DialecticalBehaviourTherapy

inPerthNorthMetroArea

MargaretCole11thJuly2006第一頁，共三十三頁。編輯課件

GoalToBuildALifeWorthLiving第二頁，共三十三頁。編輯課件Steps1.ClearStructure2.DoBehaviourTherapy3.AddValidation4.AddDialectics5.AddMindfulness第三頁，共三十三頁。編輯課件1.ClearStructure第四頁，共三十三頁。編輯課件AssumptionsAboutClients&Therapy1.Clientsaredoingthebesttheycan2.Clientswanttoimprove3.Clientsneedtodobetter,tryharderandbemoremotivatedtochange4.Clientsmaynothavecausedalloftheirownproblemsbuttheyhavetosolvethemanyway5.Thelivesofsuicidalborderlineindividualsareunbearableastheyarecurrentlybeinglived6.Clientsmustlearnnewbehavioursinallrelevantcontexts7.Clientscannotfailintherapy8.Therapiststreatingborderlineclientsneedsupport

第五頁，共三十三頁。編輯課件AssumptionsaboutTherapy&Therapists1.Themostcaringthingatherapistcandoishelpclientschangeinwaysthatbringthemclosertotheirultimategoals(unwaveringcentredness)2.Clarity,precisionandcompassionareoftheutmostimportanceintheconductofDBT3.Thetherapeuticrelationshipisarealrelationshipbetweenequals(therearedifferencesinexpertisebutnoarbitrarypowerdifferential)4.Principlesofbehaviourareuniversal,affectingtherapistsnolessthanclients5.DBTtherapistscanfail6.DBTtherapycanfailevenwhentherapistsdonot7.Therapiststreatingborderlineclientsneedsupport第六頁，共三十三頁。編輯課件Agreements

TherapistAgreementsEVERYREASONABLEEFFORTAGREEMENTETHICSAGREEMENTPERSONALCONTACTAGREEMENTCONSULTATIONAGREEMENT第七頁，共三十三頁。編輯課件TherapistConsultationAgreementsDIALECTICALAGREEMENTCONSULTATIONTOTHECLIENTAGREEMENTCONSISTENCYAGREEMENTOBSERVINGLIMITSPHENOMENOLOGICALEMPATHYAGREEMENTFALLIBILITYAGREEMENT第八頁，共三十三頁。編輯課件ClientAgreementsONEYEARTHERAPYAGREEMENTATTENDANCEAGREEMENTSUICIDALBEHAVIOURSAGREEMENTTHERAPY-INTERFERINGBEHAVIOURSAGREEMENTSKILLSTRAININGAGREEMENTRESEARCHANDPAYMENTAGREEMENT

第九頁，共三十三頁。編輯課件2.DoBehaviourTherapy第十頁，共三十三頁。編輯課件Theconsequencesofabehaviouraffecttheprobabilityofthebehaviour’soccurringagain.Everytherapistresponseexperiencedbytheclientcanbeneutral,punishingorreinforcing,thuseverycontingentresponseisaninformalcontingencyprocedure.第十一頁，共三十三頁。編輯課件BehaviouralAssessmentThereisnosubstituteforgoodbehaviouralanalysistodeterminewhatispromptingandmaintainingmaladaptivebehaviourChainAnalysis第十二頁，共三十三頁。編輯課件AssessNecessaryIntervention1.Arethebehavioursinthepersonsbehaviouralrepertoire? No–BehaviouralSkillsTraining2.Areineffectivebehavioursbeingreinforced? Yes–ContingencyManagement

3.Areeffectivebehavioursinhibitedbyunwarrantedfearsorguilt?Isthepersonemotionphobic? Yes–Exposure4.Areeffectivebehavioursinhibitedbyfaultybeliefsandassumptions? Yes–CognitiveModification第十三頁，共三十三頁。編輯課件3.AddValidation

第十四頁，共三十三頁。編輯課件LevelsofValidation1.Stayingawake–unbiasedlisteningandobserving2.Accuratereflection–summarising3.Articulatetheunverbalisedemotions,thoughtsorbehaviourpatterns–takeaslightleapandreadbeyondwhatthey’vesaid,maybesafertousea“multiple-choiceapproach”4.Validationintermsofpastlearningorbiologicaldysfunction5.Validationintermsofpresentcontextornormativefunctioning6.Radicalgenuineness–beingyourselfwiththeclientasyouarewithothers,sametoneofvoice,samelanguage,notsteppingintoarole第十五頁，共三十三頁。編輯課件4.AddDialectics第十六頁，共三十三頁。編輯課件Dialectics1-AWorldView1.ThePrincipleofInterrelatednessandWholeness

Systemsperspectiveonreality(identityisrelational)2.ThePrincipleofPolarity

Realityisnotstaticbutiscomprisedoninternalopposingforcesoutofwhichsynthesisisachieved.

“Contradictorytruthsdonotnecessarilycanceleachotheroutordominateeachother,butstandsidebyside,invitingparticipationandexperimentation”Goldberg(1980)

3.ThePrincipleofContinuousChange

Change,orprocess,ratherthanstructureorcontent,istheessentialnatureoflife.

Roleofconflictandoppositioninthechangeprocess.

第十七頁，共三十三頁。編輯課件Dialectics2

Dialogue&RelationshipAboutbalancingwiththeclient–see-sawexampleChangebypersuasionPersonalaccountofevents,exposingcontradictorypositionsThespiritofadialecticalpointofviewisnevertoacceptafinaltruthorindisputablefact.Thinking“whatisbeingleftoutofourunderstanding?”(Toavoidsplitting,whichalmostalwaysresultsfromaclinicianassumingthatthey,andsometimestheyalone,have“thetruth”aboutaclientorclinicalproblem)第十八頁，共三十三頁。編輯課件ActivePassivity VS ApparentCompetencePassive,helplessproblemsolvingTriestogetotherstohelpEmotionfocusedcopingSometimesappearcompetentAbletocopeinsomesituationsCopingfollowedbycrisisDifficultygeneralisingDilemma:NeedshelpbutfeelsshameforaskingIsitlackofmotivationorlackofskills?TherapisttoodemandingvstoorescuingDialecticalDilemma’sPosedbyBorderlineClients第十九頁，共三十三頁。編輯課件DialecticalTherapistCharacteristicsFindingabalancebetweenapparentlyopposingstancesOrientedtoChange VS OrientedtoAcceptanceNecessityofchangeClientswishtochangePrinciplesofBehaviourChangeAcceptanceexactlyinthismomentAsthingsarerightnowInherentwisdomand“goodness”ofcurrentmoment第二十頁，共三十三頁。編輯課件“Mistakesareinevitable;whatthetherapistdoesafterwardsisabetterindexofgoodtherapy”

Linehan第二十一頁，共三十三頁。編輯課件DialecticalTherapistTechniquesFindingabalancebetweenapparentlyopposingstancesValidation VS ProblemSolvingActiveobservingReflectionSearchforvalidityActiveapproachBehaviouralfocus第二十二頁，共三十三頁。編輯課件DialecticalBehaviourPatterns:

BalancedLifestyleWalkingthemiddlepaththroughthefollowingareasSkillenhancement VS Self-acceptanceProblemsolving VS ProblemacceptanceAffectregulation VS AffecttoleranceSelf-efficacy VS HelpseekingIndependence VS DependenceTransparency VS Privacy第二十三頁，共三十三頁。編輯課件5.AddMindfulness第二十四頁，共三十三頁。編輯課件GeneralGoalofSkillsTrainingTolearnandrefineskillsinchangingbehavioural,emotionalandthinkingpatternsassociatedwithproblemsinliving,thatis,thosecausingmiseryanddistress.第二十五頁，共三十三頁。編輯課件GeneralPointsShotgunapproach–someoftheskillswillworkforsomeofthepeoplesomeofthetimeThepartsoftheskillsarerarelynew,butthecombinationoftenisClientsneedtobeconvincedthatwhatthey’relearningisgoingtobeuseful,relevanttothem(‘marketing’theskills)Clientswilloftenhaveattendedothergroups,needtodiscusshowthismightbedifferent(e.g.notprocessoriented)Emphasizegoaloflong-termreliefvs.immediatereliefEmphasizeneedforpractice,practice,practice第二十六頁，共三十三頁。編輯課件TheSkillsCoremindfulnessInterpersonaleffectivenessEmotionregulationDistresstolerance第二十七頁，共三十三頁。編輯課件Mindfulness“bringinganunshakeablefriendlinessanddeepdegreeofcuriosityandinteresttowhatishappeninginandaroundyou…anddoingthisagainandagainandacclimatisingtothiswayofbeing”TarchinHearn“Mindfulnessintotalityhastodowiththequalityofawarenessthatapersonbringstoactivities”MarshaLinehan第二十八頁，共三十三頁。編輯課件InterpersonalEffectiveness

Asking&SayingNoObjectivesEffectiveness

HowtogetwhatyouwantRelationshipEffectiveness

Howtomaintainther