[11-12주차] DBT Principles in Action: CHAPTER 12 Validation

INTRO

• Just listening, looking, being there with and for someone else is validating.
• It frequently fails us when we are treating an individual with a high degree of emotional sensitivity and reactivity, a long history in a pervasively invalidating environment, and therefore a strong tendency toward self-invalidation. We try to validate; it doesn’t work. It doesn’t go as we expect. We don’t make the kind of connection to which we are accustomed.
  • Not uncommon in DBT, these circumstances require that we develop a deeper, sharper, and more variegated understanding of what we mean by validation, especially because validation plays a crucial role in the treatment.

The functions of validation in DBT

• So the first function of validation was to assist the patient in maintaining or regaining emotional balance during problem solving.
• It is one of the factors that hold the patient in therapy.
• If the therapist can identify and validate the primary emotional response (in this case, shame), and in so doing can help the patient remain in contact with that emotion, he begins to learn new ways to modulate the painful emotion.
  • In this respect, validation serves as a step in an exposure procedure, one of the four change strategies in DBT.

What is validation?

• Step 1: Recognizing and Understanding a Behavior
  • 공감이 타당화의 전제 조건
  • We validate what is already valid. We simply confirm its validity; we don’t create validity by validating.
  • At times we recognize and understand a behavior, and we strategically withhold(보류) validation.
    • 남편을 잃은 친구가 자신에게 관심을 주지 않아 실망을 표현하는 환자에게 공감하기 어려웠던 치료자를 저자가 역할극 통해 수퍼비전한 내용
      • (저)자: “If you think you need your friend’s attention as much as her husband does, maybe you should tell her that you are dying too.”
      • (환)자 역할하는 치료자: “Why would I do that?”
      • 저: “Maybe your friend pays more attention to people who are dying.”
      • 환: “but she should be upset about it—he’s been her husband for 25 years! I think I might be expecting too much from her, or maybe my timing is bad.”
      • 저: “I see what you mean, that makes complete sense.” And then I could validate her initial response, her disappointment: “You’re right, but you know, I can also see how you would be disappointed.”
• Step 2: Determining the "Truth Value" of the Behavior
  • Validation with Respect to the Past
    • We consider a behavior valid if we can understand that it is aligned with the individual’s unique learning history or biological constitution.
    • 과거의 관점에서 타당화할 수 있음: 현재 시점에서는 이해할 수 없는 행동이라 하더라도 과거 시점에서 보면 이해 가능할 수 있음
  • Validation with Respect to the Future
    • 과거에 벌어진 사건으로 인한 절망감과 분노 때문이 아니라 장애인의 더 나은 이동을 가능케 하기 위해 분투한 환자의 사례
  • Validation with Respect to the Present
    • Reasoning with Respect to Accepted Authority and Reasoning with Respect to Consensus
      • However, when we learn that the patient is devoted to the fellowship and the teachings within a given Alcoholics Anonymous (AA) meeting that opines strongly against the use of psychiatric medications, we realize that the behavior is valid in the current context based on accepted authority, within AA, and based on the consensus of the subgroup of people in that AA
    • Empirical Reasoning
      • 귀납적 추론: 이해할 수 없는 행동도 시행착오 학습 과정의 보상들에 의해서 형성된 결과일 수 있음
    • Deductive Reasoning
      • 기이해 보여도 환자 나름의 논리가 있을 수 있음. 환자 사고의 타당성을 치료자가 더 잘 이해할수록 환자와 함께 그 논리에 도전할 수 있음.
    • Wise Mind Reasoning
      • 외부에서는 어떤 식으로 봐도 이해가 안 되지만, 때로는 환자의 wise mind가 가리키는 대로 갈 때 더 좋은 결과가 나올 수 있다는 것
• Step 3: Communicating the Validity of a Behavior
  • 치료자가 얼마나 내담자의 언어로 이해한바를 전달할 수 있는지가 중요하고, 비언어적인 표현 방식도 매우 중요함.
  • 치료자가 하는 말마다 "아니오"라고 말하는 여자 청소년의 사례
    • When we validate we have to consider the patient’s age, cognitive style, culture or subculture, vocabulary, and particularities of rhythm and tone. Most of all, we need to notice whether our attempt at validation was received. Sometimes we need to return again and again, sticking with the effort to validate.
  • functional validation: 말이 아닌 행동으로.
  • validate하기 위해 agree할 필요는 없다. disagree하더라도 validate할 수 있다.
    • <u>validate하기 위해 agree하기 시작하면 치료자 의견에 대한 환자의 의존을 낳게 되고, 이는 환자가 고통을 견디고 스스로 validate하는 능력을 키우는 것을 저해한다</u>
    • “No wonder you guys don’t want to clean up the dining room; no one likes to do that. But you know you will lose snacks tomorrow night if you don’t clean up tonight.”
  • validating이 꼭 따뜻한 어조로 이루어질 필요는 없다. 둘은 별개이다

Valid versus invalid

• Why do we choose to validate some behaviors and not others? The short answer is that <u>we sometimes choose to invalidate behaviors because they will interfere with progress toward the patient’s previously stated goals</u>. They are invalid with respect to the stated ends-in-view.
• 치료 목표에 반하는 행동은 그것이 이해할 수 있는 행동이라 하더라도 Communicate 하지 않으며, 치료 목표를 좇을 수 있게 invalidate한다.

What are the targets of validation?

• Emotions
  • 차를 모는 가운데 자신과 문자를 주고 받다가 사고로 죽은 친구에 관해 무덤덤하게 말하는 환자의 사례
  • 저자는 스스로의 강한 감정과 무덤덤한 환자의 반응 사이에서 struggling하다가 한 걸음 뒤로 물러나 환자가 스스로의 감정과 사고에 초점 맞출 수 있도록 3분 동안 침묵함
  • 이후 환자는 눈물 흘리며 속내를 꺼내기 시작.
    • It was almost too much to bear. <u>My task was to bear witness to her painful thoughts and her emotional expressiveness. This is what we mean by emotional validation.</u>
  • mindfulness가 중요
  • 일차 감정과 이차 감정을 구분하고, 이차 감정이나 행동을 통해 벗어나려는 일차 감정이 무엇인지 고려하는 것도 중요함
• Thoughts
  • 생각은 fact가 아니라 reality에 대한 진술일 뿐임을 기억. 환자의 입장에서 validate하되
  • 다양한 근거에 비추어 볼 때 invalid한 것은 무엇인지 파악하여 문제해결적으로 접근할 수 있어야 함
  • 자살 사고 자체는 그런 생각이 들 수 있음을 validate하되 자살 행동은 invalidate
• Actions
  • 내적 기준이 높은데(늘 시험을 잘 봐야 해: 행동) 성적이 잘 나오지 않아(성적이 이렇게 나오지 않다니 믿을 수 없다: 생각) 속상해 하는 아이의 사례
    • 성적이 잘 안 나올 수도 있고 그런 이유들이 있었음을 얘기하는 게 이 아이에게는 공감이 안 됨
    • 좋은 공감의 예. 아이의 내면에서 상황을 바라보고 공감: “I know your standards are very high, and we are proud of you that you work so hard(행동을 공감). Given how high your standards are, it must be just terrible to get a lower grade than you are capable of.(생각 및 감정 공감)”
  • 환자가 지닌 shoud에 먼저 치료자가 공감을 표시하면, 환자는 감정에 초점 맞추는 것이 가능해짐.
  • 궁극적으로는 사고나 행동에서의 경직성을 감소시키는 것이 목적
• Capabilities
  • The therapist recognizes and highlights capabilities as they occur during the session, or as they emerge in the patient’s story.
  • There are so many opportunities to validate capabilities, to simply note them, and it is my impression that we underutilize this helpful intervention. A patient completes her diary card, clearly having given her full attention to each rating; I highlight her strength in self-monitoring and cooperation with the treatment.
• Person-as-a-Whole
  • Validating particular behavioral responses does not necessarily validate the person-as-a-whole. For instance, I might validate my patient’s reluctance to attend a skills training group, given his social anxiety, in a manner that inadvertently also suggests that he is a person who gives up too easily.
  • 위 예시에서처럼 일부 행동을 validate하는 것이 한 사람에 대해 invalidate하게 되는 결과를 낳을 수 있음. 항상 unconditional positive regard하는 것이 중요.

When do we validate (and when do we not)?

• When we are pushing for change and using one of a multitude of problem-solving strategies, we can easily underestimate the patient’s difficulty in tolerating our best-intended interventions. As we push forward toward change, we usually need to validate emotional pain and the difficulty of trying new behaviors.
  • I have pushed the patient to change behavior, and, despite the patient’s hard effort, the process has been wearing on both of us. Realizing that I have been pushing for change without balancing it with acceptance, I enter the next session with the plan to “just listen,” essentially to just check on how my “partner in problem solving” is doing, what she is thinking. It is something of a “heart-to-heart” exchange about how things are going, and functions as a breather for both of us.
• 공감은 하되 너무 들어주게 되면 오히려 환자의 역기능적 행동 강화할 수 있기 때문에, 공감 이후에는 바로 해야 하는 일을 하자고 말할 수 있어야 함.
  • “I get it; but now come on, you have to get up right now!”

What are the six levels of validation?

• Validation Level 1
  • By being truly present, he creates an atmosphere that conveys to the patient, “Your behavior has substance, meaning, makes sense, and is worthy of my attention.”
  • It’s the most natural thing in the world if you care about someone, and yet it’s very hard to do.
  • In this respect, doing psychotherapy in DBT is itself a type of mindfulness practice
  • Factor That Interfere with Level 1 Validation
    • "apparent competence" 지닌 내담자 감정은 읽기 어려울 수 있다
    • 라포의 정도를 잘못 평가할 수 있다. 우리가 생각하는 것과 달리 작은 일에도 쉽게 라포가 깨질 때가 많다.
    • 치료에 협력하는 것처럼 보일 때조차 표면적으로만 그런 것일 때도 있다. 보이는 것이 다가 아니다.
• Validation Level 2
  • 환자의 말을 재진술하고 제대로 이해한 것이 맞는지 확인하는 것이 반복돼야 함.
  • Factor That Interfere with Level 2 Validation
    • When we see our reflection in a pond, it resembles us most accurately when the pond’s surface is still. Similarly, when we reflect something back to our patient, even using the patient’s words, we are most likely to be accurate if we are still.
• Validation Level 3
  • Level 2가 명시적 의사소통이라면 Level 3은 암묵적 의사소통
  • The interplay between Levels 1, 2, and 3—listening, reflecting, finding common ground, finding differences, correcting errors, repairing ruptures—goes on almost constantly in a good psychotherapy relationship.
• Validation Levels 4 and 5
  • we communicate to the patient our understanding that his behaviors make sense in two ways: (1) with respect to his history and biology (Level 4) and (2) with respect to his current context (Level 5).
  • 과거 관점과 현재 관점 모두에서 validate 가능하다면 현재 관점 먼저 취하라. 그래야 과거부터 지금까지 이어지는 병력에서 볼 때 타당한 반응이 아니라 병력과 관계 없이 누가 봐도 타당한 반응임을 말함으로써 환자에게 더 공감적으로 들릴 수 있음.
    • 친구 커플 앞에서 자신이 먹는 것에 관해 지적한 남자친구에 대한 여성 내담자의 굴욕감과 분노는 섭식장애 여부를 떠나 당연한 것임
    • I could have followed the successful Level 5 validation with a Level 4 one: “I wonder if it made things even worse because of your history with your mom?”
• Validation Level 6
  • radical genuineness: To practice radical genuineness means that the way the therapist interacts with the patient will look similar to the way she acts with friends and family, except she will also be doing therapy.
  • 일상생활에서 하던 것과 치료가 큰 차이가 없어야 한다는 것은 그만큼 인격적 성숙을 위해 노력해야 한다는 것 아닌가

Validation and the Acceptance Paradigm

• <u>When the therapist can succeed in entering into and staying in the present moment, using both the mind and body, the patient is likely to explicitly or implicitly notice that the therapist is truly present—in that moment, and in that space, awake and alert. This kind of presence already validates the whole being of the patient.</u>
• Level 1 establishes a platform from which the therapist uses the other five levels.
• 회기 안의 상호작용에서 모든 것이 계속 변화하고 모든 순간이 의미 있다고 치료자가 느낀다면 환자도 그것을 알아차릴 수 있다
  • To the degree that the therapist, sitting with the patient, maintains awareness of the **impermanence of reality**, she will treat each moment as full and unique, and the patient is likely to experience the therapist as completely present and genuine, noticing and reflecting the reality of the patient in the moment.
• **Emptiness & Interrelatedness**: The patient and therapist are not simply fellow travelers on the path of life, next to one another; they are actually intertwined, interdependent, and operate as one as they work together.
  • 이런 경지까지 갈 수 있을지..
• Thins are perfect as they are

Validation and the Change Paradigm

• 노출 치료와 같은 고전적 조건 형성 시 validation이 중요함
• 조작적 조건형성에서는 강화해야 할 행동에 대해서만 validation
• At other times, we deliberately fail to validate a thought, or even deliberately invalidate it, highlighting that it is not credible or useful, hoping to weaken a thought in that person’s repertoire.
• Finally, validation itself is taught as an important interpersonal skill in DBT

Validation and the Dialectical Paradigm

• 엄마-딸 갈등 시 양쪽 모두의 입장을 validate
• 환자-치료자 의도가 상충할 때 환자 입장 공감 후 치료자 입장 전달
• 모든 게 얽혀 있기 때문에 하나를 validate하면 다른 하나를 invalidate하게 될 가능성이 있다. 순차적으로 validate
  • By validating and reinforcing the urge to flee, we may be invalidating the child’s capabilities for staying and standing up to the bully. This is actually not so unusual. There are always so many trends running in parallel, that to effectively validate one we may need to remain cognizant of others that coexist. This could lead to validation of one phenomenon, then another, in sequence.
• 타이밍이 중요함. 한 사람이 과거에 다른 사람에게 잘못 행동했다 하더라도 후에 다른 사람에게 선행을 베풀었다면, 과거의 잘못 때문에 현재 선행을 validate하지 않는 우를 범하지 말아야 함. 잘못된 행동에 대해서는 발생 시점에 개입
• 변증법은 절충이 아니다. 수용할 때와 변화할 때 각각 100% 전념(?)
  • it involves a commitment to the act of acceptance, all the way, and a commitment to change, all the way. It is the essence of dialectics in DBT.

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