焦点解决疗法结合暴露疗法提升强迫症患者治疗动机

英文原文

Clinicians Only: What I do during an exposure to help increase client motivation and engagement - Solution Focused Brief Therapy combined with Exposure and Response Prevention (ERP) I’ve always had an interest in brief therapy modalities. I began introducing concepts of Solution Focused Brief Therapy (SFBT) with my OCD and anxiety patients many years ago, but never really have come across other professionals who use SFBT in their ERP work. This article explores how I have used SFBT and combined it with Exposure and Response Prevention to help increase patient engagement and motivation throughout the therapy process. SFBT is excellent in helping patients focus more on what they are able to think, feel and act in ways that help them move toward their goals. Part of the process of SFBT is to emphasize goals and ways in which clients are already moving toward them. Of course, some of these goals may be inconsistent or incomplete, but highlighting what they’ve done to help move closer to their goals is part of the SFBT process. What I do during exposure exercises with a client: Goal setting is particularly important when it comes to SFBT work. During an exposure, I will have my clients speak about their goals for therapy. This is an opportunity for you to correct any misconceptions they may have about their goals for treatment. Sample questions may be ‘What does 10 out of 10 recovery look like when it comes to your OCD?” or “If a miracle happened and your OCD was managed well, what would that look like.” Make sure that the goals are stated in a positive form and realistic. If the client indicates that their miracle would include their OCD going away, you can educate them on what healthy recovery looks like. A client may say “I would like to feel less anxious” however, this statement lacks detail. The therapist may want to consider asking what they would be doing if they were tolerating the anxiety better or what would be different in their life if they were managing their anxiety better. Questions that may be helpful for you to ask the client include: What would be different, how would your partner know that things are different in how well you are managing your OCD? Lastly, goals need to be stated in the active form. Help them focus on what they would be doing differently if they had their OCD managed well. Actively framing the goals helps build tasks for therapy. A goal stated in the active form may be “I will work on exposures daily for at least one hour.” Example: If I were managing my OCD well at a 10 out of 10 it would look like me practicing my exposures for at least 1 hour per day. Meditating at least 20 mins per day. Focusing on my school and engaging with my partner more. I would be exercising regularly (at least 30 mins per day) and making sure that I am going to sleep at 10 pm every day. After I ask the client the question about what a 10 out of 10 would look like in OCD recovery, I ask on a scale of 1-10 (where 1 is poorly managing your OCD and 10 is managing your OCD well) where they are on that scale. If the client responds with a number lower than a 10 (for example a 5 out of 10), it would be worthwhile asking what would they need to do to get to a 6 out of 10 today (one increment higher than their present place value). It’s important that you do ask them what they can do today as it helps empower them to see that there are things that they can do that can help them move closer to their goal. Example: If I were at a 6 out of 10 in my OCD recovery I would be doing the exposures we talked about in session that are more tolerable. I would be waking up 10 mins earlier to practice my meditation. I’d be going out for walks every day. I would be listening to my OCD scripts on repeat throughout the day. I would then ask them what they envision a 7 out of 10 in OCD recovery looks like and have them write it out (two increments higher). Lastly, I would have them write out any barriers that may get in the way of them getting to a 6 out of 10 and 7 out of 10 in their OCD recovery. For each barrier, I will have them come up with a plan of how to manage with each. The next session: I would have them revisit each written statement at the next session (likely mid-exposure as well). I’ll also ask them to rerate where they are on a scale of 1-10 in their OCD recovery. They are to repeat the process again by evaluating where they are by reading the 10 out of 10 statement and come up with a new statement based on where they are on the scale. For example. If they are now at a 6 out of 10, I’ll have them revisit the 7 out of 10 statement and make any necessary changes. I will then have them create a new statement for 8 out of 10. Another discussion about barriers would follow. Many would argue that engaging in such discourse with the client would limit the exposure. I do caution that the practitioner considers when it would be appropriate to use the suggested techniques. If the practitioner believes it would serve as a distraction it may be best to engage with the material at a later time (outside of the exposure). If the exposure situation is created so that the client cannot 'escape' the exposure after the session, I would be more willing to engage the client mid-exposure. For instance, if I had the client take a cloth and rub it on a contaminant and rub that on themselves, their possessions and their surroundings I would be more inclined to implement SFBT techniques during the exposure. For those interested in how I implement solution-focused brief therapy strategies on an ongoing basis throughout my therapy program, please read below: There are specific elements that I have taken from SFBT that I found useful when working with ERP clients: 1) A search for progression change 2) Goal setting 3) Use of the miracle question 4) Use of scaling questions 5) A search for exceptions 6) A message including compliments and a task. Search for Progression Change: After conducting my assessment with a client, I often encourage the client to be on the lookout for any changes that may occur between the time of our assessment and the next meeting. Many people attending session are likely feeling discouraged and frustrated with their OCD or have likely had OCD therapy in the past that has failed. I often provide reading material after the first session to help them understand more about their OCD and what treatment looks like. It is unlikely that significant change would happen after an assessment appointment, but it is likely that the client has taken some steps that may help them see that they are already doing things to create positive changes in their recovery. Inquiring at the next meeting if a slight change has occurred is imperative to the process. This provides an opportunity to inquire about what they may have been doing differently and how some of their symptoms may have changed. Dewan, Steenbarger, and Greenberg (2004) made the important point that the language in which discussion of how pre-session change proceeds is important: It frames such change as something the client is doing rather than as something happening to the client. Clients often feel discouraged and demotivated when attending OCD sessions, helping them by pointing out that they are already doing something that produces change can help them feel in control. Questions the elicit change talk could include: What have you done differently since reading the material I sent? Have you noticed any changes in your thinking about your OCD that you think would be helpful? How are you beginning to see your OCD/anxiety differently that could create change today? If there are no results to be reported, simply reminding them that change does not typically happen all at once is important. However, your goal is to attempt to find ‘change talk’ in their dialogue. Therapists can also use scaling tools to identify change. A follow-up inquiry could be “You mentioned feeling anxious attending the last session. On a scale of 1-10 (1 low anxiety and 10 high anxiety) how anxious were you and what is it at today? If it is lower, the therapist can ask what they specifically have done to help bring it down. If they do report a decrease help them identify action items that they have done that have helped them. The therapist may want to provide encouragement and promote more of the activity that has helped them (if productive for the therapy goal and aligns with OCD treatment protocol). If they performed a ritual or safety behaviour to attend the session it may be helpful to educate them on healthier coping strategies. Ongoing Sessions: I often search for change by asking a question at the beginning of our therapy work. I usually ask questions centred around change after they have been exposed to an OCD-related reading. For example, I may ask, “Can you tell me three positives as to how you are seeing the OCD differently, since our last session?” and “What changes have you made since our last session since reading the material I suggested?”. Ritual Reduction: Goals are stated in the here and now. When goals are created in the therapy session it is useful to help bridge the gap between what the future goal is and what they can do today. For instance, if the client’s goal is to hang out with her daughter who she believes is contaminated, it may be helpful during the ritual reduction stage to help the client navigate how they can do that this week and become more tolerable to it. Therefore the goal may look like “This week I am going to attempt to sit with my daughter while watching a movie in the living room until the anxiety goes down to zero.” When I do these types of ritual reduction strategies, I always check in with the client to see what they are willing to do this week and build a plan around their agreed ritual reductions. Focusing on specific attainable goals will help the client feel in control and recognize that they can act to create change. I often create a chart to help them observe their progress in ritual and anxiety reduction. Searching for Exceptions Searching for exceptions in their dialogue will help the client recognize that they are already doing things to help create change in their life. A client may say that they feel hopeless that they are not tackling their ritual reductions or exposures as they should. A therapist might say “None of us are perfect, but I can’t believe you are not engaging with any of the material that you have been exposed to in some way. Can you tell me more about how that may have happened this week? You may also say “Tell me how you are thinking about the material when you do have a minute to think about your OCD recovery?” At times it may be even helpful to side with them on their ‘extreme self-presentation.’ This may look like agreeing that they don’t seem to have enough time to devote the energy they need to commit to therapy and they come back at a time when they are ready to commit. This may open the dialogue as to what they can do to change if they wish and what they are doing differently between sessions. Some clients may ‘fight’ to stay in therapy once you agree with them that they may not be ready. Compliments and Reviewing the Task Compliments are helpful and are used to affirm the client’s strengths. The compliment helps the client by conveying that they have real strengths and that their strengths are being used in sessions already to help achieve their goals. Each session provide a task for the client. Initially, this could be homework or ritual reduction. Later on, this could be an exposure exercise or core belief record (if you are using CBT).

中文翻译

仅供临床医生参考：我在暴露疗法中如何提升来访者动机和参与度——焦点解决短期疗法结合暴露与反应阻止疗法 我一直对短期治疗模式很感兴趣。多年前，我开始向我的强迫症和焦虑症患者介绍焦点解决短期疗法（SFBT）的概念，但从未真正遇到过其他在ERP工作中使用SFBT的专业人士。本文探讨了我如何运用SFBT并将其与暴露与反应阻止疗法结合，以在整个治疗过程中提升患者的参与度和动机。 SFBT在帮助患者更多地关注他们能够思考、感受和行动的方式，以朝着目标前进方面非常出色。SFBT过程的一部分是强调目标以及来访者已经在朝着这些目标前进的方式。当然，其中一些目标可能不一致或不完整，但突出他们为更接近目标所做的努力是SFBT过程的一部分。 我在与来访者进行暴露练习时的做法： 目标设定在SFBT工作中尤为重要。在暴露过程中，我会让来访者谈论他们的治疗目标。这是你纠正他们对治疗目标可能存在的任何误解的机会。示例问题可能是“当谈到你的强迫症时，10分满分（10 out of 10）的康复是什么样子？”或“如果奇迹发生，你的强迫症得到良好管理，那会是什么样子。”确保目标以积极和现实的形式陈述。如果来访者表示他们的奇迹包括强迫症消失，你可以教育他们什么是健康的康复。 来访者可能会说“我希望感觉不那么焦虑”，然而，这种陈述缺乏细节。治疗师可能要考虑询问如果他们更好地耐受焦虑，他们会做什么，或者如果他们更好地管理焦虑，他们的生活会有什么不同。 可能对你有帮助的问题包括：会有什么不同，你的伴侣如何知道你管理强迫症的方式有所不同？ 最后，目标需要以主动形式陈述。帮助他们专注于如果他们的强迫症得到良好管理，他们会做什么不同的事情。积极构建目标有助于为治疗建立任务。以主动形式陈述的目标可能是“我将每天至少进行一小时的暴露练习。” 示例： 如果我的强迫症管理得非常好，达到10分满分，那会是我每天至少练习暴露一小时。每天至少冥想20分钟。专注于我的学业并与伴侣更多互动。我会定期锻炼（每天至少30分钟）并确保每晚10点睡觉。 在我询问来访者关于强迫症康复10分满分是什么样子的问题后，我会问他们在1-10的量表上（其中1是管理强迫症很差，10是管理强迫症很好）他们处于哪个位置。如果来访者回答的数字低于10（例如5分），值得询问他们今天需要做什么才能达到6分（比当前位置高一个增量）。重要的是你要问他们今天能做什么，因为这有助于赋予他们力量，让他们看到有些事情他们可以做，以帮助他们更接近目标。 示例： 如果我的强迫症康复处于6分，我会做我们在会谈中讨论过的更可耐受的暴露练习。我会早起10分钟练习冥想。我会每天出去散步。我会整天重复听我的强迫症脚本。 然后我会问他们想象强迫症康复7分是什么样子，并让他们写下来（高两个增量）。最后，我会让他们写出可能阻碍他们达到强迫症康复6分和7分的任何障碍。对于每个障碍，我会让他们想出如何应对的计划。 下一次会谈： 我会让他们在下次会谈（可能也在暴露过程中）重新审视每个书面陈述。我还会要求他们重新评估他们在强迫症康复量表上的位置。他们通过阅读10分满分陈述来评估自己的位置，并根据量表上的位置提出新的陈述，重复这个过程。例如，如果他们现在处于6分，我会让他们重新审视7分陈述并进行必要的修改。然后我会让他们为8分创建一个新的陈述。随后会进行另一次关于障碍的讨论。 许多人会认为与来访者进行这样的对话会限制暴露。我确实提醒从业者考虑何时适合使用建议的技术。如果从业者认为这会分散注意力，最好在稍后时间（暴露之外）处理材料。如果暴露情境被创建为来访者在会谈后无法“逃避”暴露，我更愿意在暴露过程中与来访者互动。例如，如果我让来访者拿一块布在污染物上擦拭，然后擦拭自己、他们的物品和周围环境，我更倾向于在暴露过程中实施SFBT技术。 对于那些对我如何在治疗计划中持续实施焦点解决短期疗法策略感兴趣的人，请阅读以下内容： 我从SFBT中提取了特定元素，发现在与ERP来访者工作时很有用： 1) 寻找进展性变化 2) 目标设定 3) 使用奇迹问题 4) 使用量表问题 5) 寻找例外 6) 包含赞美和任务的信息。 寻找进展性变化： 在与来访者进行评估后，我经常鼓励来访者留意从评估到下次会议之间可能发生的任何变化。许多参加会谈的人可能对强迫症感到沮丧和挫败，或者可能过去有过失败的强迫症治疗。我经常在第一次会谈后提供阅读材料，帮助他们更多地了解强迫症和治疗的样子。评估预约后不太可能发生重大变化，但来访者可能已经采取了一些步骤，帮助他们看到自己已经在做一些事情来创造康复中的积极变化。在下一次会议中询问是否发生了轻微变化对这一过程至关重要。这提供了一个机会，询问他们可能做了什么不同的事情，以及他们的一些症状可能如何改变。Dewan、Steenbarger和Greenberg（2004）提出了重要观点：讨论会前变化如何进行的语言很重要：它将这种变化框定为来访者正在做的事情，而不是发生在来访者身上的事情。来访者在参加强迫症会谈时常常感到沮丧和动力不足，通过指出他们已经在做一些产生变化的事情来帮助他们，可以让他们感到掌控。 引发变化谈话的问题可能包括： 自从阅读我发送的材料后，你做了什么不同的事情？ 你是否注意到关于强迫症思维的任何变化，你认为会有帮助？ 你今天如何开始以不同的方式看待强迫症/焦虑，从而创造变化？ 如果没有结果可报告，简单地提醒他们变化通常不会一下子发生是重要的。然而，你的目标是尝试在他们的对话中找到“变化谈话”。治疗师也可以使用量表工具来识别变化。后续询问可能是“你提到上次会谈时感到焦虑。在1-10的量表上（1低焦虑，10高焦虑）你当时有多焦虑，今天是多少？如果降低了，治疗师可以询问他们具体做了什么来降低它。如果他们确实报告了下降，帮助他们识别他们所做的有助于他们的行动项目。治疗师可能希望提供鼓励并促进更多有助于他们的活动（如果对治疗目标有益且符合强迫症治疗方案）。如果他们为了参加会谈而进行了仪式或安全行为，教育他们更健康的应对策略可能有所帮助。 持续会谈： 我经常通过在治疗工作开始时提问来寻找变化。我通常在来访者接触强迫症相关阅读后提出以变化为中心的问题。例如，我可能会问，“你能告诉我自从上次会谈以来，你如何看待强迫症的三个积极方面？”和“自从上次会谈阅读我建议的材料后，你做了什么改变？”。 仪式减少： 目标以此时此地的形式陈述。当在治疗会谈中创建目标时，有助于弥合未来目标与他们今天能做什么之间的差距。例如，如果来访者的目标是与她认为被污染的女儿共度时光，在仪式减少阶段帮助来访者导航他们本周如何做到这一点并变得更能耐受它可能有所帮助。因此，目标可能看起来像“本周我将尝试与女儿一起在客厅看电影，直到焦虑降为零。”当我进行这些类型的仪式减少策略时，我总是与来访者确认他们本周愿意做什么，并围绕他们同意的仪式减少制定计划。专注于具体可实现的目标将帮助来访者感到掌控，并认识到他们可以采取行动创造变化。我经常创建一个图表来帮助他们观察仪式和焦虑减少的进展。 寻找例外： 在他们的对话中寻找例外将帮助来访者认识到他们已经在做一些事情来帮助创造生活中的变化。来访者可能会说他们感到绝望，因为他们没有像应该那样处理仪式减少或暴露。治疗师可能会说“我们都不完美，但我无法相信你完全没有以某种方式参与你接触过的材料。你能告诉我更多关于本周这可能如何发生的吗？你也可以说“告诉我当你有时间思考强迫症康复时，你如何思考这些材料？”有时，甚至在他们“极端自我呈现”方面站在他们一边可能有所帮助。这可能看起来像同意他们似乎没有足够的时间投入治疗所需的精力，他们可以在准备好承诺时回来。这可能开启关于如果他们愿意，他们可以做什么改变，以及他们在会谈之间做了什么不同的事情的对话。一些来访者一旦你同意他们可能没有准备好，可能会“争取”留在治疗中。 赞美和回顾任务： 赞美是有帮助的，用于肯定来访者的优势。赞美通过传达他们拥有真正的优势，并且他们的优势已经在会谈中被用来帮助实现目标，从而帮助来访者。每次会谈为来访者提供一个任务。最初，这可能是家庭作业或仪式减少。后来，这可能是一个暴露练习或核心信念记录（如果你在使用CBT）。

文章概要

本文探讨了如何将焦点解决短期疗法（SFBT）与暴露与反应阻止疗法（ERP）结合，以提升强迫症患者的治疗动机和参与度。文章详细介绍了在暴露练习中使用SFBT技术的方法，包括目标设定、奇迹问题、量表问题等，强调通过积极构建目标、寻找进展性变化和例外，以及提供赞美来增强患者的掌控感和动力。作者分享了具体案例和策略，如仪式减少和变化谈话，旨在帮助临床医生在治疗中有效整合SFBT，促进患者康复。

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