英文原文
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. 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.” 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. 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. 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
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治疗（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。本文探讨了我如何使用SFBT并将其与暴露与反应预防相结合，以在整个治疗过程中提高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，以帮助他们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客户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，但突出他们为帮助更接近目标所做的事情是SFBT过程的一部分。目标设定在SFBT工作中尤为重要。在暴露过程中，我会让我的客户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“对于你的强迫症，10分满分恢复是什么样子？”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。如果客户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恢复。客户可能会说“我希望感觉不那么焦虑”，然而，这种说法缺乏细节。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情况有所不同？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“我将每天进行至少一小时的暴露练习。”在我询问客户关于强迫症恢复10分满分是什么样子的问题后，我会询问他们在1-10的评分表上处于什么位置（其中1表示管理强迫症很差，10表示管理强迫症很好）。如果客户回答的数字低于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）。重要的是你确实询问他们今天能做什么，因为这有助于赋予他们权力，让他们看到有些事情他们可以做，可以帮助他们更接近目标。然后我会询问他们设想强迫症恢复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恢复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每个障碍的计划。下一次会谈：我会让他们在下次会谈中重新审视每个书面陈述（可能也在暴露过程中）。我还会要求他们重新评估他们在强迫症恢复中在1-10评分表上的位置。他们需要再次通过阅读10分满分陈述来评估自己的位置，并根据他们在评分表上的位置提出新的陈述。例如，如果他们现在处于6分，我会让他们重新审视7分陈述并进行任何必要的修改。然后我会让他们为8分创建一个新的陈述。接着会进行另一次关于障碍的讨论。许多人会认为与客户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，使得客户在会谈后无法“逃避”暴露，我更愿意在暴露过程中与客户互动。例如，如果我让客户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。我从SFBT中提取了一些特定元素，发现在与ERP客户工作时很有用：1）寻找进展变化 2）目标设定 3）使用奇迹问题 4）使用评分问题 5）寻找例外 6）包含赞美和任务的信息。寻找进展变化：在与客户进行评估后，我经常鼓励客户留意我们的评估和下次会议之间可能发生的任何变化。许多参加会议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，以帮助他们更多地了解他们的强迫症以及治疗是什么样子。评估预约后不太可能发生重大变化，但客户可能已经采取了一些步骤，可能帮助他们看到他们已经在做一些事情来创造恢复中的积极变化。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变化。Dewan、Steenbarger和Greenberg（2004）提出了重要观点，即讨论会谈前变化如何进行的语言很重要：它将这种变化框定为客户正在做的事情，而不是发生在客户身上的事情。客户在参加强迫症会谈时经常感到沮丧和动力不足，通过指出他们已经做了产生变化的事情来帮助他们，可以帮助他们感到掌控感。引发变化谈话的问题可能包括：自从阅读我发送的材料以来，你做了什么不同的事情？你是否注意到关于你的强迫症的任何变化，你认为会有帮助？你如何开始以不同的方式看待你的强迫症/焦虑，从而今天创造变化？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”。治疗师也可以使用评分工具来识别变化。后续询问可能是“你提到上次会谈时感到焦虑。在1-10的评分表上（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帮助降低它。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）。如果他们执行了仪式或安全行为来参加会议，教育他们更健康的应对策略可能是有帮助的。持续会谈：我经常通过在治疗工作开始时提问来寻找变化。我通常在客户接触强迫症相关阅读材料后提出围绕变化的问题。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“自从阅读我建议的材料以来，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和今天能做什么之间的差距。例如，如果客户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客户导航他们本周如何做到这一点并变得更能耐受它可能是有帮助的。因此，目标可能看起来像“本周我将尝试在客厅看电影时与女儿坐在一起，直到焦虑降为零。”当我进行这些类型的仪式减少策略时，我总是与客户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客户感到掌控感，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他们在仪式和焦虑减少方面的进展。寻找例外：在他们的对话中寻找例外将帮助客户认识到他们已经在做一些事情来帮助创造生活中的变化。客户可能会说，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，但我不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这周可能如何发生的吗？你也可以说“告诉我当你有时间思考你的强迫症恢复时，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是有帮助的。这可能看起来像是同意他们似乎没有足够的时间投入他们需要承诺治疗的能量，他们可以在准备好承诺的时候回来。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。一些客户可能在你同意他们可能没有准备好后“争取”留在治疗中。赞美和回顾任务：赞美是有帮助的，用于肯定客户的优势。赞美通过传达客户有真正的优势，并且他们的优势已经在会谈中被用来帮助实现目标来帮助客户。每次会谈为客户提供一个任务。最初，这可能是家庭作业或仪式减少。后来，这可能是暴露练习或核心信念记录（如果你在使用CBT）。
文章概要
本文介绍了如何将焦点解决短期治疗（SFBT）与暴露与反应预防（ERP）结合，以提升强迫症患者的治疗动机和参与度。文章详细阐述了SFBT在目标澄清、奇迹问题、评分问题、寻找例外和赞美等核心技术的应用，强调通过积极目标设定、小步骤进展和关注客户已有优势来增强治疗动力。作者分享了在暴露过程中使用SFBT的具体方法，如询问“10分满分恢复”愿景、使用1-10评分表评估进展、处理障碍等，并讨论了在ERP中整合SFBT的时机和注意事项。文章还涵盖了寻找进展变化、仪式减少和持续会谈中的SFBT策略，旨在帮助客户感到掌控感并促进积极变化。
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，当医生帮助有强迫症的人时，他们可以用一种叫SFBT的方法，让病人更愿意参加治疗。比如，医生会问“如果你的强迫症完全好了，你会做什么？”这样病人就能想象美好的未来。然后，医生用1到10打分，问病人现在感觉怎么样，并鼓励他们做一点点小事，比如今天多走一步，就能让分数提高一点。这样，病人会觉得“我能做到”，更有信心。
焦点解决心理学理论评价：这篇文章完美体现了焦点解决短期治疗的核心原则，即聚焦于客户的资源、优势和未来可能性。通过目标澄清技术，如奇迹问题和评分问题，治疗师引导客户从问题导向转向目标导向，强化了“小改变带来大不同”的理念。寻找例外和赞美环节，突出了客户已有的积极行动，这符合SFBT的建构主义视角，相信客户是自身问题的专家。将SFBT与ERP结合，展示了如何在不评判的情况下，增强治疗动机，这是一种创新的整合实践，彰显了SFBT的灵活性和实用性。
在实践上可以应用的领域和可以解决人们的十个问题：在实践上，这种方法可应用于心理健康治疗、教育辅导、职场咨询和个人成长领域。它可以解决人们的十个问题：1. 提升治疗参与度，让客户更主动投入康复过程；2. 增强自我效能感，帮助人们相信“我能行”；3. 减少焦虑和压力，通过小步骤建立信心；4. 改善目标设定能力，使目标更具体可行；5. 加强人际关系，通过积极沟通促进理解；6. 克服拖延习惯，鼓励立即行动；7. 培养乐观心态，聚焦未来可能性；8. 提升问题解决技能，从例外中寻找解决方案；9. 增强情绪调节能力，通过评分监控进展；10. 促进整体幸福感，帮助人们看到生活中的积极变化。