DialecticalBehaviourTherapy：辩证行为疗法.ppt

Dialectical Behaviour Therapy in Perth North Metro Area Margaret Cole 11th July 2006 Goal To Build A Life Worth Living Steps 1.Clear Structure 2.Do Behaviour Therapy 3.Add Validation 4.Add Dialectics 5.Add Mindfulness 1.Clear Structure Assumptions About Clients&Therapy 1.Clients are doing the best they can 2.Clients want to improve 3.Clients need to do better,try harder and be more motivated to change 4.Clients may not have caused all of their own problems but they have to solve them anyway 5.The lives of suicidal borderline individuals are unbearable as they are currently being lived 6.Clients must learn new behaviours in all relevant contexts 7.Clients cannot fail in therapy 8.Therapists treating borderline clients need support Assumptions about Therapy&Therapists 1.The most caring thing a therapist can do is help 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 DBT 3.The therapeutic relationship is a real relationship between equals(there are differences in expertise but no arbitrary power differential)4.Principles of behaviour are universal,affecting therapists no less than clients 5.DBT therapists can fail 6.DBT therapy can fail even when therapists do not 7.Therapists treating borderline clients need support Agreements Therapist Agreements EVERY REASONABLE EFFORT AGREEMENT ETHICS AGREEMENT PERSONAL CONTACT AGREEMENT CONSULTATION AGREEMENT Therapist Consultation Agreements DIALECTICAL AGREEMENT CONSULTATION TO THE CLIENT AGREEMENT CONSISTENCY AGREEMENT OBSERVING LIMITS PHENOMENOLOGICAL EMPATHY AGREEMENT FALLIBILITY AGREEMENT Client Agreements ONE YEAR THERAPY AGREEMENT ATTENDANCE AGREEMENT SUICIDAL BEHAVIOURS AGREEMENT THERAPY-INTERFERING BEHAVIOURS AGREEMENT SKILLS TRAINING AGREEMENT RESEARCH AND PAYMENT AGREEMENT 2.Do Behaviour Therapy The consequences of a behaviour affect the probability of the behaviours occurring again.Every therapist response experienced by the client can be neutral,punishing or reinforcing,thus every contingent response is an informal contingency procedure.Behavioural Assessment There is no substitute for good behavioural analysis to determine what is prompting and maintaining maladaptive behaviour Chain Analysis Assess Necessary Intervention 1.Are the behaviours in the persons behavioural repertoire?No Behavioural Skills Training 2.Are ineffective behaviours being reinforced?Yes Contingency Management 3.Are effective behaviours inhibited by unwarranted fears or guilt?Is the person emotion phobic?Yes Exposure 4.Are effective behaviours inhibited by faulty beliefs and assumptions?Yes Cognitive Modification 3.Add Validation Levels of Validation 1.Staying awake unbiased listening and observing 2.Accurate reflection summarising 3.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 dysfunction 5.Validation in terms of present context or normative functioning 6.Radical genuineness being yourself with the client as you are with others,same tone of voice,same language,not stepping into a role 4.Add Dialectics Dialectics 1-A World View 1.The Principle of Interrelatedness and Wholeness Systems perspective on reality(identity is relational)2.The Principle of Polarity Reality 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 Change Change,or process,rather than structure or content,is the essential nature of life.Role of conflict and opposition in the change process.Dialectics 2 Dialogue&Relationship About balancing with the client see-saw example Change by persuasion Personal account of events,exposing contradictory positions The 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”about a client or clinical problem)Active Passivity VS Apparent Competence Passive,helpless problem solving Tries to get others to help Emotion focused coping Some times appear competent Able to cope in some situations Coping followed by crisis Difficulty generalising Dilemma:Needs help but feels shame for asking Is it lack of motivation or lack of skills?Therapist too demanding vs too rescuing Dialectical Dilemmas Posed by Borderline Clients Dialectical Therapist Characteristics Finding a balance between apparently opposing stances Oriented to Change VS Oriented to Acceptance Necessity of change Clients wish to change Principles of Behaviour Change Acceptance exactly in thi