第十三章 同理整合：在CFT中构建案例模型
170C 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 CFT Made SimpleCompassionate Integration: Case Formulation in CFT 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. 173CFT Made Simple 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.Compassionate Integration: Case Formulation in CFT 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 175CFT Made Simple 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 176Compassionate Integration: Case Formulation in CFT 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. 177178 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 CFT Made SimpleCompassionate Integration: Case Formulation in CFT 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.