[3주차] DBT Principles in Action: CHAPTER 4. The Change Paradigm

Intro

change paradigm into a sequential problem-solving protocol, which is used again and again in sessions.

 

치료 타깃을 함께 결정했고, 치료 계획에 헌신하는 데 도움이 되는 환자의 강점을 확인했다면 그 다음에는 the therapist focuses the session on the highest-priority target, beginning with life-threatening behaviors.

 

targetting and monitoring / commitment / chain analysis and case conceptualization + 4 theories (include skills deficit theory)

 

1. behavioral chain analysis
2. 체인 안의 여러 링크 간의 공통점 파악하여 환자와 공유하고 가장 설득력 있는 가설 채택. This process is known as insight.
3. solution analysis
4. change procedures
   1. skills training procedures
   2. cognitive modification procedures
   3. contingency procedures: 조작적 조건형성에 기반. 적응적 행동을 강화하고 부적응적 행동을 소거
   4. stimulus control and exposure procedures: 고전적 조건형성 기반
5. 치료자 환자 각자 역할 명확히 하고, 과제 수행에 대한 환자의 전념을 강화하는 commitment strategies 실행

 

치료 상황에서 우발적 변수가 많기 때문에 skills/strategies를 overlearned하여 유연하게 대처할 수 있어야 함.

 

Keeping all seven in mind enhances our flexibility in staying connected to patients, oriented to the targets, and able to access problem-solving strategies promptly when indicated.

 

"BEING BEHAVIORAL" IN DBT

논문 출판의 어려움에 직면해 있던 상황에서 저자가 받은 행동치료 경험에 관한 서술

• For any cognitive-behavioral therapist, what he did was quite ordinary; for me it provided an “aha” moment regarding a problem-solving therapy. Still, it worried me. He might be too specific, too practical, too optimistic, and too naïve to do battle with the hidden forces that had blocked my progress up to that point.
• If we run into trouble, maybe some of those insights will come in handy. Another “aha” moment: Action first, insight would follow.
• 심리치료가 아니라 마치 골프를 배우는 것, 즉 코칭처럼 느껴져서 관둘까 생각함.
• In one session I had learned firsthand about the style and stance of pushing for change in psychotherapy. Steve was straightforward, direct, and pragmatic; his style was matter-of-fact, friendly, and optimistic. There was no mystery, no sense of exploring the depths. He asked for my goal, made it more specific, and he took it as our treatment goal. We got moving so quickly, I felt we had already embarked on a journey together. As simple as the message was, it was a surprise to me: In order to change behavior, you have to change behavior.
• Progress was to occur between sessions; sessions were to prepare for the work of the week.
• I set up the “Swenson plan,” as we called it. I would write every day, 7 days a week, even during vacation, for 6 months, from 8:00 to 9:30 a.m. I delegated some of my work to others.
• 치료자의 조언대로 정해진 시간에만 논문을 씀 -> The structuring of my writing periods was so clear and so confined to the 90 minutes per morning, that I no longer felt that I “needed” to write later in the day. I wasn’t plagued with the ever-present feeling that I should be writing. I experienced a sense of “flow” as I wrote, and a sense of freedom later during the day.
• Still, he managed to convey respect for me, and I felt like we were a team on a mission. In practicing DBT, I have reflected on these lessons a thousand times.

 

TARGETING AND MONITORING

DBT is, first and foremost, a therapy driven by the pursuit of outcomes— goals that are subdivided into specific behavioral targets to be accomplished sequentially.

1. At the beginning of treatment, therapist and patient collaboratively reframe the presenting problem behaviors as specific behavioral targets, understood as obstacles to the achievement of the patient’s goals.
2. The targets then determine the agenda of the treatment as a whole and the agenda of each session. Progress on the targets is monitored every day by the patient with diary cards (self-monitoring forms to be completed each day), and every week by the therapist with the review of those diary cards.
3. Therapist and patient monitor the discrepancy between targeted outcomes and current functioning, always attempting to close the gap.
4. In this respect, targeting is not just an activity that takes place at the beginning of treatment or at the beginning of each session; it is a constant preoccupation.

“What is the current target in your session?” he should have an answer.

cf) CHAPTER 7 & 8

 

COMMITMENT

cf) CHAPTER 10

 

ASSESSMENT (BEHAVIORAL CHAIN ANALYSIS) AND CASE CONCEPTUALIZATION

Once we are treating a specified behavioral target, we assess the controlling variables of that target through behavioral chain analysis, and through that assessment we arrive at a case conceptualization that drives our treatment planning and implementation.

 

Assessment and case conceptualization in DBT are both organized on the template provided by a behavioral chain, and problem solving during sessions is explicitly aimed at making revisions in the behavioral chain.

 

지도 없이 가다가는 drift and fumbling하게 됨.

 

CLASSICAL CONDITIONING AND EXPOSURE PROCEDURES

The three terms are, respectively and sequentially, the cue, the emotion, and the escape. The cue elicits the emotion; the emotion is uncomfortable, possibly unbearable; and the individual escapes from the emotion into some other behavior. The escape is often the presenting problem, such as cutting or substance use.

 

The Cue

keyword: unpairing

 

The Emotion

부정적 정서를 야기하는 단서로부터 회피하여 일시적으로 부정적 정서가 완화되면 회피하는 행동이 강화되지만 그만큼 삶의 제약이 커짐. 무엇보다 그 단서가 정말 피해야 할 만큼 위협적인지 철저히 평가할 수가 없음.(대체로 그 정도로 위협적이지 않은 경우가 많고, 그 단서에 연관된 과거 어떤 경험들로 인해 과대평가되는 경우가 많음.)

 

The Escape

→ Cue of the present moment (which automatically and instantaneously elicits a cue in memory from past traumatic incident)
→ Emotion (heavily influenced by emotional response to past incident, as stored in memory)
→ Escape response (often a dysfunctional behavior that is one of the targets of treatment)

1. to block escape behaviors(distress tolerance skills)
2. to enhance exposure to the unbearable emotions(mindfulness and emotion regulation skills)
3. to identify and "treat" the cues(interpersonal effectiveness skills and stimulus control procedures)

The main point here is that DBT therapists, in following the principles of classical conditioning (and deconditioning, or exposure), are on the alert for escape behaviors, for the emotion prompting the escape, for the cue prompting the emotion, and putting them together. (중략) We must be unflinching in hearing about the cues, and alert to our own urge to escape along with the patient, and pay attention to the subtle ways the patient does so.

 

신뢰 관계를 두텁게 하기 위한 GIVE skills

Needing to establish a trusting relationship and a sense that this is a safe context in which to expose to painful cues and intense emotions, the therapist acts in an objective but compassionate manner toward the patient. DBT’s “GIVE” skills—those interpersonal skills that help to preserve and strengthen relationships—are excellent guidelines. The therapist is gentle, which allows for trust to develop; is interested in the patient, which promotes a sense of security; is validating toward the patient, which results in the patient’s feeling understood; and uses an easy manner, which helps to encourage steadiness and persistence in spite of waves of emotion and urges to escape.

 

OPERANT CONDITIONING AND CONTINGENCY PROCEDURES

Context -> Target Behavior -> Consequences

 

The Context

stimulus context, antecedent conditions in which the target behavior occurs.

 

The Target Behavior

Most obviously, we target behaviors on the patient’s list of treatment targets, developed at the beginning of treatment and modified over time. We also target behaviors of the patient that cross the therapist’s personal limits

 

Although most of the target behaviors of which I have spoken in this book are problematic behaviors of the patient, there are two other relevant sets of behaviors.

• First, we target the patient’s adaptive behaviors to increase them, and in doing so, we rely on the same operant conditioning story, considering how to reinforce those behaviors.
• Second, we target the behaviors of the therapist that interfere with the treatment

 

The Consequences

(1) are contingent upon the target behavior and
(2) influence the future likelihood that the target behavior will happen again in a similar context.

 

The process of figuring out those variables central to the operant story is known as functional analysis. We determine the “function” of the behavior by determining what problem is solved by that behavior; in the example, the function of my asking-for-money behavior is most likely to fulfill my desire for coffee. Or it could turn out that the function is to get something, anything, from you, or to inconvenience you. Determining the function of the behavior, which requires assessment, determines what is reinforcing the behavior in that context.

 

Because these patients usually are highly sensitive and reactive emotionally to their sharp perceptions of others’ emotions, the use of contingencies needs to be handled with care, and on a trial-and-error basis, to discover what works.

 

회피 행동 소거에는 validating interventions이 수반돼야 함.
“I realize that this is an upsetting topic, and it makes sense that you might want to avoid it, but let’s see if we can find a way to help you face it.”

 

DBT에서 정적 강화에 부정적인 반응이 뒤따를 수 있다(압박감 or 강화 뒤에 처벌이 뒤따랐던 과거 경험 등으로 인해). 인내, 창의력, 시행착오 과정이 필요하다. 환자에 대한 치료자의 존중과 따뜻함을 통해 환자가 안전감을 느낄 수 있다면, 적응적 행동에 대한 정적 강화가 효과적일 수 있다. But this baseline can become nontherapeutic if it creates an unrealistic atmosphere of unconditional regard and warmth.

 

환자의 반응에 따라 수용과 변화의 밸런스를 맞추는 것이 중요함.

 

환자에게 필요한 행동이 아니라 치료자의 선호와 가치에 부합하는 행동을 강화하고 있지 않은지 살필 필요가 있음. -> 축구 경기의 심판과 같은 객관성과 용기, 즉각적 반응이 요구되며, consultation team에 도움을 요청할 수도 있음.

 

SKILLS DEFICITS AND SKILLS TRANING

she practiced it again and again in the group, with considerable instruction, modeling, support, and reinforcement.

 

다양한 상황에서 타깃 행동을 일반화하는 것이 필요함.

 

skills deficits은 행동 체인의 전 과정에서 나타날 수 있음.

 

The skills trainer may not be in a position to see that the patient who seems to learn a skill is blocked from using it by problematic cognitions (e.g., “It won’t work anyway”), by intense emotions (e.g., too frightened or ashamed to try something new), or by problematic contin gencies (e.g., the environment will not reinforce the patient for using the new skill, and in fact may reinforce him for using the same old problem behaviors). -> 외부에서 보기에는 스킬을 사용하는 것처럼 보이기 때문에, 실제로는 그렇지 않을 때 무엇이 스킬 사용을 저해하는지 모르고 넘어갈 수 있다. 지속적으로 스킬을 시도해 보고, 스킬 사용을 저해하는 요인들을 평가하여 문제해결해야 함.

 

하나의 기술 습득에도 많은 시간과 노력이 들어가지만 한 번 달성하면 삶을 변화시키기도 함.(이 절에서 소개된 'no'를 말하기 어려워하는 사례의 경우)

 

하지만 기술 습득에서 환자가 얼마나 동기를 지녔는지가 중요. Needless to say, the first principle of skills training is that the patient needs to recognize that she needs the skill.. (중략) But even with the willing patient, the effective skills trainer is aware of needing to “sell” each new skill by helping patients find their particular need for it.

 

COGNITIVE MEDIATION AND COGNITIVE MODIFICATION

Prompting event -> Beliefs, assumptions -> Actions and emotions

 

문제 행동을 강화하는 problematic cognitions을 거의 언제나 찾을 수 있음.

 

상황, 정서, 행동, 인지가 모두 문제 행동에 연관됨.

 

치료에서 problematic cognitions이 발견될 때 사소한 것이라도 그냥 넘어가지 말고

 

For instance, if a patient were to say, “I’m just not a competent person,” the therapist might respond, “Yes, I know, you have the thought that you are not very competent.” The patient, recognizing the challenge, might then go on, “But I mean I’m really not very competent.” The therapist might just leave it at that point, having underlined the problematic thought; or clinical judgment might lead to something like, “Yes, I know that you have a lot of conviction that that thought is true,” and so on.

 

At other times, the therapist might just respond to a patient’s negative statement “There is no solution to this” with a brief comment such as, “Yeah, I realize you don’t believe there is a solution.” If the thought is proving to be persistent and damaging, the therapist might further comment, “This thought keeps coming back, and it’s paving the road to hell for you.”

 

cognitive restructuring

 

contingency clarification

 

The therapist stance includes a readiness to detect problematic cognitions, which might prove to be more pervasive and influential than they seem. 잘 보이지 않는 곳에 숨어 있는 벌레를 잡는 것과 비슷.

 

Having detected the presence of problematic cognitions, the therapist needs the kind of skill to identify them, name them, and in some cases challenge them in a manner that is quick, tactful, and sensitive. This intervention resembles the ability of an artist, a painter, who can apply quick brushstrokes during the process of painting, just enough to highlight or revise a certain spot on the canvas, not so much as to overdo it.

 

환자가 지닌 역기능적 사고의 valid/invalid한 부분을 모두 짚음으로써 환자가 스스로 자신의 생각을 평가할 수 있게 도움.

 

APPLICATION OF CHANGE PRINCIPLES IN A CASE

It’s important to remember that if the therapist is engaging in one change procedure, bringing one theory to bear, she is actually addressing the story lines of all four stories.