正式反馈的发展与临床应用

摘要:正式反馈通过系统收集当事人的效果反馈来追踪其治疗进展,进而识别缺乏治疗进展的个案,并通过促进治疗策略的调整来阻止治疗失败。正式反馈是近20年来发展出的一种循证治疗手段,其目的为进一步提高当事人的咨询效果。正式反馈的发展大致经历了临床有效性检验和实用性发展两个阶段。正式反馈可用于促进个体、夫妻和团体咨询的效果,也可用于评估临床督导效果、确定督导个案和指导临床督导。未来研究可探讨咨询师对待正式反馈的态度,拓展正式反馈的使用价值,建立正式反馈系统的本土化常模。     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

心理治疗中的正式反馈

<正>式反馈是近年来发展出的一项提高临床实践的有效方法,它是指利用标准化的治疗效果测量工具,系统监控当事人评定的治疗进展情况,并将当事人的进展信息提供给治疗师,以供其随后的治疗作参考之用。治疗效果问卷评定系统和合作-改变效果管理系统是目前使用较为广泛的正式反馈测量工具。正式反馈的使用不仅能够改善偏离预期进展当事人(not on track,NOT)的治疗效果,提高当事人治疗进展的速率,同时还能够促进治疗双方更好的合作。正式反馈的作用机制可以使用概念化反馈干预理论和交互作用论进行解释。影响正式反馈作用效果的因素包括反馈本身的特征、当事人初始症状严重程度、治疗师方面因素以及治疗的时长等。未来研究需关注正式反馈的研究方法、作用机制及其跨文化研究的差异。     

The self in the couple relationship: part 1

This paper discusses the importance of the ‘good-enough’ development of the core self in the couple relationship. It argues that difficulties in the development of the self lie behind a significant number of troubled couple relationships. Part 1 focuses on individual psychotherapy and how changes to the core self are often attended by shifts in the marital relationship. It traces how this occurs through clinical material and analyses what kinds of changes to the self are needed for the couple relationship to function well. Psychodynamic theory is used to understand the core changes over time and how these are related to significant second-order change in the couple relationship. The construct of the ‘transitional space’ is used to theorize the couple relationship. Implications for the practice of individual psychotherapy are discussed. In Part 2, the significance of change in the experience of the self of one or both partners for a successful outcome of couples therapy is discussed, along with the place of work with individual partner(s) in the course of conjoint couples therapy.     

Making the case for using personalised outcome measures to track progress in psychotherapy

The practice-based evidence movement has become increasingly influential in the practice of counselling. One element of this approach is the recommendation that therapists regularly administer standardised or nomothetic measures to track the progress made by their clients. When this feedback indicates that therapy is off course (i.e. out of kilter with the projected course of effective treatment) therapists are alerted to the risks of potential dropout and encouraged to take some form of corrective action. Despite an expanding evidence base supporting this strategy for improving psychotherapeutic outcomes, there are also concerns that the generic measures adopted do not always possess the specificity and sensitivity required to capture the unique experiences of individual clients. The paper argues that personalised or idiographic assessments can be designed to match the language and priorities of individual clients and so provide a more nuanced measure with which to track the course of therapy and promote informed reflective conversations between client and clinician on when and whether a change in direction is needed. However the idiographic alternative is not an easy option and practical as well as theoretical challenges in adopting this approach to monitoring treatment outcomes are acknowledged and discussed. Finally the virtue of using a strategy that combines nomothetic and idiographic measures is considered.     

Expectations About Couple Therapy Over Time

One common factor of therapy, expectations, has been demonstrated to be a significant contributor to outcome in individual therapy. Despite this, little is known about expectations about couple therapy. This paper presents the qualitative results of a study exploring clients’ expectations before beginning couple therapy and after six sessions. Results indicate that clients form pre-therapy expectations about their therapist, the process of therapy, and their partner. Results also showed that after six sessions, clients’ expectations about therapy were often met or modified in ways that were positive. Implications for therapists and researchers are included.     

Couples treatment for major depression: critique of the literature and suggestions for some different directions

Current couples approaches to the treatment of depression show considerable promise for some couples, but have substantial room for improvement – in terms of efficacy as well as applicability and acceptability to a broader population. Although conjoint approaches have been shown to be efficacious in reducing couple distress and are possibly efficacious in ameliorating depression that co-occurs with couple distress, methodological problems hamper generalization from the published findings. Therefore, it is not clear that most depressed persons are likely to benefit from currently available conjoint formats. Most basically, there may often be obstacles that prevent or delay partner involvement, highlighting the need for treatments that can enhance relationship functioning without relying on a conjoint format. Existing treatment delivery systems may also fail to reach a considerable segment of the population. Developing a more flexible set of options for implementing couple-focused treatment, as well as rethinking dominant assumptions about depression, may be integral to extending the viability of couples therapy for depression.     

Observing attachment behavior in couples: the Adult Attachment Behavior Q-Set (AABQ)

Knowledge as to how attachment behavior is observable in couple interaction can be very useful to clinicians who use attachment theory or related theories to guide their work with couples. The development of the Adult Attachment Behavior Q-Set (AABQ), a 100-item Q-sort designed to be consistent with Main's Adult Attachment Interview (AAI) coding system, is described. Videotaped discussions were coded for a sample of 28 couples. The majority of the couples were married and had sought therapy for couple problems. Reliability of coding was adequate. Evidence for validity was promising, with a match of 84% between the AAI and AABQ for secure versus insecure, and 70% for the three categories of secure, dismissing, and preoccupied. Even though additional reliability and validity information are needed for the AABQ, it holds promise for providing insights into couple dynamics that could be useful in guiding interventions and in evaluating the outcome of couple therapy.     

Low-level relationship aggression and couple therapy outcomes.

Increasing evidence supports the efficacy of conjoint therapies that focus on intimate partner violence for couples who engage in mild to moderate physical aggression but want to preserve the relationship and end the aggression. However, there has been no examination of how this population responds to couple therapy that does not have a specific focus on aggression. This lacuna in the research literature is of concern because couples with a history of low-level aggression often seek couple therapy, but couple therapy without a focus on violence is thought to potentially exacerbate aggression. In the current study, the authors examined the efficacy of non-aggression-focused behavioral couple therapy for couples with and without a history of mild physical aggression. One hundred thirty-four couples, 45% of whom had experienced low-level aggression in the year prior to therapy, completed up to 26 sessions of couple therapy and 2 years of follow-up assessments. Results demonstrated no significant differences in relationship and individual outcomes by history of aggression. In addition, couples maintained very low levels of physical aggression during and after treatment and showed reductions in psychological aggression when relationship and individual functioning improved.     

The Mating Game

SUMMARY

Mate selection processes of couples have been of interest to a multitude of disciplines ranging from biology to psychology to social psychology. Debates usually center around “like marries like” or “opposites attract.” While generally the research indicates, at least with regard to social variables, that similarities among couples is the norm, little systematic empirical research exists which examined this basic belief. Family therapists, also adhering to this basic assumption in their notions of couple selection, collusion, and reciprocal patterns of interaction, have not empirically tested this assumption either. The present paper examines the literature from the biological, psychological, and social psychological disciplines and discusses these assumptions in family therapy theory. A discussion of the implications for couple therapy is then presented.     

Effectiveness of Couple Therapy in Practice Settings and Identification of Potential Predictors for Different Outcomes

Even though couple therapy is efficacious, there is no improvement in up to 50% of the couples. Also effect sizes found in effectiveness studies in real-world settings are considerably lower than those found in efficacy studies. There is a need to understand more about couple therapy effectiveness in practice settings and the factors responsible for different outcomes. A German nationwide study on the effectiveness of couple counseling including 554 couples applied the same methodology as two earlier studies in the same field. A remarkable consistency was found over the three independent studies in the burden with individual and relationship distress as well as in the rates of improvement. This supports the insight that the improvements reached through couple therapy in practice settings are only about half of the effect sizes reached in efficacy trials. Additionally this study investigated 64 factors, which were found to be influential for relationship quality and stability in earlier studies, for their impact on outcome. Factors present at initiation and termination of therapy were found, which correlate significantly with outcome and with separation of the couple in the follow-up. These factors could be included in prediction models for improvement and separation of the couple. The implications for the practice of couple therapy and for future research are discussed.     

Experiences Delivering a Marital Intervention for Couples With Children With Autism Spectrum Disorder

Previous researchers have indicated that parents of children with autism spectrum disorder (ASD) are vulnerable to relationship stress, lower marital satisfaction, and potential relationship dissolution. We describe the experiences of three couples who participated in a 10-week, in-home couples therapy intervention using Emotionally Focused Therapy (EFT). Each couple and their progress through the intervention are described using therapist and supervisor reflections, and qualitative evaluation interviews with the participants after termination. Based on the experiences of the couples, we conclude that couples would benefit from an in-home couples therapy intervention aimed to strengthen their relationships.     

Clinical engagement of Canadian First Nations couples

Although intervention with Canadian First Nations (FN) clients has been discussed in the literature, the area of couple therapy remains unexplored. Moreover, the specific process of engaging couples in treatment by non‐FN therapists has not been examined. To address this critical aspect of couple treatment, this exploratory paper elaborates on significant factors that influence the engagement process and discusses (1) residual effects of the residential school era, (2) contemporary sociopolitical issues endured by FN peoples, and (3) sensitivity regarding cultural imperatives, beliefs and practices. Finally, to promote effective engagement with FN couples several suggestions and corresponding case vignettes are provided.     

Family and couples therapy with gay and lesbian clients: acknowledging the forgotten minority

Family and couples therapy in the main concentrates on heterosexual clients, and has thus been described as limited in its outlook, or discriminatory. It is argued that family and couples therapy is at present not offered to gay and lesbian clients because of an absence of appropriate referrals, the inability of therapists to recognize the sexual orientation of their clients, a belief that skills held by therapists are not appropriate for this client group, or because of the homophobia of the therapist. It is suggested that family and couples therapy should be more readily available for gay and lesbian clients, and a number of different issues which these families might face are discussed. This includes problems associated with the gay adolescent and the gay or lesbian parent, as well as the gay or lesbian couple. It is concluded that established forms of intervention are effective with gay clients, provided that the specific needs and problems of the gay and lesbian community are addressed by the therapist.     

The Effect of Expectations on Intention to Persist in Therapy

ABSTRACT

Little is known about the impact of expectations on persistence in couple and family therapy. A better understanding of the factors that contribute to persistence in therapy is key to understanding therapeutic dropout. We report results of a secondary grounded theory analysis of individual, couple, and family therapy clients' therapy expectations and their intention to persist in therapy. Participants were 19 clients of MFTs. Results indicate that clients carry expectations about the therapist, therapy process, duration, and outcome. Positive disconfirmation (Tambling & Johnson, 2010) of negative expectations contributed to therapy persistence.     

The Effectiveness of Collaborative/Therapeutic Assessment for Psychotherapy Consultation: A Pragmatic Replicated Single-Case Study

This pragmatic study evaluated the effectiveness of a collaborative assessment intervention as an approach to midtherapy consultation, which has yet to be empirically tested. Ten adult participants in ongoing psychotherapy with a variety of presenting concerns, primarily consisting of general mood and adjustment issues, received a brief assessment-based intervention based on Finn's (2007) Therapeutic Assessment model. Following the collection of assessment questions and the administration of a multimethod assessment battery, clients and therapists participated in a joint feedback session with the assessor. Clients were then followed as their psychotherapy continued. The results of idiographic and aggregate analytic approaches revealed significant reductions in client-reported symptomatic distress, as evidenced by a medium effect size (d = –.50) and a significant change in the trajectory of distress. Client reports of the process of psychotherapy revealed a significant increase in the clients’ ratings of the working alliance. The findings suggest that a midtherapy consultation using collaborative/therapeutic assessment methods is beneficial but that further rigorous investigation is needed.     

Assigning Homework to Couples and Families

Homework assignments, or “out-of-session assignments,” have gained popularity among couple and family therapists due to their potential to solidify the work achieved during the course of therapy and to help clients take responsibility for their own change. Homework assignments also serve as a testing ground in therapy to determine what works and what does not. This article provides an update on some of the empirical literature on homework assignments and its reported effectiveness in the domain of couples and family therapy. It also highlights the need for and the effectiveness of out-of-session assignments during the course of treatment.     

Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

Daily Events for Clinical Couples: Examining Therapy Interventions,Positive Events,Arguments, and Exercise in the Beginning Stage of Therapy

This study examined the daily association of several events within the beginning phase of couple therapy. Events examined were as follows: trying something from therapy, an argument, a positive event, and physical exercise. Participants were 33 couples in a treatment‐as‐usual setting who completed the Daily Diary of Events in Couple Therapy (DDECT). A dyadic multilevel model was used to explore the daily associations between predictor and outcome variables. Results showed when male partners tried something from therapy at rates greater than the average their female partners reported a more positive relationship while when female partners tried something from therapy at rates greater than the average it contributed to a more negative relationship. In addition, results showed that clients in couple therapy rarely try things from therapy on a daily basis. Finally, relative to other predictors trying something from therapy had a smaller, but significant relationship with outcomes.     

Sudden gains in treatment-as-usual couple therapy for military veterans

Previous studies of couple therapy have conceptualized change as a gradual process. However, there is growing evidence that, for many clients, the majority of gains in other treatment modalities are often achieved between just 2 sessions. Isolating the frequency, nature, and predictors of these sudden gains (SGs) in couple therapy can add to a growing understanding of how and why couple therapy works. In a sample of 67 couples receiving treatment-as-usual couple therapy in two Veterans Affairs hospitals, 25% of individuals experienced a SG in relationship satisfaction. The magnitude of these SGs were large (d = 1.62) and fully explained the total pre-post change for individuals who experienced them. Individuals with SGs showed significantly greater satisfaction gains during therapy; however SGs were not related to relationship satisfaction or relationship status at 18-month follow-up. SGs were predicted by the content of the previous session, putative change mechanisms of communication, intimacy, and behavior, as well as the partner's SGs during the same period. Results suggest that SGs are an important component of change during couple therapy for some individuals, challenging the assumption of continuous change in previous studies. In addition, predictors of SGs were generally consistent with theoretical and empirical examinations of mechanisms of change in couple therapy.