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7. 识别来访的想法

第7章：识别客户的思绪

你有机会完成上一章的家庭作业吗？这里有一个我捕捉到的灾难化认知扭曲的例子。我在车里，开车去见一些不太熟悉的同事。我拿起咖啡，五分钟后不小心把大部分洒在了新买的白色衬衫上。你能猜到我的想法吗？我会看起来像个完全的白痴；每个人都会认为我完全无能。然而，事实上我只是把夹克披在衬衫上——虽然不太好看，但绝对不是灾难。你捕捉到自己的任何认知扭曲了吗？你识别到客户关于自我、他人或未来的思绪了吗？

如果你完成了家庭作业，请花点时间反思你学到了什么。如果你没有完成家庭作业，回想上周发生的一个令人不安的经历。识别你的思绪，然后问自己，我的思绪是否包含对自我、他人或未来的不切实际的判断？它们是否是认知扭曲？

设定议程

在上一章中，我们重点讨论了如何决定哪些思绪值得处理。现在我们知道要寻找什么，是时候动手学习如何寻找了。

议程项目 #1：识别自动思绪

议程项目 #2：有用的提问

议程项目 #3：客户的图像

议程项目 #4：识别思绪的其他策略

议程项目 #5：如何知道使用哪些问题？

议程项目 #6：将思绪与感受、生理反应和行为联系起来

处理议程

请记住，识别客户思绪的目的是理解某个情境对客户意味着什么，或者他是如何解读这个情境的。我们希望帮助客户识别他们的热想法。简而言之，热想法解释了客户的情绪和行为，并且是对自我、他人或未来的不切实际的负面评价。

客户在开始识别自己的负面想法时会有各种反应。许多客户在理解是什么维持了他们的困难，并能识别思绪、情绪、生理反应和行为之间的关系时，会感到更有掌控感。其他客户在意识到自己的想法有多么负面时，可能会变得更加困扰。重要的是要解释，虽然审视负面想法可能会很难，但这第一步是为了感觉更好。

议程项目 #1：识别自动思绪

听起来很简单，但如果你想了解客户在想什么，直接问就可以了。以下的“直接问”问题是通常所需的所有问题。

“直接问”问题
  • 一般探究问题
    • 你在想什么？
    • 当时你在对自己说什么？
    • 你脑子里在想什么？
  • 提示问题
    • 还有其他想法吗？
    • 还有什么？
  • 反思陈述
    • 所以你当时在想……（重复最后一个想法）
    • 通常重复最后一个想法或陈述会鼓励客户进一步展开更多的想法。然后你可以选择添加一个提示问题。
  • 澄清问题
    • 你能告诉我更多关于那个想法的信息吗？

当你问客户“你在想什么？”时，使用温和、好奇的语气，鼓励自我反思。通常很有帮助的是指明你正在探讨的情境。例如，苏珊的治疗师问：“当你收到烧烤邀请时，你在想什么？”不要忘了慢慢来，给客户时间。有时候需要几个问题才能让客户识别出他们的想法。

让我们看看我们在第5章中开始处理的苏珊的例子。如果你还记得，她新学校的校长邀请她和其他新老师参加一个烧烤聚会。你已经知道情况（收到烧烤邀请），你已经知道她的感受（紧张、担心、尴尬），你知道她的生理反应（胃部紧绷、肩膀紧张），你知道她的行为（把邀请放在一边，没有回应）。现在你想识别苏珊的思绪，特别是帮助她识别她的热想法。让我们看看如果她的治疗师使用“直接问”问题会发生什么。

治疗师： 苏珊，你已经很好地识别了你的感受、生理反应和行为。让我们看看是否也能识别你的想法。当你被邀请参加聚会时，你脑子里在想什么？

请注意，治疗师首先正面强化了苏珊在识别感受、生理反应和行为方面的表现。然后她指明了情境，再问了一个一般探究问题。

苏珊： （停顿）我不知道，就是不想去；其他新老师都会在那里。

“不想去”是苏珊想要做的行为，这是一个事实。“其他新老师都会在那里”也是一个事实。这些想法不包含对自我、他人或未来的不切实际的判断；它们不解释她的感受；也不包含认知扭曲。苏珊还没有识别出热想法。

治疗师： 还有其他想法吗？

治疗师使用了一个提示问题。

苏珊： 嗯，就是我不会融入。

苏珊开始识别她的热想法。“我不会融入”是关于自我的想法。她的治疗师希望继续探索。

治疗师： 还有其他与“我不会融入”相关的想法吗？

治疗师使用了另一个提示问题。

苏珊： 我觉得我会站在那里显得很尴尬，没有人会和我说话。我会非常紧张，可能会出一身汗。

这是一个客户使用“我觉得”而不是“我认为”的例子。当这种情况发生时，简单地重复句子说：“你当时在想……”

治疗师： 你当时在想，我会站在那里显得很尴尬，没有人会和我说话，我可能会出一身汗。

苏珊： 没错，不只是他们不会和我说话，而是没有人会想和我说话。

此时，苏珊已经识别了关于自我的想法：我不会融入；关于自我和未来的看法：我会站在那里显得很尴尬，可能会出一身汗；以及关于他人和未来的看法：没有人会想和我说话。

她的治疗师随后问苏珊是否愿意在《理解你的反应》工作表上写下她的想法。有些客户喜欢自己写，有些客户喜欢治疗师写。我认为这并不重要。如果我在写，我会在写的时候大声重复客户的思绪。我发现这会鼓励客户开始思考自己的想法，而不仅仅是体验它们。

让我们看看苏珊的工作表是什么样的。

苏珊的《理解你的反应》工作表

情境 想法 情绪 生理反应 行为
收到烧烤邀请 我不会融入 紧张、担心、尴尬 胃部紧绷、肩膀紧张 把邀请放在一边，没有回应
我会站在那里显得很尴尬 紧张 出汗
没有人会和我说话 伤心
没有人会想和我说话 孤独

理解你的反应

情境 感受（1-10评分） 生理反应（1-10评分） 行为 想法
校长邀请我和其他三位新老师参加烧烤 紧张（7）
担心（8）
尴尬（6）		 胃部紧绷（4）
肩膀紧张（5）		 没有回应 • 我不想去。
• 其他新老师都会在那儿。
• 我不会融入。
• 我会站在那里显得很尴尬。
• 没有人会想和我说话。
• 我可能会出一身汗。

议程项目 #2：有用的提问

有时当你问客户他们在想什么时，他们给出的回答并不是热想法。例如，罗尔在去食堂时感到非常尴尬。当他的治疗师问他当时在想什么时，他回答说：“我不知道，我只是觉得尴尬。”这时，治疗师需要提出更多问题来帮助罗尔识别他的想法。

这个情境对客户意味着什么？

发现某个情境对客户意味着什么的一种方法是直接询问。你可以使用以下任何一个问题：

  • 这个情境对你意味着什么？
  • 这个情境对你、其他人或未来意味着什么？
  • 这个情境中让你感到如此困扰的是什么？
  • 这个情境对你来说为什么是个问题？

起初，我使用这些问题时感到非常尴尬。客户刚刚告诉我一个情感上困难的情境，而我在问他们这意味着什么或为什么是个问题。然而，我始终发现这些问题非常有帮助。像所有问题一样，重要的是使用温和、好奇的语气，传达你希望理解客户经历的愿望。

让我们回到苏珊的例子。她的治疗师决定继续探索，使用上述额外的问题，确保她完全理解为什么苏珊觉得烧烤邀请如此困扰。

治疗师： 我想确保我理解为什么烧烤邀请对你来说如此困扰。

苏珊： 不是邀请本身，而是和其他新老师一起去那里。

治疗师： 和其他新老师一起去那里让你感到如此困扰的是什么？

她的治疗师使用了一个问题，继续探究这个情境对苏珊意味着什么。

苏珊： 很难说清楚。我猜是我不会融入；（停顿）我最大的恐惧是他们不想成为我的朋友。

治疗师： 听起来最大的恐惧是“他们不想成为我的朋友”？

苏珊： 没错，没有人会想成为我的朋友，我会一个人在那里。

在上面的例子中，问题“这个情境中让你感到如此困扰的是什么？”帮助苏珊发现了她的潜在想法。让我们再看一个例子，看看如何使用这些问题。

轮到你了！

这个情境对苏珊意味着什么？

在她的第五次治疗中，苏珊希望关注她在课间休息时的感受。她在课间休息时越来越焦虑和不安，试图完全避免这种情况但未成功。她的治疗师问苏珊能否举一个例子说明发生了什么。苏珊解释说，她独自站在操场上，不和任何人交谈，努力表现出她在监督孩子们的样子。她感到非常孤独，希望其他老师能和她说话。苏珊补充说，这种情况昨天再次发生了。她的治疗师认为这是一个很好的情境来探讨。她知道苏珊的感受（焦虑）和行为（独自站立）。她希望理解苏珊的想法。

治疗师： 当你在课间休息时站在操场上，你在想什么？

苏珊： （看上去很悲伤）其他老师都不和我说话。

苏珊的想法是一个事实，它并没有表明这个情境对苏珊意味着什么。看看下面的三种可能的回应，选择一个能帮助苏珊识别这个情境对她意味着什么的回应。

  1. 帮我理解其他老师不和你说话对你来说为什么是个问题。
  2. 你试过和他们说话吗？
  3. 当其他老师不和你说话时，你有什么感受？

最佳回应：1. 帮我理解其他老师不和你说话对你来说为什么是个问题。

治疗师： 帮我理解其他老师不和你说话对你来说为什么是个问题。

苏珊： 主要问题是，我独自站着，而其他老师都和朋友站在一起，互相交谈。

再看看下面的三种可能的回应，选择一个能帮助苏珊探索这个情境对她意味着什么的回应。

  1. 当其他老师不和你说话时，你有什么感受？
  2. 你独自站着，而其他老师都和朋友站在一起交谈，这对你的意义是什么？
  3. 当你说其他老师不和你说话时，有多少其他老师在课间休息时在外面？

最佳回应：2. 你独自站着，而其他老师都和朋友站在一起交谈，这对你的意义是什么？

治疗师： 你独自站着，而其他老师都和朋友站在一起交谈，这对你的意义是什么？

苏珊： 这意味着其他老师不想和我讲话，因为没有一个老师接近我。

在这个点上，苏珊已经识别了一个解释她在课间休息时感到困扰的热想法。她的热想法“其他老师不想和我讲话”是关于他人的想法。她的治疗师可以继续使用“直接问”问题和关于情境意义的问题，探讨是否有其他热想法。

当情境涉及另一个人时

许多困难的情境不仅涉及客户本人，还涉及其他人物。询问客户他们认为另一个人的行为反映了对方如何看待或感觉他们，这会很有帮助。例如，在苏珊的情境中，她的治疗师问：“你觉得其他老师不和你说话意味着他们对你有什么看法？”苏珊回答说，她认为这意味着他们不想了解她，喜欢待在自己的小圈子里。

一个很好的跟进问题是，客户是否有任何特质导致另一个人以这种方式行事。例如，苏珊的治疗师问她是否有任何特质导致其他老师不包括她。苏珊回答说，她害羞且笨拙，无法融入。

上大学

练习 7.1：(a) 尤纳斯提问，(b) 迪亚娜希望练习

专注于识别情境对客户的意义

专注于感受

另一种探索客户想法的方法是询问与特定感受相关的想法。当客户非常清楚自己的感受但难以识别自己的想法时，我经常使用这种方法。

有许多方式可以询问与客户感受相关的想法。我曾用这些问题探讨了各种各样的感受，包括悲伤、受伤、烦躁、失望、愤怒和焦虑。我经常要求客户花一点时间，回到情境中，专注于感受，然后问以下一个问题：

  • 与这种感受相关的想法是什么？
  • 当你有这种感受时，脑子里在想什么？
  • 在你开始有这种感受之前，脑子里在想什么，或者你的想法是什么？

让我们来看一个例子，看看如何使用这些问题。贾丝明刚刚得知住在外地的祖父身体不适。她感到非常内疚，因为她已经有几个月没有去看望他了。

治疗师： 当你得知你祖父身体不适时，你在想什么？

贾丝明： 我只是感到非常内疚。

治疗师： 还有其他想法吗？

治疗师首先使用了一个“直接问”问题。当贾丝明无法识别热想法，只是反复提到她的感受时，治疗师决定尝试识别与贾丝明感受相关的想法。

贾丝明： 没有，只是这种非常强烈、压倒性的内疚感。

治疗师： 你能回到当时的情境中，当你的母亲告诉你祖父身体不适时吗？

贾丝明： 当然，我记得很清楚。

治疗师： 你能专注于你的内疚感吗？真正让自己感受到这种内疚。 （停顿）我在想，这种内疚感背后的想法是什么？

贾丝明： 我只是觉得一个好孙女应该更经常地看望祖父；现在他病了，老了。

列出担忧

当客户处于情绪困扰时，他们往往会担忧。担忧是焦虑的重要组成部分，但感到抑郁、内疚、羞愧和愤怒的客户也常常会担忧。担忧是指预期坏事会发生。当我的客户感到焦虑或担忧时，我通常从列出所有他们担心会发生的事情开始。列表越具体，就越有用。请记住，我是在寻找客户预期会发生的事情，而不是他们预期会有的感受。例如，“我担心在做演讲时会感到焦虑”或“我担心我的演讲不会顺利”不如“我担心我会忘记我的演讲内容”具体。

以下是一些好的问题，可以帮助你深入了解客户具体担忧或焦虑的事情：

  • 你焦虑或担忧会发生什么？
  • 你有没有特别担忧的具体事情？
  • 最坏的情况是什么？或者最糟糕的场景是什么？
  • 你想象会发生什么？

苏珊的治疗师意识到她还没有完全理解苏珊在烧烤聚会上担忧会发生什么。治疗师说：“我能看出你对烧烤聚会感到非常焦虑。如果我们能列出你担心会发生的事情，包括最糟糕的场景，可能会有帮助。” 于是他们一起列出了以下清单：

  • 当我到达时，每个人都在互相交谈，没有人会和我打招呼。
  • 如果我走近一位新老师，她会转过身不理我。
  • 我会独自站在那里，没有人和我交谈。
  • 如果我走到其他老师面前打招呼，我会无话可说。
  • 清晰地想象自己站在烧烤旁边，显得非常尴尬，手里拿着一杯酒。我看到自己独自站在那里，而其他人都在互相交谈。

列出具体的担忧可以是非常有用的工具来管理焦虑。通常，当客户看到他们的担忧被写出来时，他们会意识到其中一些是不现实的。 我希望你尝试一个快速练习。想想一个即将发生的你有些焦虑或担忧的事件。现在，写下你担心可能会发生的所有坏事，并查看这份清单。尽量使你的担忧清单尽可能具体和明确。你的担忧看起来是否更容易管理？也许有些担忧是合理的，那么你可以开始解决问题。列出担忧可以把焦虑从一大团不好的感觉变成你可以着手解决的具体担忧。这是暂停你自动负面路径的又一种方法。

练习 7.2：伊莎贝拉列出她的担忧

练习帮助客户列出他们的担忧。

议程项目 #3：客户的图像

认知行为疗法（CBT）中最令人兴奋的工作之一是与客户的图像合作（Hackmann, Bennett-Levy, & Holmes, 2011）。图像可以是非常有用的工具，帮助客户识别他们的热想法。

使用图像重现情境

有时当你问客户“你在想什么？”时，他们可能会回答“我不知道。”我通常会接着问一个“直接问”的问题，比如：“你脑子里有没有闪过什么？”通常这足以促使客户开始谈论他们的想法，但有时客户仍然会说“我不知道”，或者告诉我一个不是热想法的想法。在这种情况下，帮助客户识别他们想法的一个方法是让他们花一点时间，想象自己回到了那个情境中。当客户想象自己回到那个情境时，他们当时的一些感受会重新浮现，他们对自己的想法有更好的访问。

在使用图像重现情境时，你可以利用五种感官；然而，让客户想象看到情境和听到当时说的话或其他环境声音通常是重现情境最有效的方式（Richardson, 1999）。

以下是一个例子，展示了如何通过图像重现情境帮助查尔斯识别他的想法。 查尔斯最近结婚，有一个两个月大的婴儿。他过去有过酗酒问题，现在正努力适度饮酒。他来到治疗时说他“搞砸了”。他告诉治疗师，几天前他和朋友们出去喝酒，回家后感到非常沮丧，喝了三杯威士忌。

治疗师： 你能描述一下那天晚上发生了什么吗？

查尔斯： 我去了酒吧，和朋友们喝了几杯。当我回到家时，我感到非常沮丧，然后喝了三杯威士忌。

治疗师： 当你在酒吧时，你在想什么？

查尔斯： 我不知道，我只是觉得非常糟糕。

治疗师： 好的，让我们尝试一个练习。闭上眼睛，想象自己回到了那个酒吧。你能看到什么？听到了什么？

查尔斯： 我看到自己坐在吧台前，周围有很多人。我听到音乐声和人们的谈话声。

治疗师： 当你坐在那里时，你脑子里在想什么？

查尔斯： 我突然想到，我不能照顾好我的妻子和孩子。我是一个失败者，我永远无法改变。

通过这个练习，查尔斯能够识别出他当时的具体想法，这些想法是他感到沮丧和无助的根源。

查尔斯的案例

查尔斯： 当我回家时，我感到非常沮丧，我只是想着如果喝一杯我会感觉好一些。

没有唯一正确的回应方式。在讨论饮酒之前，查尔斯的治疗师希望了解他在酒吧里发生了什么，让他变得如此沮丧。

治疗师： 当你和朋友们在外时，你还记得你当时的感觉吗？

查尔斯： 正常，有点低落。

治疗师： 那你的想法呢？

查尔斯： 没有什么，就是和朋友们闲聊。

认知行为疗法（CBT）理论告诉我们，如果客户感到痛苦，一定有某种想法引发了这种痛苦。查尔斯的治疗师希望发现查尔斯当时在想什么，导致他感到如此沮丧。

治疗师： 我想我们能否回到酒吧的情境中，试着弄清楚当时你的情况，特别是你的想法和感受。在你开始感到低落之前，你还记得任何特定的事件吗？

查尔斯： 我的朋友们都在谈论棒球比赛，而我那天晚上不得不留在家里照顾孩子。他们一边喝酒一边谈论各种计划，我知道我做不到这些，因为我现在周末都和妻子和儿子在一起。

治疗师： 你能回到那个晚上的记忆中吗？花点时间看看酒吧，环顾四周。（停顿）看看你朋友们的脸。你能听到他们谈论他们去的比赛吗？现在听听他们谈论其他计划。花点时间真正回到酒吧的记忆中，看看你能否记起当朋友们聊天时你的脑海里在想什么。

治疗师使用了视觉和听觉图像。

查尔斯： 我想我开始觉得他们玩得很开心，而我现在只能换尿布和工作。感觉我的生活走到了尽头。我妻子再也不想要性生活了，她只是抱怨自己有多累。

一旦查尔斯能够识别他的想法，他的沮丧和饮酒就更有道理了。

探索图像

强烈的负面情绪往往伴随着强烈的情感引发图像。例如，害怕蜘蛛的客户倾向于有巨大的恐怖蜘蛛的图像（Pratt, Cooper, & Hackmann, 2004），社交焦虑的客户倾向于有负面的自我形象，如口吃、出汗或表现得极其尴尬（Hirsch, Clark, Mathews, & Williams, 2003）。图像也可以是关于过去的。长期以来，人们知道患有创伤后应激障碍（PTSD）的客户经常会有创伤事件的闪回形式的侵入性图像。研究人员和临床医生发现，有各种问题的客户可能有侵入性图像，这些图像加剧了他们的痛苦。例如，抑郁症患者经常有过去负面事件的侵入性图像（Wheatley & Hackmann, 2011）。

一些客户可以轻松识别他们的图像；然而，许多客户只有在被特别问及图像是否伴随他们的情感反应时才会意识到这些图像（Brewin, Christodoulides, & Hutchinson, 1996）。在我的文章《将图像纳入思维记录》（Josefowitz, 2017）中，我描述了不同类型的可以帮助客户识别其图像的问题。你可以在 http://www.newharbinger.com/38501 找到《识别客户图像的问题》手册。

开始时的一般问题

  • 你有与这种情况相关的任何图像或记忆吗？
  • 当你想到这种情况时，是否会浮现出任何图像或记忆？

探索担忧

许多焦虑的客户对所担心的事件有非常清晰的图像。如果你的客户有一个最坏的场景，请务必询问他是否真的在脑海中看到了最坏的情况发生。

询问伴随客户情感的图像

询问客户是否有伴随其情感的图像或记忆。你有任何图像或记忆伴随你的情感吗？当你有这种情感时，你是否会在脑海中看到自己或他人的图像或画面？

询问伴随客户言语想法的图像

客户通常有关于自己的想法（我不合群）、关于他人的想法（我父亲总是批评我）和关于未来的思考（我的老板会拒绝支付加班费）。你可以问：“当你有这个想法时，你是否能看到或想象这种情况发生？你在脑海中看到自己或他人的画面了吗？你看到自己或他人在做什么或说什么？”

一些客户的图像是非常详细和复杂的。许多客户会对自己讲述长篇复杂的故事；其他人则有非常短暂、稍纵即逝的图像。尝试注意你自己的图像。

苏珊的案例

苏珊有一个非常清晰的图像，她站在校长家的后院，显得非常尴尬。她手里拿着一杯饮料，微微出汗。她独自一人，而其他人都在愉快地交谈。她的治疗师问她图像中是否有声音或她是否听到任何东西。苏珊说她能听到其他老师在交谈和大笑，而她则在圈子外，无话可说。

图像包含浓缩的意义。一旦你识别了客户的图像，你可以问这些图像对他们自己、他人或未来意味着什么。图像通常具有与热想法相同的意义，并且强化了热想法（Josefowitz, 2017）。在苏珊的案例中，她的图像强化了她的热想法，即没有人愿意和她交谈，她不合群。

练习 7.3：阿比尔探索他的图像

练习帮助客户识别他们的图像。

视频 7.2：使用图像探索想法

议程项目 #4：识别想法的其他策略

客户的希望、问题和情绪变化也可以提供对其想法的线索。

当想法是希望或问题时

作为希望或问题的想法提出了独特的挑战，因为它们并不能清楚地解释情境的意义。这意味着你需要继续探索这些想法，以便识别热想法。让我给你一些例子。

卡尔的案例 卡尔非常沮丧。当他的治疗师询问他的想法时，他悲伤地叹了口气，说他真的希望有一天能有孩子。这个希望并不是一个能捕捉到他沮丧本质的想法。如果卡尔真的充满希望，他就不会感到沮丧。当客户感到沮丧或焦虑时，他们有时会表达出他们感到绝望或担忧的事情。卡尔的治疗师跟进问道：“我听到你希望有孩子；你是否担心这不会发生？”卡尔泪流满面地回答：“是的，我认为对我来说有孩子几乎是不可能的，这是我最重要的事情。”卡尔的想法“我有孩子的希望渺茫”开始解释了他的悲伤。

凯伦的案例 凯伦也很沮丧。当她的治疗师询问她的想法时，她泪流满面地说她一直在想“我的丈夫会离开我吗？”问题在于你不能为一个疑问句寻找证据——你需要一个陈述句来寻找证据。你可以通过重新表述问题或探索客户如何回答问题来将其转化为陈述句。例如，凯伦的治疗师重新表述了她的问题，问凯伦：“你是不是在想‘我的丈夫会离开我’？”

看看罗尔的治疗师是如何帮助他进一步探索一个以问题形式出现的想法的

大约一周前，罗尔的老板要求他与一些初级同事一起开展一个新项目。他一直拖延联系他们。罗尔能够识别自己的感受，并告诉治疗师他感到尴尬（8分）和焦虑（8分）。治疗师随后问他他在想什么。

罗尔： 我一直在想，为什么我没有得到晋升？

治疗师： 当你想“为什么我没有得到晋升”时，你在心里是怎么回答这个问题的？

罗尔： 我想我可能是觉得我不够有能力。

治疗师： 所以你给自己的一个答案是“我不够有能力”。你还有其他答案吗？

罗尔： 嗯，我还觉得我的同事和老板不尊重我，也不尊重我的工作。

当罗尔的治疗师开始探索他是如何回答这个问题时，他开始识别出关于自己的想法（我不够有能力）和关于他人的想法（我的同事和老板不尊重我，也不尊重我的工作）。

练习 7.4：卡罗尔想申请一份工作

练习探索事实、希望或问题形式的想法。

利用客户情绪的变化

当客户谈论困难情境时，他们往往会变得情绪化。客户情绪的变化通常伴随着关于自我、他人或未来的重要的想法。例如，如果客户看起来悲伤、脸红或变得激动，这是一个“抓住”重要想法的机会。我通常会说：“我注意到你看起来很悲伤[或我注意到你看起来很不安]；你在想什么？”

让我们看一个苏珊在第六次会谈中提到的例子。苏珊走进会谈时说她想谈谈与丈夫的关系。她以非常平静的方式开始，说昨晚她说自己累了，想早点睡觉。她的丈夫变得生气，并告诉她她总是累，不再想做任何有趣的事情。苏珊在描述丈夫的反应时开始流泪。她的治疗师想识别出与她情绪变化相关的想法。

治疗师： 你回忆起你丈夫的话时，看起来很伤心。

苏珊： 是的，听到他说我不再想出去玩，真的很糟糕。

治疗师： 我想知道，当你流泪时，你在想什么？

苏珊：（看起来非常悲伤，眼泪更多）我在想，如果我不变得更有趣，他会离开我，我将孤身一人。

轮到你了！

注意罗尔的情绪变化

到目前为止，罗尔主要关注的是工作问题。在第七次会谈中，他进来告诉治疗师，他的最小侄女可能患有一种严重的疾病。他用平静的语气解释道：“当我想起我的侄女可能生病的可能性时，我知道整个家庭都必须找到应对的方法，尽管这会很难。” 然后他继续说道： 罗尔： 我们将在周一拿到实验室检查结果，那时就能确定我侄女是否真的患病。（他的声音哽咽，深呼吸了一下，看起来非常难过。）

治疗师如何利用罗尔情绪的变化来帮助他识别对实验室检查结果的想法？

请看下面三个可能的回应，并选择一个能帮助罗尔识别其想法的回应：

  1. 这真是个艰难的局面。我希望你照顾好自己。
  2. 你刚才看起来非常难过，我在想当你想到拿到实验室检查结果时，你在想什么？
  3. 我能理解你有多难过，但我也听到你认为应对这件事很重要。你是怎么应对的？

回应 #2 是最有可能帮助罗尔识别伴随其情绪变化的想法的。在回应 #1 中，治疗师试图表示支持，但没有询问罗尔的想法，也没有提供罗尔没有要求的建议。在回应 #3 中，治疗师试图表现出同情，但没有明确问题就转向了解决问题。

议程项目 #5：如何知道该使用哪些问题？

知道该使用哪些问题是很难的，没有唯一正确的答案。以下是我在一般顺序中使用的提问总结。你可能最初会觉得在治疗过程中手边保留这份清单很有帮助。（你可以在 http://www.newharbinger.com/38501 下载《识别客户想法的问题》手册。）你使用这些问题越多，它们就越会显得自然。

  • 你在想什么？还有其他想法吗？
  • 当客户的情绪发生变化时，询问他们的想法。
  • 这种情况对你意味着什么？或者这种情况对你自己、他人或未来意味着什么？
  • 这种情况对你来说是个问题吗？
  • 有哪些想法伴随你的情绪？
  • 让我们列出你的担忧。你有最坏的情况吗？
  • 你有图像吗？
  • 如果想法是一个问题：你在心里怎么回答这个问题？
  • 如果想法是一个希望：你担心什么？

使用这些问题帮助迈克尔识别他的想法

让我们使用其中一些问题来帮助迈克尔，一个28岁的客户，识别他的想法。迈克尔的主要议程是解决他对与新女友关系的焦虑。他不明白自己为什么会如此焦虑。我们首先从识别他感到焦虑的情境开始。迈克尔告诉我，他的女友很少对他表达口头的爱意；她几乎从不说想念他或见到他很开心。他描述了一条刚收到的短信，上面写着：“今晚一起吃饭。” 在谈到她的行为时，他几乎要哭了。以下是我是如何探索他的想法的；当然，还有很多其他可能的有益回应。在阅读对话时，请考虑你会怎么说。

迈克尔： 她几乎从不说想念我或见到我很高兴。她刚刚发短信说“今晚一起吃饭”。

治疗师： 当你读到这条短信时，你在想什么？

迈克尔： 我觉得她不在乎我。

治疗师： 你觉得她不在乎你。这对你意味着什么？

迈克尔： 这意味着我们的关系没有我想象的那么亲密。我觉得自己不重要。

治疗师： 你感到自己不重要。这让你有什么感受？

迈克尔： 我感到非常难过，甚至有点绝望。

治疗师： 你感到非常难过和绝望。你有没有最坏的情况？

迈克尔： 最坏的情况是她根本不在乎我，最终会离开我。

治疗师： 你担心她根本不在乎你，最终会离开你。这种担忧对你来说有多严重？

迈克尔： 非常严重。我几乎无法集中精力做其他事情。

治疗师与迈克尔的对话

治疗师： 当你收到那条短信时，当时你在想什么？

迈克尔： 我不知道，收到这样的短信感觉不好（眼睛里充满了泪水）。

治疗师： 我看到你几乎要哭了。你脑子里在想什么？ 我注意到他的情绪变化，认为这可能表明了一个重要的想法。

迈克尔： 我知道她在遇到我之前曾与另一个男人交往了两年。我一直在想，她是不是也这样对待他？

迈克尔的第一个想法是一个事实：她在遇到我之前曾与另一个男人交往了两年。他的第二个想法是一个问题：她是不是也这样对待他？我选择探索他是如何回答这个问题的，因为这个想法似乎带有更多的情感。

治疗师： 你是怎么回答“她是不是也这样对待她之前的男朋友”这个问题的？

迈克尔： 我认为她对待他不同，否则那段关系不会持续那么久。

我想要探索迈克尔认为他的女朋友对待她之前的男朋友不同的意义。

治疗师： 如果她确实对待她之前的男朋友不同，这对你会意味着什么？

迈克尔： 这意味着她不像对待她之前的男朋友那样关心我，也许她根本不关心我。

在这个时候，迈克尔开始更加情绪化地谈论他担心女朋友对这段关系不够投入，以及他在她心中并不重要。

议程项目 #6：将想法与情感、生理反应和行为联系起来

在这个治疗阶段，你已经识别了一个对客户来说有问题的具体情境，并使用四因素模型探索了客户的反应。识别这四个因素之间的关系为客户提供了理解维持其问题的结构，并为你组织客户的治疗提供了方法。在这里，《理解你的反应》工作表非常有用：你和客户可以查看这份文件，以开发一个模型来理解维持其问题的因素。

我通常会让客户查看《理解你的反应》工作表，并询问他是否看到这四个因素之间的联系。客户经常会自发地评论说，他的反应更有道理，或者鉴于他的想法，他的感受或行为是有道理的。如果客户没有看到他的想法与情感、生理反应和行为之间的联系，我会指出来。例如，我可能会说：“当我看到你的想法时，我认为你感到[一种情感，比如沮丧]或做出[一种行为，比如拖延]是有道理的。你觉得有道理吗？”如果客户同意我的观点，我会让他用自己的话解释这四个因素之间的联系。

让我们看看苏珊完成的《理解你的反应》工作表，以了解我们如何帮助她理解自己的困难

理解你的反应

情境 情感 (1-10) 生理反应 行为 思想 (1-10)
校长邀请我和其他三位新教师参加烧烤 紧张 (7) 胃紧绷 (4) 没有回复 我不想去。
忧虑 (8) 肩膀紧张 (5) 其他新教师也会在那里。
尴尬 (6) 我不会融入。
我会站在那里显得尴尬。
没有人会想和我说话。
我可能会全身出汗。

治疗师： 让我们看看你写下的内容。（苏珊和她的治疗师一起查看工作表。）当你看这张表时，你注意到这四个因素之间有什么联系吗？

苏珊： 有点……我之前没有意识到我有这么多想法。

苏珊的治疗师希望积极强化苏珊识别自己想法的能力。她希望苏珊自己发现想法与感受和行为之间的联系，而不是直接告诉苏珊。

治疗师： 你做得非常好，成功地识别了你的想法。你看到你的想法与你的感受、生理反应和行为之间的联系了吗？

苏珊： 是的。我觉得如果这些想法在我脑中闪过，我感到焦虑是有道理的。

治疗师： 我认为你是对的，而且你说得很好。这些想法确实解释了你的感受。 请注意，苏珊的治疗师如何强化苏珊对想法与感受之间关系的理解；她告诉苏珊她很好地表达了这种关系，并重复了这种联系。

在这个阶段，苏珊的治疗师会引入审视她的想法的概念，看看是否有支持她信念的证据。在下一章中，我们将介绍如何寻找支持客户想法的证据。

我总是探索所有四个因素吗？

对于大多数客户，我使用《理解你的反应》工作表。然而，你可以从客户问题的一个方面开始。例如，记得我在第五章提到的客户艾尔丝贝斯，她因为儿子不做家庭作业和家务而生气。我们从监测她生气的情境开始。对于其他客户，如果行为不是呈现问题的一部分，我从探索感受、生理反应和想法开始。一旦客户理解了感受与想法之间的联系，我们再加入探索他的行为。

评估客户的工作表

以下是我在评估是否需要花更多时间探索客户《理解你的反应》工作表的任何方面时使用的五个标准。如果客户觉得完成工作表没有帮助，我会检查它是否完成得好；如果完成得不好，我会继续与客户合作。你可以在 http://www.newharbinger.com/38501 下载《理解你的反应检查表》。

  1. 情境是否是对发生事实的描述，还是包含了感受、生理反应、行为或想法？
  2. 感受是否真的是感受，还是一个想法或行为？
  3. 客户是否对其感受和生理反应进行了评分？
  4. 行为是否是对事实的描述，还是包含了感受、生理反应或想法？
  5. 思想是否是热思想？
    • 思想是否关于自我、他人或未来？
    • 思想是否与客户的感受相关？

练习 7.5：索菲亚完成《理解你的反应》工作表

练习评估《理解你的反应》工作表。

作业：练习认知行为疗法

在继续下一章之前，花些时间完成以下作业。

应用所学知识到临床案例

完成以下练习：

  • 练习 7.1：(a) 优纳斯提出一个问题，(b) 迪亚娜想上大学
  • 练习 7.2：伊莎贝拉列出她的担忧
  • 练习 7.3：阿比尔探索他的图像
  • 练习 7.4：卡罗尔想申请一份工作
  • 练习 7.5：索菲亚完成《理解你的反应》工作表

将所学知识应用到你的生活中

在尝试完成整个《理解你的反应》工作表之前，先练习识别你自己的想法和感受。

作业 #1：识别你自己的感受和想法

这周选择两个你至少有中等强度负面反应的情境。描述情境，识别并评估你的感受，然后使用《识别客户想法的问题》来识别你的想法。将你的回答记录在《我的感受和想法是什么？》工作表上，你可以在 http://www.newharbinger.com/38501 下载该工作表。

我的感受和想法是什么？

情境 感受 (1-10) 想法
什么？谁？在哪里？什么时候？ 我有什么感受？ 我在想什么？

作业 #2：完成《理解你的反应》工作表

一旦你练习了《我的感受和想法是什么？》工作表，你就可以尝试完成整个《理解你的反应》工作表。以下是工作表的副本，你也可以在 http://www.newharbinger.com/38501 下载。识别你的想法后，问问自己这些想法是否关于自我、他人或未来。

理解你的反应

情境 感受 (1-10) 生理反应 行为 想法
什么？谁？在哪里？什么时候？ 我有什么感受？ 我的身体有什么反应？ 我做了什么？ 我在想什么？

将所学知识应用到你的治疗实践中

现在是时候尝试同样的练习，但这次是与客户一起进行。

作业 #3：识别客户的情感和想法

选择一个容易合作的客户，并按照以下步骤进行：

  1. 识别一个有问题的情境。
  2. 引入《我的感受和想法是什么？》工作表，这是你在作业 #1 中完成的，解释你希望使用它来帮助识别客户的情感和想法。
  3. 识别并评估客户的情感。
  4. 使用《识别客户想法的问题》。
  5. 帮助客户将其想法与其情感联系起来。

作业 #4：与客户一起完成《理解你的反应》工作表

如果上一个练习进展顺利，尝试与客户一起完成《理解你的反应》工作表。第一次尝试时，你可能会感到不自在，担心客户的反应。这是尝试新事物时的正常反应。然而，尽量放下你的担忧，专注于任务。

回顾

回答议程项目下的问题。

议程项目 #1：识别自动想法

  • 识别负性自动想法的最直接方法是什么？

议程项目 #2：有用的问题

  • 如何询问情境对客户的意义？

议程项目 #3：客户的图像

  • 你可以使用哪两个好的问题来询问客户的图像？

议程项目 #4：识别想法的额外策略

  • 如果想法是一个问题或希望，如何进一步探索？

议程项目 #5：如何知道该使用哪些问题？

  • 你可以使用哪些问题来帮助客户识别他们的想法？

议程项目 #6：将想法与情感、生理反应和行为联系起来

  • 查看四个因素之间的关系为什么是有帮助的？

对你来说什么是重要的？

  • 你希望记住的观念或概念是什么？
  • 你希望应用到自己生活中的观念或技能是什么？
  • 你希望这周与哪个客户尝试什么？（选择一个具体的客户。）

进一步阐述的知识点

  1. 识别客户的思绪

    • 定义：客户在问题情境中的自动想法，这些想法可能是关于自我、他人或未来的。
    • 例子：
      • 客户自发提到的想法：在治疗过程中，客户可能会自发提到一些想法，如“我做不到”、“他们都不喜欢我”等。识别这些想法是关于自我、他人还是未来，可以帮助治疗师更好地理解客户的情绪和行为。

  2. 帮助客户识别思维陷阱

    • 方法：
      • 提供手册：给客户《思维陷阱》手册，帮助他们了解不同的认知扭曲类型。
      • 具体练习：要求客户在一周内识别并记录三个思维陷阱，并使用《我的思维陷阱是什么？》工作表。
    • 目标：帮助客户认识到自己的不合理思维模式，并逐步纠正这些思维陷阱。

  3. 回顾和反思

    • 识别热想法：
      • 特征：热想法通常是强烈的情绪反应背后的想法，具有高度的情绪性和即时性。
    • 识别不切实际的评价：
      • 重要性：识别关于自我、他人或未来的不切实际的评价，有助于客户更好地理解自己的情绪和行为，从而进行有效的调整。
    • 解释客户的感受：
      • 不同类型的情绪：与抑郁相关的思绪通常是消极和绝望的；与焦虑相关的思绪通常是担忧和恐惧的；与愤怒相关的思绪通常是责备和不满的；与内疚相关的思绪通常是自我谴责的。
    • 认知扭曲：
      • 三种认知扭曲：
        • 灾难化：假设最坏的情况会发生。
        • 过度概括：基于单一的负面证据做出广泛的概括。
        • 非黑即白的思维：没有灰色地带，只有极端的评价。

  4. 设定议程

    • 识别自动思绪：帮助客户识别在问题情境中出现的自动思绪。
    • 有用的提问：提出有用的问题，帮助客户深入探讨自己的思绪。
    • 客户的图像：了解客户内心的图像，这些图像可能是他们思绪的可视化。
    • 识别思绪的其他策略：使用多种策略帮助客户识别和记录自己的思绪。
    • 选择合适的问题：根据具体情况选择合适的问题，帮助客户更好地理解自己的思绪。
    • 将思绪与感受、生理反应和行为联系起来：帮助客户理解思绪如何影响他们的感受、生理反应和行为。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 识别自动思绪的重要性

    • 定义：自动思绪是客户在特定情境中立即产生的想法，这些想法通常是无意识的，但会影响客户的情绪和行为。
    • 例子：
      • 苏珊的案例：苏珊在收到烧烤邀请时产生了多个自动思绪，如“我不会融入”、“我会站在那里显得很尴尬”等。这些思绪解释了她的紧张、担心和尴尬的情绪，以及她的行为（把邀请放在一边，没有回应）。

  2. 帮助客户识别自动思绪的方法

    • 直接问：使用简单的“直接问”问题，如“你在想什么？”、“当时你在对自己说什么？”等。
    • 提示问题：使用提示问题，如“还有其他想法吗？”、“还有其他与这个想法相关的吗？”等。
    • 反思陈述：重复客户的最后一个想法，鼓励他们进一步展开。
    • 澄清问题：使用澄清问题，如“你能告诉我更多关于那个想法的信息吗？”等。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的热想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 理解客户的反应

    • 定义：理解客户的反应涉及识别他们在特定情境中的感受、生理反应、行为和想法。
    • 例子：
      • 苏珊的案例：苏珊在收到烧烤邀请时感到紧张、担心和尴尬，身体反应是胃部紧绷和肩膀紧张，行为是没有回应邀请。她的想法包括“我不想去”、“其他新老师都会在那儿”、“我会站在那里显得很尴尬”等。这些想法解释了她的感受和行为。

  2. 有用的提问

    • 目的：通过提问帮助客户识别他们的自动思绪，特别是热想法。
    • 方法：
      • 直接问：直接询问客户他们在想什么。
      • 提示问题：使用提示问题，如“还有其他想法吗？”、“还有其他与这个想法相关的吗？”等。
      • 澄清问题：使用澄清问题，如“你能告诉我更多关于那个想法的信息吗？”等。
      • 情境意义：询问客户这个情境对他们意味着什么，使用如“这个情境对你意味着什么？”、“这个情境对你、其他人或未来意味着什么？”等问题。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的热想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 理解客户的反应

    • 定义：理解客户的反应涉及识别他们在特定情境中的感受、生理反应、行为和想法。
    • 例子：
      • 苏珊的案例：苏珊在课间休息时感到焦虑和孤独，她的行为是独自站在操场上，不和任何人交谈。她的想法是“其他老师都不和我说话”，这解释了她的感受和行为。

  2. 有用的提问

    • 目的：通过提问帮助客户识别他们的自动思绪，特别是热想法。
    • 方法：
      • 直接问：直接询问客户他们在想什么。
      • 提示问题：使用提示问题，如“还有其他想法吗？”、“还有其他与这个想法相关的吗？”等。
      • 澄清问题：使用澄清问题，如“你能告诉我更多关于那个想法的信息吗？”等。
      • 情境意义：询问客户这个情境对他们意味着什么，使用如“这个情境对你意味着什么？”、“这个情境对你、其他人或未来意味着什么？”等问题。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的热想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 当情境涉及另一个人时

    • 定义：在涉及其他人的困难情境中，询问客户他们认为另一个人的行为反映了对方如何看待或感觉他们。
    • 例子：
      • 苏珊的案例：苏珊的治疗师问她，其他老师不和她说话意味着什么。苏珊回答说，她认为这意味着其他老师不想了解她，喜欢待在自己的小圈子里。
    • 跟进问题：询问客户是否有任何特质导致另一个人以这种方式行事。例如，苏珊的治疗师问她是否有任何特质导致其他老师不包括她。

  2. 专注于感受

    • 定义：通过询问与特定感受相关的想法，帮助客户识别他们的自动思绪。
    • 方法：
      • 直接问：直接询问客户他们在特定情境中的想法。
      • 引导问题：要求客户回到当时的情境中，专注于感受，然后问与感受相关的想法。
    • 例子：
      • 贾丝明的案例：贾丝明感到非常内疚，因为她已经几个月没有看望身体不适的祖父。治疗师通过引导问题帮助贾丝明识别与内疚感相关的想法。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的热想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 列出担忧

    • 定义：列出客户担忧的具体事件，帮助他们管理和应对焦虑。
    • 方法：
      • 具体问题：使用具体的问题，如“你焦虑或担忧会发生什么？”、“最坏的情况是什么？”等。
      • 详细清单：鼓励客户列出详细的担忧清单，使焦虑具体化。
    • 效果：当客户看到他们的担忧被写出来时，他们可能会意识到其中一些是不现实的，从而更容易管理。

  2. 使用图像重现情境

    • 定义：通过让客户想象自己回到特定情境中，帮助他们识别当时的想法。
    • 方法：
      • 五种感官：利用视觉、听觉、触觉、嗅觉和味觉来重现情境。
      • 具体问题：引导客户描述他们看到的、听到的和感受到的。
    • 效果：当客户回到情境中时，他们当时的感受和想法会重新浮现，有助于识别热想法。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的热想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 识别客户的想法

    • 定义：通过探索客户在特定情境中的想法，帮助他们理解自己的情绪和行为。
    • 方法：
      • 具体问题：使用具体的问题，如“你当时在想什么？”、“有什么特定的事件让你感到低落吗？”等。
      • 情境重现：让客户回到特定的情境中，通过视觉和听觉图像帮助他们回忆当时的想法和感受。
    • 效果：一旦客户能够识别他们的想法，他们的情绪和行为就会更有道理，更容易管理和解决。

  2. 探索图像

    • 定义：通过探索客户的情感引发图像，帮助他们识别和理解自己的负面情绪。
    • 方法：
      • 一般问题：使用一般的问题，如“你有与这种情况相关的任何图像或记忆吗？”等。
      • 具体问题：针对特定情境，询问客户是否有相关的图像，如“当你想到这种情况时，是否会浮现出任何图像或记忆？”等。
      • 最坏场景：询问客户是否在脑海中看到了最坏的情况发生。
    • 效果：图像可以帮助客户更具体地识别和理解他们的负面情绪，从而更好地管理和解决。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法或图像时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法和图像。
    • 记录和反思：鼓励客户记录自己的想法和图像，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和图像，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和图像，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 询问伴随情感的图像

    • 定义：通过询问客户是否有伴随其情感的图像或记忆，帮助他们识别和理解自己的情感。
    • 方法：
      • 一般问题：使用一般的问题，如“你有任何图像或记忆伴随你的情感吗？”等。
      • 具体问题：针对特定情感，询问客户是否在脑海中看到自己或他人的图像，如“当你有这种情感时，你是否会在脑海中看到自己或他人的图像或画面？”等。
    • 效果：图像可以帮助客户更具体地识别和理解自己的情感，从而更好地管理和解决。

  2. 询问伴随言语想法的图像

    • 定义：通过询问客户是否有伴随其言语想法的图像，帮助他们识别和理解自己的想法。
    • 方法：
      • 具体问题：使用具体的问题，如“当你有这个想法时，你是否能看到或想象这种情况发生？”等。
      • 详细描述：引导客户详细描述他们在脑海中看到的图像，如“你看到自己或他人在做什么或说什么？”等。
    • 效果：图像可以帮助客户更具体地识别和理解自己的想法，从而更好地管理和解决。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法或图像时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法和图像。
    • 记录和反思：鼓励客户记录自己的想法和图像，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和图像，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和图像，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 探索以问题形式出现的想法

    • 定义：通过探索客户以问题形式出现的想法，帮助他们识别和理解更深层次的想法。
    • 方法：
      • 具体问题：询问客户他们在想什么问题，以及他们如何回答这些问题。
      • 逐步引导：通过逐步引导，帮助客户识别出关于自己和他人的具体想法。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的想法，从而更好地管理和解决情绪问题。

  2. 利用客户情绪的变化

    • 定义：通过观察客户在谈论困难情境时的情绪变化，识别与这些情绪变化相关的重要想法。
    • 方法：
      • 观察情绪：注意客户的情绪变化，如悲伤、脸红或激动。
      • 具体问题：在客户情绪变化时，询问他们在想什么，如“我注意到你看起来很悲伤；你在想什么？”
    • 效果：这种方法可以帮助治疗师及时捕捉到客户的内心想法，从而更有效地进行干预和支持。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 注意客户的情绪变化

    • 定义：通过观察客户在谈论困难情境时的情绪变化，识别与这些情绪变化相关的重要想法。
    • 方法：
      • 观察情绪：注意客户的情绪变化，如悲伤、脸红或激动。
      • 具体问题：在客户情绪变化时，询问他们在想什么，如“你刚才看起来非常难过，你在想什么？”
    • 效果：这种方法可以帮助治疗师及时捕捉到客户的内心想法，从而更有效地进行干预和支持。

  2. 使用适当的问题

    • 定义：通过使用适当的问题，帮助客户识别和理解自己的想法。
    • 方法：
      • 常见问题：使用一系列常见的问题，如“你在想什么？”、“这种情况对你意味着什么？”等。
      • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的想法，从而更好地管理和解决情绪问题。

  3. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  4. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 注意客户的情绪变化

    • 定义：通过观察客户在谈论困难情境时的情绪变化，识别与这些情绪变化相关的重要想法。
    • 方法：
      • 观察情绪：注意客户的情绪变化，如悲伤、脸红或激动。
      • 具体问题：在客户情绪变化时，询问他们在想什么，如“你刚才看起来非常难过，你在想什么？”
    • 效果：这种方法可以帮助治疗师及时捕捉到客户的内心想法，从而更有效地进行干预和支持。

  2. 探索客户的回答

    • 定义：通过探索客户对问题的回答，帮助他们识别和理解更深层次的想法。
    • 方法：
      • 具体问题：询问客户他们在想什么问题，以及他们如何回答这些问题。
      • 逐步引导：通过逐步引导，帮助客户识别出关于自己和他人的具体想法。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的想法，从而更好地管理和解决情绪问题。

  3. 将想法与情感、生理反应和行为联系起来

    • 定义：通过识别客户的想法与情感、生理反应和行为之间的关系，帮助他们理解维持其问题的结构。
    • 方法：
      • 使用工作表：使用《理解你的反应》工作表，帮助客户查看四个因素之间的联系。
      • 提问引导：通过提问引导客户认识到想法与情感、生理反应和行为之间的联系。
    • 效果：这种方法可以帮助客户更全面地理解自己的问题，从而更好地管理和解决情绪问题。

  4. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  5. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 使用《理解你的反应》工作表

    • 定义：通过使用《理解你的反应》工作表，帮助客户识别和理解特定情境中的感受、生理反应、行为和想法。
    • 方法：
      • 填写工作表：指导客户详细填写工作表中的各个部分。
      • 讨论工作表：与客户一起讨论工作表内容，帮助他们识别四个因素之间的联系。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的问题，从而更好地管理和解决情绪问题。

  2. 强化客户的理解

    • 定义：通过积极强化客户的理解，帮助他们建立感受与想法之间的联系。
    • 方法：
      • 正面反馈：在客户识别出某些想法时给予正面反馈，增强他们的信心。
      • 引导发现：通过提问引导客户自己发现想法与感受之间的联系，而不是直接告诉他们。
    • 效果：这种方法可以帮助客户更深入地理解自己的问题，从而更好地管理和解决情绪问题。

  3. 评估客户的工作表

    • 定义：通过评估客户的工作表，确保他们正确地填写并理解了四个因素之间的关系。
    • 方法：
      • 检查标准：使用具体的评估标准，检查客户是否正确填写了工作表。
      • 进一步探讨：如果客户没有正确填写工作表，继续与客户合作，帮助他们改进。
    • 效果：这种方法可以帮助治疗师更准确地了解客户的问题，从而提供更有效的治疗支持。

  4. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  5. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 练习评估《理解你的反应》工作表

    • 定义：通过练习评估《理解你的反应》工作表，帮助客户更好地理解和识别自己的感受、生理反应、行为和想法。
    • 方法：
      • 完成工作表：指导客户详细填写工作表中的各个部分。
      • 评估标准：使用具体的评估标准，检查客户是否正确填写了工作表。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的问题，从而更好地管理和解决情绪问题。

  2. 应用所学知识到临床案例

    • 定义：通过完成具体的练习，帮助客户将所学的知识应用到实际的临床案例中。
    • 方法：
      • 具体练习：完成一系列练习，如识别客户的感受和想法、探索客户的图像等。
      • 案例分析：通过分析具体的案例，帮助客户更好地理解自己的问题。
    • 效果：这种方法可以帮助客户将理论知识转化为实际操作，从而更有效地解决情绪问题。

  3. 将所学知识应用到自己的生活中

    • 定义：通过练习识别自己的感受和想法，帮助客户将所学的知识应用到自己的生活中。
    • 方法：
      • 选择情境：选择两个自己有中等强度负面反应的情境。
      • 填写工作表：使用《我的感受和想法是什么？》工作表，详细记录自己的感受和想法。
    • 效果：这种方法可以帮助客户更好地理解自己的情绪和想法，从而更有效地管理和解决情绪问题。

  4. 处理客户的反应

    • 正面强化：在客户识别出某些想法时给予正面反馈，增强他们的信心。
    • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 记录和反思：鼓励客户记录自己的想法，并在治疗过程中进行反思。

  5. 实践建议

    • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
    • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 识别自动想法

    • 定义：识别客户在特定情境下产生的负性自动想法。
    • 方法：
      • 直接提问：直接询问客户在某个情境中他们在想什么。
      • 情感评估：评估客户的情感，帮助识别与情感相关的想法。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的负性自动想法，从而更好地管理和解决情绪问题。

  2. 有用的问题

    • 定义：通过使用有用的问题，帮助客户更深入地理解情境对他们个人的意义。
    • 方法：
      • 情境意义：询问客户某个情境对他们意味着什么。
      • 具体问题：使用具体的问题，如“这种情况对你意味着什么？”
    • 效果：这种方法可以帮助客户更全面地理解自己的问题，从而更好地管理和解决情绪问题。

  3. 客户的图像

    • 定义：通过询问客户的图像，帮助客户识别和理解他们的内心视觉。
    • 方法：
      • 具体问题：使用具体的问题，如“你脑海中出现了什么图像？”
      • 逐步引导：通过逐步引导，帮助客户识别和描述这些图像。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的内心视觉，从而更好地管理和解决情绪问题。

  4. 识别想法的额外策略

    • 定义：通过使用额外的策略，帮助客户更深入地探索他们的想法。
    • 方法：
      • 问题或希望：如果想法是一个问题或希望，进一步探索客户的回答或担忧。
      • 具体问题：使用具体的问题，如“你在心里怎么回答这个问题？”或“你担心什么？”
    • 效果：这种方法可以帮助客户更具体地识别和理解他们的想法，从而更好地管理和解决情绪问题。

  5. 如何知道该使用哪些问题

    • 定义：通过使用合适的问题，帮助客户识别和理解他们的想法。
    • 方法：
      • 常见问题：使用一系列常见的问题，如“你在想什么？”、“这种情况对你意味着什么？”等。
      • 逐步引导：通过逐步引导，帮助客户识别出更深层次的想法。
    • 效果：这种方法可以帮助客户更具体地识别和理解自己的想法，从而更好地管理和解决情绪问题。

  6. 将想法与情感、生理反应和行为联系起来

    • 定义：通过识别客户的想法与情感、生理反应和行为之间的关系，帮助他们理解维持其问题的结构。
    • 方法：
      • 使用工作表：使用《理解你的反应》工作表，帮助客户查看四个因素之间的联系。
      • 提问引导：通过提问引导客户认识到想法与情感、生理反应和行为之间的联系。
    • 效果：这种方法可以帮助客户更全面地理解自己的问题，从而更好地管理和解决情绪问题。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

CHAPTER 7 Identify Your Clients’ Thoughts Did you have a chance to do the homework from the last chapter? Here is one of my catastrophizing cognitive distortions that I caught. I am in the car, driving to a meeting with colleagues I don’t know very well. I pick up coffee, and within five minutes I manage to spill a good part of it on my new white shirt. Can you guess my thoughts? I will look like a complete idiot; everyone will think I am totally incom- petent. However, the truth is I simply pulled my jacket over my shirt—and it wasn’t great, but it certainly wasn’t a catastrophe. Were you able to catch any of your own cognitive distortions? Were you able to identify your clients’ thoughts about self, others, or the future? If you did the homework, take a moment to reflect on what you learned. If you did not do the homework, think about an upsetting experience that happened last week. Identify your thoughts and then ask yourself, Do my thoughts contain unrealistic judgments about self, others, or the future? Are they a cognitive distortion? Set the Agenda In the last chapter we focused on how to decide which thoughts are worth working on. Now that we know what to look for, it’s time to get our hands dirty and learn how to look. Agenda Item #1: Identify automatic thoughts. Agenda Item #2: Helpful questions. Agenda Item #3: Your clients’ images. Agenda Item #4: Additional strategies to identify thoughts. Agenda Item #5: How do you know which questions to use? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior.

Work the Agenda Remember that the purpose of identifying your client’s thoughts is to understand what a situation means to your client, or how he interpreted the situation. We want to help our clients identify their hot thoughts. To recap, a hot thought explains your client’s feelings and behavior and is an unrealistically negative evaluation of self, others, or the future. Clients can have a variety of reactions when they start to identify their negative thoughts. Many clients feel more in control when they understand what is maintaining their difficulties and can iden- tify the relationship between their thoughts, feelings, physical reactions, and behaviors. Other clients become more distressed when they realize how negative their thoughts really are. It is important to explain that even though it can be hard to look at negative thoughts, it is a first step to feeling better. Agenda Item #1: Identify Automatic Thoughts It sounds simple, but if you want to know what your client is thinking, just ask. The following “Just Ask” questions are often all that you need. “Just Ask” Questions General Probing Questions • What were you thinking? • What were you saying to yourself at the time? • What was running through your mind? Prompting Questions • Any other thoughts? • Anything else? Reflective Statements • So you were thinking…(repeat last thought) Often just repeating the last thought or statement will encourage the client to elaborate on more thoughts. You can then choose to add a prompting question. Clarifying Questions • Can you tell me more about that thought? When you ask your client, “What were you thinking?” use a gentle, curious tone that encourages self-reflection. It is often helpful to refer to the situation you are exploring. For example, Suzanne’s therapist asked, “When you received the invitation to the barbecue, what were your thoughts?” Don’t forget to go slowly and give your client time. It can take a couple of questions before your client can identify his thoughts. Let’s look at the example we started working on with Suzanne in chapter 5. If you remember, the principal of her new school invited her to a barbecue with the other new teachers. You know about the situation (invitation to the barbecue), you already know her feelings (nervous, worried, and embar- rassed), you know her physical reaction (clenched stomach and tense shoulders), and you know her behavior (put the invitation aside and did not respond). You now want to identify Suzanne’s thoughts, and in particular you want to help her identify her hot thoughts. Let’s see what happens if her therapist uses the “Just Ask” questions. Therapist: Suzanne, you have done a good job identifying your feelings, physical reactions, and behav- ior. Let’s see if we can also identify your thoughts. When you were invited to the party, what thoughts went through your mind? Notice her therapist starts by positively reinforcing Suzanne for identifying her feelings, physical reactions, and behavior. She then refers to the situation before asking a general probing question. Suzanne: (pausing) I don’t know, just that I don’t want to go; the other new teachers will all be there. The thought I don’t want to go is the behavior Suzanne wants to do. It is a fact. The thought All the other new teachers will be there is also a fact. These thoughts do not contain unrealistic judgments about self, others, or the future; they do not explain her feelings; and they do not contain a cognitive distor- tion. Suzanne has not yet identified a hot thought. Therapist: Any other thoughts? The therapist uses a prompting question. Suzanne: Well, just that I won’t fit in. Suzanne is starting to identify her hot thoughts. I won’t fit in is a thought about self. Her therapist wants to keep exploring. Therapist: Are there other thoughts that go with I won’t fit in? The therapist uses another prompting question. Suzanne: I feel that I will just stand there looking awkward, and no one will talk to me. I will be so anxious, and I will probably get all sweaty. This is an example of a client using “I feel,” when what Suzanne really means is “I think.” When this happens, simply repeat the sentence saying, “You were thinking,…” Therapist:You were thinking, I will just stand there looking awkward, no one will talk to me, and I will probably get all sweaty. Suzanne:That’s right, it’s not just that they won’t talk to me, it’s that no one will want to talk to me. At this point Suzanne has identified a thought about herself: I won’t fit in; thoughts about herself and the future: I will stand there looking awkward, and I will probably get all sweaty; and a thought about others and the future: no one will want to talk to me. Her therapist then asked Suzanne if she would like to write down her thoughts on the Understand Your Reaction worksheet. Sometimes clients like to write, and sometimes they like me to write. I don’t think it matters. If I am writing, I repeat my client’s thoughts out loud as I write. I find that this encour- ages my client to start thinking about his thoughts, rather than just experiencing them. Let’s see what Suzanne’s worksheet looks like. Understand Your Reaction SituationFeelings (Rate 1–10)Physical Reactions (Rate 1–10)BehaviorsThoughts What? Who? Where? When?What did I feel?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersNervous (7)Clenched stomach (4)Has not responded• I don’t want to go. Worried (8) Tense shoulders Embarrassed (6) (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Agenda Item #2: Helpful Questions Sometimes when you ask your clients what they are thinking, they respond with thoughts that are not hot thoughts. For example, Raoul felt very awkward going to the lunchroom. When his therapist asked what he was thinking, he responded, “I don’t know, I just feel awkward.” His therapist needs to ask additional questions to help Raoul identify his thoughts. WHAT DOES THE SITUATION MEAN TO YOUR CLIENT? One way to discover what a situation means to your client is to ask him directly. You can use any of the following questions: •What does this situation mean to you? •What does this situation mean about you, other people, or the future? •What is it about this situation that is so distressing for you? • How is this situation a problem for you? Initially, I felt very awkward using these questions. My clients had just told me about an emotion- ally difficult situation, and I was asking what it meant to them or why it was a problem. However, I have consistently found these questions to be very helpful. Like all questions, it is important that you use a gentle, curious tone that conveys your desire to understand your client’s experiences. Let’s go back to Suzanne. Her therapist decided to keep exploring, using the additional questions identified above, in order to be sure she fully understood why Suzanne found the invitation to the bar- becue so distressing. Therapist:I want to be sure I understand what it is about the invitation to the barbecue that is so distressing for you. Suzanne:It’s not the invitation, it’s going there with all the other new teachers. Therapist:What is it about being there with all the other new teachers that is so distressing for you? Her therapist uses one of the questions to keep probing what the situation means to Suzanne. Suzanne:It’s hard to figure out. I guess that I won’t fit in; (pausing) I think my biggest fear is that they won’t want to be my friend. Therapist:Sounds like the big fear is “they won’t want to be my friend”? Suzanne:That’s right, that no one will want to be my friend, and I will be there all alone. In the example above, the question “What is it about this situation that is so distressing for you?” helped Suzanne figure out her underlying thought. Let’s look at another example and see how you can use these questions. Your Turn! What Does This Situation Mean to Suzanne? In her fifth session, Suzanne wanted to focus on her feelings at recess. She was increasingly anxious and uncomfortable during recess duty and had been trying unsuccessfully to avoid it completely. Her thera- pist asked if Suzanne could give an example of what happens. Suzanne explained that she stands alone in the schoolyard, does not talk to anyone, and tries to look as if she is supervising the children. She feels very lonely and wishes the other teachers would talk to her. Suzanne adds that this exact situation happened yesterday. Her therapist believes this is a good situation to work with. She knows Suzanne’s feelings (anxious) and her behavior (she stands alone). She wants to understand Suzanne’s thoughts. Therapist:When you are standing in the schoolyard at recess, what are you thinking? Suzanne:(looking sad) None of the other teachers are talking to me. Suzanne’s thought is a fact. It does not indicate what the situation means to Suzanne. Look at the three possible responses below and pick the one that will help Suzanne identify what the situation means to her.

  1. Help me understand what it is about the other teachers not talking to you that is a problem for you.
  2. Have you tried talking to them?
  3. What do you feel when the other teachers don’t talk to you? Response #1 is the best answer to help Suzanne identify what the situation means to her and to help Suzanne identify her hot thoughts. Response #2 starts problem solving, and response #3 takes therapy into a different direction. Therapist: Help me understand what it is about the other teachers not talking to you that is a problem for you. Suzanne: The main problem is that I stand alone, while all the other teachers stand with a friend and talk to each other. Look at the three possible responses below. Choose the response that will help Suzanne explore what the situation means to her.
  4. When the other teachers don’t talk to you, how do you feel?
  5. What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other?
  6. When you say the other teachers don’t talk to you, how many other teachers are outside at recess? Response #2 is the best response to explore what the situation means to Suzanne. Response #1 would be a good response if you wanted to identify her feelings, and response #3 would be a good response if you wanted to understand the situation. Therapist: What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other? Suzanne: It means that the other teachers don’t want to talk to me, because none of them approaches me. At this point, Suzanne has identified a hot thought that explains her distress at recess. Her hot thought The other teachers don’t want to talk to me is a thought about others. Her therapist could con- tinue using the “Just Ask” questions and the questions about the meaning of the situation to explore whether there were other hot thoughts.

WHEN THE SITUATION INVOLVES ANOTHER PERSON Many difficult situations involve other people besides your client. It can be helpful to ask what your client thinks the other person’s behavior means about how he or she thinks or feels about your client. For example, in Suzanne’s situation, her therapist asked, “What do you think the other teachers not talking to you means about how they feel toward you?” Suzanne responded that she thought it meant that they did not want to get to know her and liked to stay in their own little cliques. A good follow-up question is whether there is anything about your client that causes the other person to behave in this manner. For example, Suzanne’s therapist asked if there was anything about her that would cause the other teachers not to include her. Suzanne responded that she was shy and awkward and would not fit in. Go to College Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Practice identifying what situations mean to your clients. FOCUS ON FEELINGS Another approach to exploring your client’s thoughts is to ask what thoughts go with specific feel- ings. I often use this approach when my client is very aware of his feelings but is having trouble identify- ing his thoughts. There are a number of ways I ask what thoughts go with my client’s feelings. I have used these ques- tions to explore a great variety of feelings, including sad, hurt, annoyed, disappointed, angry, and anxious. I often ask my client to take a moment, go back to the situation in his mind, and focus on the feeling. I then ask one of the following questions: •What thoughts go with this feeling? •Help me understand, when you have this feeling, what thoughts go through your mind? •Just before you started to have this feeling, what went through your mind, or what were your thoughts? Let’s look at an example of how you could use these questions. Jasmine just found out that her grandfather, who lives out of town, was not feeling well. She has been feeling overwhelming guilt that she had not visited him in a few months. Therapist:When you found out that your grandfather was not feeling well, what were your thoughts? Jasmine:I just felt so guilty. Therapist:Any other thoughts?

The therapist starts by using one of the “Just Ask” questions. When Jasmine was unable to identify a hot thought but kept repeating her feelings, the therapist decided to try and identify the thoughts that went with Jasmine’s feelings. Jasmine:No, just this really strong, overwhelming feeling of guilt. Therapist:Can you go back in your mind to when your mother told you that your grandfather was not well? Jasmine:Sure, I can remember it really clearly. Therapist:Can you focus on your feeling of guilt? Really let yourself feel the guilty feeling. (pausing) I am wondering what thoughts go with this guilty feeling. Jasmine:I just think that a good granddaughter would visit more regularly; now he is sick and old. Video 7.1: Identify Thoughts LIST WORRIES Often when clients are in emotional distress, they worry. Worry is a big component of anxiety, but clients who feel depressed, guilty, ashamed, and angry also often worry. Worry is about expecting bad things to happen. When my client is anxious or worried, I start by making a list of all the “bad things” he is worried will happen. The more concrete the list, the more useful it is. Remember, I am looking for what my client is expecting to happen, not what he is expecting to feel. For example, “I am worried I will be anxious when giving a presentation,” or “I am worried that my presentation will not go well” are less concrete worries than “I am worried I will forget my talk.” Below are some good questions to explore what specifically your client is worried or anxious will happen: •What are you anxious or worried is going to happen? •Is there anything you are specifically worried about happening? •What is the worst that could happen? Or what is your worst-case scenario? •What do you imagine happening? Suzanne’s therapist realized that she did not fully understand what Suzanne was worried would happen at the barbecue. The therapist said, “I can tell that you are pretty anxious about the barbecue. I thought it would be helpful if we could make a list of what you are worried will happen, including your worst-case scenario.” Together they made the following list: When I get there, everyone will be talking to each other, and no one will say hi to me. If I approach one of the new teachers, she will turn her back on me. I will stand there alone, with no one to talk to. If I go up to one of the other teachers and say hi, I will have nothing to say. Clear image of standing next to the barbecue, looking very awkward, holding a glass in my hand. I see myself standing there all alone as everyone else is talking together. Making a specific list of worries can be a very helpful tool to manage anxiety. Often, when clients see their worries written out, they realize that some are unrealistic. I want you to try a quick exercise. Think of an upcoming event that you are somewhat anxious or worried about. Now, write down every bad thing you are worried might happen, and look at the list. Try to make your worry list as specific and concrete as possible. Do your worries seem more manage- able? Maybe some of your worries are reasonable, in which case you can start to problem solve. Making a list takes anxiety from a big ball of bad feelings to specific worries you can start to address. It is one more way to hit the pause button on your automatic negative path.  Exercise 7.2: Isabella Lists Her Worries Practice helping your clients list their worries. Agenda Item #3: Your Clients’ Images Some of the most exciting work in CBT involves working with clients’ images (Hackmann, Bennett- Levy, & Holmes, 2011). Imagery can be a very useful tool to help clients identify their hot thoughts. USE IMAGERY TO RECREATE THE SITUATION Sometimes when you ask your client, “What were you thinking?” he will respond with, “I don’t know.” I usually follow up with one of the “Just Ask” questions. I might say, “Was anything going through your mind?” Often that is enough to prompt my client to start talking about his thoughts, but sometimes my client still says, “I don’t know,” or tells me a thought that is not a hot thought. In that case, one way to help your client identify his thoughts is to ask him to take a moment and imagine himself back in the situation. When a client imagines being back in the situation, some of the feelings he had at the time come back and he has better access to his thoughts. When you recreate a situation using imagery, you can use all of the five senses; however, asking clients to imagine seeing the situation and hearing anything that was said or any other sounds in the environment is often the most effective way to recreate the situation (Richardson, 1999). Here is an example of how recreating the situation in imagery helped Charles identify his thoughts. Charles is newly married and has a two-month-old baby. He has had trouble with alcohol in the past and is trying to drink moderately. He comes to therapy saying he “blew it.” He tells his therapist that a few nights ago he went out with his buddies to a bar for a drink. When he got home he was very depressed and had three glasses of scotch.

Charles: I was so depressed when I got home, I just thought if I had a drink I would feel better. There is no one right way to respond. Before she addressed the drinking, Charles’s therapist wanted to understand what had happened at the bar that he became so depressed. Therapist:When you were out with your buddies, do you remember what you were feeling? Charles:Just normal, sort of down. Therapist:And your thoughts? Charles:Nothing, just hanging out with the guys. CBT theory tells us that if a client becomes distressed, there was a thought that fueled the distress. Charles’s therapist wanted to discover what Charles was thinking that led to his feeling so depressed. Therapist:I am wondering if we could go back to the situation in the bar and try and figure out what was going on with you, in particular your thoughts and feelings. Before you started feeling down, can you remember any particular incident? Charles:My buddies were all talking about the baseball game, and I hadn’t gone with them as I had to stay home with my kid that night. They were drinking and talking about all these plans that I knew I couldn’t do, ’cause I now spend weekends with my wife and son. Therapist:Can you go back to the night in your mind? Take a moment to see the bar, look around. (pauses) See your buddies’ faces. Can you hear them talking about the game they went to? Now hear them talking about the other plans. Take a moment to really go back to the bar in your mind. See if you can remember what is going through your mind as your buddies were talking. The therapist uses both visual and auditory imagery. Charles: I guess I started thinking what a great time they were having, and that now all I do is change diapers and work. Feels like my life is at a dead end. My wife never wants sex anymore; she just complains about how tired she is. Once Charles can identify his thoughts, his depression and drinking make a lot more sense. EXPLORE IMAGES Strong negative feelings are often accompanied by intense affect-provoking images. For example, clients who are scared of spiders tend to have images of huge horrible spiders (Pratt, Cooper, & Hackmann, 2004), and clients who are socially anxious tend to have negative images of themselves in social situations. A socially anxious client may have an image of himself stuttering, sweating, or behav- ing in an extremely awkward manner (Hirsch, Clark, Mathews, & Williams, 2003). Images can also be about the past. It has long been known that clients with post-traumatic stress disorder (PTSD) fre- quently have intrusive images in the form of flashbacks of the traumatic event. What researchers and clinicians are discovering is that clients with a variety of problems can have intrusive images that contribute to their distress. For example, often clients who are depressed have intrusive images of nega- tive events that occurred in the past (Wheatley & Hackmann, 2011). Some clients can easily identify their images; however, many clients become aware of their images only when specifically asked whether images accompany their emotional reaction (Brewin, Christodoulides, & Hutchinson, 1996). In my article “Incorporating Imagery into Thought Records” (Josefowitz, 2017), I describe different types of questions that can help clients identify their images. You can find a Questions to Identify Your Client’s Images handout at http://www.newharbinger.com/38501. Start with a general question. Do you have any images or memories connected with this situation? When you think of this situation, does it bring up any images or memories? Explore worries. Many clients who are anxious have very clear images of their feared event occurring. If your client has a worst-case scenario, be sure to ask whether he actually sees the worst case happen- ing in his mind. Ask about images that accompany your client’s feelings. Do you have any images or memories that accompany your feelings? When you have this feeling, do you ever see pictures or images in your mind of yourself or other people? Ask about images that accompany your client’s verbal thoughts. Clients often have thoughts about themselves (I don’t fit in); thoughts about others (my father is always critical of me); and thoughts about the future (my boss will refuse to pay me overtime). You can ask, “When you have this thought, do you see or imagine this happening? Do you get a picture in your mind of yourself or the other person? What do you see yourself or the other person doing or saying?” Some clients’ images are very detailed and elaborate. Many clients tell themselves long, complex stories; others have very brief, fleeting images. Try to notice your own images. Suzanne had a very clear image of herself standing in the principal’s backyard, looking very awkward. She is holding a drink in her hand and is slightly sweaty. She is all alone and everyone else is happily talking together. Her therapist asked if there were any sounds in her image or if she heard any- thing. Suzanne said she could hear the other teachers talking and laughing, and she was outside the group with nothing to say. Images hold encapsulated meanings. Once you have identified your client’s images, you can ask what these images mean about himself, other people, or the future. Often images hold the same meaning as—and reinforce—the hot thought (Josefowitz, 2017). In Suzanne’s case, her images rein- forced her hot thoughts that no one would want to talk to her and that she would not fit in.  Exercise 7.3: Aabir Explores His Images Practice helping your clients identify their images. Video 7.2: Use Imagery to Explore Thoughts Agenda Item #4: Additional Strategies to Identify Thoughts Clients’ hopes, questions, and mood shifts can also provide glimpses into their thoughts. WHEN THOUGHTS ARE HOPES OR QUESTIONS Thoughts that are hopes or questions pose unique challenges because they do not clearly explain the meaning of the situation. This means that you need to continue to explore these thoughts in order to identify a hot thought. Let me give you some examples. Karl is very depressed. When his therapist asks about his thoughts, he sighs sadly and says he really hopes one day he will have children. This hope is not a thought that captures what his depression is about. If Karl were truly hopeful, he would not be feeling depressed. When clients are depressed or anxious, they sometimes express as hopes the very things they feel hopeless or worried about. Karl’s therapist follows up and asked, “I hear you hope that you will have children; are you worried that will not happen?” Karl became teary and responded, “Yes I think that for me having children is pretty hope- less, and it is the most important thing to me.” Karl’s thought, It is hopeless that I will have children, starts to explain his sadness. Karen is also depressed. When her therapist asks about her thoughts, she becomes teary and says she keeps thinking, Will my husband leave me? The problem is you can’t look for evidence for a ques- tion—you need a statement to look for evidence. You can turn the question into a statement by either rephrasing it or exploring how your client would answer the question. For example, Karen’s therapist rephrased her question by asking Karen, “Are you thinking, My husband will leave me?” Let’s see how Raoul’s therapist helped him further explore a thought that was in the form of a ques- tion. About a week ago, Raoul’s boss asked him to work on a new project with some of his junior col- leagues. He had been procrastinating over contacting them. Raoul was able to identify his feelings and told his therapist he was embarrassed (8) and anxious (8). His therapist then asked him what he was thinking. Raoul:I keep wondering, Why didn’t I get the promotion? Therapist:When you think, Why didn’t I get the promotion, how do you answer the question in your head? Raoul:I guess I think I just wasn’t competent enough. Therapist:So one answer you give yourself is, I just wasn’t competent enough. Do you give yourself any other answers? Raoul:Well, I also think my colleagues and boss don’t respect me, and don’t respect my work. When Raoul’s therapist starts to explore how he answers the question, he starts to identify thoughts about himself, I wasn’t competent enough, and thoughts about others, My colleagues and boss don’t respect me and don’t respect my work.  Exercise 7.4: Carol Wants to Apply for a Job Practice exploring thoughts that are facts, hopes, or questions. USE SHIFTS IN YOUR CLIENT’S MOOD When clients talk about a difficult situation, they often become emotional. A shift in your client’s mood usually goes with an important thought about self, others, or the future. For example, if a client looks sad, blushes, or becomes agitated, it is an opportunity to “catch” important thoughts. I usually say, “I noticed you looked sad [or I noticed you looked upset]; what were you thinking?” Let’s look at an example that Suzanne brought up in the sixth session. Suzanne came into the session saying she wanted to talk about her relationship with her husband. She started in a very calm manner, saying that last night, she said she was tired and wanted to go to bed early. Her husband became annoyed and angry and told her that she was always tired and never wanted to do anything fun anymore. Suzanne started to become teary as she described her husband’s response. Her therapist wanted to identify what thoughts went with her change in mood. Therapist:You looked teary as you remembered what your husband said. Suzanne:Yes, it was pretty awful to hear him say that I never want to go out anymore. Therapist:I am wondering what was going through your mind just now, as you got teary. Suzanne:(looking very sad and more teary) I thought that if I don’t start being more fun, that he will leave me, and I will be all alone. YOUR TURN! Notice Raoul’s Change in Mood Up to now Raoul has mainly focused on work issues. In session 7 he comes in and tells his therapist that his youngest niece may have a serious illness. He explains in a calm voice, “When I think of the pos- sibility of my niece being sick, I know the whole family will just have to find a way to cope, as hard as it will be.” He then goes on: Raoul: We will know for sure whether my niece has the illness on Monday, when we get the results of the lab tests. (His voice cracks, he takes a deep breath, and looks very upset.) How could his therapist use the shift in Raoul’s mood to help him identify his thoughts about the lab results? Look at the three possible responses below and pick the one that will help Raoul identify his thoughts:

  1. What a hard situation. I hope that you are taking care of yourself.
  2. You just looked so upset, I am wondering what was going through your mind when you thought of getting the lab results?
  3. I can see how upset you are, but I also hear how important it is to you to cope. How are you coping? Response #2 is the most likely to lead Raoul to identify the thoughts that accompany his change in mood. In response #1, the therapist tries to be supportive but does not ask about Raoul’s thoughts and is giving advice that Raoul did not ask for. In response #3, the therapist tries to be empathic and then moves to problem solving without having a good definition of the problem. Agenda Item #5: How Do You Know Which Questions to Use? It can be hard to know which question to use, and there is no right answer. Here is a summary of the questions I use, in the general order in which I use them. You may initially find it helpful to keep this list by your side during therapy. (You can download a Questions to Identify Your Client’s Thoughts handout at http://www.newharbinger.com/38501.) The more you use these questions, the more they will start to feel natural. •What were you thinking? Any other thoughts? •When a client’s mood shifts, ask about thoughts. •What does the situation mean to you? OR What does the situation mean about yourself, others, or your future? •How is this situation a problem for you? •What are some of the thoughts that go with your feelings? •Let’s make a list of your worries. Do you have a worst-case scenario? •Do you have any images? •If the thought is a question: How do you answer this question in your mind? •If the thought is a hope: What are you worried about? Let’s use some of these questions to help Michael, a twenty-eight-year-old client of mine, to identify his thoughts. Michael’s main agenda was addressing his anxiety about his relationship with a new girl- friend. He didn’t understand why he was so anxious. We began with identifying situations where he felt anxious. Michael told me that his girlfriend was rarely verbally affectionate toward him; she almost never said she missed him or that she was happy to see him. He described a text message he just received where she said, “See you tonight for dinner.” As he talked about her behavior, he became almost teary. Below is how I explored his thoughts; however, there are many other possible helpful responses. As you read through the dialogue, consider what you would have said. Therapist:When you received the text, what were your thoughts at the time? Michael:I don’t know, it just doesn’t feel good to get a text like that (eyes well up with tears). I started with using one of the “Just Ask” questions. However, Michael responded with a thought that was not a hot thought, so I wanted to try another approach. Therapist: I can see you’re becoming almost teary. What thoughts are going through your mind? I noticed the shift in his mood and thought it probably signaled an important thought. Michael: I know she had a relationship with another man for two years before me. I keep wondering, Did she treat him the same way? Michael’s first thought is a fact: She had a relationship for two years before me. His second thought is a question: Did she treat him the same way? I chose to explore how he answered the question, as there seemed to be more emotion attached to that thought. Therapist:And how do you answer the question, “Did she treat her past boyfriend in the same way”? Michael:I think she treated him differently, or the relationship wouldn’t have lasted. I wanted to explore what it meant to Michael that he thought his girlfriend had treated her previous boy- friend differently. Therapist:If she did treat her previous boyfriend differently, what would it mean to you? Michael:That she doesn’t care about me as much as her previous boyfriend, maybe that she doesn’t really care about me at all. At this point, Michael started to talk with more emotion about his fears that his girlfriend was not com- mitted to the relationship and that he was not very important to her. Agenda Item #6: Link Thoughts to Feelings, Physical Reactions, and Behavior At this point in therapy, you have identified a specific situation that is problematic for your client, and you’ve explored your client’s reaction using the four-factor model. Identifying the relationships among the four factors provides your client with a structure for understanding what is maintaining his problems, and provides you with a way of organizing your client’s treatment. Here’s where the written worksheet Understand Your Reaction comes in handy: you and your client have a document you can look at when developing a model to understand the factors that are maintaining his problem. I start with asking my client to look over the Understand Your Reaction worksheet and ask if he sees a connection among the four factors. Often a client will spontaneously comment that his reaction makes more sense, or that given his thoughts, it makes sense how he is feeling or behaving. If a client does not see the link between his thoughts and his feelings, physical reactions, and behaviors, I point it out to him. For example, I might say, “When I look at your thoughts, it makes sense to me that you would be [a feeling, for example depressed], or do [a behavior, for example procrastinate]. Does this make sense to you?” If my client agrees with me, I ask him to explain the link among the four factors in his own words. Let’s look at the Understand Your Reaction worksheet that Suzanne completed to see how we can help her understand her difficulties. Understand Your Reaction Situation Feelings (Rate 1–10) Physical Reactions BehaviorsThoughts (Rate 1–10) What? Who? What did I feel? Where? When?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersClenched stomach (4)Has not responded• I don’t want to go. Nervous (7) Worried (8) Embarrassed (6) Tense shoulders (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Therapist:Let’s look at what you wrote down. (Suzanne and her therapist look at the worksheet.) When you look at it, do you notice any connection among the four factors? Suzanne:Sort of…I wasn’t aware that I had all of those thoughts. Suzanne’s therapist wants to positively reinforce Suzanne for identifying her thoughts. Rather than telling her, she wants Suzanne to make the link between her thoughts and how she was feeling and behaving. Therapist:You did a really good job of identifying your thoughts. Do you see a connection between your thoughts and your feelings, physical reactions, and behaviors? Suzanne:I do. It makes sense to me that if all these thoughts were going through my head, I would feel anxious. Therapist:I think you are right, and you said it very well. The thoughts really explain your feelings. Notice how Suzanne’s therapist reinforces Suzanne’s understanding of the relationship between her thoughts and her feelings; she tells Suzanne that she articulated the relationship well, and repeats the connection. At this point Suzanne’s therapist would introduce the idea of examining her thoughts, to see if there is any evidence for her beliefs. In the next chapter, we are going to cover how to look for evidence for your clients’ thoughts. DO I ALWAYS EXPLORE ALL FOUR FACTORS? For most clients I use the Understand Your Reaction worksheet. However, you can start with just focusing on one aspect of a client’s problem. For example, remember my client Elsbeth, in chapter 5, who was angry at her son for not doing his homework and chores? We started with just monitoring situ- ations where she was angry. With other clients, if behavior is not part of the presenting problem, I start with exploring feelings, physical reactions, and thoughts. Once my client understands the feeling– thought connection, we add exploring his behaviors. EVALUATING YOUR CLIENT’S WORKSHEET Below are five criteria I use to evaluate whether I need to spend more time exploring any aspect of a client’s Understand Your Reaction worksheet. If a client did not find completing the worksheet helpful, I check that it was done well; if it was not done well, I keep working with my client. You can download Understand Your Reaction Checklist at http://www.newharbinger.com/38501.
  4. Is the situation a factual description of what occurred or does it include feelings, physical reac- tions, behaviors, or thoughts?
  5. Is the feeling really a feeling or is it a thought or behavior?
  6. Did the client rate his or her feelings and physical reactions?
  7. Is the behavior a factual description or does it include feelings, physical reactions, or thoughts?
  8. Are the thoughts hot thoughts? a. Are the thoughts about self, others, or the future? b. Are the thoughts related to the client’s feelings?  Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Practice evaluating the Understand Your Reaction worksheet. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.  Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Go to College Exercise 7.2: Isabella Lists Her Worries Exercise 7.3: Aabir Explores His Images Exercise 7.4: Carol Wants to Apply for a Job Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Apply What You Learned to Your Own Life Before you try completing the whole Understand Your Reaction worksheet, it is helpful to practice identifying just your thoughts and feelings. Homework Assignment #1 Identify Your Own Feelings and Thoughts This coming week, choose two situations when you had at least a moderately strong negative reaction. Describe the situation, identify and rate your feelings, then identify your thoughts using Questions to Identify Your Client’s Thoughts. Record your responses on the What Are My Feelings and Thoughts? worksheet, which you can download at http://www.newharbinger.com/38501.

What Are My Feelings and Thoughts? SituationFeelings (Rate 1–10)Thoughts What? Who? Where? When?What did I feel?What did I think? Homework Assignment #2 Complete the Understand Your Reaction Worksheet Once you have practiced the What Are My Feelings and Thoughts? worksheet, you are ready to try completing the entire Understand Your Reaction worksheet. There is a copy below, and you can also download it at http://www.newharbinger.com/38501. Once you have identified your thoughts, ask your- self if they are about self, others, or the future.Feelings (Rate 1–10)What did I feel? SituationWhat? Who? Where? When? How did my body react? What did I do? Physical Reactions Behaviors (Rate 1–10) Understand Your Reaction What did I think? Thoughts

Apply What You Learned to Your Therapy Practice It’s time to try the same exercise that you just did, but this time with a client. Homework Assignment #3 Identify Your Client’s Feelings and Thoughts Choose a client who is easy to work with and follow these steps:

  1. Identify a situation that is problematic.
  2. Introduce the What Are My Feelings and Thoughts? worksheet, which you completed in Homework Assignment #1, and explain that you want to use it to help identify your client’s feelings and thoughts.
  3. Identify and rate your client’s feelings.
  4. Use Questions to Identify Your Client’s Thoughts.
  5. Help your client link his or her thoughts to his or her feelings. Homework Assignment #4 Complete the Understand Your Reaction Worksheet with a Client If the last exercise went well, try the Understand Your Reaction worksheet with a client. The first time you try this you may feel awkward and worry about your client’s reaction. This is a normal response to trying something new. However, try to put your worries aside and focus on the task.

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Identify automatic thoughts. • What is the most straightforward way to identify negative automatic thoughts? Agenda Item #2: Helpful questions. • How can you ask what a situation means to your client? Agenda Item #3: Your clients’ images. • What are two good questions you could use to ask about your client’s images? Agenda Item #4: Additional strategies to identifying thoughts. • If a thought is a question or a hope, how can you explore it further? Agenda Item #5: How do you know which questions to use? • What are some of the questions you could use to help your clients identify their thoughts? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior. • Why is it helpful to look at the relationship among the four factors? 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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