridging form (Tsai et al., 2009). The first part (A) of the form, filled out shortly after session, asks the client to reflect on various aspects of the session. The second part (B), filled out just before the next session, asks for a brief synopsis of events between sessions and the client’s wishes for the next session’s agenda. Some therapists prefer to receive the form in advance of the session; others read it at the beginning of the next session. The form can be introduced in a simple way: Therapist: In terms of homework, here’s a worksheet that will help us focus and make the most of our time during each session. It’s called the FAP session bridging form. There are two parts to it. Fill out the first part right after our session. Fill out the second part right before you come to our next session. If you have any questions between now and then, feel free to e-­mail me. As your assessment of CRB develops, you can individualize how the form is used; for example, you can tailor it to focus on vulnerable disclosure, make direct requests, or share appreciation. Or you may introduce the form at the beginning of therapy in a way that links more directly to your understanding of the client’s potential CRB. The form offers several unique values. It provides an alternative medium for processing events in the session. Sometimes clients will write things on the form that they would not say in person, and this openness is very productive. The form also provides a written record of what happened in each session, so there is less forgetting and more sense of continuity between sessions (that’s why it’s called the “bridging” form). On the therapist side, if the client invests effort in the form, assum- ing that effort is a 2, be sure to reinforce the effort by putting aside time to read and respond to the form! In other words, completion of the form offers the opportunity to reinforce a 2. Again, various CRBs (and T1s and T2s) might occur around the session bridging form. Some clients are fastidious about doing the form “right.” Others are lackadaisical. All of this is grist for your functional analysis. SESSION BRIDGING FORM Name: Date: Part A (to be completed shortly after therapy session)

What stands out to you about our last session? Thoughts, feelings, insights? 2. On a 10-­point scale, how would you rate the following items, a through d? Not at allA little bitModerateSubstantial 1357 a) 2 4 6 8 Very Substantial 9 10 Helpfulness/effectiveness of session: What was helpful? What was not helpful? b) How connected you felt to your therapist: c) How engaged/involved you felt with the topics being discussed: oasis-ebl|Rsalles|1490374165 d) How present you were in the session: 3. What would have made the session more helpful or a better experience? Anything you are reluc- tant to say or ask for? 4. What issues came up for you in the session or with your therapist that are similar to your daily life problems? 5. What risks did you take in the session or with your therapist or what progress did you make that can translate into your outside life? Part B (to be completed just prior to the next therapy session) 6. What were the high and low points of your week? 7. What items, issues, challenges, or positive changes do you want to put on the agenda for our next session? 8.How open were you in answering the above questions, 1 through 7 (0–­100%)? 9.Anything else you’d like to add? SUMMARY • FAP processes may be woven into therapy from the first moments of your first session. • Notice potential CRBs as the client engages in the process of therapy. • Inquire about the relationship between what you notice in the moment, your client’s description of his or her presenting problems, and your client’s description of the behaviors related to those problems. • Offer a rationale for the focus on the therapy relationship and the FAP interventions. • Set up informal and formal exchanges of feedback about the process of therapy. Use the session bridging form between sessions to collect written feedback.

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