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2. 关注来访的问题和优势

第二章

关注客户的问题和优势

检查与回顾

让我们从检查和回顾开始。在上一章中，我们介绍了认知行为疗法（CBT）的基础理论，并开始使用四因素模型。请记住，四因素模型包括通过识别思想、情感、生理反应和行为来探索客户对某一情境的反应。我们还探讨了思想和行为如何维持问题。您是否尝试使用过四因素模型？当您区分思想和情感时，有什么发现吗？

如果您还没有机会使用四因素模型，可以尝试以下练习。回想过去几天内您有一次强烈负面情绪反应的情境。想象自己回到了那个情境中。现在，尝试识别您的思想、情感、生理反应和行为。之后，花点时间反思这次体验。您从中了解到了什么？

设定议程

在本章中，我将重点放在建立良好的治疗关系、理解客户当前的问题和优势，以及向客户解释认知行为疗法（CBT）。

  • 议程项目#1：建立良好的治疗关系。
  • 议程项目#2：理解客户当前的问题。
  • 议程项目#3：认识苏珊。
  • 议程项目#4：理解客户的压力源和优势。
  • 议程项目#5：认识罗尔。
  • 议程项目#6：理解客户的心理社会历史。
  • 议程项目#7：解释认知行为疗法（CBT）。

进一步的知识点阐述

  • 建立良好的治疗关系：治疗关系的质量对治疗效果至关重要。一个支持性和信任的环境可以帮助客户更开放地分享他们的感受和问题，从而促进治疗过程。治疗师应该展现出同理心、尊重和真诚，以建立这种信任关系。

  • 理解客户当前的问题：了解客户的具体问题有助于制定个性化的治疗计划。这包括识别客户的症状、触发因素、应对机制等。通过全面了解客户的问题，治疗师可以更有效地提供帮助。

  • 认识苏珊：通过具体案例来展示如何应用CBT。苏珊可能是一个面临特定问题的客户，通过她的案例，我们可以看到如何评估和处理这些问题。

  • 理解客户的压力源和优势：每个人都有自己的压力源和优势。了解这些可以帮助治疗师更好地支持客户，利用他们的优势来克服困难。例如，一个客户可能在人际交往方面有优势，但工作压力较大，治疗师可以引导他们利用人际交往的优势来缓解工作压力。

  • 认识罗尔：另一个具体案例，展示不同背景和问题的客户如何接受CBT治疗。罗尔的案例可能涉及不同的问题，如焦虑、抑郁等，通过他的案例可以进一步理解CBT的应用。

  • 理解客户的心理社会历史：客户的心理社会历史对其当前的心理状态有很大影响。了解客户的成长环境、家庭背景、教育经历等，可以帮助治疗师更全面地理解客户的问题根源。

  • 解释认知行为疗法（CBT）：向客户解释CBT的基本原理和方法，帮助他们理解治疗的过程和目标。这包括介绍CBT的理论基础、治疗步骤和预期结果。通过清晰的解释，客户可以更加积极地参与到治疗过程中。

执行议程

很快，我将向您介绍两位客户，苏珊和罗尔，我们将在整本书中学习和练习认知行为疗法（CBT）技能时与他们一起工作。但首先，让我们从所有良好治疗的起点——治疗关系开始。

议程项目#1：建立良好的治疗关系

对于所有类型的治疗，包括认知行为疗法（CBT），良好的治疗关系预示着积极的结果（Martin, Garske, & Davis, 2000; Norcross & Wampold, 2011）。有效的治疗发生在一种支持性的关系中，客户在这种关系中感到被理解和支持。无论采用哪种治疗方法，当实践CBT时，保持温暖和非评判的态度非常重要。您希望与客户建立一种合作的关系，共同解决她的问题。您带来的是心理学和CBT的知识，而客户带来的是她对自己生活的了解和经验。

多项研究表明，共情是任何有效治疗的核心组成部分（Norcross & Wampold, 2011）。我猜您会同意这一点，但请花点时间思考一下您是如何定义共情的。通常，当我问学生这个问题时，他们会回答“站在别人的角度看问题”或“理解别人的情感”。我的学生总是提到情感，几乎没有人提到思想。理解情感很重要，但理解思想同样重要（Elliott, Bohart, Watson, & Greenberg, 2011）。

让我们考虑一个例子。您的客户索雷娜告诉您，她感到悲伤和疲惫。她还告诉您，她认为自己是一个不合格的母亲，她的孩子不尊重也不爱她。如果您想真正表现出共情，您会只关注索雷娜的情感，还是也会关注她的思想？在我看来，使用四因素模型并询问情感和思想可以增强共情的连接。

多年来，一些治疗师告诉我，他们认为CBT是一种冷冰冰的治疗方法，因为我们关注思想。如果您看看前面的例子，您怎么想？在我看来，思想和情感一样私密和情感化。重要的是要记住，当您问客户他们在“想”什么时，您是在要求他们揭示自己非常私密的一部分。在这本书中，我们将重点关注如何成为一个温暖、共情的治疗师，同时使用结构化的CBT干预措施（Josefowitz & Myran, 2005）。

进一步的知识点阐述

  • 建立良好的治疗关系：

    • 重要性：良好的治疗关系是治疗成功的关键。这种关系基于信任、理解和支持。
    • 方法：保持温暖和非评判的态度，与客户建立合作的关系。治疗师应展现同理心、尊重和真诚。
    • 研究支持：多项研究表明，良好的治疗关系预示着积极的治疗结果。

  • 共情的重要性：

    • 定义：共情不仅仅是理解他人的情感，还包括理解他人的思想。
    • 四因素模型：通过询问情感和思想，可以更全面地理解客户的情况，增强共情的连接。
    • 案例分析：索雷娜的案例展示了如何通过询问情感和思想来更好地理解客户的问题。

  • CBT的误解：

    • 冷冰冰的治疗方法：有些人认为CBT过于关注思想，因此显得冷冰冰。但实际上，思想和情感一样私密和情感化。
    • 平衡共情与结构化干预：在CBT中，治疗师可以通过温暖和共情的方式使用结构化的干预措施，帮助客户更好地理解和解决问题。

通过这些知识点的阐述，希望能够帮助您更好地理解如何在CBT中建立良好的治疗关系，以及如何通过共情和结构化的方法有效帮助客户。

议程项目#2：理解客户的问题

在认知行为疗法（CBT）中，有一个固定的顺序。虽然有一定的灵活性，但通常按照以下顺序进行：

  • 探讨客户的问题，获得其当前生活状况的概览，包括困难和优势。
  • 获取心理社会史。
  • 解释CBT的一般理论和四因素模型。
  • 设定治疗目标。
  • 专注于帮助客户改变。

在治疗的初始阶段，您开始建立良好的关系，同时了解客户的问题及其对生活的影响。您还需要了解客户的优点以及她过去如何应对问题。

获取对客户问题初步理解的三个主要步骤如下：

  1. 询问客户的问题并列出清单。
  2. 探讨客户的问题如何影响她的生活以及她是如何应对的。
  3. 协作决定客户希望在治疗中首先解决哪些问题。

1. 询问客户的问题并列出清单

CBT治疗师通常会以“我能怎样帮助你？”或“告诉我，是什么让你来寻求治疗？”作为开场白。让客户用自己的话描述问题非常重要。最初，我会专注于倾听，使用总结性陈述确保理解正确，然后提出开放式问题。开放式问题鼓励深入探讨，而不仅仅是一两个字的回答。例如，“你有问题吗？”是一个封闭式问题，答案是“是”或“否”。而“你有什么样的问题？”则是一个开放式问题。可以这样理解这一阶段：当客户开始治疗时，情况是模糊不清的。好的问题能帮助您逐步聚焦，使情况变得更加清晰。

在对客户的问题有了大致了解后，列出清单有助于更全面地探讨每个问题。写下清单传达了一个信息，即治疗将针对具体问题，而不仅仅是泛泛而谈。列出清单也给治疗指明了方向。

我通常会说：“我对您的部分担忧有了一些了解。我想列出您的问题，确保我们涵盖了所有内容。”大多数非CBT治疗师不习惯在治疗中做笔记。下次您接待新客户时，试着写下客户的问题并与客户分享清单。注意这样做对治疗的影响。

2. 探讨客户的问题如何影响她的生活以及她是如何应对的

客户经常描述一些一般性问题，如婚姻困难或感到焦虑。为了理解这些问题如何影响客户的生活，需要进一步探讨。以下问题列表将有所帮助。（您可以在http://www.newharbinger.com/38501下载这些问题的手册格式。）

进一步的知识点阐述

  • 治疗的固定顺序：

    • 初步了解：通过探讨客户的问题和生活状况，获得对客户的初步了解。
    • 心理社会史：收集客户的背景信息，包括家庭、教育、职业等方面的历史。
    • 解释CBT：向客户介绍CBT的基本理论和四因素模型。
    • 设定目标：与客户共同设定具体的治疗目标。
    • 帮助客户改变：采取具体措施帮助客户实现目标。

  • 获取初步理解的步骤：

    • 询问问题并列出清单：
      • 开场问题：使用开放式问题鼓励客户详细描述问题。
      • 总结性陈述：确保理解客户的问题。
      • 列出清单：帮助客户明确问题，为治疗指明方向。
    • 探讨问题的影响和应对方式：
      • 进一步探讨：使用具体问题深入了解问题如何影响客户的生活。
      • 应对策略：了解客户过去如何应对问题，为治疗提供参考。

通过这些步骤，治疗师可以更全面地了解客户的问题，从而制定更有效的治疗计划。

探讨客户问题的问题列表

问题1：这种问题出现在哪些具体情境中？当您遇到这个问题时，您的主要思想、情感、生理反应和行为是什么？

我通常从这个问题开始。一旦有了具体情境的例子，问题通常会变得更加明确。

问题2：这个问题最糟糕的部分是什么？

问这个问题很重要，而不能仅仅假设您已经知道答案。我常常对客户的回答感到惊讶。

问题3：这个问题如何影响了您的生活？这个问题给您带来了哪些困难？特别是，是否有您停止做或避免的活动？是否有您开始做或做得更多的活动？

如果客户在避免某些特定活动，我会进一步询问她认为如果不避免这些活动会发生什么。

问题4：您尝试过哪些方法来应对这个问题？这些应对方法中有哪一些帮助了您？

您想知道是否有任何方法哪怕有一点帮助，以便日后可以扩展这种应对策略。此外，您还需要认可和支持客户为应对问题所做的任何积极努力。

问题5：这个问题是什么时候开始的？

有时客户可以立即指出一个触发情境。有时她可能没有考虑过她的困难是否与生活中的特定变化或事件有关。一系列相对较小的变化，在短时间内累积起来，可能会带来很大的压力。

进一步的知识点阐述

  • 问题1：具体情境的探讨

    • 目的：通过具体情境的描述，使问题更加具体和明确。
    • 方法：使用开放式问题，鼓励客户详细描述情境中的思想、情感、生理反应和行为。

  • 问题2：最糟糕的部分

    • 目的：了解客户认为问题中最严重或最难以忍受的部分。
    • 方法：直接提问，避免假设。客户的回答可能超出您的预期，因此需要认真倾听。

  • 问题3：问题对生活的影响

    • 目的：了解问题如何影响客户的生活，包括避免的活动和增加的活动。
    • 方法：询问具体的困难和变化，进一步探讨客户对这些变化的看法和感受。

  • 问题4：应对方法

    • 目的：了解客户已尝试的应对方法，认可和支持有效的应对策略。
    • 方法：询问客户是否有一些方法哪怕有一点帮助，并鼓励他们继续使用这些方法。

  • 问题5：问题的起始时间

    • 目的：了解问题的起始时间和可能的触发因素。
    • 方法：询问客户是否能确定一个具体的触发情境，或是否注意到生活中的某些变化或事件与问题的出现有关。

通过这些问题，治疗师可以更全面地了解客户的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

轮到你了！

在想象中练习：使用五个问题中的一个

我希望您能够想象使用我们刚刚讨论的问题。运动心理学家多年来一直知道，想象练习新技能可以显著提高技能发展（Weinberg, 2008）。我认为，如果运动员可以用想象来练习，为什么治疗师不可以呢？

您可以一边阅读一边完成这个练习，但我认为如果您能听这本书网站上的指导音频文件，这个练习会更有意义。

查看《探讨客户问题的问题列表》。选择一个您很少或从未使用过的问题。然后，选择一位您想要尝试问这个问题的客户。想象自己回到办公室。花点时间环顾四周，注意办公室的声音和气味。现在，想象自己向这位客户提出这个问题。接着，想象向另一位客户提出同样的问题。每次想象时，都设想客户做出了积极的回应。

记录下您选择的问题，并在接下来的一周里尝试与两位客户使用这个问题。

议程项目#3：认识苏珊

在这本书中，我们将跟随两位客户，苏珊和罗尔。他们是基于我的一些客户以及我指导或教授的学生的客户。首先，我想向您介绍苏珊。我们将在本章稍后介绍罗尔。

苏珊今年三十四岁，已婚，有两个年幼的孩子，分别是六岁的詹妮弗和四岁的安德鲁。她是一名四年级教师，丈夫在当地一家五金店工作。她的丈夫是她的高中初恋，她仍然深爱着他。他们住在一座中等城市的郊区。她的父母和公婆住得不远，她经常与他们见面，关系很好。

进一步的知识点阐述

  • 在想象中练习问题

    • 目的：通过想象练习，提高对新技能的掌握和应用能力。
    • 方法：选择一个少用或未用过的问题，想象自己在办公室中向客户提出这个问题。多次想象，每次设想客户做出积极的回应。
    • 实践建议：记录下选择的问题，并在接下来的一周内与两位客户实际使用这个问题。

  • 认识苏珊

    • 基本信息：
      • 年龄：34岁
      • 家庭：已婚，有两个孩子（六岁的詹妮弗和四岁的安德鲁）
      • 职业：四年级教师
      • 丈夫：在当地一家五金店工作，是她的高中初恋，她仍然深爱着他
      • 居住地：中等城市的郊区
      • 家庭关系：父母和公婆住得不远，关系良好
    • 背景：苏珊的家庭和职业背景为理解她的问题提供了重要的背景信息。了解这些信息有助于治疗师更全面地评估她的需求和挑战。

通过这些练习和案例介绍，治疗师可以更好地准备和实施有效的治疗方案。想象练习可以帮助治疗师在实际应用中更加自信和熟练，而详细的客户背景信息则为治疗提供了坚实的基础。

苏珊的案例

苏珊的医生因为她总是感到疲劳，并且被孩子、工作和其他责任压得喘不过气来，推荐她接受治疗。她的身体检查结果正常，医生认为“找人谈谈”对她会有帮助。苏珊打电话给治疗师的办公室，预约了一次面谈。

苏珊是一位身材瘦小的女人，第一次走进治疗师的办公室时，她腼腆地微笑着。她坐在沙发的边缘，紧张地环顾四周。当治疗师问“我能怎样帮助你？”时，她轻声回答：“我不确定……我不知道从哪里开始。”然后低下头。治疗师温和地问道：“告诉我是什么让你来到这里；我知道开始可能会有些困难。”苏珊解释说她不知道自己出了什么问题。她有一个很好的房子、可爱的孩子、一份好工作和一个优秀的丈夫，但她总是感到被压得喘不过气来，以至于不再享受生活。她开始哭泣，说感觉自己无法应对。治疗师请苏珊再多说一些。苏珊解释说她总是感到疲劳，为小事哭泣，对孩子发脾气。她看起来非常难过，说：“我甚至不是一个好母亲了。”

苏珊还解释说，她以前很喜欢作为一名四年级教师的工作，但现在却害怕上班。她在一所新学校教书，通勤时间需要三四十分钟。以前的学校离家步行即可到达。她经常对丈夫生气，因为他工作时间很长，她觉得自己不得不独自照顾孩子和家务，而得不到他的感激。她害怕如果自己继续这样抑郁下去，他会离开她。她一直感到焦虑，虽然她一直以来都是一个害羞的人，但现在的焦虑越来越严重，她对一切都感到担心。

让我们看看如何使用《探讨客户问题的问题列表》来开始理解苏珊的问题。

治疗师与苏珊的对话

治疗师： 听起来有很多问题。我觉得如果我们列出这些问题，然后逐一理解，会有所帮助。

苏珊的治疗师的回应既充满共情又具有结构化。苏珊感到不知所措，治疗师认为列出问题清单可以帮助她感觉这些问题更易于管理。

苏珊： 我总是感到疲劳，对孩子大喊大叫，不做任何有趣的事情，讨厌工作，怀疑教学是否是适合我的职业。

这些都是一些一般性的问题，我们还不完全理解这些问题如何影响她的生活。

治疗师： 我觉得更深入地了解一些具体情况会有所帮助。让我们挑选一个问题，更详细地探讨。我们从探讨这个问题中最糟糕的部分开始吧。（问题2）

进一步的知识点阐述

  • 苏珊的背景：

    • 基本情况：34岁，已婚，有两个年幼的孩子，是一名四年级教师。
    • 问题：总是感到疲劳，对孩子发脾气，不再享受生活，对工作失去兴趣，感到焦虑和孤独。
    • 家庭关系：与丈夫关系紧张，感到缺乏支持和感激。

  • 治疗师的回应：

    • 共情：治疗师通过温柔的语气和提问，表达了对苏珊的感受的理解和支持。
    • 结构化：通过建议列出问题清单，帮助苏珊感觉问题更易于管理。
    • 具体化：通过选择一个具体问题进行深入探讨，帮助苏珊更清晰地表达自己的感受和问题。

  • 问题2：最糟糕的部分：

    • 目的：了解客户认为问题中最严重或最难以忍受的部分。
    • 方法：直接提问，避免假设。客户的回答可能超出您的预期，因此需要认真倾听。

通过这些问题和对话，治疗师可以更全面地了解苏珊的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

注意苏珊的治疗师是如何解释她的意图的

注意苏珊的治疗师是如何解释她的意图的，她说她“想更多地了解你的情况。”同时，她通过说“这会有帮助”来增强希望。这是一个很好的例子，展示了如何将CBT的结构与建立良好的治疗关系和激发希望相结合。

苏珊的回应

苏珊： 我觉得最糟糕的是我总是对孩子大喊大叫，感觉自己无法应对。

这是一个非常笼统的陈述。您需要一个更具体的了解苏珊的困难。在看苏珊的治疗师的回应之前，思考一下您如何可以问苏珊，让她识别出具体的困难情境。

治疗师的回应

治疗师： 你能给我一些具体的例子，让我更好地了解对你来说困难的情境吗？（问题1）

苏珊： 当然，以前我回家后会给家人做饭，然后和孩子们一起玩。现在，仅仅是做饭似乎就耗尽了我所有的精力；我似乎从来没有时间和精力陪孩子们，即使有时间，我也很烦躁。

作为CBT治疗师的思考

作为CBT治疗师，您使用四因素模型来思考客户的问题。当苏珊给出一个困难情境的例子时，她是否描述了她的思想、情感、生理反应和行为？

我们已经了解了苏珊的情感（感到被压垮和烦躁/愤怒）和生理反应（疲劳）；但我们还不知道她的行为或思想。她之前提到过“我甚至不是一个好母亲了”的想法。可以猜测她在这些情况下就是这样想的，但重要的是要确认这一点。

进一步的知识点阐述

  • 治疗师的沟通技巧：

    • 解释意图：治疗师清楚地解释了她想要做什么，即“更多地了解你的情况”，这有助于客户理解治疗的目的。
    • 增强希望：通过说“这会有帮助”，治疗师增强了客户的希望，使客户感到治疗是有益的。
    • 结合结构与共情：治疗师在使用CBT的结构化方法的同时，表现出共情和支持，建立了良好的治疗关系。

  • 苏珊的回应：

    • 笼统的陈述：苏珊的回应较为笼统，需要进一步具体化。
    • 具体化问题：治疗师通过提问，引导苏珊提供具体的例子，这有助于更准确地理解她的困难。

  • 四因素模型的应用：

    • 情感：苏珊感到被压垮和烦躁/愤怒。
    • 生理反应：苏珊感到疲劳。
    • 行为：目前还不清楚苏珊的具体行为。
    • 思想：苏珊提到了“我甚至不是一个好母亲了”的想法，但需要进一步确认。

通过这些问题和对话，治疗师可以更全面地了解苏珊的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

治疗师与苏珊的对话

治疗师的提问

治疗师： 苏珊，当你感到被压垮和烦躁时，你脑海中有哪些想法？（问题1）

注意，苏珊的治疗师将她的想法与情感联系了起来。

苏珊的回应

苏珊： 我通常在想我是一个糟糕的母亲，孩子们应该有更好的母亲。但我也在想，真希望我能去睡觉，不用照顾孩子们。

试着想一个共情的评论，总结苏珊所说的话，并表明你听到了她的想法。如何询问苏珊的行为和她如何应对？在查看苏珊的治疗师的回应之前，先思考一下你会如何回应。

治疗师的回应

治疗师： 这些听起来像是非常困难的想法。很多自我批评的想法，然后希望你能去睡觉，远离这一切。告诉我，你在这些情况下是如何应对的？（问题4）

苏珊： 我只是尽量控制我的愤怒，照顾孩子们。但对他们的态度很不好。我一直在努力早点休息，减少疲劳，但这并没有帮助。

治疗师： 你有没有尝试过什么方法有帮助？

苏珊： 没有，真的没有。

如何引入问题3？

治疗师： 我想知道，自从你感觉这么糟糕以来，有没有什么事情你不再做了，或者有哪些情境你正在回避？

苏珊： 嗯，我一般和丈夫及孩子们做的有趣事情少了。最近我太累了。

这是一个非常笼统的评论。如何帮助苏珊更具体地描述她减少的“有趣事情”？

治疗师： 你说你和丈夫及孩子们做的有趣事情少了，能给我举一些例子吗？

苏珊： 我以前每周有一天半休，会带六岁的女儿和邻居们一起去下午的游乐小组。但现在我太累了，做不到这一点。另外，我和丈夫以前周末会带孩子们去公园，那是一段有趣的家庭时光；但现在很多时候我会让他们去我父母家，我可以小憩一会儿，或者丈夫自己带他们出去，不带我。

进一步的知识点阐述

  • 治疗师的提问技巧：

    • 将想法与情感联系起来：治疗师通过提问，将苏珊的情感与她的想法联系起来，帮助她更全面地表达自己的感受。
    • 共情的回应：治疗师通过共情的评论，总结苏珊的描述，表明她被理解和支持。

  • 探讨应对方式：

    • 具体化问题：治疗师通过具体的例子，帮助苏珊更详细地描述她的应对方式。
    • 确认有效的应对方法：治疗师询问苏珊是否有任何方法对她有帮助，这有助于发现有效的应对策略。

  • 问题3的引入：

    • 避免和减少的活动：治疗师通过询问苏珊是否有不再做的事情或回避的情境，帮助她认识到问题对生活的具体影响。
    • 具体化减少的活动：治疗师进一步引导苏珊列举具体的活动，使问题更加具体和明确。

通过这些问题和对话，治疗师可以更全面地了解苏珊的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

分析苏珊的回应

治疗师的观察

当你查看苏珊的回应时，苏珊是否有任何做得更多的事情？苏珊的治疗师认为她做得更多的事情是更多的休息和小睡。这是询问酒精消费、药物和药物使用变化的好时机。

苏珊的具体情况

治疗师发现，苏珊因为“太累”而停止了大部分放学后的活动，也不再与大多数朋友见面和交谈。她和丈夫也因为苏珊觉得太累，而减少了与许多朋友和家人的见面。苏珊的问题始于她换学校的时候。她在新学校感到不开心，没有交到朋友，觉得自己像个局外人。苏珊没有开始饮酒，也没有报告滥用处方药或非处方药。

初步问题清单

苏珊的治疗师建议他们写下一份初步的问题清单，列明苏珊希望在治疗中解决的问题。

苏珊提出了以下问题：

  1. 在新学校没有朋友
  2. 对孩子和丈夫大喊大叫
  3. 总是感到疲劳
  4. 不再和丈夫及孩子们一起做有趣的事情
  5. 感到抑郁和焦虑，不再享受生活
  6. 怀疑教学是否是适合自己的职业

这是一个很长的清单，治疗师和苏珊需要决定从哪个问题开始着手。

协作决定治疗起点

协作决定客户希望在治疗中首先解决的问题。如果你还记得本章前面的内容，获取客户问题初步理解的三个主要步骤是：

  1. 询问客户的问题并列出清单；
  2. 探讨客户的问题如何影响她的生活；
  3. 协作决定客户希望首先解决的问题。

我们现在准备好进入第三步。

一些客户来治疗时只有一个主要问题，但大多数客户有多个不同的问题。你和客户需要决定首先解决哪个问题，否则治疗可能会显得漫无目的。最简单的方法是直接提问：“我认为一次解决一个问题是有帮助的。当我们查看你的问题清单时，你希望从哪个问题开始？”

你希望选择一个有较大机会快速帮助客户，并且能立即对她的生活产生影响的问题。

优先处理问题的标准

Marsha Linehan（1993）提出了一些非常有用的优先处理客户问题的标准：

  1. 如果客户有自杀倾向，首要任务是确保她的安全。
  2. 如果客户的行为危险或可能严重影响她的生活，这些行为需要首先解决。例如，严重的物质滥用、缺勤工作或学校、涉及身体或情感虐待的关系。
  3. 此外，如果客户经常有干扰治疗的行为，例如迟到、侮辱治疗师或旷课，这些行为也需要解决。

分析苏珊的问题

如果我们考虑苏珊列出的每个问题，前四个问题是更具体和具体的，而感到抑郁和不再享受生活，或者怀疑教学是否适合她，则更为广泛。治疗师向苏珊解释说，因为前四个问题是更具体和具体的，所以她建议从这些问题之一开始，这样可以在较短的时间内更有针对性地帮助苏珊。然后，治疗师问苏珊希望从哪个问题开始。苏珊希望从在新学校交朋友和不再与丈夫及孩子们一起做有趣的事情这两个问题开始。

视频 2.1：认识约翰并理解客户的问题

进一步的知识点阐述

  • 治疗师的观察：

    • 休息和小睡：苏珊因为疲劳而增加了休息和小睡的时间。
    • 酒精和药物：询问酒精和药物使用的变化是重要的，以排除这些因素对问题的影响。

  • 苏珊的具体情况：

    • 停止活动：苏珊因疲劳停止了许多活动，包括与朋友和家人的互动。
    • 新学校的适应：苏珊在新学校感到不开心，没有交到朋友，感到孤立。

  • 初步问题清单：

    • 具体问题：苏珊列出的问题中，前四个问题更具体和具体，容易入手。
    • 广泛问题：感到抑郁和不再享受生活，或者怀疑职业选择，这些问题更为广泛，需要更多时间和资源来解决。

  • 协作决定治疗起点：

    • 直接提问：直接询问客户希望从哪个问题开始，有助于集中治疗目标。
    • 优先标准：根据Marsha Linehan的标准，优先处理危及安全和严重影响生活的问题。

通过这些问题和对话，治疗师可以更全面地了解苏珊的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

议程项目#4：了解客户的压力源和优势

除了了解客户的主要问题外，你还需要了解这些问题如何融入她的整体生活中。你需要了解她当前的生活状况、她的功能状态，以及除了主要问题之外的其他压力源或困难，还包括她生活中的积极支持和优势领域。

你可以通过以下方式引入这一部分：“我开始了解你的问题了。我认为如果我能对你的其他生活方面有所了解，也会对你有帮助。”请注意，我解释了我要做什么，并表示这对客户是有帮助的。

我询问的基本类别包括家庭、朋友和社会联系、休闲和家庭外的组织参与、工作或学校、健康和财务。财务包括预算能力、按时支付账单以及所有与财务责任相关的内容。在询问健康状况时，如果没有已经询问过酒精和药物使用，这也是一个好的时机。我还询问自我照顾，无论是归类在休闲还是健康下。我想知道我的客户是否参与了对她有益的活动，以及她是否定期锻炼。此外，我还询问在过去一年或几年中，客户生活中是否有任何重大变化或一系列小变化。

了解客户的压力源

让我们从查看苏珊在每个类别中的压力源或困难开始。

苏珊的困难或压力源

  • 家庭

    • 经常对孩子们和丈夫生气
    • 认为自己不再是好母亲
    • 由于丈夫工作时间长，负责照顾孩子和家务
    • 害怕如果她的情绪和行为不改变，丈夫会离开她

  • 朋友和社会联系

    • 未知

  • 休闲和组织参与

    • 未知

  • 工作或学校

    • 四年级教师，对工作感到厌倦

  • 健康

    • 总是感到疲劳
    • 其他未知

  • 财务

    • 未知

  • 变化

    • 开始在距离家30到40分钟车程的新学校教书
    • 不能再每天步行上班，而是必须开车
    • 以前经常和女朋友们一起做有趣的事情，参与孩子的课外活动
    • 以前喜欢工作

当我们使用上述表格时，可以看到我们需要更多信息的领域。苏珊的治疗师继续询问她的生活情况。她了解到苏珊一直很害羞，但有一小群亲密的朋友。然而，最近她因为太累而避免与朋友们外出。她的丈夫是主要收入来源，她因为收入比丈夫少而感到内疚，不愿意要求他在家里多帮忙。她以前喜欢工作，但今年换了学校。她在新学校很难融入，感觉自己与其他教师不同，其他教师似乎形成了一个紧密的团体。在以前的学校，她积极参与学校的戏剧活动，但在新学校，她对参加课外活动犹豫不决，因为大家似乎都互相认识。她报告说，除了缺乏能量和感到疲劳外，她的健康状况良好，没有酒精或药物使用问题。她还表示，虽然他们希望有更多的钱，但财务并不是一个主要问题。由于工作和照顾孩子，她没有时间从事爱好或休闲活动，尽管她去年很喜欢参与学校的戏剧活动。

苏珊表示，过去几年除了新工作外，没有经历其他重大压力或变化。然而，她的婆婆以前帮她照看孩子，但因健康问题无法再帮忙。她的女儿患有慢性中耳炎，苏珊经常不得不请假照顾女儿并带她去看医生。虽然女儿现在好多了，但苏珊担心即将到来的冬天。此外，苏珊最好的朋友吉尼亚搬走了，她很想念她。苏珊惊讶于过去几年生活中发生的变化数量，并意识到所有这些变化加在一起造成了很大的压力。

暂停一下

到目前为止，我们已经有了相当多的信息。然而，我们忘记了注意客户的优点和韧性。这种情况经常发生；作为治疗师，我们习惯于关注客户的问题，有时会忘记考虑他们的优点。

进一步的知识点阐述

  • 了解客户的整体生活：

    • 家庭：苏珊在家庭中面临多重压力，包括与孩子的冲突、对丈夫的依赖感和内疚感。
    • 朋友和社会联系：苏珊因为疲劳而避免与朋友交往，这导致了社会支持的减少。
    • 休闲和组织参与：苏珊几乎没有时间参与休闲活动，这进一步影响了她的心理健康。
    • 工作或学校：苏珊在新学校感到不适应，缺乏归属感，这增加了她的职业压力。
    • 健康：苏珊总是感到疲劳，但其他健康状况良好，没有酒精或药物使用问题。
    • 财务：虽然希望有更多的钱，但财务并不是主要问题。
    • 变化：苏珊经历了多个生活变化，包括新工作、婆婆无法帮忙、女儿的健康问题和朋友搬家，这些变化共同导致了巨大的压力。

  • 关注客户的优点和韧性：

    • 社交网络：尽管苏珊感到疲劳，但她仍有一小群亲密的朋友，这是一大支持。
    • 责任感：苏珊对家庭和工作的责任感很强，这体现了她的坚韧。
    • 过去的成就：苏珊曾经积极参与学校的戏剧活动，这表明她有能力和热情参与有意义的活动。

通过这些问题和对话，治疗师可以更全面地了解苏珊的问题和优势，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

了解客户的优点

了解客户的优点

在帮助客户看到她的优点之前，首先你需要看到她的优点。这听起来很容易，但实际上很难看到优点。我用来识别客户优点的一种方法是记住，好事不是凭空发生的。例如，我的一位客户说她的儿子“很幸运”，因为在实习后被邀请担任全职工作。停顿一下——根据你对世界的了解，为了让一个年轻人在实习后被邀请担任全职工作，需要发生什么？难道是仙女教母突然出现说：“这里有你的工作”吗？她的儿子必须准时上班，努力工作，表现良好，而且很可能与同事相处融洽。所有这些特征都反映了她儿子的优点。当然，他也需要一点运气，但光靠运气通常是不够的。

帮助你思考客户优点的问题

以下是基于Christine Padesky和Kathleen Mooney（2012）的工作的一些问题，可以帮助你思考客户的优点。你可以在http://www.newharbinger.com/38501下载这些问题的手册形式（探讨优点的问题）。

  • 客户生活中有哪些方面进展顺利，或在面对困难和逆境时坚持下来？ 我不仅仅指克服不寻常的挑战，还包括能够维持日常生活的常规。例如，苏珊每天准时起床，给孩子们穿衣服，去上班，为家人准备晚餐。这需要思考、关心、组织和毅力；这不是凭空发生的。认识到完成日常活动中的优点是很重要的。研究人们在日常活动中坚持的策略也很有帮助。

  • 客户是否能够完成发展任务？ 例如，客户是否能够顺利升入更高的年级，发展友谊，参加体育团队，或拥有稳定的工作？这些成就表明客户能够履行承诺，学习新信息，并与他人建立积极的关系。

  • 客户是否与某个人或动物建立了负责任和关爱的关系？ 关爱关系涉及承诺和放弃自己的需求。

  • 客户是否按照她的价值观或目标行事？ 按照价值观和目标行事可能很困难，通常需要放弃眼前想做的事情，以实现长期目标。

  • 客户在某个特定领域是否有成就或能力？ 人们往往在某些领域有成就和技能。在某个特定领域的胜任并不一定是巨大的成就；可能是你总是制作生日蛋糕的人，或者是朋友遇到电脑问题时求助的人。人们为了在这些领域取得成功而发展的应对机制通常可以转移到生活的其他领域。

思考苏珊的情况

让我们思考一下苏珊的情况，看看如何填写她的压力源和优点的不同类别。你可以在http://www.newharbinger.com/38501下载《识别客户的压力源和优点》工作表。

进一步的知识点阐述

  • 识别客户的优点：

    • 好事不是凭空发生的：通过分析客户的成就，可以发现其背后的优点和能力。
    • 具体例子：例如，苏珊每天准时起床，照顾孩子，去上班，准备晚餐，这需要思考、关心、组织和毅力。

  • 帮助思考客户优点的问题：

    • 进展顺利的方面：寻找客户在生活中进展顺利的方面，以及在面对困难时的坚持。
    • 完成发展任务：客户是否能够完成学业、发展友谊、参与团队或拥有稳定的工作。
    • 负责任和关爱的关系：客户是否与某个人或动物建立了负责任和关爱的关系。
    • 按价值观和目标行事：客户是否按照她的价值观和目标行事，这需要长期的规划和毅力。
    • 特定领域的成就：客户在某个特定领域是否有成就或能力，这些能力可以转移到其他领域。

通过这些问题和对话，治疗师可以更全面地了解客户的压力源和优点，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

苏珊的压力源和优点

家庭

困难或压力源优点或韧性领域
经常对孩子们和丈夫生气稳定的长期婚姻
认为自己不再是好母亲关心孩子的父母
丈夫工作时间长以前积极参与孩子的活动
主要负责孩子和家务维持家庭日常生活
担心如果情绪和行为不改变，丈夫会离开她为家庭提供稳定的环境，去年能够照顾生病的孩子
双方父母住在附近，关系良好害羞
婆婆住在附近，关系良好

朋友和社会联系

困难或压力源优点或韧性领域
目前避免与朋友交往有一小群长期亲密的朋友

休闲和组织参与

困难或压力源优点或韧性领域
无爱好去年组织学校戏剧活动，表现积极

工作或学校

困难或压力源优点或韧性领域
对工作感到厌倦四年级教师（表明完成了本科和研究生培训）
新学校，避免与同事互动以前喜欢工作
避免参加课外活动以前喜欢同事
参与课外活动（学校戏剧）

健康

困难或压力源优点或韧性领域
女儿有慢性中耳炎史，但目前不是问题自己的健康状况良好
不使用酒精或药物作为应对机制
女儿的中耳炎问题已解决

财务

困难或压力源优点或韧性领域
收入低于丈夫，因此感到内疚要求帮助有稳定的收入
工作有福利
没有特别的经济压力
负责的教师
组织托儿服务
认识到困难并寻求治疗

变化

困难或压力源优点或韧性领域
换了新学校，通勤时间变长尽管经历了很多变化，但仍维持稳定的家庭生活
婆婆不再帮忙照看孩子
女儿有一些健康问题
最好的朋友吉尼亚搬走了

进一步的知识点阐述

  • 识别客户的优点：

    • 家庭：苏珊虽然面临很多家庭压力，但她有一个稳定的长期婚姻，能够维持家庭日常生活，为孩子提供稳定的环境。
    • 朋友和社会联系：尽管苏珊目前避免与朋友交往，但她有一小群长期亲密的朋友。
    • 休闲和组织参与：苏珊虽然没有爱好，但去年曾积极参与学校戏剧活动，表现出积极的一面。
    • 工作或学校：苏珊虽然对新学校感到不适应，但她是一名合格的教师，以前喜欢工作和同事，积极参与课外活动。
    • 健康：苏珊的健康状况良好，没有使用酒精或药物作为应对机制，女儿的健康问题已解决。
    • 财务：尽管苏珊收入低于丈夫，感到内疚，但她有稳定的收入，工作有福利，没有特别的经济压力。
    • 变化：苏珊经历了多次生活变化，如换学校、婆婆不再帮忙、女儿的健康问题和朋友搬走，但她仍能维持家庭的稳定。

  • 客户对优点的认识：

    • 治疗初期的挑战：在治疗初期，客户往往不愿意注意到自己的优点。通过分类思考苏珊的问题和优点，可以帮助治疗师更全面地了解她的状况。
    • 意识到优点的重要性：有意识地注意到客户的优点，可以增强客户的自信心和积极性，为治疗提供更多的支持。

通过这些问题和对话，治疗师可以更全面地了解客户的压力源和优点，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

议程项目#5：认识劳尔

现在是时候认识我们在书中将要跟随的第二位客户，劳尔。

劳尔现年五十八岁，与妻子居住在一个中等城市。他有三个成年子女，都住在大约一小时车程的地方。过去二十年，他一直在税务局担任政府雇员。他的女儿回家探望时，发现他不像往常那样精神。他告诉女儿自己睡眠不好，对工作感到非常焦虑。女儿建议他去看心理治疗师，他勉强同意了。女儿打电话为他预约了治疗师。

劳尔与治疗师握手介绍自己，并报上了全名。他缓慢地走进房间，费力地坐到沙发上。他微微一笑，说这次来是女儿的主意。治疗师问他需要什么帮助。劳尔解释说，过去他曾有过几次感到抑郁的时期，但总能自己克服。最近他又感到抑郁，而且工作也不顺利。为了更好地了解劳尔的担忧，治疗师使用了《了解客户问题的问题》。劳尔说，他的问题始于一个年轻同事被提拔到本应属于他的职位上。他详细描述了招聘过程的不公平性。从那以后，他说自己在工作中难以集中注意力，最近首次收到了差评。他对这次工作评价及其可能带来的后果感到担忧。他强调，在过去的二十年里，他每年的年终评价都是良好的。

自从收到差评后，劳尔与上司之间产生了一些紧张。治疗师询问了与上司相处困难的具体情况，以及他在哪些项目上难以集中注意力。劳尔很难给出与上司紧张的具体例子，但列出了他拖延的项目。

治疗师还询问了劳尔生活的其他方面，但他非常不愿意谈论除工作问题以外的任何事情。其他一切都“很好”。他表示与妻子“没有任何问题”。他偶尔会在外出时喝几杯啤酒，但平时不喝酒。他说自己的健康状况良好。他还告诉治疗师，自己通常比较害羞，但过去五年在妻子的鼓励下加入了保龄球联盟。

治疗师认为随着治疗的进行，劳尔会逐渐信任她，她会了解更多关于他生活的其他方面。目前，她认为专注于他的工作困难会有帮助。

劳尔和他的治疗师列出了他希望在治疗中解决的问题：

  1. 感到焦虑
  2. 无法按时完成项目
  3. 睡眠质量差
  4. 与上司之间的紧张

进一步的知识点阐述

  • 劳尔的背景：

    • 家庭：劳尔与妻子居住在一个中等城市，有三个成年子女，分别住在一小时车程的地方。
    • 职业：过去二十年一直在税务局担任政府雇员。
    • 近期问题：女儿发现他精神不佳，睡眠不好，对工作感到焦虑。

  • 初次咨询：

    • 介绍：劳尔与治疗师握手介绍自己，显得有些拘谨。
    • 主要问题：劳尔解释了自己过去曾有抑郁经历，但都能自行克服。最近再次感到抑郁，工作也不顺利。
    • 具体问题：劳尔详细描述了一个年轻同事被提拔到本应属于他的职位上的不公平招聘过程。自那以后，他在工作中难以集中注意力，首次收到了差评。

  • 工作问题：

    • 紧张关系：劳尔与上司之间产生了紧张，治疗师询问了具体的情况和项目上的困难。
    • 拖延：劳尔列出了他拖延的项目，但难以具体说明与上司的紧张关系。

  • 生活其他方面：

    • 家庭：劳尔表示与妻子关系良好，其他方面都“很好”。
    • 健康：劳尔的健康状况良好，偶尔会喝几杯啤酒。
    • 兴趣：劳尔在妻子的鼓励下加入了保龄球联盟，但通常比较害羞。

  • 治疗计划：

    • 问题清单：劳尔和治疗师列出了他希望解决的问题，包括感到焦虑、无法按时完成项目、睡眠质量差和与上司之间的紧张。
    • 治疗重点：治疗师认为目前应专注于劳尔的工作困难，随着治疗的深入，逐步了解他生活的其他方面。

通过这些问题和对话，治疗师可以更全面地了解劳尔的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

轮到你了！

劳尔的压力源和优点

考虑你已经了解的关于劳尔的信息，尝试填写下面的图表。你可以在附录中找到我的答案。

类别困难或压力源优点或韧性领域
家庭与妻子关系良好，但不愿讨论其他家庭问题与妻子关系良好
朋友和社会联系很少社交，只有保龄球联盟的活动加入了保龄球联盟，有固定的社交活动
休闲和组织参与仅限于保龄球活动有固定的休闲活动
工作或学校感到焦虑，难以集中注意力，首次收到差评有丰富的职业经验，过去二十年一直表现良好
健康睡眠质量差健康状况总体良好，不饮酒
财务收入稳定，但对工作评价感到担忧有稳定的收入，没有特别的财务压力
变化年轻同事被提拔，导致工作紧张有应对变化的能力，过去能够克服抑郁

练习 2.1：鲁达参加亲子活动

练习识别客户的压力源和优点。

议程项目#6：了解客户的心理社会史

大多数治疗师都会收集客户当前问题的历史以及一般的心理社会史。有些治疗师会花一整节课详细收集历史，而另一些则会快速概述。即使你只收集简短的历史，也有助于将客户当前的问题放在其生活的整体历史中考虑，并确保倾听她的优点和韧性领域。

一般来说，当你收集历史时，试图弄清楚客户的过去经历如何与当前问题相关。作为一名认知行为疗法（CBT）治疗师，我在收集心理社会史时的方法与其他治疗师类似，但有两个主要方面我更加强调，这些方面可能与非CBT治疗师略有不同。首先，治疗师通常会问客户对过去某个事件的感受；我会确保还问到这个事件对他们意味着什么，或者他们在当时的想法是什么。我特别感兴趣的是客户从中学到了关于自己、他人和未来的消息。我会问一些问题，例如：

  • 你是如何理解这个事件的？
  • 你是如何向自己解释这个事件的？
  • 这个事件对你意味着什么？
  • 这个事件对其他人意味着什么？
  • 这个事件对你的未来意味着什么？

例如，我的一位客户丽莎在父母离婚后，和祖父母一起生活，六年级没通过。当我问她是否认为六年级没通过有什么特别的意义时，她回答说：“我不聪明，没有父母的帮助我无法管理。”这是重要的信息。另一位客户迈克尔在八岁时被叔叔性虐待，持续了三年。当我问他如何理解这种性虐待时，他解释说他认为这是因为自己有问题，不能信任任何人，而且未来总是会有坏事发生在自己身上。这些早期的信息会影响客户在当前生活中的感受、想法和行为。

第二个我强调的方面是倾听客户的优点和证据，证明他们是能干和值得爱的。我开始收集可以用来对抗负面信念的证据。虽然没有硬性规定，但我通常不会在这个治疗早期分享我对客户优点的看法。我发现如果过早分享这些看法，客户往往会拒绝接受。例如，我的客户丽莎提到她在父母离婚那年没通过六年级，但第二年通过了，并且完成了护理培训。她也是班上少数几个一毕业就被录用的学生之一。我把这些信息记在心里，以便将来在探讨她认为自己不聪明、只能在父母帮助下管理的观点时，我有证据来反驳这个信念。

进一步的知识点阐述

  • 劳尔的压力源和优点：

    • 家庭：劳尔与妻子关系良好，但不愿讨论其他家庭问题。他的优点在于与妻子的关系稳定。
    • 朋友和社会联系：劳尔很少社交，只有保龄球联盟的活动。他的优点是加入了一个固定的社交活动。
    • 休闲和组织参与：劳尔的休闲活动仅限于保龄球。他的优点是有固定的休闲活动。
    • 工作或学校：劳尔感到焦虑，难以集中注意力，首次收到差评。他的优点是有丰富的职业经验，过去二十年一直表现良好。
    • 健康：劳尔睡眠质量差。他的优点是总体健康状况良好，不饮酒。
    • 财务：劳尔收入稳定，但对工作评价感到担忧。他的优点是有稳定的收入，没有特别的财务压力。
    • 变化：劳尔因年轻同事被提拔而感到工作紧张。他的优点是有应对变化的能力，过去能够克服抑郁。

  • 了解客户的心理社会史：

    • 收集历史的目的：了解客户的过去经历如何影响当前问题，有助于将客户当前的问题放在其生活的整体历史中考虑。
    • CBT治疗师的特殊关注点：
      • 事件的意义：不仅要问客户对过去事件的感受，还要问这些事件对他们意味着什么，他们的想法是什么。
      • 优点和韧性：倾听客户的优点和证据，证明他们是能干和值得爱的。收集这些信息以备将来反驳负面信念。
    • 案例示例：
      • 丽莎：她认为自己不聪明，没有父母的帮助无法管理。但事实上，她后来通过了六年级，完成了护理培训，并且毕业后立即被录用。
      • 迈克尔：他认为自己有问题，不能信任任何人，未来总是会有坏事发生。这些早期的信念会影响他的当前生活。

通过这些问题和对话，治疗师可以更全面地了解客户的问题，从而制定更有效的治疗计划。这些问题不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

议程项目#7：解释CBT

在你对客户的问题有了了解并收集了历史之后，是时候解释CBT是如何工作的。以下是我可能会如何解释CBT的一个例子。（《向客户解释CBT》的副本可在http://www.newharbinger.com/38501获取。）

我已经听到了一些关于你的问题以及它们是如何影响你的生活的。我想告诉你我是如何工作的。我使用的是CBT模型。CBT是一种目标导向的治疗方法。我会要求你在治疗中设定一些目标，我们一起专注于实现这些目标。治疗将首先通过识别你的思想、情感、身体反应和行为，以及它们是如何相互关联的，来理解你的问题。然后，我们将通过一次专注于其中一个因素来帮助你做出一些改变。由于这些因素都是相互关联的，一个因素的变化将影响所有其他因素。

在这个阶段，我通常会选取客户生活中的一个情境，我们一起探索她的思想、情感、身体反应和行为。例如，在劳尔的情况下，我们可能会选择他在工作中与同事互动时的不适感。你不应该选择一个客户有强烈情感反应的情境，因为客户会被情绪压倒，无法听从你的指导并应用四因素模型。在使用四因素模型探索一个情境后，询问客户这是否有道理。

如果你是在与儿童或青少年工作，有许多有趣的游戏可以用来解释思想如何影响情感、身体反应和行为（参见，例如，Kendall, Choudhury, Hudson, & Webb, 2002; Stallard, 2005）。

视频 2.2：认识夏洛特并解释CBT

作业：练习CBT

在继续下一章之前，请花些时间完成以下作业。

将所学应用于临床案例

完成以下练习。

练习 2.1：鲁达参加亲子活动

将所学应用于自己的生活

尝试从自己的生活角度审视压力源和优点。

作业#1：探索自己的压力源和优点

使用以下表格写下你的压力源和优点。把它们写下来很重要，因为它可以帮助你退一步审视它们。你从中学到了什么？

类别困难或压力源优点或韧性领域
家庭
朋友和社会联系
休闲和组织参与
工作或学校
健康
财务
变化

进一步的知识点阐述

  • 解释CBT：

    • 目标导向：CBT是一种目标导向的治疗方法，治疗师会要求客户在治疗中设定目标，双方共同努力实现这些目标。
    • 四因素模型：通过识别客户的思维、情感、身体反应和行为，以及它们是如何相互关联的，来理解客户的问题。这些因素的变化会相互影响。
    • 实际应用：治疗师通常会选择一个具体的情境，与客户一起探索这些因素。选择的情境不应引起强烈的负面情感，以免客户无法集中注意力。

  • 针对儿童和青少年：

    • 游戏化教学：对于儿童和青少年，可以通过有趣的游戏来解释思想如何影响情感、身体反应和行为。这些游戏有助于他们更好地理解CBT的概念。

  • 作业：

    • 练习CBT：在继续下一章之前，完成相关的练习，将所学应用于临床案例和个人生活。
    • 探索自己的压力源和优点：使用提供的表格记录自己的压力源和优点，反思这些信息对自己有何启示。

通过这些步骤和练习，治疗师可以帮助客户更好地理解CBT的原理和方法，从而在治疗过程中更加有效地应用这些技术。这些练习不仅帮助客户了解问题的性质和影响，还能发现他们已有的应对资源，为后续的治疗提供支持和方向。

将所学应用于你的治疗实践

下一个任务

思考下周即将见到的一位客户，确定他或她目前正在处理的一个问题。

作业#2：探索客户的问题

参考《了解客户问题的问题》中的三个问题，使用你已有的信息完成以下表格。你从这个练习中学到了什么？当你见到客户时，提出必要的问题以填补缺失的信息。花点时间反思从询问额外信息中学到了什么。

客户客户的问题探索客户的问题客户的回答这是一个有用的问题吗？如果是，它是如何有用的？
问题1：这个问题如何影响了客户的生活？
问题2：客户是否因为这个问题而回避某些情境？
问题3：客户是如何应对这个问题的？

作业#3：选择一个问题来探索客户的问题

从上述三个问题中选择一个你很少或从未使用过的问题，或者从《了解客户问题的问题》中选择另一个问题进行练习。下周使用你选择的问题与两位不同的客户交流。注意每位客户的回应及你获得的信息。你可以使用以下表格记录你的体验。

你想要练习的问题客户客户1客户2客户的回应这是一个有用的问题吗？如果是，它是如何有用的？

进一步的知识点阐述

  • 将所学应用于治疗实践：

    • 选择客户：思考下周即将见到的一位客户，确定他或她目前正在处理的一个问题。这有助于你有针对性地应用CBT技巧。
    • 探索客户的问题：
      • 问题1：这个问题如何影响了客户的生活？通过这个问题，你可以了解问题对客户日常生活的影响，从而更好地理解问题的严重性和范围。
      • 问题2：客户是否因为这个问题而回避某些情境？通过这个问题，你可以了解客户的行为模式，特别是回避行为，这对于制定干预措施非常重要。
      • 问题3：客户是如何应对这个问题的？通过这个问题，你可以了解客户已有的应对策略，从而在此基础上提供更有针对性的建议和支持。

  • 选择和练习问题：

    • 选择问题：从《了解客户问题的问题》中选择一个你很少或从未使用过的问题进行练习。这有助于你扩展你的提问技巧，提高对客户问题的理解。
    • 与客户交流：使用你选择的问题与两位不同的客户交流，注意每位客户的回应及你获得的信息。这有助于你评估问题的有效性，并在实践中不断改进。

通过这些练习，治疗师可以更好地了解客户的问题，从而制定更有效的治疗计划。这些练习不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

作业#4：识别客户的压力源和优点

选择你目前正在合作的一位客户，尝试在以下领域识别他的或她的压力源：家庭、朋友、休闲/组织、工作/学校、健康、财务，以及任何最近的重大变化或压力。然后查看《探索优点的问题》，看看能否识别出任何优点和韧性领域。完成以下表格。完成后，问问自己这项练习如何影响了你对客户压力源和优点的意识。

识别客户的压力源和优点

类别困难或压力源优点或韧性领域
家庭
朋友和社会联系
休闲和组织参与
工作或学校
健康
财务
变化

让我们回顾

回答议程项目下的问题。

议程项目#1：建立良好的治疗关系

  • 客户的思想在建立同理心关系中为什么重要？

议程项目#2：了解客户的主要问题

  • 在探索客户的主要问题时，哪两个问题会有帮助？

议程项目#3：认识苏珊

议程项目#4：了解客户的压力源和优点

  • 在探索客户当前生活状况时，你希望涵盖哪三个类别？
  • 在探索客户的优点时，哪两个问题会有帮助？

议程项目#5：认识劳尔

议程项目#6：了解客户的心理社会史

  • 在收集心理社会史时，CBT治疗师可能会强调哪两个领域，而其他治疗师可能不会？

议程项目#7：解释CBT

  • 你如何向客户解释CBT？

什么对你很重要？

  • 你希望记住哪些想法或概念？
  • 你希望将哪些想法或技能应用到自己的生活中？
  • 下周你希望尝试与哪位客户一起做什么？（选择一位具体的客户。）

进一步的知识点阐述

  • 识别客户的压力源和优点：

    • 压力源：在家庭、朋友、休闲/组织、工作/学校、健康、财务以及最近的重大变化或压力等方面，识别客户的困难和压力源。
    • 优点和韧性：使用《探索优点的问题》来识别客户的优点和韧性领域。这有助于全面了解客户的情况，制定更有效的治疗计划。

  • 建立良好的治疗关系：

    • 同理心：客户的思维在建立同理心关系中非常重要，因为了解客户的内心世界可以帮助治疗师更好地理解和支持客户。

  • 了解客户的主要问题：

    • 探索问题：在探索客户的主要问题时，可以使用以下两个问题：
      • 这个问题如何影响了你的生活？
      • 你是否因为这个问题而回避某些情境？

  • 了解客户的压力源和优点：

    • 当前生活状况：在探索客户当前生活状况时，可以涵盖以下三个类别：
      • 家庭
      • 工作或学校
      • 健康
    • 优点：在探索客户的优点时，可以使用以下两个问题：
      • 你有哪些应对问题的方法？
      • 你有哪些支持系统？

  • 了解客户的心理社会史：

    • 心理社会史：在收集心理社会史时，CBT治疗师可能会强调以下两个领域：
      • 事件的意义：不仅问客户对过去事件的感受，还要问这些事件对他们意味着什么。
      • 优点和韧性：倾听客户的优点和证据，证明他们是能干和值得爱的。

  • 解释CBT：

    • 目标导向：CBT是一种目标导向的治疗方法，治疗师会要求客户在治疗中设定目标，双方共同努力实现这些目标。
    • 四因素模型：通过识别客户的思维、情感、身体反应和行为，以及它们是如何相互关联的，来理解客户的问题。这些因素的变化会相互影响。

通过这些练习和回顾，治疗师可以更好地了解客户的问题，从而制定更有效的治疗计划。这些练习不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

CHAPTER 2 Focus on Your Clients’ Problems and Strengths Let’s start with a check-in and review. In the last chapter we covered basic CBT theory, and we started using the four-factor model. Remember, the four-factor model involves exploring your client’s reaction to a situation by identifying thoughts, feelings, physical reactions, and behaviors. We also looked at how thoughts and behaviors can maintain problems. Did you try using the four-factor model? What did you notice when you differentiated thoughts from feelings? If you did not have a chance to use the four-factor model, try this exercise. Think of a situation in the past few days where you had a strong negative emotional reaction. Imagine yourself back in that situation. Now, try to identify your thoughts, feelings, physical reactions, and behavior. Afterwards, take a moment to reflect on the experience. Did you learn anything about yourself? Set the Agenda In this chapter, I want to focus on forming a good therapy relationship, understanding your clients’ presenting problems and strengths, and explaining CBT to your clients. Agenda Item #1: Develop a good therapeutic relationship. Agenda Item #2: Understand your client’s presenting problems. Agenda Item #3: Meet Suzanne. Agenda Item #4: Understand your client’s stressors and strengths. Agenda Item #5: Meet Raoul. Agenda Item #6: Understand your client’s psychosocial history. Agenda Item #7: Explain CBT.

Work the Agenda Shortly, I’ll introduce you to two clients, Suzanne and Raoul, whom we will work with throughout the book as we learn and practice CBT skills. But first, let’s start where all good therapy starts—with the therapeutic relationship. Agenda Item #1: Develop a Good Therapeutic Relationship For all types of therapy, including CBT, a good therapeutic relationship predicts a positive outcome (Martin, Garske, & Davis, 2000; Norcross & Wampold, 2011). Effective therapy happens in the context of a supportive relationship where your client feels understood and accepted. As with any form of therapy, when practicing CBT, it is important to be warm and nonjudgmental. You want to develop a collaborative relationship with your client, working together to solve her problems. You bring your knowledge about psychology and CBT, and your client brings her knowledge about her own life and experience. Multiple studies have demonstrated that empathy is a central component of any effective therapy (Norcross & Wampold, 2011). I would guess that you agree, but take a moment to think about how you define empathy. Usually, when I ask my students this question they answer, “walking in someone else’s shoes” or “understanding someone else’s feelings.” My students always mention feelings; almost no one mentions thoughts. Understanding feelings is important, but understanding thoughts is just as impor- tant (Elliott, Bohart, Watson, & Greenberg, 2011). Let’s consider an example. Sorena, your client, tells you that she feels sad and tired. She also tells you that she thinks she is an inadequate parent and that her children don’t respect or love her. If you wanted to be truly empathic, would you focus just on Sorena’s feelings or also on her thoughts? It seems to me that using the four-factor model and asking about both feelings and thoughts increases an empathic connection. Over the years, some therapists have told me that they think CBT is a cold type of therapy because we pay attention to thoughts. If you look at the previous example, what do you think? It seems to me that thoughts are as private and emotional as feelings. It is important to remember that when you ask clients what they “think,” you are asking them to reveal a very private part of themselves. In this book we will focus on how to be a warm, empathic therapist while also using structured CBT interventions (Josefowitz & Myran, 2005). Agenda Item #2: Understand Your Client’s Presenting Problems There is an order to CBT therapy. While there is some flexibility, typically the following order is implemented: •Explore your client’s presenting problem and obtain an overview of her current life situation, including difficulties and strengths. •Take a psychosocial history. •Explain CBT in general and in particular the four-factor model. •Set goals for therapy. •Focus on helping your client change. In the initial phase of therapy, you start to form a good relationship and at the same time get an overview of your client’s problems and how they are affecting her life. You also want to obtain a sense of your client’s strengths and how she has coped in the past. There are three main steps to obtaining an initial understanding of your client’s problems or why she came to therapy:

  1. Ask your client about her problems and make a list.
  2. Explore how your client’s problems are affecting her life and how she is coping.
  3. Collaboratively decide which problem(s) your client wants to start working on in therapy. Ask your client about her problems and make a list. CBT therapists usually start with “How can I help you?” or “Tell me, what brings you to therapy?” It is important for your client to explain her prob- lems in her own words. Initially, I focus on listening, using summary statements to be sure I have under- stood, and then ask open questions. Open questions encourage exploration and are not answered with just one word. For example, “Do you have a problem?” is a closed question. The answer is yes or no. “What kind of problem do you have?” is an open question. One way to think about this stage is that when your client starts therapy, the picture is blurry. Good questions help you gradually focus and sharpen the picture so that it is crisp and bright, or at least clearer. After you have a general sense of your client’s problems, it is helpful to make a list so that you can explore her problems more fully, one at a time. Writing out a list gives the message that therapy will address specific problems and not just be a place where she comes and talks in general terms. Making a list also starts to give direction to therapy. I usually say, “I am starting to have an idea of some of your concerns. I would like to make a list of your problems to be sure we have covered everything.” Most non-CBT therapists are not used to writing as part of therapy. Next time you have a new client, try writing out your client’s problems and share the list with your client. Pay attention to how making a written list affects therapy. Explore how your client’s problems are affecting her life and how she is coping. Often clients describe general problems, such as difficulty with their marriage or feeling anxious. To understand how a problem is affecting your client’s life, you need to explore further. You will find the following list of questions helpful. (You can download them in handout format at http://www.newharbinger.com/38501.) Questions to Explore Your Client’s Problems Question 1: What are some examples of situations where this problem arises? When you have this problem, what are your main thoughts, feelings, physical reactions, and behavior? I usually start with this question. Once you have examples of specific situations, the problem usually becomes much more defined. Question 2: What is the worst part of the problem? It is important to ask this question and not just assume that you know the answer. I am often surprised by my client’s answer. Question 3: How is this problem affecting your life? What are some of the difficulties this problem has created for you? In particular, are there activities you have stopped doing or are avoiding because of the problem? Are there activities you have started doing or are doing more of because of the problem? If my client is avoiding specific activities, I follow up by asking what she thinks would happen if she did not avoid them. Question 4: What have you done to try and cope with the problem? Have any of your coping methods helped? You want to know whether anything has helped, even a little, so that you can expand upon this coping strategy later. In addition, you want to acknowledge and support any active attempt to cope with the problem. Question 5: When did this problem start? Sometimes a client can immediately identify a triggering situation. Sometimes she has not thought about whether her difficulties were related to specific changes or events in her life. A series of relatively minor changes, over a short period of time, can equal a lot of stress. YOUR TURN! Practice in Your Imagination: Use One of the Five Questions I want you to imagine using the questions we just covered. Sports psychologists have known for years that imagining practicing a new skill significantly enhances skill development (Weinberg, 2008). It seems to me that if athletes can use imagery to practice, why not therapists? You can do the exercise by reading along, but I think you will find the exercise more meaningful if you listen to the guided audio file available at the website for this book. Look at Questions to Explore Your Client’s Problems. Choose a question which you rarely or never use. Now, choose a client with whom you want to try asking this question. Imagine your- self back in your office. Take a moment to look around; notice the sounds and smells of your office. Now imagine yourself asking this question with your client. Now, imagine asking this question with a different client. Each time, imagine that your client responds positively. Write down the question you choose, and try it with two clients this coming week.

Agenda Item #3: Meet Suzanne Throughout this book we are going to follow two clients, Suzanne and Raoul. They are based on a number of my clients and the clients of students I have supervised or taught. I want to start with intro- ducing you to Suzanne. We will meet Raoul later in the chapter. Suzanne is thirty-four and is married with two young children, Jennifer, age six, and Andrew, age four. She is a fourth-grade teacher and her husband works in a local hardware store. Her husband was her high-school sweetheart, and she is still in love with him. They live in the suburbs of a medium-size city. Her parents and her in-laws live nearby; she sees them regularly and they have a good relationship. Suzanne’s doctor referred her for therapy because she is always tired and feels chronically over- whelmed by the children, her job, and her other responsibilities. Her physical exam was normal, and her doctor thought it would be helpful for her to “talk to someone.” Suzanne calls the therapist’s office and makes an appointment. Suzanne is a small, thin woman who smiles timidly when she walks into her therapist’s office for the first time. She perches on the edge of the couch and looks nervously around. When Suzanne’s therapist asks, “How can I help you?” she responds softly with, “I’m not sure… I don’t know even know where to start,” and looks down. Her therapist gently asks, “Tell me what brings you here; I know it can be hard to start.” Suzanne explains she does not know what is wrong with her. She has a great house, great kids, a good job, and a great husband, but she is just so overwhelmed all the time that she isn’t enjoying life anymore. She starts to cry and says she feels like she isn’t coping. Her therapist asks Suzanne to tell her a bit more. Suzanne explains that she is always tired, cries over silly things, and quickly gets angry with the kids. She looks very sad and says, “I’m not even a good mother anymore.” Suzanne explains that she used to like her job as a fourth-grade teacher, but she dreads going into work these days. She is teaching at a new school, which is a thirty- to forty-minute commute. Her old school was walking distance from home. She is often angry with her husband. He works long hours and she feels she is expected to take care of the children and house without any appreciation from him. She is scared that he will leave her if she stays this depressed. She feels anxious all of the time. She has always been a shy person, but her anxiety is getting much worse; she worries over everything. Let’s see how we can start to understand Suzanne’s problems using Questions to Explore Your Client’s Problems. Therapist: Sounds like a lot. I think it would help if we made a list of your problems so we can start to understand them one at a time. Suzanne’s therapist’s response is both empathic and structured. Suzanne was feeling overwhelmed; her therapist thought that making a list might help her start to feel that her problems were more manageable. Suzanne lists being tired all of the time, yelling at her children, not doing anything fun, hating work, and wondering if teaching is the right job. These are all general problems, and we don’t really understand how they are affecting her life. Therapist: I think it would be helpful to understand a bit more about what is happening with you. Let’s pick one problem and look at it in more depth. Let’s start with exploring what is the worst part of this problem for you. (Question 2)

Note how Suzanne’s therapist explains what she wants to do by saying she wants “to understand a bit more about what is happening with you.” At the same time, she reinforces hope by saying “it would be helpful.” This is a good example of combining the structure of CBT with creating a good therapy relationship and instilling hope. Suzanne: I think the worst thing is that I’m always yelling at my kids and feeling like I am not coping. This is a very general statement. You want a more specific idea of Suzanne’s difficulties. Before looking at Suzanne’s therapist’s response, think about how you could ask Suzanne to identify specific situations that are difficult for her. Therapist:Could you give me some examples so I have a better idea of the situations that are difficult for you? (Question 1) Suzanne:Sure, I used to come home and make dinner for the family, and then play with my kids. These days just making dinner seems to take up all of my energy; I never seem to have time or energy to spend time with my children, and when I do, I am pretty irritated. As a CBT therapist, you are using the four-factor model to think about your clients’ problems. When Suzanne gave an example of a difficult situation, did she describe her thoughts, feelings, physical reaction, and behaviors? We have an idea of Suzanne’s feelings (overwhelmed and irritated/angry) and her physical reaction (tired); we don’t know her behavior or her thoughts. She mentioned earlier the thought I am not even a good mother anymore. You can guess that’s what she is thinking about herself in these situations, but it is important to check. Therapist: Suzanne, when you are feeling overwhelmed and irritated, what are some of the thoughts that are going through your mind? (Question 1) Notice that Suzanne’s therapist linked her thoughts to her feelings. Suzanne: I’m usually thinking that I am a terrible mother and the kids deserve better. But I am also thinking that I wish I could just go to bed and not have to take care of the kids. Try to think of an empathic comment that would summarize what Suzanne said and indicate that you had heard Suzanne’s thoughts. How could you ask Suzanne about her behavior and how she is coping? Think of how you would respond before checking what Suzanne’s therapist said. Therapist:Those sound like pretty difficult thoughts to be having. Lots of self-critical thoughts and then wishing you could just go to bed and get away from it all. Tell me, how do you cope in these situations? (Question 4) Suzanne:I just try to control my anger and take care of the kids. But I am pretty short with them. I have been trying to take it easy and go to bed early, to be less tired, but it hasn’t helped. Therapist:Have you tried anything that has helped? Suzanne: No, not really. How could you introduce Question 3? Therapist:I wonder if there are things you have stopped doing since you have been feeling so bad, or situations you are avoiding? Suzanne:Well, I generally do less fun things with my husband and children. Lately I am just too tired. This is a very general comment. How could you help Suzanne become more specific about what “fun things” she is doing less of? Therapist:When you say you do less fun things with your husband and children, can you give me some examples? Suzanne:I used to take my daughter, who is six, to a playgroup in the afternoon with some of my neighbors. I have a half day off from work each week. But I’ve been too tired to do that. Also my husband and I used to take the kids to the park on weekends, which was a fun family time; but I often send them over to my parents’ so that I can nap, or my husband takes them without me. When you look at Suzanne’s response, is there anything Suzanne has been doing more of? Suzanne’s thera- pist thought that she had been doing more resting and napping. This is a good place to ask about changes in alcohol consumption, drugs, and medication. Her therapist discovers that Suzanne has stopped doing most afterschool activities with her chil- dren as she is “too tired” and that she has also stopped seeing and talking with most of her girlfriends. She and her husband have also stopped seeing many of their friends and family because Suzanne feels that she is too tired. Suzanne’s problems started when she changed schools. She is unhappy at her new school, has made no friends, and feels like an outsider. Suzanne has not started consuming alcohol, nor did she report abusing prescription or nonprescription medication. Suzanne’s therapist suggested that they write down a preliminary list of the problems that Suzanne would like to work on in therapy. Suzanne suggested the following problems:

  1. Not having any friends at my new school
  2. Yelling at my children and husband
  3. Being tired all of the time
  4. Not doing fun things with my husband and children
  5. Being depressed and anxious and just not enjoying life anymore
  6. Wondering if teaching is the right job for me This is a long list; the therapist and Suzanne have to figure out where to start. Collaboratively decide which problem(s) your client wants to start working on in therapy. If you remember from earlier in the chapter, there are three main steps to obtaining an initial understanding of your client’s problems. First, ask about your client’s problems and make a list; second, explore how your client’s problems are affecting her life; and third, collaboratively decide which problem your client wants to start working on. We are now ready for the third step. Some clients come to therapy with one main problem, but most have a number of different prob- lems. You and your client need to decide which problem to address first, or therapy can feel like wander- ing around without a focus. The easiest approach is to be direct and say, “I think it’s helpful to try and address one problem at a time. When we look over your problem list, which problem would you like to start with?” You want to pick a problem where there is a good chance you can help your client fairly quickly and that will have an immediate impact on her life. Marsha Linehan (1993) suggested some very useful criteria for prioritizing your client’s problems. First, if your client is actively suicidal, your first priority is to make sure that she is safe. Second, if your client is behaving in a manner that is dangerous or that is likely to significantly interfere with her life, these behaviors need to be addressed. Examples of these types of behavior include major substance abuse, missing work or school, and being involved in a physically or emotionally abusive relationship. In addition, if a client regularly engages in behavior that interferes with therapy, for example, coming late to therapy, insulting the therapist, or skipping sessions, these behaviors need to be addressed. If we consider each of Suzanne’s problems, the first four that she listed are more specific and con- crete than being depressed and not enjoying life anymore or wondering whether teaching is the right job for her. The therapist explained to Suzanne that because the first four problems are more specific and concrete, she would want to start with one of these so she will be able to help Suzanne in a shorter period of time and with more focus to therapy. She then asked Suzanne which problem she wanted to start with. Suzanne wanted to start with making friends at her new school and not doing any fun things with her husband and children. Video 2.1: Meet John and Understand Your Client’s Presenting Problem Agenda Item #4: Understand Your Client’s Stressors and Strengths In addition to understanding your client’s presenting problems, you need to understand how these problems fit into her overall life. You want a picture of her current life, how she is functioning, and any other stressors or difficulties in her life besides her presenting problem, as well as the positive supports in her life and her areas of strengths. You can introduce this section by saying, “I am starting to get an understanding of your problems. I think it would be helpful if I could also get a sense of other parts of your life.” Notice that I explain what I will be doing and indicate that it will be helpful to my client. The basic categories that I ask about are family, friends and social contacts, recreation and involve- ment in organizations outside of the home, work or school, health, and finances. Finances includes the ability to budget, pay bills on time, and all that is involved in being financially responsible. When asking about health, if you did not already ask about alcohol and drug use, this is a good place to do so. I also ask about self-care, either under recreation or health. I want to know if my client is engaging in activities that are nurturing for her and if she is participating in any regular exercise. In addition, I ask whether over the past year or few years there have been any major changes in my client’s life, or a number of small changes. UNDERSTAND YOUR CLIENT’S STRESSORS Let’s start by seeing what we already know about Suzanne’s stressors or difficulties in each category. Suzanne’s Difficulties or Stressors Family • Often angry with children and husband • Believes she is no longer a good mother • Responsible for the children and home because husband works long hours • Frightened husband will leave her if she doesn’t change her mood and behavior Friends and Social Contacts• Unknown Recreation & Organizations• Unknown Work or School• Fourth-grade teacher who “dreads” work Health• Always tired • Otherwise unknown Finances• Unknown Changes• Started teaching at a new school that is a 30- to 40-minute commute from home • Can no longer walk to work every day and instead has to drive • Used to do fun things with girlfriends and participate in afterschool activities with children • Used to like her job When we use the table above, we can start to see areas where we need more information. Suzanne’s therapist continues to ask about her life. She learns that Suzanne has always been shy but has a small group of friends with whom she is close. However, recently she has been avoiding her friends, as she is just too tired to go out. Her husband is the main salary earner, and she feels guilty about asking him to help more in the home since she earns less than he does. She used to like work, but this year she changed schools. She has had trouble fitting into the new school; she feels different from the other teachers, who seem to form a tight group. In her previous school she was active in the school play, but she has been hesitant to volunteer for afterschool activities at her new school, where everyone seems to know each other. She reported that apart from lack of energy and being tired, her health was good and she had no problem with alcohol or drug use. She also indicated that generally, while they would like more money, finances were not a major problem. Between work and taking care of the children, she has no time for hobbies or recreation, though she enjoyed doing the school play last year. Suzanne indicated that she had not experienced any major stressors or changes other than her new job in the past few years. However, her mother-in-law, who used to babysit the children, had some health problems and was no longer able to help. Her daughter has had chronic ear infections. Suzanne often had to take time off from work to care for her daughter and take her to the doctor. Although her daughter is better, Suzanne is worried about the upcoming winter. Also, Suzanne’s best friend, Genia, moved away and she misses her. Suzanne was surprised at the amount of change in her life over the past few years and was able to see that all these changes together had caused a lot of stress. Let’s stop for a moment. At this point we have quite a bit of information. However, we forgot to notice strengths and areas of resilience. This often happens; as therapists, we are so used to thinking about our clients’ problems that we sometimes forget to think about their strengths. UNDERSTAND YOUR CLIENT’S STRENGTHS Before you can help your client see her strengths, first you need to see her strengths. It sounds easy, but it can be hard to see strengths. One way I use to recognize my client’s strengths is to remember that good things do not happen by magic. For example, a client of mine said her son “was lucky” because he was asked back for a full-time job after his internship. Stop for a moment—from what you know of the world, what needs to happen in order for a young man to be asked back for a full-time job after an internship? Does a fairy godmother just come and say, “Here is your job”? Her son had to get to work on time, work hard, do a good job, and probably be pleasant to work with. All of these characteristics are reflective of her son’s strengths. Now, he also had to be lucky, but luck is rarely enough. Here are some questions to help you think about your clients’ strengths based on the work by Christine Padesky and Kathleen Mooney (2012). You can download these questions in handout form (Questions to Explore Strengths) at http://www.newharbinger.com/38501. • Are there any areas of your client’s life that are going well, or any areas where your client has persevered in the face of difficulties or adversity? I do not mean just overcoming unusual chal- lenges, but also being able to maintain a routine. For example, Suzanne gets up on time every day, gets her children dressed, gets to work, and has dinner ready for her family. This takes thought, care, organization, and perseverance; it doesn’t just happen by magic. It is important to recognize strengths involved in accomplishing everyday activities. It can also be helpful to examine strategies people use to persevere in everyday activities. •Has your client been able to accomplish developmental tasks? For example, has your client been able to pass school grades, develop friendships, participate on sports teams, or have a steady job? These accomplishments suggest that your client was able to keep commitments, learn new informa- tion, and have positive relationships with other people. •Does your client have a responsible and caring relationship with either a person or an animal? Caring relationships involve commitment and putting aside one’s own needs. •Is your client acting according to her values or goals? Acting according to values and goals can be difficult and often involves putting aside what you immediately want to do in favor of long-term goals. •Is your client accomplished or competent in a specific area? People often have pockets of achieve- ments and skills. Being competent in a particular area does not have to be a huge achievement; it could be that you are the person who always makes the birthday cakes, or the person your friends turn to for computer help. Frequently the coping mechanisms that people have developed to succeed in these areas can be transferred to other areas of their lives. Let’s think about Suzanne and see how we would fill in the different categories for both her stress- ors and her strengths. You can download a Identify a Client’s Stressors and Strengths worksheet at http://www.newharbinger.com/38501. Suzanne’s Stressors and Strengths Family Difficulties or StressorsStrengths or Areas of Resilience • Often angry with children and husband• Stable, long-term marriage • Believes she’s no longer a good mother • Husband works long hours • Mainly responsible for children and home • Caring parent • Previously engaged in children’s activities • Maintains household routines • Provides stable home for family, last year able to care for sick child • Parents live nearby, good relationship • In-laws live nearby, good relationship • Shy Friends and Social Contacts • Currently avoiding friends• Small group of close, long-term friends Recreation & Organizations• Enjoyed organizing school play last year • No hobbies Work or School Difficulties or StressorsStrengths or Areas of Resilience • Dreading work• Grade four teacher (indicates completed undergraduate and graduate training) • New school, avoiding interaction with other teachers • Avoiding afterschool activities • Previously enjoyed work • Enjoyed colleagues at previous job • Participated in afterschool activities (school play) Health • Daughter has history of ear infections, not currently a problem • Own health is good • Does not use alcohol or drugs as coping mechanism • Daughter’s ear difficulties have resolved Finances Changes • Earns less than her husband and consequently feels guilty about asking for help• Earns a regular salary • Change in school• Despite all of the changes maintaining a stable home • Longer commute • Mother-in-law no longer babysits • Some health problems with her daughter • Genia, her best friend, moved away • Has a job with benefits • No particular financial stress • Responsible teacher • Organized babysitting • Recognized difficulties and coming for therapy Often in the beginning of therapy, clients are very hesitant to notice their strengths. In the next few chapters we’re going to talk more about how to use your clients’ strengths. Before we continue, ask yourself: how did thinking about Suzanne’s problems using the different categories affect your under- standing of her problems and strengths? What was it like to consciously notice her strengths?

Agenda Item #5: Meet Raoul It’s now time to meet the second client we will be following throughout the book, Raoul. Raoul is fifty-eight and lives with his wife in a medium-size city. He has three grown children who all live about an hour’s drive away. For the past twenty years he has worked at the same job as a govern- ment employee in the tax department. His daughter was home for a visit and noticed that he did not seem like himself. He told her that he was not sleeping well and was pretty anxious about work. She suggested that he see a therapist, and he reluctantly agreed. His daughter called and made an appoint- ment for him. Raoul introduced himself to his therapist with a formal handshake and gave his full name. He walked slowly into the room and lowered himself onto the couch with effort. He gave a small smile and said it was his daughter’s idea that he come. His therapist asked how she could help him. Raoul explained that in the past he has had periods when he felt depressed, but he was always able to get over them on his own. Lately he was depressed again, and things were not going well at work. To better understand Raoul’s concerns, his therapist used Questions to Explore Your Client’s Problems. Raoul said that his problems had started when a younger man was promoted to the job that should have been his. He explained in some detail how unfair the hiring process had been. Since then, he said, he has been having difficulty concentrating at work, and for the first time ever, he recently received a poor work evaluation. He is worried about the work evaluation and what the consequences would be if he receives another one. He stressed that for the past twenty years he has only received good year-end evaluations. Since the poor work evaluation there has been some tension with his boss. His therapist asked for examples of situations with his boss that were difficult, or projects where he was having difficulty con- centrating. Raoul had trouble giving specific examples of tension with his boss but was able to list the projects on which he was procrastinating. Raoul’s therapist asked about other aspects of his life, but he was very hesitant to talk about any- thing but his problems at work. Everything else was “fine.” He reported that he and his wife “have no problems.” He occasionally has a couple of beers when he goes out, but otherwise doesn’t drink. He said his health was good. He told his therapist that he was usually shy, but for the past five years he has been part of a bowling league, which his wife had encouraged him to join. His therapist assumed that as therapy progressed and Raoul learned to trust her, she would find out more about the other areas of his life. For the time being, she thought it would be helpful to focus on his work difficulties. Raoul and his therapist made the following list of problems he wanted to work on:

  1. Feeling anxious
  2. Not completing projects on time
  3. Sleeping poorly
  4. Tension with his boss

YOUR TURN! Raoul’s Stressors and Strengths Consider the information you already have about Raoul in relation to his stressors and strengths. Try to fill in the chart below. You can find my answers in the appendix. R aoul’s Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Exercise 2.1: Ruda Attends Playgroup Practice seeing a client’s stressors and strengths. Agenda Item #6: Understand Your Client’s Psychosocial History Most therapists take a history of the presenting problem as well as a general psychosocial history. Some therapists spend a whole session taking a detailed history; others ask for a quick thumbnail over- view. Even if you only take a brief history, it’s helpful to place your client’s current problems in the overall history of her life, being sure to also listen for her strengths and areas of resilience. Generally, when taking a history you are trying to figure out how your clients’ past experiences relate to their current problems. As a CBT therapist, I take a psychosocial history in a similar manner as any other therapist; however, there are two main areas that I emphasize and that might be slightly different from non-CBT therapists. First, therapists usually ask clients how they felt about a given event in their past; I make sure that I also ask what it meant to them, or what their thoughts were at the time. I am particularly interested in the messages my client learned about herself, others, and the future. Some of the questions I ask are: •How did you understand this event? •How did you explain this event to yourself? •What did this event mean about you? •What did this event mean about other people? •What did this event mean about your future? For example, a client of mine, Lisa, failed grade six when her parents divorced, and she went to live with her grandparents. When I asked if she thought that failing grade six meant anything about her, she replied, “I am not very smart, and without my parents’ help I couldn’t manage.” This is important information. Another client of mine, Michael, was sexually abused by his uncle over a period of three years, starting when he was eight years old. When I asked him how he understood the sexual abuse, he explained that he thought it happened because something was wrong with him and that he can’t trust anyone; he then added that bad things are always going to happen to him in the future. Early messages such as these will influence how your client feels, thinks, and behaves in her current life. The second area I emphasize is listening for strengths and evidence that my client is competent and lovable. I am starting to gather evidence that I can use later to counter any negative beliefs. Although it is not a hard-and-fast rule, I usually don’t share my perception of my client’s strengths this early in therapy. I have found that if I share my perception of strengths too early, it is just rejected. For example, my client Lisa, who failed a grade the year her parents divorced, mentioned that she passed the next year and completed nursing training. She was also one of the few students in her class to be offered a job immediately upon graduating. I kept that information in my back pocket, so that down the road when we start to explore her belief that she is not smart and can only manage with her parents’ help, I know that I have some evidence to counter that belief. Agenda Item #7: Explain CBT After you have an understanding of your client’s problems and have taken a history, it is time to explain how CBT works. Here is an example of how I might explain CBT. (A copy of Explain CBT to Your Client is available at http://www.newharbinger.com/38501.) I have heard a bit about your problems and how they are affecting your life. I want to tell you how I work. I use a CBT model. CBT is a goal-oriented form of therapy. I am going to ask you to set some goals for yourself in therapy and together we are going to focus on working toward them. Therapy will involve us first understanding your problems by identifying your thoughts, feelings, physical reactions, and behavior and how they fit together. We will then start to help you make some changes by focusing on one of these factors at a time. Since they are all related, a change in one factor will influence all of the other factors. At this point I often take a situation from my client’s life and together we explore her thoughts, feelings, physical reactions, and behavior. For example, in Raoul’s case we might pick his discomfort when he has to interact with his colleagues at work. You do not want to choose a situation in which your client has a very strong emotional reaction, as she will be too overwhelmed to listen to you and apply the four-factor model. After exploring a situation using the four-factor model, ask if this makes sense to your client. If you are working with children or teens, there are many wonderful games you can use to explain how thoughts can influence feelings, physical reactions, and behavior (see, for example, Kendall, Choudhury, Hudson, & Webb, 2002; Stallard, 2005). Video 2.2: Meet Charlotte and Explain CBT Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to Clinical Examples Complete the following exercise. Exercise 2.1: Ruda Attends Playgroup Apply What You Learned to Your Own Life Try looking at your life in terms of your own stressors and strengths.

Homework Assignment #1 Explore Your Own Stressors and Strengths Use the table below to write down your stressors and strengths. Writing them down is important as it helps you step back and look at them. Did you learn anything about yourself? My Own Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Apply What You Learned to Your Therapy Practice For the next assignment, think of a client you will be seeing this coming week and identify a problem he or she is currently working on. Homework Assignment #2 Explore a Client’s Problem Look at the three questions below from Questions to Explore Your Client’s Problems. Complete the following table using the information you already have. What did you learn from this exercise? When you see your client, ask the necessary questions to fill in any missing information. Take a moment to reflect on what you learned from asking about the additional information. Client: Client’s Problem: Explore Your Client’s Problems Question How has the problem affected your client’s life? Is your client avoiding any situations because of the problem? How has your client coped with the problem? Client’s Response Was this a helpful question? If yes, how was it helpful?

Homework Assignment #3 Choose a Question to Explore a Client’s Problem Choose one of the three questions above that you have rarely or never used, and that you would like to practice using, or choose a different question from Questions to Explore Your Client’s Problems. This coming week, use the question you chose with two different clients. Be sure to notice each client’s response and the information you obtained. You can use the following table to record your experience. Question You Want to Practice: Client Client #1: Client #2: Client’s Response Was this a helpful question? If yes, how was it helpful? Homework Assignment #4 Identify a Client’s Difficulties and Strengths Choose a client you are currently working with and see if you can identify his or her stressors in the following areas: family, friends, recreation/organizations, work/school, health, finances, and any recent major changes or stress. Now look at Questions to Explore Strengths. See if you can identify any strengths and areas of resilience. Complete the table below. After you have completed the table, ask yourself how the exercise impacted your awareness of your client’s stressors and strengths. Identify a Client’s Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Develop a good therapeutic relationship. • How are your client’s thoughts important in developing an empathic relationship? Agenda Item #2: Understand your client’s presenting problems. • What are two questions that would be helpful in exploring your client’s presenting problems? Agenda Item #3: Meet Suzanne. Agenda Item #4: Understand your client’s stressors and strengths. •What are three categories you want to cover in exploring your client’s current life situation? •What are two questions that would be helpful in exploring your client’s strengths? Agenda Item #5: Meet Raoul. Agenda Item #6: Understand your client’s psychosocial history. • When taking a psychosocial history, what two areas might a CBT therapist emphasize that other therapists might not? Agenda Item #7: Explain CBT. • How could you explain CBT to your clients? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

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