齐鲁医学DialecticalBehaviourTherapy：辩证行为疗法

1、Dialectical Behaviour Therapyin Perth North Metro AreaMargaret Cole11th July 20062021/10/23 星期六1GoalTo Build A Life Worth Living2021/10/23 星期六2Steps1. Clear Structure2. Do Behaviour Therapy3. Add Validation4. Add Dialectics5. Add Mindfulness2021/10/23 星期六31. Clear Structure2021/10/23 星期六4Assumptions

2、 About Clients & Therapy1. Clients are doing the best they can2. Clients want to improve3. Clients need to do better, try harder and be more motivated to change4. Clients may not have caused all of their own problems but they have to solve them anyway5. The lives of suicidal borderline individuals a

3、re unbearable as they are currently being lived6. Clients must learn new behaviours in all relevant contexts7. Clients cannot fail in therapy8. Therapists treating borderline clients need support2021/10/23 星期六5Assumptions about Therapy & Therapists1. The most caring thing a therapist can do is help

4、clients change in ways that bring them closer to their ultimate goals (unwavering centredness)2. Clarity, precision and compassion are of the utmost importance in the conduct of DBT3. The therapeutic relationship is a real relationship between equals (there are differences in expertise but no arbitr

5、ary power differential)4. Principles of behaviour are universal, affecting therapists no less than clients5. DBT therapists can fail6. DBT therapy can fail even when therapists do not7. Therapists treating borderline clients need support2021/10/23 星期六6AgreementsTherapist AgreementsEVERY REASONABLE E

6、FFORT AGREEMENTETHICS AGREEMENTPERSONAL CONTACT AGREEMENTCONSULTATION AGREEMENT2021/10/23 星期六7Therapist Consultation AgreementsDIALECTICAL AGREEMENTCONSULTATION TO THE CLIENT AGREEMENTCONSISTENCY AGREEMENTOBSERVING LIMITSPHENOMENOLOGICAL EMPATHY AGREEMENTFALLIBILITY AGREEMENT2021/10/23 星期六8Client Ag

7、reementsONE YEAR THERAPY AGREEMENTATTENDANCE AGREEMENTSUICIDAL BEHAVIOURS AGREEMENTTHERAPY-INTERFERING BEHAVIOURS AGREEMENTSKILLS TRAINING AGREEMENTRESEARCH AND PAYMENT AGREEMENT 2021/10/23 星期六92. Do Behaviour Therapy2021/10/23 星期六10The consequences of a behaviour affect the probability of the behav

8、iours occurring again.Every therapist response experienced by the client can be neutral, punishing or reinforcing, thus every contingent response is an informal contingency procedure.2021/10/23 星期六11Behavioural Assessment There is no substitute for good behavioural analysis to determine what is prom

9、pting and maintaining maladaptive behaviour Chain Analysis 2021/10/23 星期六12Assess Necessary Intervention1. Are the behaviours in the persons behavioural repertoire? No Behavioural Skills Training2. Are ineffective behaviours being reinforced?Yes Contingency Management3. Are effective behaviours inhi

10、bited by unwarranted fears or guilt? Is the person emotion phobic?Yes Exposure4. Are effective behaviours inhibited by faulty beliefs and assumptions?Yes Cognitive Modification 2021/10/23 星期六133. Add Validation2021/10/23 星期六14Levels of Validation1. Staying awake unbiased listening and observing2. Ac

11、curate reflection summarising3. Articulate the unverbalised emotions, thoughts or behaviour patterns take a slight leap and read beyond what theyve said, may be safer to use a “multiple-choice approach”4. Validation in terms of past learning or biological dysfunction5. Validation in terms of present

12、 context or normative functioning6. Radical genuineness being yourself with the client as you are with others, same tone of voice, same language, not stepping into a role2021/10/23 星期六154. Add Dialectics2021/10/23 星期六16Dialectics 1 - A World View1. The Principle of Interrelatedness and WholenessSyst

13、ems perspective on reality (identity is relational)2. The Principle of PolarityReality is not static but is comprised on internal opposing forces out of which synthesis is achieved.“Contradictory truths do not necessarily cancel each other out or dominate each other, but stand side by side, inviting

14、 participation and experimentation” Goldberg (1980)3. The Principle of Continuous ChangeChange, or process, rather than structure or content, is the essential nature of life.Role of conflict and opposition in the change process.2021/10/23 星期六17Dialectics 2Dialogue & RelationshipAbout balancing with

15、the client see-saw exampleChange by persuasionPersonal account of events, exposing contradictory positionsThe spirit of a dialectical point of view is never to accept a final truth or indisputable fact.Thinking “what is being left out of our understanding?”(To avoid splitting, which almost always re

16、sults from a clinician assuming that they, and sometimes they alone, have “the truth” about a client or clinical problem)2021/10/23 星期六18Active PassivityVSApparent CompetencePassive, helpless problem solvingTries to get others to helpEmotion focused copingSome times appear competentAble to cope in s

17、ome situationsCoping followed by crisisDifficulty generalisingDilemma:Needs help but feels shame for askingIs it lack of motivation or lack of skills?Therapist too demanding vs too rescuingDialectical Dilemmas Posed by Borderline Clients2021/10/23 星期六19Dialectical Therapist CharacteristicsFinding a

18、balance between apparently opposing stancesOriented to Change VS Oriented to AcceptanceNecessity of changeClients wish to changePrinciples of Behaviour ChangeAcceptance exactly in this momentAs things are right nowInherent wisdom and “goodness” of current moment2021/10/23 星期六20“Mistakes are inevitab

19、le; what the therapist does afterwards is a better index of good therapy”Linehan2021/10/23 星期六21Dialectical Therapist TechniquesFinding a balance between apparently opposing stancesValidation VS Problem SolvingActive observingReflectionSearch for validityActive approachBehavioural focus2021/10/23 星期

20、六22Dialectical Behaviour Patterns: Balanced LifestyleWalking the middle path through the following areasSkill enhancement VSSelf-acceptanceProblem solvingVS Problem acceptanceAffect regulationVS Affect toleranceSelf-efficacyVS Help seekingIndependenceVS DependenceTransparencyVS Privacy2021/10/23 星期六

21、235. Add Mindfulness2021/10/23 星期六24General Goal of Skills TrainingTo learn and refine skills in changingbehavioural, emotional and thinkingpatterns associated with problemsin living, that is, thosecausing misery anddistress.2021/10/23 星期六25General PointsShot gun approach some of the skills will wor

22、k for some of the people some of the timeThe parts of the skills are rarely new, but the combination often isClients need to be convinced that what theyre learning is going to be useful, relevant to them (marketing the skills)Clients will often have attended other groups, need to discuss how this mi

23、ght be different (e.g. not process oriented)Emphasize goal of long-term relief vs. immediate reliefEmphasize need for practice, practice, practice2021/10/23 星期六26The SkillsCore mindfulnessInterpersonal effectivenessEmotion regulationDistress tolerance2021/10/23 星期六27Mindfulness“bringing an unshakeable friendliness and deep degree of curiosity and interest to what is happening in and around you and doing this again and again and acclimatising to this way of being”Tarchin Hearn“Mindfulness in totality has to do with the quality of awareness that a person br