第十三章 同理整合：在CFT中构建案例模型

第13章 同情整合：CFT中的案例构建

许多治疗方法通过案例构建来形成对问题来源、维持因素以及治疗干预的系统性理解，这些理解都是围绕个体来访展开的（Eells, 2010）。特别是对于复杂的案例，案例构建为临床医生提供了一种方法，以有序的方式组织来访提供的所有信息，为基于理论的干预创造条件。在本章中，我们将探讨CFT中的案例构建。

CFT案例构建的关键组成部分

CFT中的案例概念化和构建着重于“解析”威胁反应，以此来理解历史和当前因素如何引发了来访的威胁体验，这些体验塑造了他们的行为反应（以及长期的生活方式），以及他们如何与自己和他人建立关系。CFT中的案例构建与我们的目标一致，即去病理化来访的问题，帮助我们在一个有意义的发展背景下理解来访的挑战。Gilbert (2010, 69) 描述CFT案例构建为一种理解先天和历史影响的过程，这些影响导致了重要的外部和内部威胁及恐惧，进而形成了专注于外部和内部的安全策略，这些策略可能导致意料之外的问题后果，影响自我对自我和他人的关系，同时这些关系又进一步塑造了持续的安全策略。下面的CFT案例构建工作表展示了这些要素之间的相互关系。（此工作表也可从http://www.newharbinger.com/33094下载。）接下来，我们将简要探讨每个组成部分。

内部：

• 自我的定位：
• 内部因素：
• 外部因素：
• 安全策略/防御行为
• 人际关系
• 自我对他人：
• 自我对自我：
• 内部因素：

这个工作表是由Russell Kolts基于Paul Gilbert和同情心基金会的工作开发的，用于《简化CFT》一书（http://www.compassionatemind.co.uk）。允许出于临床或培训目的免费复制和分发此表格。

他人定位：

• 外部因素：
• 关键恐惧
• 情感/羞耻记忆：
• 先天和历史影响
• 外部因素：
• 意外后果
• CFT案例构建工作表

先天和历史影响

正如我们在前几章讨论的那样，对来访问题和行为的同情理解需要基于理解这些挑战在其生活背景下的合理性，这些背景受到多种生物学和社会因素的影响。在案例构建的这部分，我们将利用来访对重要生活事件的记忆，以及我们在第六章讨论的早期依恋经验和学习历史。特别重视那些涉及关爱、威胁、忽视、虐待、孤独、羞耻及其他可能强烈影响来访如何看待自己和他人的经历的情感记忆（Gilbert, 2010）。这种历史回顾是在治疗关系中逐步建立的安全感过程中进行的。每当有新的发现时，我们就有机会展示同情，并帮助来访学会用同情、认可和理解的态度对待自己的经历，认识到这些经历是如何持续地塑造他们的人生。

这种探索有助于我们理解来访是如何看待自己（例如，是有能力的、脆弱的、有缺陷的、值得爱和关怀的或不值得的等）以及他人（安全的、危险的、可信的或不可信的）。认知治疗师和图式治疗师可能将这些基本观念称为自我图式（或其他图式），而依恋导向的治疗师则可能称之为内部工作模型。在CFT中，我们强调这些核心自我和他人形象与与他人互动的情感记忆之间的联系，以及它们所带来的感觉——表现为强烈的情绪和身体反应，来访可能难以理解和表达（Gilbert, 2010）。我们还可以考虑这些经历如何影响来访对三个圈子的体验——即以威胁、驱动和安全感模式定义的方式与自己和世界相关联——以及他们是否会在威胁或驱动体验中变得僵化，还是能够在不同情境下灵活地在情绪、动机和视角之间切换。

关键恐惧

在CFT案例构建中，这些历史影响会导致关键恐惧、核心威胁和未满足的需求。这些恐惧通常起源于童年，并围绕着诸如遗弃、拒绝、羞耻、伤害或虐待等核心主题组织（Gilbert, 1989, 2010; Beck, Davis, & Freeman, 2014）。在CFT中，区分了外部威胁和内部威胁（Gilbert, 2010）。外部威胁根植于个人与他人和外界的经历，包括被拒绝、剥削或被他人伤害的主题。内部威胁可以包括害怕失去控制、感觉自己本质上是有缺陷或不可爱的，或是被抑郁、焦虑或愤怒淹没。识别核心威胁有助于帮助来访同情地面对他们的困境，因为他们开始理解他们的历史、基本恐惧和当前困扰的经历之间的联系。

向下箭头法

面对来访提供的众多信息，有时候要准确识别出他们的核心恐惧模式可能会让人感到无从下手。一种有力且直接的方法是“向下箭头法”，这种方法源自David Burns的认知行为疗法研究（Burns, 1980）。在“向下箭头法”中，治疗师首先确定一个令来访感到困扰的具体想法或情境。一旦明确了这一点，治疗师就会连续提问：“这为什么让你感到不安？对你来说意味着什么？”（如果适合，可以在第二个问题后加上“对你而言”）。随着来访的回答，这些问题会不断重复，直到触及到核心恐惧——这一过程通常伴随着来访非言语行为的明显变化，表明核心恐惧的情感影响已经显现。与其尝试变换问题的措辞，不如向来访解释这种方法，如下例所示： 治疗师：Josh，你说你最近对儿子在课堂上的行为感到非常不安。虽然他的成绩还不错，但听起来你对他在课堂上的行为有所担忧？ 乔什： 是的，这件事让我非常生气。在家长会上，老师说Aiden有时会离开座位，而且有时过于健谈，打扰其他同学。我对此非常生气——远超过应有的程度，因为他的成绩其实很好。这真的让我很烦心。 治疗师：让我们试着找出这个问题的根本原因。很多时候，让我们感到困扰的想法或情境背后都有核心恐惧。我想试用一种称为“向下箭头”的技术。我们会反复问你一些问题，直到触及到你的核心恐惧。这样做可以吗？ 乔什： 当然可以。 治疗师：很好。你提到对Aiden在课堂上的行为感到非常不安。这为什么让你感到不安？对你来说意味着什么？ 乔什： 嗯，这是一个问题。我的意思是，老师指出了他有时会扰乱课堂秩序。 治疗师：那么她提到他有时会扰乱课堂秩序。这为什么让你感到不安？对你来说意味着什么？ 乔什： 你知道，在每个班级里总会有几个“问题学生”。我担心Aiden会被贴上“问题学生”的标签。 治疗师：这为什么让你感到不安？对你来说意味着什么？ 乔什： 你知道大家怎么看待那些孩子。他们会责怪父母。总是责怪父母。 治疗师：这为什么让你感到不安？对你来说意味着什么？ 乔什： 这意味着老师或其他家长可能会认为我是个不称职的父亲。 治疗师：那么他们可能会认为你是个不称职的父亲。这为什么让你感到不安？对你来说意味着什么？ 乔什： （停顿；低头。）也许我真的是个不称职的父亲。 治疗师：（停顿。）你觉得这可能是你的核心恐惧吗？你可能是个不称职的父亲？ 乔什： （若有所思；慢慢点头。）是的。我觉得这就是问题所在。从Aiden还没出生时我就一直在为此担心。

上述案例中，Josh的核心恐惧与内在威胁有关——他认为自己有某种特质注定他会成为一位失败的父亲。根据个人背景不同，来访还可能有与外在和内在威胁相关的多种核心恐惧。比如，Jenny就有被他人最终拒绝的外在恐惧，以及与此相关的内在恐惧——可能她自身存在某些问题促使别人拒绝她。理解这些核心恐惧可以帮助我们同情地理解来访为什么会发展出“适应不良”的应对机制。

安全策略与防御行为

核心恐惧会使来访感到极大的痛苦，许多问题都是为了逃避这种痛苦而产生的。在同情焦点疗法（CFT）中，这些被称为安全策略——旨在减轻威胁带来的痛苦的防御行为。这些策略通常基于回避，并体现在很多来访的行为中——例如，PTSD患者会避开任何可能让他回忆起创伤的情境，并通过饮酒来应对这些记忆；抑郁症或恐慌症患者不愿离开家门；愤怒的来访将情绪爆发归咎于他人；极度痛苦的青少年通过自残来处理强烈的情绪。当我们运用苏格拉底式对话探究来访当前的问题时，这些安全策略的例子往往会变得清晰可见。 识别安全策略的关键在于，不论是短期的应对行为还是长期的生活方式选择，它们通常都是基于威胁并涉及回避。这些策略的重点是尽量减少与威胁情境、思想、记忆和经历的接触，而不是建立来访真正想要的生活。同情的理解来自于在特定背景下解读这些行为。尽管孤立来看这些行为可能看似不合理甚至有害，但结合来访的核心恐惧和过往经历来看，它们实际上是合情合理的。来访正在尽其所能地应对威胁，采用我们之前讨论过的明示或暗示教给他们的策略。然而，正如你可以想象的那样，这样的防御策略往往会产生意想不到且不希望出现的后果——这就引出了下一步的分析。

意外后果

安全策略往往会产生意想不到且适得其反的后果，这些后果不仅可能维持来访的问题，还会使问题恶化或引发新的难题（Gilbert, 2010; Salkovskis, 1996）。这些策略通常涉及回避，因为来访试图减少与令人不适的情绪体验、思维（如强迫症中的强迫行为）和情境的接触。这些意外后果可能是毁灭性的，比如社交焦虑的来访为了避免社交场合的焦虑而避开社交活动，从而错失了重要的生活机会。像Jenny这样害怕被拒绝的来访可能会因为害怕被评判而避免坦诚的情感交流（Gilbert, 2010）。这些后果还可能直接伤害来访或他人，例如那些通过自残和物质滥用应对情绪困扰的人，或是为了获得社会主导感而采取攻击行为以抵御脆弱感的人。

苏格拉底式对话可以帮助来访同情地探索他们的安全策略如何与其背景和核心恐惧相关联，以及这些策略如何在他们自己的生活中产生不良后果。正如前面的案例所示，Jenny意识到她在年轻时经历了创伤性的拒绝之后，避免和退出社交场合的做法是有道理的。然而，她的策略也阻止了她建立她真正渴望的滋养性社交联系（这有助于她学会在与他人的关系中感到安全）。

Josh展示了一种更为复杂的安全策略——他在爆发后倾向于责怪妻子和孩子“让我生气”。虽然这里没有足够的空间来包含完整的对话内容，但通过苏格拉底式对话，可以帮助Josh认识到，在他愤怒爆发后几乎立即会有一股强烈的情感痛苦和羞耻感（可能与激活他作为糟糕的父亲和丈夫的核心恐惧有关）。问题可能包括：“这些情况通常是如何发展的？”“看到你的妻子或儿子因为你所说的话受到伤害是什么感觉？”以及“接下来会发生什么？”为了逃避这种痛苦，Josh会几乎立刻开始责怪他的家人——以此来免除自己对待他们的责任。这种行为为Josh带来了更多问题，因为他的家人对他不稳定的行为和指责作出反应，逐渐疏远他，并在他周围时变得小心翼翼。Josh随后注意到这种疏远，进一步强化了他作为有缺陷的父母和伴侣的感觉。

基于威胁的安全策略的意外后果可以不断塑造自我与他人之间的互动模式，使来访陷入威胁循环。当他们执行越来越深地根植于羞耻自我图式的剧本时，这些剧本阻止了他们与他人建立滋养性的联系。

与自我和他人的关系

在CFT案例构建的最后一个部分，我们考虑上述意外后果如何塑造和强化来访对自己和他人的体验和关系。CFT案例构建并不是冷酷或公式化的——在每个阶段，我们都回溯到来访的核心情感体验。这些情感体验特别重要，因为它们随着时间的推移，通过安全策略的详细阐述和后果，塑造了来访对自己和他人的隐含感受。出于对拒绝的恐惧而回避他人会导致距离和社会联系的枯萎，强化了来访认为自己不讨人喜欢以及他人冷漠和拒绝的自我认知。为了应对创伤记忆而进行的物质滥用可能导致关系问题和效能下降，塑造并强化了基于羞耻的自我观，即自己是破碎和无能的。当来访观察到（或仅仅是感受到）他们的安全策略的后果时，他们对自己和他人的体验可能会以看似压倒性和不可避免的方式被详细阐述。

就像核心恐惧一样，这些与自我和他人相处的模式（以及相关的痛苦）可能导致更多安全策略的发展，从而产生更加有问题的意外后果。随着时间的推移，来访可能会发现自己陷入了这样一个循环：他们尝试的一切——每一个努力在前一次经历的基础上都是合乎逻辑的——似乎都在加深他们的问题。通过探索构建的不同组成部分之间的联系，我们可以帮助来访同情地理解维持他们“停滞”的因素。一旦发展出这种理解，我们就可以合作帮助他们用有效、同情的应对和相处方式取代安全策略，从而在他们的生活中产生积极的后果，并建立积极的自我体验，即他们是富有同情心和有能力的。让我们来看一下Josh的完整案例构建工作表。

他人角色：拒绝、不稳定，用离开来回应愤怒 自我定位：不可爱、不可接受 情感/羞耻记忆： 不安全-矛盾型依恋——虐待的父亲，疏远的母亲。 小学时被同龄人欺负。高中时几乎没有朋友，恋爱经历令人沮丧。 先天和历史影响 内部： 感觉不可爱、无能——“我是个糟糕的父亲。” “我是个糟糕的丈夫。” 外部： 担心被抛弃和拒绝——“他们会离开我。没有人会想要我。” 核心恐惧 内部： 合理化愤怒行为 反复思考——“我可以独自一人。” “我不需要任何人。” “这是他们的错。” 外部： “要坚强并保持控制。” “在他们伤害我之前先推开他们。” 渴望得到关爱和感情。 把情绪爆发归咎于他人。 安全策略/防御行为 自我对他人： • 认为他人是拒绝的、冷漠的、不愿满足他的需求、无法应对他 自我对自我： • “失去控制” • “坏父亲，坏丈夫” • “我有缺陷”，无法维持关系 人际关系 内部： • 孤独感 • 持续的愤怒，行为问题 外部： • 妻子和孩子疏远，“如履薄冰” • 与同事关系紧张 • 对他人的同情心较低 意外后果 CFT案例构建工作表：Josh 良好的案例构建往往可以直接引导我们进入治疗计划。根据上述内容，我们可以考虑Josh可能会从苏格拉底式的对话中获益，帮助他同情地理解他的愤怒和问题在他个人特质和社会经历背景下的意义。正念训练可以帮助他识别愤怒和易怒情绪的出现，以及关于被拒绝、不可爱和对自己及他人的负面思维。使用诸如舒缓节奏呼吸、安全地方想象和写同情信等策略可以帮助他在这些情境下自我安慰，使他能够转换到更加同情的角度，并避免以前的爆发、指责和自我羞辱的循环。Josh还可以从同情自我工作中的受益，这包括发展特定技能，如对他人的心理化和共情。这项工作旨在培养同情自我对话和适应性的人际交往方式，如与家人和同事的自信训练。

总结 有些来访会面临一系列复杂的问题，这让开始治疗变得很困难。案例构建有助于整理我们对来访的观察，并规划有效的治疗策略。正如你可以想象的，开发一个案例构建并与来访共同探讨的过程通常是充满情感的。对于来访而言，意识到他们的生活是如何被塑造成一种长期带来巨大痛苦的方式——这种痛苦可能因为他们的应对尝试而加剧——可能会非常伤心。在CFT中，这个过程始终根植于同情的理解，并且将我们的探索与来访的感情体验紧密相连。在下一章中，我们将探讨一种强有力的方法，通过椅子工作的过程（已在前一章介绍）来帮助来访探索他们的情绪：多重自我练习。

本章知识点阐述

知识点阐述

同情整合与案例构建

同情聚焦治疗（Compassion-Focused Therapy, CFT）是一种心理治疗方法，旨在通过培养同情心来帮助个体应对负面情绪和心理问题。CFT中的案例构建是一个关键过程，它帮助治疗师和来访共同理解问题的起源、维持机制以及治疗方向。以下是CFT案例构建的一些关键知识点：

1. 综合理解

• 历史与现状：案例构建需要全面考虑来访的历史经历和当前状况，包括生物、心理和社会因素。
• 情感记忆：特别关注情感记忆，如关爱、威胁、忽视、虐待等，这些记忆深刻影响了来访的自我感知和人际交往模式。

2. 关键恐惧与核心威胁

• 外部威胁：来自外界环境，如被拒绝、剥削或伤害。
• 内部威胁：源自内心，如害怕失去控制、觉得自己有缺陷或不可爱，或是被负面情绪压倒。

3. 安全策略与防御行为

• 安全策略：来访为了应对威胁而采取的行为，可能是适应性的，但也可能带来意外的负面影响。
• 防御行为：来访为了保护自己免受威胁而形成的特定行为模式，这些行为可能在短期内有效，但长期来看可能不利于心理健康。

4. 人际关系

• 自我与他人：来访如何与自己和他人建立关系，包括自我评价和他人评价。
• 同情与理解：通过同情和理解，帮助来访更好地接纳自己，改善人际关系。

5. 三个圈子

• 威胁：与威胁相关的感受和行为。
• 驱动：追求目标和满足需求的动力。
• 安全感：感受到的安全和舒适状态。

通过这些步骤，CFT案例构建不仅帮助治疗师深入了解来访的情况，还促进了来访对自己经历的同情理解，从而促进心理健康和个人成长。

进一步阐述的知识点

向下箭头法

“向下箭头法”是一种认知行为疗法中的技术，用于揭示来访内心深处的核心恐惧。这种方法通过连续提问的方式，帮助来访逐步深入到他们最深层的恐惧或信念。在这个过程中，治疗师会反复问两个关键问题：“这为什么让你感到不安？对你来说意味着什么？”这些问题促使来访反思自己的感受和想法，直到触及到他们最根本的恐惧。这种技术不仅有助于识别核心恐惧，还能增强来访对自己情感反应的理解。

• 核心恐惧：在Josh的案例中，他的核心恐惧是担心自己成为一名不合格的父亲。这种恐惧可能源于过去的经历或者内心的自我评价。通过“向下箭头法”，Josh能够认识到这种恐惧的存在，并开始探讨如何应对。
• 沟通技巧：治疗师在使用“向下箭头法”时需要保持耐心和同理心，确保来访感到被支持而非被质问。此外，治疗师应该清楚地解释这种方法的目的，以便来访能够更好地参与其中。

安全策略与防御行为

安全策略是指来访用来保护自己免受威胁或痛苦的一系列行为。这些策略通常是基于回避，旨在减少与潜在威胁的接触。然而，这些策略往往会导致生活质量下降，因为它们限制了个人的成长和发展。

• 识别安全策略：治疗师需要敏锐地观察来访的言行，以识别出这些安全策略。通过了解来访的背景和经历，治疗师可以更准确地判断哪些行为是为了应对威胁。
• 替代策略：一旦识别出安全策略，治疗师就可以与来访一起工作，开发更健康、更具建设性的应对机制。这包括培养积极的思维模式、学习新的应对技能，以及建立支持系统等。
• 同情与理解：对于来访来说，了解到自己的行为虽然是出于保护自己，但并不总是最有效的解决办法，这是重要的第一步。治疗师应通过同情和理解的态度，帮助来访逐渐接受并改变这些行为。
• 长期效果：虽然安全策略短期内可能有效，但从长远来看，它们往往会阻碍个人的心理成长和社会功能。因此，帮助来访认识到这一点，并鼓励他们采取更积极的行动，是治疗过程中的重要环节。

进一步阐述的知识点

意外后果

• 安全策略的影响：安全策略虽旨在减轻短期痛苦，但长期来看，它们往往会带来负面后果，如社交焦虑者因回避社交而错失机会，或Jenny因害怕被拒绝而避免真诚交流。
• 苏格拉底式对话的作用：通过苏格拉底式对话，治疗师可以帮助来访深入探讨他们的安全策略，理解这些策略如何源于他们的背景和核心恐惧，并识别这些策略如何导致不良后果。
• 具体案例分析：Josh的案例展示了他在愤怒后的责备行为如何导致家庭成员的疏远，进而强化了他的负面自我形象。这种行为模式形成了一个恶性循环，使他难以摆脱困境。

与自我和他人的关系

• 情感体验的重要性：CFT案例构建强调来访的情感体验，这些体验影响了他们对自己和他人的看法。例如，回避社交的来访可能会逐渐形成自我贬低的认知，认为自己不受欢迎。
• 替代策略的开发：通过理解安全策略的负面影响，治疗师可以帮助来访开发更健康、更有建设性的应对机制。这包括培养积极的思维方式、学习新的应对技能，以及建立支持系统。
• 同情与理解：治疗过程中，同情和理解的态度对于帮助来访接受并改变他们的行为至关重要。通过同情，来访可以更好地理解自己的行为模式，并逐步采取更积极的行动。
• 长期效果：虽然安全策略短期内可能有效，但从长远来看，它们往往会阻碍个人的心理成长和社会功能。因此，帮助来访认识到这一点，并鼓励他们采取更积极的行动，是治疗过程中的重要环节。

这段内容详细介绍了安全策略可能产生的意外后果及其对来访心理健康的影响。它强调了使用苏格拉底式对话来帮助来访理解和改变这些策略的重要性。此外，还讨论了这些策略如何影响来访与自我和他人的关系，并提出了如何通过同情和有效的应对策略来打破这些消极模式的方法。

知识点阐述

CFT案例构建的关键要素

同情聚焦治疗（Compassion-Focused Therapy, CFT）是一种心理治疗方法，旨在通过培养同情心来帮助个体应对负面情绪和心理问题。CFT中的案例构建是一个系统化的框架，用于理解来访的问题根源、维持因素以及治疗方向。以下是CFT案例构建的一些关键知识点：

1. 综合理解

• 历史与现状：案例构建需要全面考虑来访的历史经历和当前状况，包括生物、心理和社会因素。
• 情感记忆：特别关注那些深刻影响来访自我感知和人际交往模式的情感记忆，如关爱、威胁、忽视、虐待等。

2. 核心恐惧与威胁

• 内部威胁：源自内心的恐惧，如害怕失去控制、觉得自己有缺陷或不可爱，或是被负面情绪压倒。
• 外部威胁：来自外界环境的威胁，如被拒绝、剥削或伤害。

3. 安全策略与防御行为

• 安全策略：来访为了应对威胁而采取的行为，可能是适应性的，但也可能带来意外的负面影响。
• 防御行为：来访为了保护自己免受威胁而形成的特定行为模式，这些行为可能在短期内有效，但长期来看可能不利于心理健康。

4. 人际关系

• 自我与他人：来访如何与自己和他人建立关系，包括自我评价和他人评价。
• 同情与理解：通过同情和理解，帮助来访更好地接纳自己，改善人际关系。

5. 治疗建议

• 苏格拉底式对话：通过提问和讨论帮助来访同情地理解自己的问题。
• 正念训练：帮助来访识别和管理情绪和思维。
• 自我安抚技巧：如舒缓节奏呼吸、安全地点想象和写同情信，帮助来访在压力情境下自我安抚。
• 同情自我工作：发展特定技能，如心理化和共情，促进健康的自我对话和人际交往。

通过这些步骤，CFT案例构建不仅帮助治疗师深入了解来访的情况，还促进了来访对自己经历的同情理解，从而促进心理健康和个人成长。这种方法强调了同情心在治疗过程中的重要性，帮助来访以更积极的态度面对挑战，提高生活质量。

C H A P T E R 13 Compassionate Integration: Case Formulation in CFT A number of therapies use case formulation as a framework for developing an organized under- standing of problem origins, maintaining factors, and treatment interventions that is centered on the individual client (Eells, 2010). Particularly for complex cases, a case formulation gives clinicians a way to organize all the information that clients are giving them in a way that sets the stage for theory-­based intervention. In this chapter, we’ll explore case formulation in CFT.

KEY COMPONENTS OF A CFT CASE FORMULATION The focus of case conceptualization and formulation in CFT can be thought of as “unpacking” the threat response, so we can understand how historical and current factors have triggered threat experiences in our clients that have shaped their behavioral responding (and over time, their life- styles), as well as how they relate to themselves and others. Case formulation in CFT parallels our focus on depathologizing client difficulties, in that it helps us understand their challenges in a developmental context in which they make sense. Gilbert (2010, 69) describes CFT case formula- tion as developing an understanding of innate and historical influences that give rise to key external and internal threats and fears that give rise to externally and internally focused safety strategies that produce problematic unintended consequences, which impact self-­to-­self and self-­to-­other relating, which themselves shape ongoing safety strategies. The CFT case formulation worksheet below depicts these elements in relation- ship to one another. (This worksheet is also available for download at http://www.newharbinger .com/33094.) Let’s briefly explore each component of the formulation.172 Internal: Self as: Internal: External: Safety Strategies/ Defensive Behaviors Relating Self-to-Other: Self-to-Self: Internal: This worksheet was developed for the book CFT Made Simple, by Russell Kolts, based upon work by Paul Gilbert and the Compassionate Mind Foundation (http://www.compassionatemind.co.uk). Permission is granted for the free reproduction and dissemination of this form for clinical or training purposes. Others as: External: Key Fears Emotional/Shame Memories: Innate and Historical Influences External: Unintended Consequences CFT CASE FORMULATION WORKSHEET

Innate and Historical Influences As we’ve discussed in previous chapters, a compassionate understanding of our client’s prob- lems and behaviors is based on understanding how these challenges make sense within the context of the various biological and social influences that have shaped the client’s life. In this section of the formulation, we’ll draw upon client memories of significant life events, as well as early attachment experiences and learning history, which we discussed in chapter 6. Emphasis is given to emotional memories of care, threat, neglect, abuse, aloneness, shame, and any other experiences that may have powerfully shaped how the client experiences herself and others (Gilbert, 2010). As you might imagine, this history-­taking takes place over time, as relational safeness is established within the therapeutic relationship. With each revelation, we have the opportunity to model compassion, and to help the client learn to relate to her own experiences with compassion, validation, and under- standing of how these experiences shaped her life in ongoing ways.

This exploration can help us understand how clients learned to relate to themselves (as compe- tent, vulnerable, flawed, worthy or unworthy of love and care, and so on) and to others (as safe, dangerous, trustworthy or not). Cognitive therapists and schema therapists might call these basic ideas self-­schemas (or other-­schemas), while attachment-­oriented therapists might refer to them as internal working models. In CFT, we emphasize the relationship of these core self-­and other-­ representations to emotional memories of interactions with others, and the felt-­sense that they can engender—­playing out in terms of powerful emotional and bodily reactions that clients may strug- gle to understand or verbalize (Gilbert, 2010). We can also consider how such experiences shape our clients’ experience of the three circles—­relating to themselves and the world in ways that are defined by patterns of threat, drive, and safeness—­and whether they will tend to become rigidly stuck within experiences of threat or drive, or are able to fluidly shift among emotions, motives, and perspectives in response to different situations.

Key Fears In a CFT case formulation, these historical influences can then give rise to key fears, core threats, and unmet needs. These fears often originate in childhood and organize themselves around core themes such as abandonment, rejection, shame, and harm or abuse (Gilbert, 1989, 2010; Beck, Davis, & Freeman, 2014). In CFT, a distinction is made between external threats and internal threats (Gilbert, 2010). External threats are anchored in one’s experiences with others and the outside world, and include themes like rejection, exploitation, or being harmed by others. Internal threats can include things like fears of losing control, of being fundamentally flawed or unlovable, or of being overwhelmed by depression, anxiety, or anger. Identifying core threats can be useful in helping clients relate compassionately to their struggles, as they begin to understand relationships between their histories, their basic fears, and troubling experiences they have in the present.

THE DOWNWARD ARROW METHOD Given the sheer amount of material our clients may present to us, it can sometimes feel tricky to identify a client’s core fear schemas. A powerful, straightforward method for doing so is the downward arrow method, drawn from David Burns’s CBT work (Burns, 1980). In the downward arrow method, the clinician begins by identifying a troubling thought or situation that is bothering the client. Once the situation or thought is identified, the clinician responds with the questions (stated together in a single verbalization), “Why is that upsetting to you? What does it mean?” (The words “about you” can be inserted at the end of the second statement, if appropriate). After the client responds, the statements are repeated until the client and therapist find themselves at the core threat—­a moment often marked by a visible shift in the client’s nonverbal behavior, as the emo- tional reality of stating the core threat hits home. Rather than trying to vary the wording of the statements, it can be useful to let the client in on the technique, as demonstrated in the vignette below: Therapist: Josh, you were saying that you’ve been really upset lately about your son’s behavior in the classroom. Although his report card was good, it sounds like you have concerns about his behavior in class? Josh: Yeah, I’ve really been worked up about it. At our conference, the teacher said Aiden had been up out of his seat and was sometimes overly talkative, distracting other students. I’ve gotten really angry about it—­way beyond what was called for, because his grades are good. It just really bothers me. Therapist: Let’s see if we can get to the bottom of this. A lot of times, there are core fears lying underneath troubling thoughts and situations that really bother us. I’d like to try a technique called the downward arrow. What we’re going to do is that I’m going to ask you about this situation, and then repeat a couple of questions to you over and over when you respond. Don’t be annoyed by that—­these questions will lead us right to your core fear. Does that sound all right? Josh: Why not? Therapist: Good. You mentioned getting really upset about Aiden’s behavior in class. Why is that upsetting to you? What does it mean? Josh: Well, it’s a problem. I mean, the teacher identified him as sometimes being disruptive. Therapist: So she mentioned he’s sometimes disruptive. Why is that upsetting? What does it mean? Josh: 174 Well, in every class, there are a few “problem kids,” you know. I’m worried that Aiden will be labeled as one of the problem kids in his class. Therapist: Why is that upsetting? What does it mean? Josh: You know what people do with those kids. They blame the parents. They always blame the parents. Therapist: Why is that upsetting? What does it mean? Josh: It means that the teacher or the other parents might think that I’m a bad father. Therapist: So they might think that you’re a bad father. Why is that upsetting? What does that mean? Josh: (Pauses; looks down.) Maybe I am a bad father. Therapist: (Pauses.) Do you think that might be your core fear? That you might be a bad father? Josh: (Looks pensive; slowly nods.) Yeah. I think that’s it. I’ve been worried about that since before Aiden was born. We see above that Josh’s core fear relates to an internal threat—­that there is something about him that guarantees he will fail as a father. Depending on their backgrounds, clients may also have core fears related to both external and internal threats. Jenny, for example, presents with the exter- nal fear that others ultimately will reject her no matter what she does, and a related internal fear—­ that perhaps there is something wrong with her that prompts such rejection. Understanding these core fears can often provide a compassionate context for understanding the development of “mal- adaptive” coping on the part of the client.

Safety Strategies and Defensive Behaviors Core fears can create great distress in our clients, and many of their problems will be rooted in attempts to avoid this distress. In CFT, these are called safety strategies—­defensive behaviors designed to minimize threat-­related distress. Often rooted in avoidance, these strategies are at work in many of our clients—­the PTSD patient who avoids situations that remind him of the trauma, and drinks to cope with memories of it; the depressed or panic-­disordered patient who doesn’t leave the house; the angry client who blames everyone else for her outbursts; the acutely distressed teen who cuts his arm to cope with powerful emotions. As we use Socratic dialogue to explore our clients’ presenting problems, examples of such safety strategies will often become apparent. The key to recognizing safety strategies—­whether they are acute coping behaviors or long- standing lifestyle choices—­is that they tend to be threat-­based, and often involve avoidance. Such strategies are focused on minimizing contact with threatening situations, thoughts, memories, and experience—­not on building the sort of lives that clients want to have. Compassion comes from understanding these behaviors in context. As nonsensical or even harmful as they may seem in isolation, in the context of the client’s core threats and historical background, we see that they make complete sense. The client is doing whatever he can to cope with the threat, often using strategies that were overtly or covertly taught to him in ways we’ve discussed. However, as you might imagine, such defensive strategies often have unintended and undesirable consequences—­ which leads us to the next step of the formulation.

Unintended Consequences Safety strategies very frequently have unintended and maladaptive consequences which can serve to maintain the client’s problems, make them worse, or create other difficulties (Gilbert, 2010; Salkovskis, 1996). They often involve avoidance, as the client tries to limit contact with aver- sive emotional experiences, thoughts (as in the case of compulsions in OCD), and situations. These unintended consequences can be crippling, as we see in the socially anxious client who avoids social situations and misses out on potentially important life opportunities in order to avoid the anxiety caused by such situations. Clients like Jenny who fear rejection may avoid emotionally honest conversation out of fears of being judged (Gilbert, 2010). These consequences can also be overtly harmful to the client or other people, as we see in those who struggle with self-­harm and substance abuse to cope with emotional distress, or who engage in aggression to create feelings of social dominance to ward off feelings of vulnerability. Socratic dialogue can be used to assist clients in compassionately exploring both how their safety strategies relate to their backgrounds and core fears, and how these strategies produce unde- sirable consequences in their own lives. As we’ve seen in previous vignettes, Jenny has been able to observe that her strategies of avoiding and withdrawing from social situations made sense in light of the traumatic rejection experiences she had when she was younger. At the same time, her strate- gies prevent her from having the potentially nurturing social contacts that she ultimately desires (and which would help her learn to feel safe in relation to others). Josh presents with a more nuanced safety strategy—­his tendency to blame his wife and child for “making me angry” after an outburst. While space precludes including the interchange here, through Socratic dialogue, Josh could be helped to recognize that almost immediately following his anger outbursts, there is a powerful rush of emotional pain and shame (likely related to activation of his core fears of being a bad father and husband). Questions might include: “How do these situ- ations usually play out?” “What does it feel like to see that your wife or son has been hurt by some- thing you’ve said?” and “What happens next?” To escape this pain, Josh would move almost immediately to blaming his family—­relieving himself of the responsibility of how he had treated them. As we can imagine, this behavior creates more problems for Josh, as his family responds to his volatility and blaming by distancing from him and “walking on eggshells” when he is near. Josh then observes this pulling back, reinforcing his sense of himself as a flawed parent and partner. The unintended consequences of these threat-­based safety strategies can continually shape patterns of self-­to-­self and self-­to-­other relating that keep clients stuck in their threat circles. While they play out scripts that ever more deeply entrench them in shame-­based self-­schemas, those scripts prevent them from engaging in nurturing connections with others.

Relating to Self and Others In the final component of a CFT case formulation, we consider how the unintended conse- quences described above can shape and reinforce how our clients experience and relate to them- selves and to others. There’s nothing cold or formulaic about CFT case formulation—­at each stage, we’re linking back to the core affective experiences of the client. These affective experiences are particularly important in terms of how clients’ implicit feelings about themselves and others are shaped over time by the elaboration and consequences of safety strategies. Avoiding others out of fear of rejection produces distance and the withering of social contacts, reinforcing our clients’ self-­perceptions of being unlikeable and of others as cold and rejecting. Substance abuse to cope with traumatic memories can lead to relationship problems and decreased effectiveness, shaping and reinforcing a shame-­based view of themselves as broken and incompetent. As clients observe (or simply feel) the consequences of their safety strategies, their experience of themselves and others can be elaborated in ways that seem overwhelming and inescapable. Like core fears, these patterns of relating to self and others (and related distress) can lead to the development of more safety strategies that produce even more problematic unintended conse- quences. Over time, clients can find themselves feeling trapped in a cycle in which everything they try—­each effort making complete sense in light of the preceding experiences—­seems to deepen their problems. By exploring the linkages between the different components of the formulation, we can help our clients compassionately understand the factors that maintain their “stuckness.” Having developed that understanding, we can then work collaboratively to help them replace safety strate- gies with effective, compassionate coping and relating that will yield positive consequences in their lives and build positive self-­experiences of being compassionate and competent. Let’s look at a completed case formulation worksheet for Josh. Others as: Rejecting, inconsistent, responding to anger by leaving him alone Self as: Unlovable, unacceptable Emotional/Shame Memories: Insecure-Ambivalent Attachment – abusive father, distant mother. Bullied by peers in elementary school. Few friends in high school, frustrating dating history. Innate and Historical Influences Internal: Unlovable, incompetent— “I’m a bad father.” “I’m a bad husband.” External: Abandonment and rejection– “They will leave me. No one will want me.” Key Fears Internal: Rationalizing anger behavior Ruminating—“I can go it alone.” “I don’t need anyone.” “It’s their fault.” External: “Be strong and in control.” “Push others away before they can hurt me.” Demand caring and affection. Blame others for outbursts. Safety Strategies/ Defensive Behaviors Self-to-Other: • Others as rejecting, uncaring, unwilling to meet his needs, unable to handle him Self-to-Self: • “Out of control” • “Bad father, husband” • “Something wrong with me,” incapable of relationships Relating Internal: • Feelings of isolation • Continued anger, behaviors External: • Wife, child distant, “walking on eggshells” • Strained relationships with co-workers • Low empathy toward others Unintended Consequences CFT CASE FORMULATION WORKSHEET: JOSH A good case formulation frequently leads us straight into treatment planning. Considering the formulation above, we can consider that Josh would likely benefit from Socratic dialogue to help him compassionately understand how his anger and problems make sense in the context of his temperament and social shaping. Mindfulness training would help him learn to recognize the arising of anger and irritability as well as thoughts of rejection, unlovability, and negative ruminations about himself and others. Strategies such as soothing rhythm breathing, safe place imagery, and compassionate letter-­w riting would help him soothe himself in such situations, enabling him to shift into a more compassionate perspective and avoid his previous cycle of outbursts, blaming, and self-­ shaming. Josh would also likely benefit from compassionate self work, which emphasizes the devel- opment of specific skills such as mentalizing and empathy for others and himself. This work would be aimed at developing compassionate self-­talk and adaptive ways of relating to his family and coworkers, such as assertiveness training.

SUMMARY Some of our clients will present with a dizzying array of challenges that can make it difficult to know where to begin treatment. Case formulation helps to organize our observations about clients and to plan effective treatment strategies. As you might imagine, the process of developing a for- mulation and exploring it with the client can be an emotional one. It can be heartbreaking for clients to realize how their lives have been shaped in ways that have created terrible suffering for them over time—­suffering that may have been exacerbated by their own attempts to cope. In CFT, this process is continuously rooted in compassionate understanding and in connecting our explora- tion to the client’s affective experience. In the next chapter, we’ll explore a powerful way of helping clients explore their emotions through the process of chair work (introduced in the previous chapter): the Multiple Selves exercise.