7 治疗初期打下基础

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.