动态解构心理治疗训练:第3部分
3. 归因技术
归因方法自然地遵循叙述顺序，并提供了一种打开意义的方法. 请参阅 归因 方法和 管理自我毁灭和适应不良行为 在第八章中， 具体的技术 在 治疗手册 以获得更完整的描述.
BPD患者对价值、能动性和动机有极端和极化的归因. 他们表现出非黑即白的思维. 使用归因技术，治疗师询问不同或相反的观点. 例如, 如果病人说, “喝酒给我带来的只有麻烦,从而降低了饮酒的价值, 治疗师可以回答, “你喜欢喝酒的哪些方面??如果病人说, “我男朋友把我当垃圾对待,治疗师可以通过询问将患者从外部代理转移到内部代理, “你有时会觉得自己应该被当作垃圾对待吗??如果病人说, “自从我女朋友离开我后，我感到很孤独,从而表达了一种依赖的动机, 治疗师可以通过询问引入相反的自主动机, “你女朋友离开你后，你是不是也松了口气??如果病人对以上任何一个问题的回答是肯定的, 治疗师可以提供综合评论, e.g. “So, 看来你喜欢喝酒的某些方面, 但不要喜欢你所经历的所有负面后果.”
以下六个案例说明了归因技术的不同方面. 前两例是同一患者在不同的治疗阶段 and illustrate how the ability to integrate polarized attributions can improve over time. The next four cases illustrate how 归因 techniques help patients progress…how to help them gain a more complex and realistic perspective of themselves and others and thus develop a more integrated and coherent self.
案例1:一个病人在开启新意义的过程中与固有的不确定性作斗争
前两例是同一患者在不同的治疗阶段. 在第一个小插曲中，患者处于第三阶段的开始. 她现在经常与两极分化的归因双方保持联系, but is struggling with how to cope with the sense of uncertainty inherent in bringing the opposing attributions together into an integrated and coherent self. 复苏是一把双刃剑, 极化的一个好处是, 非黑即白的思维是指一个人的观点总是非常确定的, 简单的, 和明确的.
案例1:评论
在这段视频中，病人正在与一种不确定感作斗争. She has progressed in treatment sufficiently that she is now in touch with both sides of her polarized attributions. 然而, she finds she cannot weigh out one more than the other and characterizes this uncertainty as the hardest part about treatment. 她现在面临着必须做出平衡和明智的决定，这些决定可能没有“正确”的答案. Uncertainty regarding attributions and decisions is one of the difficulties inherent in having an integrated self and moving into an adult role, 这也是在第三阶段对治疗和康复产生矛盾心理的原因之一.
案例1:关键点
- 病人通常需要确定性
- Their polarized attribution system and black and white thinking help them maintain certainty about themselves and others
- Treatment can sometimes increase anxiety by enabling patients to develop more complex perspectives that entail seeing both sides of issues
案例2:患者从对自己和他人的综合归因中获益.
本病例与病例1属于同一患者. 她现在已经接近第四阶段的末期，准备结束治疗. 在第四阶段，患者必须接受治疗师的失望和局限. 在下面的小插曲中, the patient is able to acknowledge feelings of both love and hatred towards the therapist and describes how the ability to acknowledge and hold these opposing emotions and related attributions has contributed to self-acceptance and improved interpersonal relationships.
案例2:评论
在这个小插曲中, the patient has clearly become more comfortable with having more balanced and integrated attributions of self and others. 我认为她达到了一种反思的矛盾状态, 在哪里她能同时拥有爱与恨. The patient’s ability to maintain an integrated and reflective perspective coincides with the development of self-acceptance and has clearly helped her social functioning, 从她与另一个小组成员相遇的描述中可以看出.
这个小插曲也说明了在第四阶段结束时, 病人能够更好地理解过去和现在关系的异同. 这个病人能够感知到与父母关系之间的联系, 她的治疗师, 另一个小组成员.
案例2:关键点
- 在第四阶段, 病人必须接受治疗和治疗师的失望和限制
- The ability to acknowledge complex and conflicting feelings and attributions towards self and others contributes to self-acceptance and improved interpersonal functioning
- 到第四阶段结束时, patients are better able to understand both similarities and differences between past and present relationships
案例3:整合依赖与自主的对立愿望
This case is of a woman who is expressing opposing motivations of dependency and autonomy in her relationships with men. 治疗师试图帮助患者澄清和整合这些对立的动机.
案例3:评论
在一般情况下, attribution interventions are most effectively applied under conditions of an adequate therapeutic alliance 在病人阐述了一个叙述顺序之后. This patient is in a reflective state and ready to explore her opposing motivations for closeness and dependency, 相对于自主和控制. 在这个小插曲中, the therapist simply attempts to help the patient to elaborate and become more aware of both sides of her conflict.
案例3:关键点
- 归因技术一般应在适当的治疗联盟条件下应用, 当病人处于反思状态时, 在病人阐述了一个叙述顺序之后
- 患者可能会有相反的、不完整的亲密和依赖动机, 相对于自主和控制
案例4:对药物使用产生矛盾心理
在这种情况下, 与前一个病例的患者相比，患者较少反思，也较少意识到自己的归因. 在治疗师的帮助下, 他开始识别并承认对他滥用止痛药的两极分化的归因. 在调查药物使用事件时, 或者其他适应不良行为, a primary aim is to help patients to understand both the positive and negative aspects of the behavior so that they can make an informed decision as to whether to continue it (see 管理自我毁灭和适应不良行为 在第八章中， 具体的技术 以获得更完整的讨论).
案例4:评论
在这个小插曲中, 病人开始时对他服用扑热息痛的经历进行了片面的积极描述. 他说这能让他在独自一人的时候玩得开心，也能让他轻松入睡. Note that the therapist is very careful not to fall into the trap of taking the other side of the opposition by pointing out all the problems inherent in using Percocet. 如果治疗师这么做了, 这可能会引发患者和治疗师之间关于患者药物使用的冲突. 在两个对立的阵营之间保持中立, 这种冲突留在病人体内, 它在哪里有潜力被探索和解决. 病人现在可以开始整合他对扑热息痛的极化归因, 这样他就可以在知情的情况下决定是否继续使用它.
案例4:关键点
- 干预适应不良行为时, 比如药物滥用, a primary aim of the therapist is to help patients understand both positive and negative aspects of their behavior so that they can make an informed decision as to whether to continue it
- 要有效率, it is of paramount importance that the therapist does not side with either the patient’s desire to continue using the substance, 或者是病人想停止用药的愿望
案例5:将代理机构从外部转移到内部
在这种情况下，一个男人正在与代理的归因作斗争. 在DDP中，代理的归属必须决定谁是变化的代理? 在给定的叙述中，谁有权力、责任或责任? 在小插曲中, the therapist helps this patient to switch from an external attribution of agency to an internal attribution of agency, 然后把这两种观点结合起来.
案例5:评论
This vignette provides a good illustration of a type of 归因 technique called an internalizing comment. 内化评论可以帮助患者摆脱受害者的角色, 所以对病人特别有用 愤怒的受害者状态，其中代理是外部化的(见第六章); 存在状态).
在这个小插曲中，病人在抱怨不公正的批评. 他认为自己是被上司不公平地批评的无辜受害者. 治疗师通过询问病人他认为谁是他最糟糕的批评者来进行内化评论. 病人很好地利用了这句话，并开始讨论自责的问题. 换句话说，能动性已经从他者转移到了自我. 治疗师随后给出综合评论, 总结患者对自我责备和他人责备的两极化归因.
案例5:关键点
- 代理与权力、责任和指责有关
- Patients with chronic conditions tend to either externalize agency (blame others for their problems) or to internalize agency (take on all the credit or blame)
- An internalizing comment moves agency from external to internal and can be particularly useful for deconstructing the 愤怒的受害者状态
- 综合评论带来了归因的两个极端(例如.g. 内部和外部代理)进入意识
案例6:形成对饮酒的综合归因
The final case in this attribution series is of a woman with poorly integrated and polarized attributions towards her drinking behavior. 治疗师试图帮助患者整合价值和能动性的归因.
案例6:评论
在这个小插曲的早期，病人的代理完全外化了，她处于受害者的角色. 希望她进入戒毒所的是她的母亲和祖母, 而她只是按照他们告诉她的去做.
The therapist then attempts to bring to consciousness her polarized attributions of agency by reminding the patient that she had previously expressed a personal desire to quit drinking and go into rehab. 遵循治疗师的意见, 病人能够重新获得代理权，并对她的饮酒采取相反的立场, 她说她害怕把那些毒药放进她的身体里害怕会有不好的事情发生.
然后治疗师就病人的两极化代理提供一个综合的评论, 别人对她的要求和她对自己的要求肯定会让人感到困惑. The patient appears to benefit from these interventions and ends the vignette in a much more reflective and integrative state of mind.
还要注意，治疗师不会偏袒任何一方，也不会强迫病人戒酒, but respects that the patient will be able to make reasonable decisions regarding her drinking behavior once she is able to achieve an integrated perspective.
案例6:关键点
- 有两极化的归因是很常见的, 包括机构, 酗酒和其他适应不良行为
- The therapist should respect patients’ ability to make reasonable decisions about their substance use once they are able to achieve an integrated perspective