ACT疗法:案例对话
朱松2008-2-9 11:19:03
下面是一个ACT治疗师在评估一个慢性忧虑者的改变日程：
Therapist: What else have you tried to do?
治疗师(下简称“T”)：你还做过什么？
Client: Well,sometimes I try to talk myself out of it. I say, "This is silly, you are making a mountain out of a molehill."
来访者（下简称“C”）:嗯，有时我试图劝阻自己。我说：“太蠢了，你这是小题大做。”
T：In other words, criticize and chastise yourself. And the purpose of this criticism...?
也就是说，你责备和惩罚自己。你的目的是……？
C: To get me to stop it.
让自己停下来。
T: To get yourself to change-to stop worrying.
让自己有所改变——停止担心。
C: Yeah... The things I worry about are silly. I mean some of the things that come into my mind are just nuts.
是的……我的担心很愚蠢。我的意思是，我脑袋里冒出来的有些东西简直就是胡说八道。
T: And the idea is that if you could get rid of those worries-those thoughts-then the anxiety would be less and you'd be able to face your daily situation better.
你是说，如果你能去除那些担心——那些想法——那么焦虑就减少，你就能够更好的面对日常情况。
C: Right, but it is pretty hard to convince myself to stop it, so sometimes it works but sometimes it doesn't.
对，但是说服自己停下来相当困难，因此有时有用，有时没用。
T: So if you could just convince yourself that you don't need to worry, then it would work and things would start moving ahead. OK. So far we've got criticism, chastising, and attempts to convince yourself to stop. What else have you tried?
如果你能说服自己，你就无需担心了，那就有用了，事情就会向前发展。好。到目前为止，你受到了责备、惩罚，还试图说服自己停下来。你还做过什么？【94】
T: And this. Coming in here. Is it part of that effort to change how bad you feel as well?
……这也是你改善坏感觉的努力当中的一部分吗？
C: Of course. I'm not sure what I will get out of this really, but if I could feel even a little better about myself, it would be worth it.
当然。我不确定真能从中得到什么，但是如果自我感觉哪怕能好一点，也值得。
T: So you're hoping to remove some of the bad feelings and get more good feelings because then you would be able to move on.
你希望少一些坏感觉，多一些好感觉，这样你就解脱了。
C: (Pause) I guess so.
（犹豫片刻）我猜是的。
T: So this is another thing to try. Good. So let's add this therapy to the list. It is another thing you've done to feel better.
这是你的另一个尝试。好，我们把这个治疗加到列表中。这是你为了感觉更好已经做过的另一件事。
C: I've tried almost everything I know to feel better.
为了感觉好点，我几乎尝试了所知的所有事情。
T: I'm sure you have. You have indeed. And this-therapy-is yet another attempt.
我确信你做过。你真的做过。这个治疗是又一次尝试。
C: You say it as though there is an alternative.
听你的意思好像有选择的余地。
T: Well. I don't know. Right now I just want to be clear about what you have tried and how it has worked.
哦。我不知道。现在我只想弄清你已经尝试过什么，以及效果如何。【95】
下面的来访者就是前面提到那个慢性忧虑者，我们来看看如何评估规则系统的起效方式：
C: Right, but it is pretty hard to convince myself of it, so sometimes it works but sometiems it doesn't.
是的，但说服自己相当困难，所以有时有用，有时没用。
T: So if you could just convince yourself, then it would work. OK. Let me ask you this. Your mind says that when you convince yourself that your concerns are silly, you will stop having those concerns, you will become less anxious, and then you will do better. Right?
你是说如果能说服自己，就有用。好。我来问你。你的想法是，当你说服自己相信，你所关心的是愚蠢的时候，你就不再关心了，焦虑就会轻些，你就会好些。对吗？
C: Right.
是的。
T: OK. And dose that work? What does your experience tell you?
好。有用吗？凭你的经验？
C: Sometimes. But I can't always talk myself out of them.
有时有。但我不是总能劝阻自己。
T: And even when it does work, if we expand the time frame a bit, would you say that over time, as you've followed the rules your mind has laid out for you, that your concerns overall are less or more?
就算是有用，如果我们把时限延长一点，或者说随着时间的发展，如果你遵循头脑里的规则，总体来看，你所关心的会多还是会少？
C: ...Overall it is more.
……总的来说会更多。
T: That seems like a paradox, doesn't it? I mean, you do what your mind says, sometimes it even seems to work, and then somehow it seems as though the concerns and worries are getting bigger, no smaller. They are more important, not less.
这像是个悖论，对吧？我的意思是，你做的正是你想的，有时似乎是有用的，而有时不知道又是怎么搞的，好像关心和担心变得更多了，而不是更少了，更重要了，而不是不那么重要了。
C: So what should I do?
那么我应该怎么办？
T: What does your mind tell you to do?
你的心里是怎么说的？
C: Try harder.
再努力。
T: Interesting. And have you tried harder?
有意思。你有努力吗？
C: And harder and harder.
越来越努力。
T: And how has that worked? Has it paid off in a long-term or fundamental way, so that by doing it you have transformed the situation and it is no longer a problem? Or are you, unbelievably enough, sinking in deeper as you try harder and harder?
效果如何？是起到了长期的本质的作用，情况得到了改变，问题不存在了呢？还是陷得更深了？
C: ... I'm sinking in deeper.
……我陷得更深了。
T: If we had an investment advisor with that track record, we would have fired him long ago, but here your mind keeps leading you into efforts that don't really, fundamentally, pay off, but it keeps following you around with its "blah, blah,blah," and it is hard not to give it one more try. I mean what else can you do but what your mind tells you to do? But maybe we are coming to a point in which the question will be, "Which will you go with? Your mind or your experience?" Up to now, the answer has been "your mind," but I want you just to notice also what yor experience tells you about how well that has worked.
如果是一名有记录的投资顾问，我们早就解雇他了。而你的想法带着你不懈的做着无谓的努力，一直在你边上巴拉巴拉的说废话，你想不再试试都很难。除了心里的声音让你做的而外，你还能些做什么呢？也许我们正逼近问题的所在，“你将和谁在一起？是想法还是经验？”现在，答案是“想法”，但我想让你也注意到经验告诉你怎样能起作用。【97】
下面的对话演示了创造性无望（creative hopeless）的介绍。
T: You have told me a lot of things you have tried to do, and it seems to me that you have tried to do just about everything that is logically there to be done. You've done all the obvious and reasonable things. You've thought hard, you've worked hard. You've looked for the angles. And now here you are in therapy...still trying. But you've hired me. I work for you. So it is my obligation to point something out:"This isn't working, right?"
你讲了你试过的很多事情，在我看来，你做的正是逻辑上该做的事情。你做了所有明显的合理的事情。你努力思考，努力做事。
你寻找问题的各个方面。
现在你来治疗……还是尝试。但你已经雇用了我。我为你工作。所以我有责任指出：“这没什么用，对吧？”
C: I haven't figured it out yet.
我还是没明白。
T: Here is another way to say what you just said: Even trying to figure it out isn't working so far.
你的这句话也可以这么说：即使设法弄明白了也没用。
C: Not yet.
还是没有。
T: Not yet. What if it won't? What if this whole thing is a setup?
还是没有。如果还将没有呢？
如果整件事就是个局呢？
C: A setup?
局？
T: Well, in other areas if you had worked this hard, you'd have a lot of good things to show for it. Isn't it true in your experience, although it doesn't seem that it should be this way, that the more you've struggled with emotional discomfort and disturbing thoughts-the more you have tried to get rid of them-the more difficult it has becaome? They don't seem to respond to conscious control. These feared reactions haven't gotten smaller, they have gotten bigger.
嗯，在其它方面，如果你这么努力，你已经有很多好东西可以炫耀了。以你的经验来看，难道不是这样的吗？虽然好像不是这样的。你越是与坏情绪和烦人的想法奋争，你越想除掉它们，就变得越是困难。它们似乎不像是对有意控制作出的反应。这些害怕的反应不是变小，而是变大了。
C: I don't know how to get rid of them. I'm hoping you can help. How should I get rid of them? What am I doing wrong?
我不知道怎么去除它们。我希望你能。我应该如何去掉他们？我做错了什么?
T: Those are important questions because they show very cleraly what has been going on, but let's not get off on that issue quite yet. Let's start with what you know directly. You feel stuck.
这些问题很重要，因为这显示发生了什么，但我们先不要开始这个问题。让我们直接从你所知道的开始。你感到进退维谷。
C: Big time.
一流。
T: It is not clear what to do next, but it doesn't seem as though there is a way out.
下面要做什么并不清楚，但是好像没有出路。
C: Exactly.
没错。
T: So I'm here to say something:"You are stuck. There is no wa
C：So why am I coming in to see you? It sounds as if you are saying I will never be successful.
听你这么说，我再也好不起来了。那我干嘛来看你?
T: My purpose is not to help you win this struggle. That does not mean that you are hopeless or you can't be successful. In fact, my goal is to help you have your life work, and I 100% think I can help you do that if you are willing to face these monsters your have been running from.
我的目标不是帮你赢得挣扎。但那并不意味你没有希望了，也不意味你好不起来了。事实上，我的目标在于帮你把生活运转起来。如果你愿意面对你一直在逃离的这些怪物，那我100％地相信能帮到你。
C: If it is easy to have your life work, why haven't I done it?
如果运转生活那么容易，为什么我做不到呢?
T: I neve said it was easy. It is hard. Not hard effortful-it is hard tricky. This is a very tricky trap-one that catches us all. Look, it is absolutely clear to me that if you knew what to do, you would have done it. I don't believe for a minute that you are broken, weird, perverse, or self-destructive. You have done the absolute best you can. You have everything you need to move ahead from here to live a vital, committed, meaningful life. It is just that we have to start from here-here is where you are. So you look and you see whether your experience doesn't tell you that you are caught in a struggle you seemingly can't win. Are you willing to trust that experience, allow it to influence you, and then to move from here? That is what your life is asking of you right now.
我从没说过容易。这很难。不是难在需要努力上——而是很难处理。
这是个危险的陷阱——能逮住我们所有人.
看，事情对我来说很清楚，如果你知道要做什么，早就做了。我根本不相信你有问题，不相信你是离奇的、反常的，不相信你在自我破坏。你已经做的绝对是最好的了。你拥有所需要的一切，这能让你离开这里，去过充满活力的、具有责任感的、有意义的生活。我们要做的正是从这里开始——从你这里开始。你看看，你会发现你的经验是否没有告诉你，你被似乎不可能赢得的挣扎给困住了。你愿意信任经验吗？让其影响你？然后离开这里？那是你的生活在邀请你。（107】
下面的来访者诊断为惊恐障碍，治疗师试图阐明来访者的无效控制策略的本质：
T: What else did you observe?
你还注意到了什么？
C: Well, when I was about to go into the department meeting, I noticed I checked several times to see whether I still had my bottle of Valium in my purse. I kenw it was in there-I alsways carry it anyway-but I checked it maybe four times within 5 minutes right before the meeting.
嗯，当我打算进去会议室时，我发现自己检查了好几次钱包中是否有安定药瓶。我知道有——我总是带着它——但是在开会前的5分钟之内我大概检查了4次。
T: What do you think the checking was in the service of[1]?
你认为检查的作用是什么？
C: I guess reassuring myself that it was there.[2]
我想，如果在，我就放心了。
T: So that you could...
这样你就能……
C: Well, so that I could always quick sneak a pill if things got too bad. I have learned to open the bottle with one hand and sort of[3] tuck a pill in the knuckle joint. Like a magician does. Then I cough or something, and I get it in my mouth. It tastes pretty bad, but actually if I just let it dissolve it works faster anyway, so I don't need water or anything.
是的，这样，如果情况不对，我就能迅速偷吃一片。我已经学会用一只手打开瓶子，藏一片药在膝关节里。就像魔术师那样。然后咳嗽什么的，将药送进嘴里。味道很不好，但如果让其在嘴里溶解，实际上起效更快，所以我也不需要水什么的。
T: So one thing you observed is that before you go into the department meeting you make sure you have a way of dealing with your anxiety. And you check for the bottle to reassure yourself that you have that way out even if you can't just leave the room.
所以你注意到的一件事是，在进入会议室之前，你证实自己有处理焦虑的方法。你检查药瓶让自己安心，即使你不能离开房间，你也有办法处理。
C: Yeah.
是的。
T: And that is in the service of keeping the anxiety away.
作用是，远离焦虑。
C: For sure.
没错。
T: Can I say it this way?: Access to tranquilizers is probably one way you dig.[4]
我能这样说吗？：镇静剂的使用也许就是你寻找的方法。【119】
