Intro
Earlier in her teachings of DBT, Linehan described the cognitive-behavioral problem-solving strategies as the “bitter-tasting but effective pill,” and the validation strategies as the “sugar coating” that helped the pill go down.
To accept patients with compassion and to intervene with accuracy, therapists needed to develop their own heightened levels of acceptance and awareness. The cultivation of acceptance and awareness was grounded in the principles and practices of mindfulness.
& add to improvise with DBT's change, acceptance, and dialectical paradigms.
behaviorism, mindfulness, dialectical philosophy
THE CHALLENGES OF LEARNING TO PRACTICE DBT
DBT의 주요 범주를 기억하고 치료 시 그 중에서 세부적으로 취사선택함: Those interventions are grouped into a handful of overarching categories: assessment strategies, structural strategies, change procedures, acceptance strategies, and dialectical strategies. The therapist might say to himself, “I need to push for behavioral change,” and rapidly consider the options among the problem-solving procedures, accompanied by tonal choices from the change-oriented irreverent communication style. He can thereby keep his mind focused on the in-the-moment needs and choices, stay in contact with the destination and his imagination, quickly and fluidly locate the best strategic choice, and proceed.
원리에 기반한 패러다임 접근의 유연성에 대한 저자의 간증: I came to realize later that there had been three of us in the room: the patient, me, and the manual. Once I realized that I could group the myriad interventions into a few categories—assessment, change, acceptance, and dialectics—I could navigate through sessions with more intuition, speed, movement, and flow even as I remained focused on the current behavioral target, keeping track of the patient and remaining in touch with myself. I experienced greater freedom and greater confidence.
CASE EXAMPLE OF PRINCIPLE-BASED TREATMENT
reframing the nine diagnostic criteria as representing five categories of dysregulation (emotional, interpersonal, behavioral, cognitive, and self) that are addressed in four modules of skills training..
회기 주제를 정하지 않고 감정적으로 자기 할말만 하는 환자를 앞에 둔 치료자의 고심. 수용할 것인지 변화를 요구할 것인지. -> It felt to me as if asking for her diary card at that moment would be like asking a bleeding car accident victim in an emergency room for her insurance information. On the other hand, if I were to avoid asking, out of fear of her response, I might be treating her as if she were fragile, reinforcing a dysfunctional pattern of mood-dependent behavior. With a matter-of-fact tone and “acting opposite” my own urge to avoid asking for the diary card, I interrupted her, indicating that we could come back to the situation about the ex-boyfriend, and asked to see her diary card. With respect to the paradigms, I shifted from acceptance to change and began using problem-solving strategies.
변화를 택한 치료자에 대한 내담자의 싸늘한 반응에 치료자는 수용과 변화의 밸런스를 맞추고자 함. 그리고 치료자 내부에서 발생하는 직면과 사과/구원의 충동을 마음챙김함. -> I tried to remain alert to subtle changes in nonverbal communications, and tried to remain balanced. I noticed an urge to confront her, and an opposing urge to apologize to her and rescue her.
딜레마에 빠졌을 때 변증법적 행로 택함: It then occurred to me that perhaps what had happened between us was not new to her, but was something that interfered with her relationships in general. I said, “Tracy, I think I was a bit clumsy the way I interrupted you, but I just wonder if this happens to you sometimes, and I wonder if we can learn something from this, both of us, that will help us hang in there with each other?” Having recognized that we were stuck, wanting to maintain movement, trying to recognize the validity both in what I had done and in her response, I tried to make “lemonade out of lemons.”
모든 전략을 다 기억할 순 없다. 수용, 변화, 변증법이라는 패러다임을 알고 이 패러다임 안에서 치료의 방향을 정한다.
주의1: 변화나 변증법 패러다임 안에 있더라도 수용은 늘 함께 해야 한다.
주의2: DBT는 CBT의 일환이고 따라서 수용과 변증법에 비해 변화(goal-oriented paradigm)가 늘 우선이다.
1주차 피드백
수용, 변화, 변증법이라는 DBT의 큰 틀에서 치료 접근을 어떻게 하는지 저자가 직접 치료한 사례를 통해서 생생하게 보여주는 것이 흥미로웠습니다(2챕터). DBT의 기본은 CBT이기 때문에 체계화된 전략들을 가지고 있지만 CBT와의 차이는 보다 즉흥적이고 직관적인 요소들이 많이 들어가게 된다는 점 같습니다. 수용, 변화, 변증법의 타이밍을 결정하는 것은 교과서에서 배울 수 있는 것이 아니라는 생각도 들었고요.
BPD 치료를 미식축구에 비유하는 것도 흥미로웠습니다(1챕터). 치료자가 life-worth-living 편에 서되 suicide-and-death team의 wisdom도 볼 수 있어야 한다는 것이 특히 중요하다고 생각했어요. 저자가 리네한의 말을 직접 인용한 부분(They have to be able to “get into hell” with the patient and see what it looks and feels like, and to help the patient “find a way out of hell.”)을 보면 환자가 경험하는 지옥을 치료자도 같이 경험할 각오가 되어 있지 않고서는 BPD 치료에 뛰어들면 안 될 것 같기도 하고요. 역전이를 통해서 환자가 느끼는 고통을 대리적으로 느낄 수 있을 것이고, 이를 통해 자기파괴적으로 보이는 많은 행동들의 wisdom을 어느 정도는 이해할 수 있지 않을까 싶기도 합니다.
보다 나은 미래를 상상하고 그에 맞는 목표를 세울 수 있는 힘 자체가 환자에게 없거나 미약하고, 이를 촉진하려는 치료자의 시도에 회의나 분노로 반응할 수 있기 때문에 첫 회기에 이미 어느 정도 난관에 부딪히게 될 가능성을 염두에 두어야 할 것 같습니다. 저자가 이 부분을 잘 보여주고 있고, 특히 환자의 양가적 태도에 공감적으로 반응하면서 어떻게 난관을 통과하는지 보여주고 있으나 많이 어렵게 느껴집니다.
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