[5주차] DBT Principles in Action: CHAPTER 6. The DBT Tree

FACTORS IN THE CONTEXT OF THE DBT TREE

The Soil: Acceptance, Change, and Dialectics

수용(마음챙김), 행동주의, 변증법적 태도를 지지하는 환경인가?

The Vegetation Surrounding the Tree: Programs and Philosophies in the Environment

As critical as analyzing and correcting the soil mix, it is also worthwhile to consider the influence of surrounding forms of “vegetation,” by which I refer to the other treatment philosophies and programs sharing the same resource pool.

The Climate: Resources for the DBT Tree

By climate in the natural environment I refer to certain kinds of resources: rain, sun, wind, and temperature. Corresponding resources in the atmosphere of a DBT program would include money, time, personnel, materials, space, and so on.

soil과 vegetation이 갖춰졌다 하더라도 climate이 안 받쳐주면 프로그램이 잘 운영되기 어려움. 셋 중 무엇 하나라도 빠지면 안 됨.

THE BRANCHES OF THE TREE

The large part of each branch, closest to the trunk, represents an element in DBT that is relatively the same from program to program; it represents a necessary ingredient of a DBT structure. The finer and finer branches represent elements of a DBT program that might be adapted to the particular context and particular patient population.

The Goals Branch

1. pretreatment: 치료에 대한 오리엔테이션, 치료 계획에 대한 전념의 합
2. Stage 1: 파괴적 행동에서 보다 안정화된 행동으로.
   1. 삶을 위협하는 행동의 감소
   2. 치료를 방해하는 행동의 감소
   3. 삶의 질을 저해하는 행동의 감소
   4. 행동 기술 향상
3. Stage 2: 괴로움을 감소시키고 정서조절 능력을 향상시킴
4. Stage 3: 삶의 목표를 정하고 자기존중감을 향상시킴
5. Stage 4: 자유, 의미, 지속가능한 기쁨을 목표로 함

The Functions Branch

1. Enhance patient capabilities. / skill training (<- mode of treatment)
2. Improve patient motivation. / individual psychotherapy
3. Generalize the patient’s capabilities to the natural environment. / telephone coaching calls between patient and therapist
4. Increase the capabilities and improve the motivation of therapists. / DBT consultation team meetings
5. Structure the treatment environment. / the DBT director and case manager

The Assumptions and Theory Branch

It's like a working philosophy

1. biosocial theory
   1. the biologically based emotional vulnerabilities
   2. the invalidating environment
   3. the severe, chronic emotional dysregulation(위 둘의 산물)
2. the assumptions made in DBT
   1. about patients
   2. about therapy

치료 대상에 따라 수정하거나 더하고 빼는 것이 가능함

The Agreements Branch

1. those made by the patient
2. those made by the therapist
3. those made by members of the DBT consultation team.

The Strategies Branch

위 네 가지 가지가 치료 프레임이라면 전략 가지는 그 프레임을 갖고 "doing"하는 것에 연관됨.

1. acceptance-based strategies
   1. validation strategies
   2. reciprocal communication strategies
   3. environmental intervention strategies
2. change-based strategies
   1. problem-solving strategies
   2. irreverent comunication strategies
   3. consultation-with-the-patient strategies
3. dialectical strategies
   1. contracting strategies
   2. session-beginning strategies
   3. targeting strategies
   4. session-ending strategies
   5. terminating strategies
4. special treatment strategies
   1. patient crises
   2. suicidal behaviors
   3. patient therapy-interfering behaviors
   4. telephonevcalls
   5. ancillary treatments
   6. patient–therapist relationship issues.

APPLICATION: MODIFYING DBT FOR TREATMENT OF SUBSTANCE USE DISORDERS

1. getting a commitment (pretreatment) Substance use disorders would be addressed in pretreatment insofar as there would be an orientation about the treatment of substance use disorders in the program, agreements about the expectations of substance-related behavioral patterns and the targeting of those patterns, and a focus on obtaining the strongest possible commitment to reducing or abstaining from using substances.
2. establishing behavioral control (Stage 1) where the program helps each patient establish more stability, control, and connection to replace instability, impulsivity, and chaos.
   1. life-threatening behaviors
   2. therapy-interfering behaviors
   3. severe quality-of-life-interfering behaviors But most commonly, it turns out that the targeting of substance use behaviors takes place in the third target category of reducing severe, quality-of-life-interfering behaviors..
3. acquiring the capacity for nonanguished emotional experiencing (Stage 2)
4. pursuing individual goals and self-respect (Stage 3)
5. increasing the experience of freedom, meaning, and joy (Stage 4).

• 물질남용 행동의 치료가 어떤 stage에서 진행돼야 하는지 결정했다면, subtargets을 정해야 함. 아래와 같은 일련의 단계를 따름.
  • Decrease substance use.
  • Decrease physical distress associated with substance use.
  • Decrease urges, cravings, and temptations to use substances.
  • Decrease the option to use drugs.
  • Decrease contact with cues for drug use.
  • Increase reinforcement for “clear mind” behaviors.
  • Clear mind (a state of mind resulting from the reinforcement and consolidation of clear mind behaviors).
• 이 챕터의 후반부에 Functions 가지와 Strategies 가지 등을 다루지만 너무 일반적인 얘기라 "application"이라는 제목에 어울리지 않음.

 

5주차 코멘트

-> 토양, 식생, 기후에 관한 비유를 챕터 초반에 들고 있는데, 토양은 수용, 변화, 변증법 이라는 DBT 철학을 얼마나 지지하는 환경인지에 관한 것 같고, 식생은 저자가 DBT를 실행할 때 정신분석적 치료 지향이 강한 환경이라 힘든 점이 있었다고 하는 걸 보면, 이론적 지향이 다른 식생에서 DBT가 실행될 때 애로사항이 있을 수 있음을 예상해야 한다고 말하려는 듯했습니다. 기후는 돈, 시간, 공간 등 현실적인 측면이 얼마나 지원되는지 여부와 관련 있어 보이고요. 토양과 식생의 차이가 좀 애매하다고 느껴져요.

Goals 가지에서 스테이지 구분은 상담 목표 설정의 일반적인 가이드라인으로 잡아도 무방할 것 같다고 생각했고, 그 뒤에 이어지는 내용들은 이론적인 부분이라 눈에 잘 안 들어옵니다. Application도 뭔가 구색 맞추기 같은 느낌으로, 설명이 좀 피상적이라고 느꼈고요.