减低危害心理疗法和培训联盟.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,ANDREW TATARSKY,PHD,安德鲁,塔塔斯基博士,HARM REDUCTION PSYCHOTHERAPYAND TRAINING ASSOCIATES,减低危害心理疗法和培训联盟,KIEV,UKRAINE,乌克兰基普,JULY 27-29,2009,2009,年,7,月,27-29,WWW.ANDREW TATARSKY.COM,Improving the Quality of Harm Reduction Programs,：,An Overview of Integrative Harm Reduction Psychotherapy,促进减低危害项目质量,:,综合的减低危害心理疗法概述,MY PATH TO HARM REDUCTION PSYCHOTHERAPY,我是如何步入减低危害心理疗法领域的,WHAT IS HARM REDUCTION?,什么是减低危害？,BRIEF HISTORY,简史,CLINICAL RATIONALE,临床原理,LIMITATIONS AND CLINICAL CHALLENGE,局限和临床挑战,HARM REDUCTION PSYCHOTHERAPY,减低危害心理疗法,THEORETICAL MODELS,理论模型,History and Evolution of Harm Reduction Psychotherapy,减低危害心理疗法的历史和发展,Times are changing,与时俱进,Harm reduction is part of national policy of many nations mainly as public health intervention,目前在很多国家，减低危害是公共卫生干预的国家政策,Harm reduction is catching on at the local,state and federal level in USA,减低危害在美国的地区、州级和联邦政府层面正在日益发展,Treatment rather than incarceration,进行治疗，而不是监禁,From criminal justice to public health approach,从犯罪和司法到公共卫生的方式,Times are changing cont.,与时俱进（续）,Increased interest in harm reduction psychotherapy around the world as adjunct to public health interventions,在世界范围内，人们对减低危害心理疗法产生了更浓厚的兴趣，把其作为公共卫生干预的辅助措施,Evidence-based practice riding the HR wave,在减低危害的浪潮中，始终以基于证据的实践作为基础,Increased recognition of need to treat substance use issues in context of co-occurring issues,认识到物质滥用的治疗要放在多种问题同时发生的背景中考虑,HR Announces a Paradigm Shift,减低危害宣告着方式的转变,From disease model to psychobiosocial model,从疾病模式转变到社会心理生理学模式,From abstinence-only to harm reduction,从单纯的彻底戒断毒品到减低危害,New view of substance users,substance use problems and appropriate treatment,对物质滥用者、物质滥用问题及适当治疗方法的新观点,What is Harm Reduction?,什么是减低危害？,Philosophy,哲学体系,Shifts from:abstinence-only to reducing drug-related harm,转变：从单纯的戒断毒品到减低危害,Compassionate pragmatism(Marlatt),有同情心的实用主义,(Marlatt),Meet patients where they are,从病人的实际情况出发,Come as you are,尊重天性,Any positive change(Chicago Recovery Alliance),积极的改变,/,正向改变（芝加哥康复联盟）,Compassionate,respectful,accepting,supportive.collaborative,富有同情心、尊重、接纳、支持、协作,Philosophy cont.,哲学体系（续）,Abstinence may be the best outcome for many,but not a prerequisite or requirement for treatment,在很多情况下，彻底戒断是最好的结果，但并非是治疗的前提或必要条件,Start where people are:“low threshold”,从病人的实际情况出发：“低门槛”,Challenge stigmatization of drug use and user,描述药物滥用和滥用者的挑战,Understand them within their frame of reference,在药物滥用者的准则体系内理解他们,Builds on participants strengths,以参与者的力量为基础,Collaborate on setting up treatment,从治疗之初即开始协作,Brief History of Harm Reduction Psychotherapy,减低危害心理治疗的简史,1970s Experiments in Amsterdam and Liverpool in response to failure of traditional treatment to address explosion of drug use.,在上世纪七十年代，毒品滥用问题爆发，但传统治疗方法往往付诸失败，因此在阿姆斯特丹和利物浦开始了减低危害的试点工作。,Early 1990s Harm reduction arrives in USA as public health response to HIV-AIDS epidemic.Saving lives trumps ideology.Syringe exchange,substitution treatment,condom distribution.,在上世纪九十年代早期，减低危害被运用到美国的公共卫生领域，旨在应对艾滋病疫情。挽救生命成了主流思想，并开始了针具交换、替代治疗、安全套发放等。,Brief History of Harm Reduction Psychotherapy cont.,减低危害心理疗法的简史（续）,Mid-1990s “Harm reduction psychotherapy”was defined by Tatarsky(1998)as“psychological interventions that seek to reduce the harm associated with active substance use without having abstinence as the initial goal”.,1998,年，“减低危害心理疗法”被塔塔斯基博士定义为“旨在减少物质滥用人群由于使用毒品带来的危害，而不是彻底戒断的一种心理治疗干预。”,Intersection of psychotherapists from psychodynamic,cognitive-behavioral and humanistic perspectives with the harm reduction movement.,减低危害运动与精神动力疗法、行为认知疗法和人文主义的观点有交叉。,Major contributors include Marlatt,Denning,Little,Rotgers,Rothschild,Tatarsky and Kellogg.,主要有贡献的人包括：马尔拉特、邓宁、李特尔、罗特杰、罗斯彻尔德、塔塔斯基、凯洛格。,Limitations and Clinical Challenges In the USA,在美国的局限性和临床挑战,Majority of problem users,especially those with co-occurring disorders,are not being treated effectively,大部分有问题的吸毒者，特别是那些有并发症的，都是由于没有得到有效的治疗,(NSDUH,2007),57.8 million people binged on alcohol in the past month,在上个月内有,5780,万人饮酒作乐,22.3 million persons aged 12 or older were classified with substance dependence or abuse in the past year9.0 percent of the population,）,去年内有,2230,万,12,岁或,12,岁以上人的被归为物质依赖或滥用者。（总人口的,9%),2.4 million received treatment at a specialty facility,只有,240,万人得到专业机构的治疗,Limitations and Clinical Challenges In the USA cont.,在美国的局限性和临床挑战,(,续,),75-93%of drug and alcohol treatment only offers abstinence goal,75%,至,93%的毒品和酒精治疗仅提供彻底戒断的目标,Very low rates of retention and abstinence in treatment as usual,通常，治疗中的维持率和戒断率非常低,Kellogg,2007,reviewed outcome studies showing 15%-35%retention at 12 weeks and 8%abstinent at 12 weeks,2007,年，凯洛格回顾了结果研究的文献，发现,12,周内只有,15%-35%,的维持率，而,12,周内的戒断率只有,8%,Treatment Limitations and Clinical Challenges In Russia,俄罗斯的治疗局限和临床挑战,Of 2 million IDUs,only 10%are in drug treatment(UNODC,2005),200,万的注射毒品人群中，只有,10%,得到了药物治疗。,25%of IDUs use rehabilitation services(National Research Centre of Addiction 2004),25%,的注射毒品人群接受了康复服务。,Barriers to treatment reported by users were financial,fear of registration and associated stigma and perceived low efficacy of treatment(Bobrova,et at,2006),药物滥用者反馈的治疗障碍包括：经济困难、害怕被登记、相关的歧视、认为治疗的有效性很低,(Bobrova,et at,2006),Registration perceived as“stamp on the forehead”,stigma“for all your life”,“narcoman”was outcast.,登记就意味着“在额头上打印了标记”，歧视将“伴随一生”，“吸毒者”被排斥。,Treatment Limitations and Clinical Challenges In Russia cont.,俄罗斯的治疗局限和临床挑战,(,续,),Distrust of treatment services,对治疗的不信任,(Mendolevich,2004),Users(68%)have negative attitudes toward drug tx in Russia due to poor tx outcomes,no counseling,uncaring stigmatizing attitudes and short tx.,在俄罗斯，,68%,的滥用者对脱毒有负面看法，这是由于脱毒治疗效果非常差，没有咨询服务，医生持不负责的歧视态度，治疗时间很短。,(Bobrova,2007),Recommend“a more holistic approach incorporating a range of services that address the diversity of treatment needs”,给俄罗斯的建议是：“结合一系列服务，建立一套更加全面的工作方法，以满足多样化的治疗需求。”,Limitations and Clinical Challenges,局限和临床挑战,Many users dont want abstinence and avoid treatment,很多吸毒者不想彻底戒断，他们逃避治疗,Some research support and clinical experience,来自研究结果和临床经验,Split between substance abuse and mental health treatment,物质滥用治疗和心理健康治疗被分割开,Much mental health treatment wont treat active substance users,很多的心理健康治疗并不关注正在使用毒品的人,70%+of public sector behavioral health patients in the USA are diagnosed with co-occurring disorders,在美国，,70%,以上行为健康存在问题的病人都被诊断有并发症,Problem substance use increases risk of unsafe sex and infection,有问题的物质滥用增加了不安全性行为和感染疾病的风险,The State of the Art of MMT in China,（,Small Group Work,）目前中国的,MMT,所处的阶段（小组活动）,Successes,成功之处,Limitations,局限性,Clinical challenges,临床挑战,Why are drug users considered hard to treat?,为什么药物滥用者总是被认为难以治疗？,The User,滥用者,Providers,服务提供者,Institutions,机构,Society/Culture,社会,/,文化,Large Group Sharing,大组分享,Clinical Rationale,临床原理,Broad diversity of users vary in every variable,不同的药物滥用者在方方面面都不一样,Substance use severity,goals,co-occurring psychiatric disorders,socio-economic status,motivational stage of change,health status,personality strengths and vulnerabilities,race,cultural context,etc.,物质滥用严重程度、目的、并发的精神疾病、社会经济情况、改变的动机阶段、健康状况、个性力量与脆弱性、种族、文化背景等。,Biopsychosocial process model of substance misuse,物质滥用的社会心理生理过程模式,Clinical Rationale cont.临床原理,(,续,),Multiple meanings and adaptive value of substances,物质的多重意义和适应值,Many issues may need to be addressed before motivation to modify substance use grows,在动员物质滥用者作出改变前，需要解决很多问题,An understanding of the role of substances has positive impact on treatment,理解物质的作用对治疗效果可产生正性影响,Need for individualized,matched treatment without predetermined goals,不能预先设定目的，应按照个人情况制定适合的治疗（个性化）,Harm Reduction Psychotherapy,减低危害心理治疗,A new paradigm for helping people change,帮助人们实现改变的全新方法,Integrative approach for co-occurring disorders,治疗并发症的综合方法,Best suited to enhance therapeutic alliance and address problems attracting and retaining patients,非常适合用于加强治疗联盟、解决吸引和留住病人的问题,Therapeutic framework that can enhance the delivery of substitution treatment and other modalities,这样的治疗框架可以加强替代治疗和其它干预形式的提供,Harm Reduction Psychotherapy cont.,减低危害心理治疗,(,续,),Embraces core principles of harm reduction,减低危害的核心原则,Seeks to reduce harmful consequences without requiring abstinence,旨在不要求彻底戒断的情况下，减少有害结果。,Starts where the patient is,从病人的情况出发,Embraces small incremental change,接受小的、循序渐进的改变,Addresses drug use in the context of the whole person in context,将滥用者做为“整体的人”来考虑，从而解决毒品使用问题,Key Theoretical Models,核心理论模式,Biopsychosocial Process Model of Addiction,有关成瘾的社会心理生理学过程模式,Multiple Meanings Perspective,从多重问题的观点看待药物滥用问题,Motivational Stages of Change,改变的动机阶段,Psychobiosocial Process Model of Addiction,有关成瘾的社会心理生理学过程模式,Mis-use and addiction are the result of an interaction of psychological,biological and social,vulnerabilities,unique to each person that renders substances and other potentially risky behavior desirable,药物的滥用和成瘾是个人在心理、生理和社会因素上的,脆弱性,造成的结果，这些情况增加了物质滥用和其它潜在危险行为的可能性。,The psychobiosocial,consequences,of chronic use contribute to increased desire and escalation in use,慢性滥用的心理、生理和社会学,结果,增加了对药物的渴求和用量。,The Psychobiosocial Process Model of Substance Misuse and Addiction,物质滥用和成瘾的社会心理生理学过程模式,Vulnerabilities,脆弱性,Genetics,trauma,deficits in affect and self-regulation and interpersonal relations,psychiatric disorders,stress,despair,poverty,access,culture,sex-work,HIV,stigmatized group membership,遗传、创伤、不良影响、自律、人际关系、精神疾病、压力、失望、贫穷、可获得性、文化、性工作、艾滋病、被歧视的群体,Drug Use is Pleasurable,使用药物是愉悦的,Multiple personal meanings,real and symbolic functions,self-medication,escape,self-soothing,affect management,self-sufficiency,defiance,pleasure,freeing suppressed aspects of self(anger,sexuality,playfulness),etc.,多重的个人意义、真实和象征功能、自我用药、逃避、自我抚慰、影响管理、自足、违抗、快感、释放情感压力（愤怒、性欲、嬉闹），等等,Psychobiosocial Consequences of Chronic Use,慢性滥用的心理、生理和社会结果,Neurochemical depletion,social stigmatization and isolation,cognitive deficits,self care deteriorates,self-esteem plummets,conditioning,physical deterioration,incarceration,神经系统化学物质耗竭、社会歧视和隔绝、认知不足、自理能力变差、自尊下降、条件作用、身体状况下降、被羁押,Unique Fit,独特的感受,Intensify Desire,渴求加剧,Treatment Implications,治疗的意义,Vulnerabilities and consequences may need to be identified or resolved before drug use can be addressed directly,在直接处理药物滥用问题前，应先识别出脆弱性和后果。,Addressing any relevant issue changes the system,解决相关问题可以改变整个体系,This changes ones relationship to substances and motivation to change,治疗改变人和药物的关系，并促进改变,Even if risk behavior is not the primary focus of treatment,即便危险行为也不是治疗的主要焦点,Multiple Meanings Model,多重问题模式,An experience near way of thinking about the roles that substances play in peoples lives,这是从物质滥用在人生活中的角色考虑得出的经验,Substance use may be the language people speak-acting rather than feeling and speaking,物质滥用也许是人们的一种言语表达方式,-,用行动来表达而不是用感情或言语。,(desymbolization-Krystal),Substance use often carries,expresses or reflects multiple meanings simultaneously,物质滥用通常同时包含、表达或者反映了很多问题,Meanings reside inside of meanings,一个问题里面往往蕴含着另外的问题,Multiple Meanings Model,cont.,多重问题的模式（续）,Addictive relationship both expresses and disguises meaning,成瘾现象既表达也同时掩盖了很多问题。,Substance use can be the entry point for the process of rediscovering and integrating disowned aspects of self expressed by substance use,物质滥用可能是重新发现和整合个人没有表达方面的切入点,The users meaning-metaphor is most effective way to engage the exploration,吸毒者的,问题表象,是开始探索他们真正问题的最有效途径,Categories of Meaning-Metaphor,象征意义的分类,Self-medication of suffering,自我用药的后果,Opiates-rage,depression,阿片类：愤怒、抑郁,Stimulants-depression,sense of inadequacy,兴奋剂：抑郁、感觉底气不足,Alcohol/benzodiazapines-anxiety,酒精,/,苯二氮卓类：焦虑,Cannabis-boredom,social phobia,大麻：无聊、社交恐怖症,Hallucinogens-spiritual emptiness,迷幻剂：精神空虚,Adaptive attempt to repair personality deficits,为修复人格缺陷的调整尝试,Four“sectors of vulnerability”Khantzian,有四方面的“脆弱性”,self-care deficit,自我照顾的不足,problems managing feelings,管理情绪的问题,self-esteem problems,自尊问题,interpersonal problems,人际关系问题,Categories of Meaning-Metaphor,象征意义的分类（续）,Provides identity,e.g.drug user,junkie,身份标示：吸毒者、瘾君子,Interpersonal or relational expression,人际关系或者关系的表达,Rebellion against inner critic,反抗内心批判,(superego,超自我,),Categories of Meaning-Metaphor cont.,象征意义的分类（续）,Identity integrator:reconnects users to traumatized,disowned aspects(rageful,lustful,creative,imaginative,terrified,loving,grieving)or“selves”(the rebel,lover,caveman,the guys in the back seat),身份的整合：让吸毒者联系到自己受的伤害、负面的感觉（愤怒、贪婪、创造、想象、害怕、爱意、伤感），或者是“自我”（反叛者、爱人、野人、隐藏的自我）,Habit,习惯,Coping mechanism,应对机制,Disease(diseased or damaged self,toxic inner saboteur,biological illness),疾病（生病或者伤害自己、内心有心魔、生理疾病）,Spiritual search for transcendence,connectedness beyond the small self,精神上寻找伟大感觉或者寄托，以超越渺小的自我,Trauma,Dissociation and Substance Use,创伤、精神分离和物质使用,Traumatic sexual or violent assault,loss,neglect,rejection,abandonment,impingement,lack of attunement and threats of these can trigger the fear of physical,psychological or“soul death”.,性创伤、暴力侮辱创伤、失落、被忽略、被拒绝、被抛弃、被侵犯、缺乏协和、受到威胁，这些都能引发生理和心理上的恐惧，或者“灵魂死亡”。,“Freezing response”,“immobility response”,i.e.dissociation attempts to avoid the threat results in:,“,冰冻反应”，“凝固反应”，如精神分离以避免受到下列情况的威胁：,Un-discharged instinctual energy/anxiety,不能释放的本能能量,/,焦虑,(Levine),Dissociation of related feelings,wishes,needs,aspects of self that threaten to increase to threat,感情、愿望、需求的失落，自己的某方面受到威胁,Trauma,Dissociation and Substance Use cont.,创伤、精神分离和物质使用（续）,Powerlessness leads to compliance or other attempts to protect oneself or regain what was lost,无能为力导致顺从，或是其它试图保护自己的方式，或是想获得自己失去的东西,Multiple Meanings and Functions of Substances in Relation to Trauma,多种问题，以及创伤和物质使用的关系,Provides some control over trauma and its symptoms,吸毒能提供对创伤和创伤症状的控制,Self-medicate,self-soothe the primary and secondary symptoms of trauma,对创伤的主要和次要症状进行自我用药、自我安慰。,Support dissociation,i.e.“fuzzing out”,“blotto”,精神分离，即“逃离”，“麻醉自己”,Induce a sense of aliveness in the midst of dissociated deadness,在毫无生气的情况下让自己感觉还活着,Multiple Meanings and Functions of Substances in Relation to Trauma cont.,多种问题，以及创伤和物质使用的关系（续）,Facilitate temporary reconnect