[8주차] DBT Principles in Action: CHAPTER 9 Case Conceptualization in DBT

INTRO

• Unlike some models, DBT therapists do not actually “conceptualize the case,” they conceptualize the variables that maintain a given target behavior.
• Case conceptualization begins with, first, identifying the target behavior of interest, typically the highest-priority target behavior at that moment of the treatment.
• Second, the therapist identifies the stage of treatment.

COGNITIVE-BEHAVIORAL PRINCIPLES AND VOCABULARY IN CASE CONCEPTUALIZATION

• By trial and error we were discovering which variables were associated with suicide attempts, which variables lent themselves to change-oriented interventions, and which variables had to change before others could be approached.
• The process of conceptualizing, reconceptualizing, and refining those conceptualizations over time, probing and assessing, intervening and observing, can be a helpful way for the therapist to stay engaged in a process of inquiry and intervention without submitting to the temptation of “knowing” what is the critical variable before the data are sufficient.
  • In and of itself, this process of collaborative inquiry is an important therapeutic activity.
• Based on DBT theory and guided by the principles of cognitive-behavioral science at its core, as DBT therapists we are especially interested in certain kinds of links.
  • First, there are those links that reflect the patient’s biologically based emotional sensitivity, reactivity, and slow return to baseline.
  • Second are the links that reflect invalidation of the patient by the environment.

DBT 행동 연쇄 분석에서 타깃 행동 감소를 위해 고려해야 하는 13가지 통제 변인

1. Emotional vulnerability, objectively identified in biosocial theory as heightened sensitivity, reactivity, and slow return to baseline
2. Invalidating episodes, in which the patient is invalidated by the environment
3. Emotional vulnerability, subjectively experienced as agonizing by the patient
4. Self-invalidation
5. Active passivity
6. Apparent competence
7. Unrelenting crisis
8. Inhibited grieving
9. Problematic contingencies
10. Problematic emotions
11. Problematic cognitions
12. Skills deficits
13. Manifestations of a biologically based psychiatric disorder(Medications)
14. Contextual factors reinforcing problem behaviors: family, social network, professional (non-DBT) network
15. Contextual factors reinforcing problem behaviors: DBT treatment program
16. Resilient and adaptive behavioral factors
17. Contextual factors strengthening resilient and adaptive factors

MINDFULNESS PRINCIPLES IN CASE CONCEPTUALIZATION

• But to believe in it in a manner that filters perceptions and interventions, that preselects data supporting it, can blind the therapist to the reality of the next moment, the next session, the information contradictory to the propositions up to that point.
  • So, as much as the therapist embraces the blueprint as a road map to change, he does not become attached to a particular equation to explain the outcome of the chain.
• non attachment as BEGINNER'S MIND: 내담자에 대한 청사진을 갖고 있되 회기 안에서는 내려놓을 수 있어야 함.
• 또 다른 마음챙김의 원리는 Impermanent
• “reality is perfect as it is.”: The reality of the present moment, the reality of the individual sitting in front of the therapist, trumps(능가하다) the “road map” provided by the case conceptualization, every time.
  • In a sense, whatever is the explicit case conceptualization is not only partial, but is also temporally behind the progression of reality.
• 사례개념화는 뱀이 허물 벗듯이 새롭게 나타나는 증거에 맞게 탈피할 수 있는 것이어야 함.
  • 사례개념화는 현 시점에서 상황을 보다 넓게 조망할 수 있게 하는 비계(scaffolding)가 될 수 있지만, 그렇게 하여 접하게 된 새로운 현실을 수용함과 함께 사례개념화를 변화시키는 것이 중요함.
    • 얼굴 성형을 신체변형의 관점에서 보게 됨으로써, 내담자의 폭력적인 행동이 자기혐오의 이차적 반응임을 이해하게 된 저자의 사례: 사례개념화로 내담자를 이해할 수 없다고 느끼자 사례개념화를 제쳐두고 현실을 보고자 애씀

DIALECTICAL PRINCIPLES IN CASE CONCEPTUALIZATION

• 외현적 이해와 암묵적 이해(직관)가 항상 공존함.
• 외현적 이해가 암묵적 이해를 제약하지 않도록 항상 깨어 있어야 함. 즉 암묵적 이해와 맞지 않는 외현적 이해나 데이터가 있으면 왜 이런 불일치가 나는지 생각해 봐야 함.
• 내 머리속 이해가 아닌 내담자의 현실과 마주하기 위해 노력해야 하며, 시행착오, 직관과 발견 등을 통해 가능함.
  • It is much the same when driving with a global positioning system (GPS). The GPS provides an explicit conceptualization of how to get from here to there, but in the process of driving, of looking out the window and seeing reality as it is at this moment, adjustments are constantly being made.
• And still something can be missing. I might overlook a “hidden link” in the behavioral chain, a contextual factor in the patient’s interpersonal or vocational environment, or a sense of disengagement in myself, the patient, and/or the family.
• Dialectical assessment is listed as a DBT dialectical strategy, which involves always looking for what is left out of the current picture, the current formulation.
  • And often I find that what is left out is the ingredient that moves everything else forward.
  • And often that missing ingredient is not to be found by a logical review of the case, but more implicitly, intuitively.
• 일반적인 행동주의적 사례개념화만으로는 불충분하다는 것.
• We never know in advance where the key elements of the case conceptualization reside: in the patient, in the family, in the therapist, in the team, or in someone or something else. We proceed with an open mind, alert to fresh observations and surprises; they are more the rule than the exception.

PRACTICAL SUGGESTIONS FOR CONSTRUCTING AND USING CASE CONCEPTUALIZATION

1. 근거가 적더라도 사례개념화는 빨리 하는 것이 좋다. 완벽한 사례개념화는 없으며 늘 변화하는 사례개념화만 있을 뿐이다.
2. 회기 안에서 사례개념화는 놓아 두고 머리와 가슴 모두로 임하라.
3. 사례개념화를 하기 위해서는 가용한 모든 정보를 동원하라.
4. behavioral chain analysis vs. missing link analysis: 전자는 문제 행동을 분석하는 것이고 후자는 건강한 행동이 나타나지 않는 이유를 분석한다는 점에서 다르다.
5. 사례개념화를 구체화하기 위해 노력하되 그것이 내담자의 현실이 아님을 받아들여라.
6. behavioral chain analysis에 더 적합한 데이터가 있다. 이를 찾기 위해 항상 스스로에게 물어야 한다. 이것은 기능적 혹은 역기능적 link인가, 역기능적이라면 동일한 목표를 달성하기 위한 기능적 대안을 상상할 수 있는가?
7. 사례개념화는 생물사회 이론뿐만 아니라 DBT의 전제(즉, DBT의 practical philosophy)에 맞아야 한다.
8. At the same time, while considering hypotheses explaining the dysfunctional sequence of links, try to envision a functional sequence of links that might work for this patient in lieu of the problematic sequence.
9. 잘못된 사례개념화로 드러난다 하더라도 현상을 조직화함으로써 치료자 자신의 인지/정서를 조절하고 치료에 동기부여하는 데 도움이 된다는 점에서 유용하지 않은 사례개념화는 없다.
10. 사례개념화는 복잡할 필요가 없다. 특히 치료 초기에는 더 그렇다.
11. 치료자의 머리속에만 있는 사례개념화는 죽은 사례개념화다. 내담자와 공유하고, 시행착오 과정을 거쳐서 수정하라.
12. big picture를 그리기 위해 사례개념화에 도움이 될 만한 메타포를 의식적으로 떠올려라.