英文原文
Eating disorders is a diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) that includes severe disturbances in eating behavior. In this article, solution-focused counseling is presented as an effective treatment for eating disorders. Solution-focused counseling is a comprehensive clinical model that has been influenced by the pioneering work of Steve de Shazer and his colleagues at the Brief Family Therapy Center in Milwaukee, Wisconsin. We have found solution-focused counseling to be a fitting model for eating disorders because it is a strength-based approach that emphasizes clients' existing and potential resources. Solution-focused counseling offers an alternative to the prevailing problem-focused treatment approaches for eating disorders that might provoke resistance during the change process. In addition, this model is distinct from the solution-focused approach developed by de Shazer insofar as it incorporates features of primary importance to counseling, including a multicultural perspective and an eclectic approach. A limited number of solution-focused approaches for eating disorders have already been developed. Berg and Steiner (2003) have described using solution-focused therapy for children with eating disorders. O'Halloran (1999) has described using a solution-focused approach for working with a family that included an adolescent with anorexia nervosa. Solution-focused techniques for eating disorders have also been used in an art therapy model and a multi-modal prevention treatment program. In addition, narrative therapy, an approach that is similar yet distinct from solution-focused models, has been applied to eating disorders. To date, however, no comprehensive solution-focused approach that incorporates important features of counseling (e.g., multiculturalism, eclecticism) is found in the literature. Due to the relatively high prevalence of eating disorders, it is expected that most counselors will at some time encounter clients who suffer from these conditions. Accordingly, it is important for counselors to develop effective treatment strategies for eating disorders. The purpose of this article is to present solution-focused counseling as a valuable model for the treatment of eating disorders, and to illustrate how its principles can be applied to a variety of therapeutic interactions. The organization of this article is as follows. First, various issues are described in relation to eating disorders, including etiology, comorbidity, and treatment. Next, the theory and practice of solution-focused counseling is described. Then, a case example that illustrates the application of solution-focused counseling to eating disorders is provided. Finally, implications and recommendations pertaining to the practice and research of solution-focused counseling in relation to eating disorders are discussed. In solution-focused counseling, a problem implies the existence of exceptions, that is, times when positive coping skills are applied or when the problem is solved. Solution-focused counseling presupposes that there are always exceptions (actual or potential) to a problem. In solution-focused counseling, a clinical problem is formally conceptualized as problem/exception. Solution-focused counseling typically involves five stages which can be applied in many different ways: (a) coconstructing problem definitions and corresponding goals, (b) identifying and amplifying exceptions to problems, (c) assigning tasks, (d) evaluating the effectiveness of tasks, and (e) reevaluating problems and goals. During the first stage, the client and counselor collaborate to coconstruct problem definitions and goals. Problem definitions are subsumed by the problem/exception conceptualization. For example, if a client were to define the problem as ineffective coping for anxiety, the problem would be conceptualized as ineffective coping for anxiety/effective coping for anxiety. The change process would involve identifying and amplifying times when the client coped effectively with anxiety. During the second stage, presuppositional questions are used to help clients identify exceptions. For example, the counselor asks, "When has there been a time when you coped better with the problem?" instead of "Has there been a time when you coped better with the problem?" The former question carries with it an expectation of exceptions, and encourages the client to re-evaluate their relationship to the problem. Exceptions are amplified by encouraging clients to do more of the behaviors that helped them cope successfully with the problem in the past, to observe times in the present when they are dealing better with the problem, and to ascribe significant and positive meaning to exceptions. If exceptions are identified, clients are helped through various questions to amplify exceptions. Examples of such questions are "How did you make that happen?" "What does this (i.e., the exception) say about you and your ability to solve the problem?" and "What are the possibilities?" If clients are unable to identify exceptions, counselors might encourage them to consider small, albeit positive changes that occurred. If clients still report that there have been no exceptions, then counselors attempt to identify potential exceptions. A question aimed at identifying potential exceptions might be "What will it be like when you are dealing better with the problem?" This question is derived from the crystal ball technique, a method that encourages clients to picture themselves at a higher level of functioning sometime during a hypothetical future. A similar technique, known as the miracle question, focuses the client’s imagination on exceptions in the future: “Suppose that one night there is a miracle and while you are sleeping the problem that brought you into therapy is solved: How would you know? What would be different?” During the third stage, tasks are assigned to build on progress made during the previous stages. This stage is aimed at clarifying and building on progress made during previous sessions, including defining problems, setting goals, and identifying and amplifying exceptions. The fourth stage involves evaluating the effectiveness of tasks. During this stage, counselors follow up on tasks given in the previous session. This may involve helping clients clarify the problem, goal, and identify and amplify exceptions derived from tasks that were given in the prior session. The fifth stage, re-evaluating problems and goals, involves clients and counselors examining how well therapeutic progress has matched the attainment of goals. At this stage, counseling is either continued or terminated. If the goals have been reached or clients have made significant progress toward the goals, then the counselor might ask the client if further counseling is needed at this time. Ideally, clients and counselors reach a consensual agreement about termination. If clients indicate further counseling is needed, then problems and goals are reconstructed. The contention that counseling is unfinished indicates that the goals have not yet been satisfactorily constructed or attained. Clients might indicate that a goal has been reached and that there is a new goal. In such cases, it is important to help clients re-examine and clarify the problems and goals. The plan of action might need to be more attainable, more specific, and/or more relevant to clients’ problems. A strategic approach to eclecticism in solution-focused counseling allows for the compatible, systematic, and effective use of diverse theories and techniques within our model. Accordingly, if the theories and techniques from another model fit with a client’s worldview or if the client initiates such content, it may be used within the change process of solution-focused counseling. The process/content distinction has been used as a metatheoretical lens to describe strategic eclecticism within various models. Process refers to what is done to bring about change (e.g., methods, interventions, and techniques). Content is defined as the object of change in any given clinical theory. Held (1992) has also defined two levels of content: formal content and informal content. Formal content refers to the counselor’s assumptions about problem formation; that is, “explanatory concepts that must be addressed across cases to solve problems.” Informal content refers to the client’s subjective views about the causes of problems. The formal content in solution-focused counseling is problem/exception. Similar to other process-oriented models, this formal content is conceptualized in general terms. The problem is not elaborated beyond the model's problem/exception ascription. Instead, informal content is used as the principal metaphor in treatment. Because the formal content in solution-focused counseling is so general, it allows for the incorporation of formal contents of other models as informal contents that are, in turn, subsumed at the formal content level of solution-focused counseling. In solution-focused counseling, multiculturalism is broadly defined to address various domains, including age, ethnicity, family structure, gender, disability, race, sexual orientation, socioeconomic status, religion, and spirituality. Solution-focused counseling stresses the importance of developing self-awareness, acquiring knowledge, and building skills relevant to clients' diverse cultural worldviews. It is also important for solution-focused counselors to gain an understanding of how the cultural worldviews of their clients influence the formulation of problems and solutions. Accordingly, solution-focused counselors strive to learn the collective worldviews of diverse cultural groups and, also, the subjective perspectives of individuals within these groups. Further, solution-focused counselors recognize how their own worldviews influence clients and hence make efforts to do so in ways that contribute to cocreating constructive therapeutic dialogues. In order to work sensitively and competently with clients from diverse cultural backgrounds, relational questions have been developed to identify and amplify exceptions. Questions such as “Who else in your life will notice when you are functioning better?” “What will they say?” and “If they were here right now, what might they say about the times when the problem is diminished?” can help move a client toward identifying and amplifying exceptions while simultaneously allowing the counselor to gain crucial information about the client’s cultural frame of reference. Solution-focused counseling speaks to Paul’s (1967) suggestion that outcomes be evaluated in relation to how well they address the question of “what treatment by whom, is most effective for this individual, under what set of circumstances.” The multicultural perspective and the strategic approach to eclecticism in solution-focused counseling allows counselors to tailor interventions based on the unique aspects of each client. Any informal content may be used or introduced to frame a problem and solution providing it fits with the client's worldview. Similar to how solution-focused counseling has been used for a variety of clinical problems, this model can be effectively applied to eating disorders. The following case illustrates the application of solution-focused counseling for clients with eating disorders. Lisa, a 27-year-old single Japanese American female, was self-referred for counseling. During the first session, extensive background information was obtained from the client. The client was a graduate student and worked part-time. She had lived with her parents and younger sister since the family moved from Japan to a medium-sized city in the United States. As Lisa began to make friends in the United States, she experienced increasing conflicts with her parents. Lisa reported that she experienced intense confusion about her cultural identity, and had begun to use eating as a way to cope with the stress generated by this uncertainty and her volatile home life. Lisa then began socializing with a circle of acculturated, Asian-American female friends that she met at the university. She participated with these friends in what the group referred to as "puke parties." On Friday evenings, the group would get together to watch movies while binging on food. Toward the end of the evening, each of them would make themselves vomit in front of the group. Lisa soon began to binge and purge on a regular basis when alone as a way to cope with her emotional distress. However, Lisa experienced feelings of guilt following these episodes that, in turn, exacerbated her shame. In particular, she expressed anxiety about the possibility of her parents learning that she was out of control. On the basis of the presentation, the counselor determined that the client met the DSM-IV-TR (2000) criteria for bulimia nervosa. At the end of the first session, the counselor suggested to Lisa that she may be able to come up with alternative ways of coping with conflicts with her parents and herself. The client agreed and expressed motivation to explore ways to break the cycle of her binging and purging. During the second session, Lisa elaborated that she was uncomfortable dealing with two conflicting cultural identities. She explained, “It’s like I’ve got a foot in two worlds, Japanese and American. I'm on shaky ground with both of them.” The client's understanding of the problem was formally conceptualized within solution-focused counseling’s problem/exception formal content as uncomfortable with cultural identity/comfortable with cultural identity. Toward the end of the second session, the counselor asked Lisa to imagine looking into a crystal ball to foresee what her life would look like when she felt more comfortable with her identity. Lisa stated, “I’d be laughing more when I’m with my American friends.” The counselor then asked Lisa to be “on the lookout” for additional exceptions to her problem. During the third session, Lisa reported that she had identified two exceptions to her feelings of cultural confusion. Earlier in the week, Lisa received a high grade on a group presentation at the university. This achievement brought pride to both herself and her parents. Accordingly, Lisa and the counselor identified this academic achievement as an exception. Further, Lisa had befriended another Asian American student while working on a group project in another class. When asked what made spending time with her friend exceptional, Lisa explained, “He’s really funny. He makes me laugh really easily. He doesn’t have any expectations about who I should be like my parents or the girls do.” To build on this exception, Lisa agreed to spend time with her new friend at least once before the next session. Lisa also expressed a willingness to be more mindful of additional exceptions. Research has suggested that cognitive-behavioral interventions are consistent with some Asian cultural values because of its educational approach. Accordingly, during the third session the counselor assessed that the formal content corresponding to rational emotive behavior therapy (REBT; Ellis, 2001), one of the most widely practiced cognitive-behavioral approaches, was a good fit with the client’s worldview. In keeping with solution-focused counseling's strategic eclecticism, the formal content of REBT (i.e., irrational beliefs) was used as informal content for solution-focused counseling's problem/exception theory. The problem was re-conceptualized as irrational beliefs/rational beliefs. More specifically, the counselor helped Lisa identify and challenge irrational beliefs that occasioned her binging and purging as well as her feelings of identity confusion. The change process was organized around helping the client identify and amplify exceptions to irrational beliefs. The client was particularly receptive to REBT's concept of unconditional self-acceptance and during the third session the counselor helped her identify and dispute irrational beliefs that occasioned her feelings of shame. At the end of the third session, the counselor suggested that Lisa obtain and read an REBT self-help book for eating disorders. Subsequent sessions were organized around reviewing the client's progress at using REBT techniques. Each instance in which the client was effective at using REBT techniques was considered an exception that was, in turn, amplified in keeping with the change process of solution-focused counseling. Lisa also reported that she began to feel more comfortable about possessing a dual cultural identity. She stated, “Before, I felt like both cultures were fighting over me. Now, I’m beginning to feel like there is room for me to function both as a Japanese woman and an American one.” Although Lisa was still experiencing some confusion regarding her cultural identity, she reported feeling more accepting of herself despite these discrepancies. During the fourth session, Lisa reported that she decided to break ties with her friends who engaged in binging and purging. By the fifth session, the client reported that she ceased binging and purging, started a healthy diet, and began to associate with a new circle of friends from the university. By the sixth session, the client reported that she seldom, if ever, felt ashamed about anything. She continued to have some conflicts with her parents as well as within herself, but she felt more prepared to deal with these. At the end of the sixth session, the client and counselor agreed that counseling was no longer necessary. A telephone follow-up with the client one year later revealed that Lisa continued abstaining from binging and purging and was maintaining a healthy diet. She also reported that her relationship with her parents was significantly improved. Similar to how solution-focused counseling has been used for a variety of clinical problems, this approach can be effectively applied to eating disorders. In contrast to the prevailing problem-focused treatment approaches for eating disorders, solution-focused counseling emphasizes clients’ resources and emphasizes a collaborative therapeutic relationship to enhance cooperation during the change process. In solution-focused counseling, it is crucial for counselors to gain an understanding of how the worldviews of clients influence problem and goal definitions. In the case example, a thorough assessment of the client's worldview and cultural background informed how the counselor conceptualized problems and tailored interventions. It is especially important for solution-focused counselors to be prepared to develop innovative clinical strategies when working with clients with eating disorders. In particular, we suggest that counselors adopt eclectic strategies within solution-focused approaches to eating disorders. The strategic approach to eclecticism in solution-focused counseling allows for the use of divergent theories and techniques within the change process. An eclectic approach to solution-focused counseling also speaks to the importance of addressing the diversity of clients in a multicultural society. In the case example, although REBT's problem-focused is counter to a solution-focused approach, theories and techniques from REBT were used precisely because it was assessed to fit with the client's worldview. It is suggested that future research be designed to assess outcome effectiveness related to solution-focused counseling applications to eating disorders. Such studies would contribute to establishing best practices in the area of solution-focused approaches to eating disorders and for solution-focused counseling in general. Finally, although we have described in this article a solution-focused approach specific to eating disorders, we have also effectively used this approach for related problems that are experienced by many clients, including addiction, anxiety, and perfectionism. Accordingly, we suggest that solution-focused counseling holds promise as an effective treatment for various clinical issues that are related to eating disorders and which fall along a continuum of severity and type.
中文翻译
进食障碍是《精神障碍诊断与统计手册》第四版修订版（DSM-IV-TR；美国精神病学协会，2000年）中的一个诊断分类，包括严重的饮食行为紊乱。本文提出焦点解决咨询作为进食障碍的有效治疗方法。焦点解决咨询是一种综合临床模型，受到史蒂夫·德·沙泽尔及其在威斯康星州密尔沃基简短家庭治疗中心的同事的开创性工作的影响。我们发现焦点解决咨询是适合进食障碍的模型，因为它是一种基于优势的方法，强调来访者现有和潜在的资源。焦点解决咨询为当前主流的以问题为中心的进食障碍治疗方法提供了替代方案，后者可能在改变过程中引发抵抗。此外，该模型与德·沙泽尔开发的焦点解决方法不同，因为它融入了对咨询至关重要的特征，包括多元文化视角和折衷方法。已有少数针对进食障碍的焦点解决方法被开发出来。伯格和斯坦纳（2003年）描述了使用焦点解决疗法治疗儿童进食障碍。奥哈洛兰（1999年）描述了使用焦点解决方法处理包含神经性厌食症青少年的家庭。焦点解决技术也已在艺术治疗模型和多模式预防治疗项目中用于进食障碍。此外，叙事疗法——一种与焦点解决模型相似但不同的方法——已被应用于进食障碍。然而，迄今为止，文献中尚未发现包含咨询重要特征（如多元文化主义、折衷主义）的全面焦点解决方法。由于进食障碍的患病率相对较高，预计大多数咨询师在某个时候会遇到患有这些疾病的来访者。因此，咨询师制定有效的进食障碍治疗策略非常重要。本文的目的是将焦点解决咨询作为治疗进食障碍的有价值模型进行介绍，并说明其原则如何应用于各种治疗互动。本文的组织结构如下。首先，描述与进食障碍相关的各种问题，包括病因、共病和治疗。接下来，描述焦点解决咨询的理论和实践。然后，提供一个案例示例，说明焦点解决咨询在进食障碍中的应用。最后，讨论与进食障碍相关的焦点解决咨询实践和研究的意义和建议。在焦点解决咨询中，问题意味着例外的存在，即应用积极应对技能或问题得到解决的时刻。焦点解决咨询预设问题总是存在例外（实际或潜在的）。在焦点解决咨询中，临床问题被正式概念化为问题/例外。焦点解决咨询通常包括五个阶段，可以以多种不同方式应用：（a）共同构建问题定义和相应目标，（b）识别和放大问题的例外，（c）分配任务，（d）评估任务的有效性，以及（e）重新评估问题和目标。在第一阶段，来访者和咨询师合作共同构建问题定义和目标。问题定义被纳入问题/例外概念化中。例如，如果来访者将问题定义为对焦虑的无效应对，那么问题将被概念化为对焦虑的无效应对/对焦虑的有效应对。改变过程将涉及识别和放大来访者有效应对焦虑的时刻。在第二阶段，使用预设性问题帮助来访者识别例外。例如，咨询师问：“什么时候你更好地应对了问题？”而不是“有没有什么时候你更好地应对了问题？”前一个问题带有对例外的期望，并鼓励来访者重新评估他们与问题的关系。通过鼓励来访者多做过去帮助他们成功应对问题的行为，观察当前他们更好地处理问题的时刻，并赋予例外重要和积极的意义来放大例外。如果识别出例外，咨询师会通过各种问题帮助来访者放大例外。例如：“你是怎么做到的？”“这（即例外）说明了你和解决问题的能力什么？”以及“有哪些可能性？”如果来访者无法识别例外，咨询师可能会鼓励他们考虑发生的微小但积极的变化。如果来访者仍然报告没有例外，那么咨询师会尝试识别潜在的例外。旨在识别潜在例外的问题可能是：“当你更好地处理问题时，会是什么样子？”这个问题源自水晶球技术，一种鼓励来访者在假设的未来某个时间想象自己处于更高功能水平的方法。类似的技术，称为奇迹问题，将来访者的想象力集中在未来的例外上：“假设有一天晚上发生了一个奇迹，当你睡觉时，带来治疗的问题解决了：你会怎么知道？会有什么不同？”在第三阶段，分配任务以建立在先前阶段取得的进展上。此阶段旨在澄清和建立在先前会话中取得的进展，包括定义问题、设定目标以及识别和放大例外。第四阶段涉及评估任务的有效性。在此阶段，咨询师跟进先前会话中给出的任务。这可能涉及帮助来访者澄清问题、目标，并识别和放大源自先前会话中给出的任务的例外。第五阶段，重新评估问题和目标，涉及来访者和咨询师检查治疗进展与目标达成程度的匹配情况。在此阶段，咨询要么继续，要么终止。如果目标已达到或来访者在目标上取得显著进展，那么咨询师可能会询问来访者此时是否需要进一步咨询。理想情况下，来访者和咨询师就终止达成共识。如果来访者表示需要进一步咨询，那么问题和目标将被重构。咨询未完成的论点表明目标尚未令人满意地构建或达成。来访者可能表示一个目标已达到，并且有一个新目标。在这种情况下，帮助来访者重新检查和澄清问题和目标非常重要。行动计划可能需要更可实现、更具体和/或更与来访者问题相关。焦点解决咨询中的折衷战略方法允许在我们的模型中兼容、系统和有效地使用不同的理论和技术。因此，如果另一个模型的理论和技术符合来访者的世界观，或者来访者发起此类内容，则可以在焦点解决咨询的改变过程中使用。过程/内容区别已被用作元理论镜头来描述各种模型中的战略折衷主义。过程指的是为带来改变所做的事情（例如，方法、干预和技术）。内容被定义为任何给定临床理论中的改变对象。赫尔德（1992年）还定义了两个内容层次：正式内容和非正式内容。正式内容指的是咨询师关于问题形成的假设；即“必须跨案例解决的解释性概念”。非正式内容指的是来访者对问题原因的主观看法。焦点解决咨询中的正式内容是问题/例外。与其他过程导向模型类似，这种正式内容以一般术语概念化。问题不会超出模型的问题/例外归属进行详细阐述。相反，非正式内容被用作治疗中的主要隐喻。因为焦点解决咨询中的正式内容非常一般，它允许将其他模型的正式内容作为非正式内容纳入，这些内容反过来又被纳入焦点解决咨询的正式内容层次。在焦点解决咨询中，多元文化主义被广泛定义以解决各种领域，包括年龄、民族、家庭结构、性别、残疾、种族、性取向、社会经济地位、宗教和灵性。焦点解决咨询强调发展自我意识、获取知识和建立与来访者多元文化世界观相关技能的重要性。焦点解决咨询师理解来访者的文化世界观如何影响问题和解决方案的制定也很重要。因此，焦点解决咨询师努力了解不同文化群体的集体世界观，以及这些群体内个体的主观视角。此外，焦点解决咨询师认识到自己的世界观如何影响来访者，并因此努力以有助于共同创造建设性治疗对话的方式行事。为了敏感和胜任地与来自不同文化背景的来访者合作，已经开发了关系性问题来识别和放大例外。例如：“你生活中还有谁会注意到你功能更好时？”“他们会说什么？”以及“如果他们现在在这里，他们可能会对问题减轻的时刻说什么？”这样的问题可以帮助来访者识别和放大例外，同时让咨询师获得关于来访者文化参照框架的关键信息。焦点解决咨询回应了保罗（1967年）的建议，即结果应根据其如何解决“在什么情况下，由谁提供什么治疗对这个人最有效”的问题进行评估。焦点解决咨询中的多元文化视角和折衷战略方法允许咨询师根据每个来访者的独特方面定制干预措施。任何非正式内容都可以使用或引入来构建问题和解决方案，只要它符合来访者的世界观。类似于焦点解决咨询如何用于各种临床问题，该模型可以有效地应用于进食障碍。以下案例说明了焦点解决咨询在进食障碍来访者中的应用。丽莎，一位27岁的单身日裔美国女性，自我转介进行咨询。在第一次会话中，从来访者那里获得了广泛的背景信息。来访者是一名研究生，兼职工作。自从家人从日本搬到美国一个中等城市以来，她一直与父母和妹妹住在一起。当丽莎开始在美国交朋友时，她与父母的冲突日益加剧。丽莎报告说，她对自己的文化身份感到强烈困惑，并开始用饮食来应对这种不确定性和动荡家庭生活带来的压力。丽莎然后开始与她在大学遇到的一群已适应文化的亚裔美国女性朋友交往。她与这些朋友参与了该群体所称的“呕吐派对”。周五晚上，该群体会聚在一起看电影，同时暴饮暴食。在晚上结束时，她们每个人都会在群体面前让自己呕吐。丽莎很快开始定期独自暴食和催吐，以应对她的情绪困扰。然而，丽莎在这些事件后感到内疚，这反过来加剧了她的羞耻感。特别是，她表达了对父母可能知道她失控的焦虑。根据表现，咨询师确定来访者符合DSM-IV-TR（2000年）对神经性贪食症的标准。在第一次会话结束时，咨询师建议丽莎可能能够想出替代方法来应对与父母和自己的冲突。来访者同意并表示有动力探索打破暴食和催吐循环的方法。在第二次会话中，丽莎详细说明她对处理两种冲突的文化身份感到不舒服。她解释说：“就像我一只脚踩在两个世界，日本和美国。我在两者上都立足不稳。”来访者对问题的理解在焦点解决咨询的问题/例外正式内容中被正式概念化为对文化身份不舒服/对文化身份舒服。在第二次会话结束时，咨询师要求丽莎想象看水晶球，预见当她对自己的身份感到更舒服时，她的生活会是什么样子。丽莎说：“我和美国朋友在一起时会笑更多。”然后咨询师要求丽莎“留意”她问题的额外例外。在第三次会话中，丽莎报告说她识别出了两种对她文化困惑感的例外。本周早些时候，丽莎在大学的小组演示中获得了高分。这一成就给她自己和父母带来了自豪感。因此，丽莎和咨询师将这一学业成就识别为例外。此外，丽莎在另一门课的小组项目中结识了另一位亚裔美国学生。当被问及什么使与朋友共度时光成为例外时，丽莎解释说：“他真的很搞笑。他让我很容易笑。他对我应该像父母或女孩们那样没有任何期望。”为了建立在这个例外上，丽莎同意在下一次会话前至少与新朋友共度一次时光。丽莎还表示愿意更加留意额外的例外。研究表明，认知行为干预与一些亚洲文化价值观一致，因为其教育方法。因此，在第三次会话中，咨询师评估与理性情绪行为疗法（REBT；埃利斯，2001年）——最广泛实践的认知行为方法之一——相对应的正式内容与来访者的世界观非常契合。遵循焦点解决咨询的战略折衷主义，REBT的正式内容（即非理性信念）被用作焦点解决咨询的问题/例外理论的非正式内容。问题被重新概念化为非理性信念/理性信念。更具体地说，咨询师帮助丽莎识别和挑战引发她暴食和催吐以及身份困惑感的非理性信念。改变过程围绕帮助来访者识别和放大非理性信念的例外来组织。来访者对REBT的无条件自我接纳概念特别接受，在第三次会话中，咨询师帮助她识别和辩驳引发她羞耻感的非理性信念。在第三次会话结束时，咨询师建议丽莎获取并阅读一本关于进食障碍的REBT自助书。随后的会话围绕回顾来访者使用REBT技术的进展来组织。来访者有效使用REBT技术的每个实例都被视为例外，并按照焦点解决咨询的改变过程进行放大。丽莎还报告说，她开始对拥有双重文化身份感到更舒服。她说：“以前，我觉得两种文化都在争夺我。现在，我开始觉得有空间让我既作为日本女性又作为美国女性发挥作用。”尽管丽莎仍然对自己的文化身份感到一些困惑，但她报告说尽管存在这些差异，她更能接受自己。在第四次会话中，丽莎报告说她决定与参与暴食和催吐的朋友断绝关系。到第五次会话时，来访者报告说她停止了暴食和催吐，开始了健康饮食，并开始与大学的新朋友圈交往。到第六次会话时，来访者报告说她很少（如果有的话）对任何事情感到羞耻。她与父母以及自己内部仍然有一些冲突，但她感觉更有准备处理这些。在第六次会话结束时，来访者和咨询师同意咨询不再必要。一年后的电话随访显示，丽莎继续戒除暴食和催吐，并保持健康饮食。她还报告说与父母的关系显著改善。类似于焦点解决咨询如何用于各种临床问题，该方法可以有效地应用于进食障碍。与当前主流的以问题为中心的进食障碍治疗方法相比，焦点解决咨询强调来访者的资源，并强调协作治疗关系以增强改变过程中的合作。在焦点解决咨询中，咨询师理解来访者的世界观如何影响问题和目标定义至关重要。在案例示例中，对来访者世界观和文化背景的全面评估影响了咨询师如何概念化问题和定制干预措施。焦点解决咨询师在与进食障碍来访者合作时，准备好制定创新临床策略尤为重要。特别是，我们建议咨询师在进食障碍的焦点解决方法中采用折衷策略。焦点解决咨询中的折衷战略方法允许在改变过程中使用不同的理论和技术。焦点解决咨询的折衷方法也回应了在多元文化社会中解决来访者多样性的重要性。在案例示例中，尽管REBT的以问题为中心与焦点解决方法相反，但REBT的理论和技术被使用正是因为评估其符合来访者的世界观。建议未来的研究设计评估与焦点解决咨询应用于进食障碍相关的结果有效性。此类研究将有助于建立进食障碍焦点解决方法领域以及焦点解决咨询总体上的最佳实践。最后，尽管我们在本文中描述了针对进食障碍的焦点解决方法，但我们也有效地将该方法用于许多来访者经历的相关问题，包括成瘾、焦虑和完美主义。因此，我们认为焦点解决咨询有望成为与进食障碍相关的各种临床问题的有效治疗方法，这些问题在严重程度和类型上存在连续体。
文章概要
本文基于关键词“Exception analysis in SFBT for eating disorder recovery”，介绍了焦点解决咨询作为进食障碍有效治疗方法的理论和应用。文章首先概述了进食障碍的定义、类型和流行病学数据，强调其高患病率和治疗挑战。核心部分详细阐述了焦点解决咨询的理论基础，特别是问题/例外概念化，以及五个阶段：共同构建问题与目标、识别和放大例外、分配任务、评估任务有效性、重新评估问题与目标。文章通过一个日裔美国女性丽莎的案例，具体展示了如何应用例外分析来帮助进食障碍康复，包括使用水晶球技术、奇迹问题等识别和放大例外，并结合理性情绪行为疗法等折衷策略。文章强调焦点解决咨询的优势在于其基于优势、多元文化和折衷的方法，能够有效应对进食障碍的复杂性，并展望了未来研究和应用的可能性。
高德明老师的评价
用12岁初中生可以听懂的语音来重复翻译的内容：这篇文章讲的是，有一种叫“焦点解决咨询”的方法，可以帮助那些吃饭有问题的人，比如暴饮暴食或者不吃东西。这个方法很特别，它不总盯着问题看，而是去找那些“例外”时刻——就是有时候你做得好的时候，比如能控制住自己不吃太多，或者心情好时吃得健康。就像丽莎姐姐，她一开始总因为文化身份困惑而乱吃东西，但咨询师帮她找到了例外，比如她考试考得好、交了个搞笑的朋友，这些让她感觉变好了，慢慢就不暴食了。这个方法就像寻宝游戏，找到你已有的优点和成功时刻，然后让它们变得更多！ 焦点解决心理学理论评价：从焦点解决心理学视角看，这篇文章精彩地展示了例外分析在进食障碍康复中的核心作用。文章强调问题/例外概念化，这完美体现了SFBT的核心理念：问题中总蕴含着例外，改变始于识别和放大这些例外。通过预设性问题、水晶球技术和奇迹问题，咨询师引导来访者从问题导向转向解决方案导向，这充分展现了SFBT的建构性和未来导向性。案例中丽莎的康复过程，正是通过识别学业成就和友谊等例外，逐步构建新身份和应对策略，这验证了SFBT“小改变引发大变化”的原则。文章还突出了SFBT的多元文化和折衷整合能力，将REBT等理论融入例外分析框架，显示了SFBT的灵活性和适应性。这种以优势为基础、聚焦可能性的方法，为进食障碍治疗提供了充满希望的新路径。 在实践上可以应用的领域和可以解决人们的十个问题：焦点解决咨询的例外分析可广泛应用于心理健康、教育、职场和家庭等多个领域。具体可以解决人们的十个问题包括：1. 帮助进食障碍患者识别和放大健康饮食的例外时刻，促进康复；2. 协助焦虑个体发现平静或应对成功的例外，减少焦虑发作；3. 支持抑郁者找到情绪稍好的例外，逐步提升情绪；4. 引导成瘾者识别戒断或控制的例外，增强戒断动力；5. 帮助完美主义者发现接受不完美的例外，减轻压力；6. 协助人际关系困扰者找到和谐互动的例外，改善关系；7. 支持学业或工作压力大者识别高效或轻松的例外，提升表现；8. 引导身份困惑者（如文化冲突）找到认同感的例外，增强自我接纳；9. 帮助家庭冲突成员发现和平相处的例外，促进家庭和谐；10. 协助创伤后应激者识别安全或平静的例外，加速恢复。这些应用都聚焦于来访者已有的资源和可能性，通过例外分析实现积极改变。