介绍 to 动态解构心理疗法 Training: Part 5
V. 制定
We will end this video training program with a discussion of enactment. 制定 is a central aspect of pathology and is discussed in Chapter 1 of the 治疗手册. 制定 refers to the tendency for many patients to engage others in interactions that tend to reinforce patients’ distorted and polarized attributions of themselves and others. As therapists, we often feel compelled to respond to our patients in maladaptive ways. It takes an active effort on the part of the therapist to maintain a therapeutic stance and adherence to DDP methods. Our tendency to leave a therapeutic framework is the main reason why on-going clinical supervision or consultation is so essential for successful treatment of this patient population.
的 治疗手册 没有一个单独的章节专门用于制定. 然而，第八章的每一部分， 具体的技术之后是对共同法规的讨论. Common types of therapist enactment and/or contraindicated techniques of DDP include: directing discussion towards childhood experiences, 身体症状, or medication; confidently completing patient narratives for them; asserting that a given feeling or action is justified/unjustified; assertively attributing a certain motivation, value or emotion to the patient or others; persuading, 鼓励, 让人安心, or advising in response to passivity or hopelessness; providing a rationale, 否认, 道歉, or interpretation in response to criticism or disagreement; answering questions about therapist lifestyle or feelings; and acquiescing to patient requests to change the usual treatment parameters. 这些也列在DDP依从性量表中 附录 手册的. 的 DDP adherence scale can be used to rate the overall adherence of a given therapy session.
案例1:第四阶段的难度
这个病例是一个处于第四阶段治疗的年轻女性. Stage IV is an especially difficult stage for therapists to stay adherent to DDP principles as the transference intensifies and as therapists struggle with their own worries about termination (see also Case 3 Commentary in 另类-真实).
案例1:评论
在这幅插图中，病人在 犯罪行为人国. She is very down on herself and feels hopeless that her marriage will ever improve.
This state tends to provoke very strong countertransference reactions on the part of therapists, 谁又会想要去拯救或安抚. Countertransference is intensified in the context of forthcoming termination, with a strong wish to see the patient better by the time of discharge. 因此, we see the therapist in this vignette having difficulty empathically exploring the patient’s depressive state, 而是试图修复它.
在询问病人是否觉得自己是一个好母亲之后, the therapist tries to reassure the patient that she is worthwhile. Reassurance in this situation represents an enactment of the patient’s attribution of the therapist as helpless rescuer and only deepens the patient’s depression and hopelessness. A better intervention would have been to work towards exploring and integrating polarized attributions she has towards herself as a mother and towards her relationship with her husband. 而不是, the therapist enters into another enactment by attempting to validate the patient’s feelings of anger and does not allow the patient to explore the central thematic question of whether her anger is justified (in 第二阶段 中心主题问题是，“我有权利生气吗??”).
在随后的面试中, the therapist tries to resolve the marital difficulty by stating, “Maybe there’s some component of you being so angry at yourself and at him that that’s what makes it all blow up worse.” This is followed by a suggestion that the patient should try to be less angry at herself. Both of these interventions violate the dictum to stay neutral 病人之间的矛盾 (see Association, 案例1评论以及第五章， 治疗姿态). 的 interventions enact the patient’s self-attribution in the 犯罪行为人国 as having all the agency, 只要她能改变，婚姻就会好起来. 的 patient ends the segment by essentially stating that she can’t change because she is irredeemably bad.
It’s very easy for therapists to enter into enactments with patients suffering from more severe chronic conditions, 比如边缘型人格障碍. 的y often make us feel compelled to respond in unproductive ways. Our immense challenge as therapists is to somehow maintain self-awareness and reflection, while remaining empathically attuned to the patient’s discourse and staying between the conflicts. 幸运的是，我们不需要完美，只要“足够好”就可以了。.
案例1:关键点
- 的 guilty perpetrator state tends to provoke very strong countertransference reactions on the part of therapists, 谁又会想要去拯救或安抚, 尤其是在终止的时候
- Reassurance in this situation represents an enactment of the patient’s attribution of the therapist as helpless rescuer and only deepens the patient’s depression and hopelessness
- Attempting to validate a patient’s feelings of anger can be another form of enactment since it does not allow patients to explore the 第二阶段 central thematic question of whether their anger is justified
- 制定 occurs when therapists leave the therapeutic stance and fail to stay neutral, 病人之间的矛盾
- A therapeutic stance involves maintaining self-awareness and reflection, while remaining empathically attuned to the patient’s discourse and staying neutral between the conflicts