综合的降低危害心理治疗的治疗任务.ppt

MANAGING THE THERAPEUTIC ALLIANCE 管理治疗联盟 THE THERAPEUTIC RELATIONSHIP HEALS 治疗关系的治愈 STRENGTHENING CAPACITIES FOR CHANGE 加强改变能力 ASSESSMENT AS TREATMENT 治疗评估 EMBRACING AMBIVALENCE 接受矛盾 GOAL SETTING 设定目标 PROMOTING POSITIVE CHANGE 促进正性改变,Therapeutic Tasks of Integrative Harm Reduction Psychotherapy 综合的降低危害心理治疗的治疗任务,What Is Therapeutic Alliance? 治疗联盟是什么？,Defined as “the ability to work purposefully together 可以定义为 “共同有目的的努力的能力”. Sets the therapeutic stage 设定治疗阶段 Anchors the patient in therapy 留住病人坚持治疗 “Contains” the process providing “safety, structure and support” (Khantzian) “包含”提供“安全、框架和支持”的过程（坎特泽安） Context for other therapeutic tasks and the delivery of other modalities 其它治疗任务的背景，引出其它模式 The alliance and interventions are negotiated with each client 联盟和干预要同每位病人协商,Primacy of Therapeutic Alliance 治疗联盟的首要地位,Over 50 years of research show it is the best predictor of therapeutic success 50多年来的研究表明，它是治疗成效的最佳预测工具 A key contributor to positive outcomes in substance abuse research 它是物质滥用研究正性结果的主要贡献力量 Strength of alliance is based in agreement about goals, tasks and quality of bond (Safran and Moran, 2001) 联合的力量是以目标、任务和联系的质量为基础的(撒法兰和莫兰2001）,Primacy of Therapeutic Alliance 治疗联盟的首要地位,“Positive expectations about therapy, greater session attendance and a positive perception of the working alliance predict greater client satisfaction and, in turn, more positive drinking related outcomes” (Dearing, et al. 2007) 治疗的正性期望、众多的治疗参与和对现行联合的积极认识预示着病人极大的满意，甚至是更多的酗酒相关问题的良好治疗结果。（徳尔宁等2007） Offering patients goal choice increases retention and positive outcomes for moderation and abstinence (Marlatt, 1998) 为病人提供目标选择增加了病人对治疗的坚持和适度使用和戒除的正性结果（马尔拉特1998） Relationship between good alliance and ARVT adherence 良好联合和抗病毒治疗依从性的关系,Initial Engagement （1） 初次接触,Make contact with patient, connection will keep patient coming; but what kind? 和病人建立联系，联系能保持病人不流失，但该是什么样的联系呢？ Get patients definition of problem and reason for coming 了解病人对问题的界定和前来就诊的原因 What does patient want? 病人想要什么？ Initial goals: assessment, better understanding, safer use, reduced use, abstinence 初步目标：评估、更好地了解、安全使用、减低使用量、戒除 Long term 长期性 Regarding substance use and other issues (we can talk about anything) 物质滥用和其它问题（我们可以谈论任何问题）,Initial Engagement（2） 初次接触,Reflect understanding and empathy as question open to clarification (Did I hear you right?)- “formulation” 表现理解和共情，通过问题来公开确认对问题的理解（我这样理解对么？）-“构想” Agree on initial goals and treatment plan 在初步目标和治疗计划上达成一致,Maintaining the Therapeutic Alliance 保持治疗联盟（1）,How do we make contact in ways that build, maintain and repair alliance throughout therapy? 我们如何建立联系，使得联系在治疗过程中能够建立、保持和修复联盟？ How can we be used differently by different patients in ways that are helpful to their growth? 我们如何让自己适应不同的病人，并提供有利他们发展的帮助? We have to change as they change 病人变，我们也要跟着变,Maintaining the Therapeutic Alliance 保持治疗联盟（2）,When do we lead and when do we follow? 我们什么时候需要引导，什么时候需要跟进？ What are the clinical challenges? 临床挑战有哪些？ Disruptions are inevitable and repairing them can be therapeutic opportunities 中断是不可避免的，修复中断也可能就是治疗的机会。,Engagement Skills 让病人参与的技巧,Active listening 积极的倾听 “start where the patient is” 从病人的立场出发 Try to put aside your presumptions 尽量避免事先推断 Listen with no agenda except to be helpful 不拘泥于定式，尽量倾听，并提供帮助 Face not knowing 不必认脸 Manage countertransference 处理好反移情 Collaborative inquiry 合作式询问 keeps client and clinician on the same side 病人和医生的立场一致 focus on clarification 重点在澄清问题 open-ended questions 开放式提问,Engagement Skills Cont. 让病人参与的技巧,Empathy for clients experience 对病人的经历表达共情 Imagine and feel clients experience 设想和感觉病人的遭遇 Reflect what you hear- “did I hear you right?” 反馈你所听到的“我这样理解对么？” Clients process informs focus告知病人的过程应注重于 Client chooses goals - this motivates them 目标选择由病人决定-这样他们才更有动力 Therapist must be attuned and flexible 治疗者要适合他们并灵活处理,Practicing Active Listening（1） 练习积极的倾听,Two Person Exercise-Listening with no agenda 2人练习-无事先准备的倾听 Take five minute turns 每人说5分钟 The speaker talks about something he/she wants to change in life (sell house, start exercising, quit smoking, drink less coffee, learn tennis) 说自己想在生活中做出改变的事情（比如卖掉房子、开始锻炼、戒烟、少喝咖啡或学打网球） Active Listening: the listener listens with curiosity, respect and empathy and gives speaker permission 倾听者应以好奇、尊重和共情的态度倾听，并给予说话人认可 Listener can ask clarifying questions 倾听者可以提问以澄清问题,Listener tries to figure out meanings and stage of change ndirelated to speakers behavior in question 倾听者试图从讲话人的相关行为问题中听出讲话人的含义和行为改变阶段 Listener reflects back understanding and elicits dialogue for clarification 倾听者应向讲述者反馈自己所理解的并引出对话以澄清自己的理解是否正确,Practicing Active Listening(2) 练习积极的倾听,Practicing Active Listening (3) 练习积极的倾听,Large Group Discussion 大组讨论 What was is like to be listened to in this way? What made you feel listened to; eye contact, body language, etc.? 以这样的方式被倾听会是一种什么样的感觉？什么才能使你感觉对方在注意听自己说话：眼神接触？身体语言？等等。 What was it like being the listener? Easy, hard, how might you use this, did you do it well? 扮演倾听者的感觉如何？容易，困难，你为什么会这样认为，你觉得你扮演倾听者扮演得如何？,Countertransference 反移情,All of our reactions to patient can be important information 所有我们对病人的反应都是重要的 Be alert to and manage social, personal and evoked countertransference (enabling, giving up, frustration) 警惕并且控制社会、个人和被激起的反移情（促因、放弃、沮丧） Acting it out can derail treatment 表现出来会妨碍治疗 We must question our preconceptions about 我们必须对我们先前有关下列问题的想法提出质疑 Patients motivations 病人的动机 Needs and strengths 需求和能力 Goals and expectations 目标和预期 Therapeutic readiness 治疗的准备程度,Countertransference and Clinician Qualities- Small Group Discussion 反移情与临床质量-小组讨论,Share at least one example of social, personal and induce countertransference 分享至少一个来自社会，个人与反移情有关的例子 Given the complexity and diversity of needs, characteristics and strengths within the drug using population, what are recommended qualities that will enhance understanding and engagement of this patient group? Give examples. 举例说出吸毒人群复杂而多样的需求，以及他们的特征和优点，针对这类病人群体可以推荐哪些能加强对他们的理解和参与治疗的方法？,The Therapeutic Relationship Heals 治疗关系的治愈,Creates a safe space for identifying harm, setting goals and working toward change 为识别危害、设定目标和朝着改变而努力创造安全的空间 Supports client in finding lost aspects of herself 帮助病人找回失去的自我 Relationship allows reworking of interpersonal issues that have been expressed through drug use 治疗关系使得以往通过滥用毒品来表现的人际问题重回正轨 Resolving problems in therapeutic relationship may be one of the keys to changing addictive behavior 解决治疗关系中的难题可能是改变成瘾行为的关键因素之一 Supports the development of self management skills支持发展自我管理技能,Strengthening Skills for Change 加强改变的技能,Pre-contemplation and contemplation 预先思考和自省 The patient is engaged in a process of self-change we support 病人开始参与到我们所支持的自我改变过程 Certain self-management skills are necessary for changing oneself 某些自我管理技能对自我改变是必须的 It may be necessary to help the client strengthen these skills as prerequisite to change 帮助病人加强这些技能是改变的前提条件 Build “adult self”, “witness”, “conductor” 建立“成人自我”，“目击者”, “指挥者”,Skills for Change 改变的技能,Curiosity motivates self-inquiry 好奇会促进自我询问 Awareness/Self-monitoring (observing ego, mindfulness) enables the client to identify events, thoughts and feelings related to substance use 意识/自我监督（观察自我、警觉）能够使病人确定与滥用有关的事件、思维和感觉 Affect tolerance enables the interruption of impulsive action with substances 效果忍受能够阻止滥用的冲动行为,Skills for Change Techniques 能力改变技巧,These are strengthened through modeling in the context of the therapeutic relationship 这些技巧可以通过治疗关系模式得以加强 Therapists empathic curiosity and questions 治疗医师的共情式好奇和问题 Techniques 技巧 Awareness training 意识培训 Relaxation training 放松培训 Charting and journaling 图表和日记 Meditation 禅定、冥想 Yoga 瑜伽 Exercise 锻炼,Awareness and Relaxation Training 意识和放松培训,Noticing, mindfulness, awareness training 通知、警觉、意识培训 Get a stress reading 获得压力读数 Focus on sensations of the breath 注重呼吸的感觉 Breathe a little more slowly and deeply 慢慢深呼吸 Focus on a word or phrase of feeling you want 集中精神在能够描述你想获得的感觉的一个词或短语上 Imagine you are in a place you have felt that 想象你身处在你所期望的地方 Get another stress reading 获得其它压力读数 Debrief 简述,Assessment as Treatment 在治疗中进行评估,Initial basis for therapeutic alliance and treatment plan 治疗联盟和治疗计划的初步基础 Ongoing therapeutic activity 正在进行的治疗行动 As problems are clarified, goals can be set 问题一旦明确，目标就能确定 Our assessment facilitates patients self assessment: 我们的评估能够帮助病人的自我评估 Substance use severity 药物滥用的严重程度 Relationship to psychobiosocial variables与心理-生物-社会变量的关系 Multiple meanings 多重含义 Stage of change 改变的阶段 Other important issues 其它重要问题 Hierarchy of needs, order of importance 需求的不同层次和重要性顺序,Assessment Techniques 评估技巧,Microanalysis of current use pattern 现有使用模式的微观分析 Describe your pattern of using in a typical week or month. When? How much? Under what circumstances? What precedes, follows? 描述你一周或一个月内典型的使用模式。何时？多少？在什么情况下？之前会做什么，之后会发生什么？ How does substance use fit in with other aspects of life? How does it help? How does it hurt? 药物滥用如何融入你的生活？对你有哪些帮助？对你有哪些损害？ What did you want from drug and how did it work out? Did use meet your expectations? Ever regret it? 你想从滥用中获得什么？它是如何奏效的？滥用是否达到了预期的效果？你没有后悔过么？,Assessment Techniques 评估技巧,Microanalysis of current use pattern 现有使用模式的微观分析 Severity: Enhance a social situation? (recreational) intermittent problem? (abuse), Compulsive, loss of control, craving? (addictive/dependent) 严重程度：巩固社会状态？(娱乐式）偶尔的问题？（滥用式），强迫性的、失去控制、非常想要？（依赖/成瘾） What might you like to change about use? 你希望通过什么来改变滥用？ Chart the above between meetings 会议中为上述问题的回答列表记录,Drug, Set, Setting 毒品，心理、环境 Zinberg, Denning辛伯格，邓宁,Clinical tool for describing biopsychosocial relationships of drug use 描述吸毒心理-生理-社会关系的临床工具 Zinberg suggested drug effects best understood in terms of mindset and setting 辛伯格建议毒品的效果只有从思维心理和环境的角度才能获得最佳的理解 Denning works with it this way 邓宁用这种方式来解决这一问题 Drug 毒品 Set心理 Setting环境,Addressing Ambivalence点明矛盾 Motivational Intervention 动机促进,Contemplation phase 思考阶段 Ambivalence vs. denial 矛盾和自我否定 There is always ambivalence about changing 对待改变总会有矛盾 Splitting ambivalence may explain addictive flight 分离矛盾可能会解释什么是成瘾逃避 Helping client to experience ambivalence allows consideration of new goals帮助病人体验矛盾能够使之思考新的目标 Bring the ambivalence into the room 将矛盾带进房间 “Standing in the Spaces” (Bromberg) “站在太空中”（布隆伯格）,Embracing Ambivalence Techniques 接受矛盾的技巧,Techniques 技巧 Empathize with both sides of conflict 对冲突得双方都要有共情 Keeps the conflict within the client 将冲突保持在病人身上 Taking sides pulls the therapist into conflict with the other side of the conflict 选择任何一方都会使治疗医师与另一方产生对立 Cost/Benefit analysis 成本/收益分析 “Decisional balance” “决策平衡” A systematic focus on the pros and cons of using and stopping 对使用和停用的好处和坏处的系统关注 Voice Dialogue (Stone and Winkleman) 声音对话（斯通和温克勒曼） Chairwork (Kellogg) 椅子工作,The Decisional Balance 决策平衡,Harm Reduction Goal Setting 减低危害目标设定,Contemplation and preparation/decision stages 思考和准备/决定阶段 Supports client choice, agency and motivation 支持病人的选择、权利和动机 Goals motivate change 目标动机改变 The question of goals promotes curiosity about what is wrong 对目标的问题将促进对不妥之处的好奇 Empowers patient to consider what is wrong and what changes they want to make 赋权于病人，让他们自己考虑哪里不妥以及他们想要什么样的改变 Goals change as issues are clarified or resolved 问题被澄清或解决，则目标也会跟着改变 Small changes begin the process of change, build “self-efficacy” and are typically how change occurs 微小的改变也是改变的开始，它能帮助建立自我形象，改变都是以这种方式发生的,Ideal Use Plan 理想的使用计划,Create a hypothetical plan with the patient 与病人共同创建一个假设的计划 “If you were to create a plan for using your substances of choice that would provide the greatest amount of benefit with the lowest level of risk, what might it look like?” “如果让你创建一个计划，你自己自由选择物质，通过使用最安全的剂量而能够获得最大的收益，那么这样的计划应该是什么样子的？” How much? How often? With whom? What practices? 多少？多久一次？和谁？怎么使用？ What other changes would you need to make to support it? 其它还需要怎样的改变来支持你所创建的计划？,Ideal Use Plan 理想的使用计划,Hypothesis-test it; attempt to put it in practice 用假设来考验计划，设想将计划在现实中执行 Is it realistic? Can it be implemented? 计划可行么？现实中能够执行么？ Problems in implementation clarify issues needing attention and revision of the plan 执行当中的问题帮助确定需要关注的问题和如何修改计划 Think about how you feel with this exercise 想一下，你认为这样练习怎么样,Strategizing for Positive Change 为正性改变制定策略,Preparation and action stages 准备和行动阶段 Thinking through and envisioning how a desired change can be implemented and supported 仔细考虑并预想如何执行和支持一个期望的计划 Focus on cognition and behavior 关注认知和行为 Measuring, counting, pacing, alternatives, charting, thinking through, remembering, having a partner 测量、计数、步调、可选方案、列表、仔细考虑、回想、找寻伙伴 Strategies can be tried out as experiments 策略可以以试验的方式开展 What works and what doesnt emerges from patients experience 根据病人的经历就能知道什么可行什么不可行,The ideal use plan is like driving to a destination 理想的使用计划就像驾车驶往目的地 Where do I want to go? (Analogous to goal setting) 我想要去哪里（就像目标设定） What is the route? (Analogous to strategizing) 路线怎么选择？（正如策略制定） What are good defensive driving skills? (Self-management skills) 什么是良好的自我保护驾驶技术？（自我管理技术） Important skills include 重要的技术包括 Goals 目标 Strategies 策略 Awareness 意识 affect management 效果管理,Driving as Metaphor for Self-managing Change 用驾驶的比喻来说明自我管理,Working Toward Positive Change朝正性改变努力 Selected techniques 选择技巧,Education about harm reduction psychobiosocial model, multiple meanings and stages of change 减低危害心理-生物社会模式、改变的多种方式和阶段的教育 Adopt an experimental attitude toward change 在改变上采取实验性的态度 “Play” with the habit rather than enforcing change 要同习惯融合而非强制推行改变 Stop technique: hold breath and slow it down. 停止技巧：屏住呼吸，降低节奏,Working Toward Positive Change朝正性改变努力 Selected techniques 选择技巧,Self-monitoring in the moment and journaling