DialecticalBehaviourTherapy：辯證行為療法

1、Dialectical Behaviour Therapyin Perth North Metro AreaMargaret Cole11th July 2006第一頁，共三十三頁。GoalTo Build A Life Worth Living第二頁，共三十三頁。Steps1. Clear Structure2. Do Behaviour Therapy3. Add Validation4. Add Dialectics5. Add Mindfulness第三頁，共三十三頁。1. Clear Structure第四頁，共三十三頁。Assumptions About Clients & The

2、rapy1. 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 are unbearable as the

3、y are currently being lived6. Clients must learn new behaviours in all relevant contexts7. Clients cannot fail in therapy8. Therapists treating borderline clients need support第五頁，共三十三頁。Assumptions about Therapy & Therapists1. The most caring thing a therapist can do is help clients change in ways th

4、at 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 arbitrary power differential)4.

5、 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 support第六頁，共三十三頁。AgreementsTherapist AgreementsEVERY REASONABLE EFFORT AGREEMENTETHICS AGREEMEN

6、TPERSONAL CONTACT AGREEMENTCONSULTATION AGREEMENT第七頁，共三十三頁。Therapist Consultation AgreementsDIALECTICAL AGREEMENTCONSULTATION TO THE CLIENT AGREEMENTCONSISTENCY AGREEMENTOBSERVING LIMITSPHENOMENOLOGICAL EMPATHY AGREEMENTFALLIBILITY AGREEMENT第八頁，共三十三頁。Client AgreementsONE YEAR THERAPY AGREEMENTATTEND

7、ANCE AGREEMENTSUICIDAL BEHAVIOURS AGREEMENTTHERAPY-INTERFERING BEHAVIOURS AGREEMENTSKILLS TRAINING AGREEMENTRESEARCH AND PAYMENT AGREEMENT 第九頁，共三十三頁。2. Do Behaviour Therapy第十頁，共三十三頁。The consequences of a behaviour affect the probability of the behaviours occurring again.Every therapist response expe

8、rienced by the client can be neutral, punishing or reinforcing, thus every contingent response is an informal contingency procedure.第十一頁，共三十三頁。Behavioural Assessment There is no substitute for good behavioural analysis to determine what is prompting and maintaining maladaptive behaviour Chain Analys

9、is 第十二頁，共三十三頁。Assess 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 inhibited by unwarranted fears or guilt? Is the person emotion ph

10、obic?Yes Exposure4. Are effective behaviours inhibited by faulty beliefs and assumptions?Yes Cognitive Modification 第十三頁，共三十三頁。3. Add Validation第十四頁，共三十三頁。Levels of Validation1. Staying awake unbiased listening and observing2. Accurate reflection summarising3. Articulate the unverbalised emotions, t

11、houghts or behaviour patterns take a slight leap and read beyond what theyve said, may be safer to use a “multiple-choice approach4. Validation in terms of past learning or biological dysfunction5. Validation in terms of present context or normative functioning6. Radical genuineness being yourself w

12、ith the client as you are with others, same tone of voice, same language, not stepping into a role第十五頁，共三十三頁。4. Add Dialectics第十六頁，共三十三頁。Dialectics 1 - A World View1. The Principle of Interrelatedness and WholenessSystems perspective on reality (identity is relational)2. The Principle of PolarityRea

13、lity 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 participation and experimentation Goldberg (1980)3. The Principle of Continuous C

14、hangeChange, or process, rather than structure or content, is the essential nature of life.Role of conflict and opposition in the change process.第十七頁，共三十三頁。Dialectics 2Dialogue & RelationshipAbout balancing with the client see-saw exampleChange by persuasionPersonal account of events, exposing contr

15、adictory 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 results from a clinician assuming that they, and sometimes they alone, have “the truth abou

16、t a client or clinical problem)第十八頁，共三十三頁。Active PassivityVSApparent CompetencePassive, helpless problem solvingTries to get others to helpEmotion focused copingSome times appear competentAble to cope in some situationsCoping followed by crisisDifficulty generalisingDilemma:Needs help but feels sham

17、e for askingIs it lack of motivation or lack of skills?Therapist too demanding vs too rescuingDialectical Dilemmas Posed by Borderline Clients第十九頁，共三十三頁。Dialectical Therapist CharacteristicsFinding a balance between apparently opposing stancesOriented to Change VS Oriented to AcceptanceNecessity of

18、changeClients wish to changePrinciples of Behaviour ChangeAcceptance exactly in this momentAs things are right nowInherent wisdom and “goodness of current moment第二十頁，共三十三頁?！癕istakes are inevitable; what the therapist does afterwards is a better index of good therapyLinehan第二十一頁，共三十三頁。Dialectical The

19、rapist TechniquesFinding a balance between apparently opposing stancesValidation VS Problem SolvingActive observingReflectionSearch for validityActive approachBehavioural focus第二十二頁，共三十三頁。Dialectical Behaviour Patterns: Balanced LifestyleWalking the middle path through the following areasSkill enhan

20、cement VSSelf-acceptanceProblem solvingVS Problem acceptanceAffect regulationVS Affect toleranceSelf-efficacyVS Help seekingIndependenceVS DependenceTransparencyVS Privacy第二十三頁，共三十三頁。5. Add Mindfulness第二十四頁，共三十三頁。General Goal of Skills TrainingTo learn and refine skills in changingbehavioural, emoti

21、onal and thinkingpatterns associated with problemsin living, that is, thosecausing misery anddistress.第二十五頁，共三十三頁。General PointsShot gun approach some of the skills will work for some of the people some of the timeThe parts of the skills are rarely new, but the combination often isClients need to be

22、 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 might be different (e.g. not process oriented)Emphasize goal of long-term relief vs. immediate reliefEmphasize need for practice,

23、 practice, practice第二十六頁，共三十三頁。The SkillsCore mindfulnessInterpersonal effectivenessEmotion regulationDistress tolerance第二十七頁，共三十三頁。Mindfulness“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 beingTarchin Hearn“Mindfulness in totality has to do with the quality of awareness that a person brings to activities Marsha Linehan第二十八頁，共三十三頁。Interpersonal EffectivenessAsking & Saying NoObjectives EffectivenessHow to get what you wantRelationship Eff