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。     

促进当事人的改变：基于治疗性最近发展区的视角

作为心理治疗的有效区域, 治疗性最近发展区是指当事人当前适应问题经验的能力和通过治疗师的协助能够达成的潜在能力之间的距离。早期的同化模型理论更注重对心理治疗改变过程的描述, 治疗性最近发展区理论则能够进一步解释治疗师在不同阶段的帮助策略。在研究上, 治疗性最近发展区理论建立在非传统的方法论基础上, 通过不断累积个案的质性研究, 帮助治疗师理解和解释不同咨询效果的互动过程, 并使理论得到持续发展; 在临床上, 治疗性最近发展区为理解心理治疗过程中倒退现象提供了新视角, 并能够有效指导在治疗过程中采取挑战性还是支持性策略。未来研究可从临床上探索经验丰富的治疗师的实践智慧, 也可选取较大跨度的治疗对话序列, 对不同流派的特点, 从不同参与者的视角出发进行研究, 进而深化对心理治疗过程机制的理解。     

心理治疗的消极后果

心理治疗消极后果是指由于心理治疗本身直接导致的来访者病情恶化。消极后果表现形式多样,对其测量应全面而仔细确证。消极后果的影响因素众多,包括来访者中有人格病理诊断、人际功能障碍、他评病情严重、对治疗期望不正确和动机低下;治疗师缺乏共情、对来访者出现负性反移情、低估来访者病情和错误使用治疗技术;潜在有害疗法。对其预防包括治疗前对治疗师和疗法进行规范和治疗中采用聚焦来访者的研究减少消极后果发生率。最后提出目前研究中存在测量、研究单位选择和伦理等难题,未来研究应全面呈现研究数据、采用RCT研究确定消极后果发生率、用交互作用研究模式寻找消极后果影响因素以及对中介变量的研究探询消极后果发生机制。     

阅读进度反馈信息对工作同盟和咨询效果的影响

进度反馈指将对当事人的标准化测量结果和解释反馈给咨询师的干预, 其目的在于矫正咨询师对咨询效果主观评估的偏差, 提高咨询效果。考虑到咨询师和当事人“面对面”的标准反馈程序不符合我国社会文化习惯, 采用多层结构方程模型, 分析了自然情境下非“面对面”的进度反馈对工作同盟和咨询效果的影响。结果发现, 在组间水平, 反馈组的工作同盟质量更好; 在组内水平, 工作同盟与症状是相互预测的关系。在结案时, 反馈组在抑郁症状和咨询的有帮助性上效果更好。结论是进度反馈对工作同盟和咨询效果有积极影响。研究从工作同盟和中国人的关系角度拓展了对进度反馈作用机制的认识, 为进度反馈的应用提供了基于实践干预有效的证据。     

心理咨询中好坏效果案例咨询互动的内容分析

目的:了解好坏效果案例咨访互动的特点及差异。方法:运用内容分析法对5个好效果案例和3个坏效果案例的会谈谈话轮进行评定。结果:在治疗师介入上,好坏效果案例存在显著差异;在当事人回应上,二者差异不显著;在治疗性最近发展区上,二者在"确认-安全"和"确认-可忍受冒险"两个区段存在显著差异,其他区段差异不显著。结论:临床工作中可多使用支持性技术,适当结合挑战性技术,并增多落入"确认-可忍受冒险"区段的比例。     

心理咨询过程-效果研究现状及展望

心理咨询过程-效果研究考察咨询过程变量对咨询效果的影响。以人为中心流派、认知流派、行为流派、精神分析流派等都为该研究领域提供了理论基础。主要研究内容有咨询师的反应方式、会谈中的当事人行为、工作同盟、会谈中的重要内容等过程变量与效果的关系。该领域积累的成果还不多,这可能与过程-效果关系本身的复杂性有关,同时研究方法尚有许多欠缺,如考察复杂关系时使用的研究设计过于简单、测量工具不统一导致结果难以比较,有些测量工具不成熟信效度不高。未来的研究除了努力克服这些问题外,还应多考虑理论构建、内隐变量的调节和中介作用、当事人变量,在研究方法上应更为综合和多样化     

反馈寻求行为的影响因素和本土化发展

反馈寻求行为是指个体积极主动地向上级或其他个体寻求与自身绩效、角色定位和工作目标等相关的反馈信息。研究者系统的梳理了反馈寻求行为的概念界定、测量方式、影响因素及实施效果,强化了中国本土文化的权变作用。未来研究应继续完善反馈寻求行为的概念,开发符合时代特征的测量工具,拓展研究层次,并结合中国特殊的组织情境,对反馈寻求行为做进一步探讨。     

治疗性评估的效果和机制及其在中国文化情境中的发展

治疗性评估是一种评估和干预的半结构化模型,强调当事人和评估者的协作,在实现评估目标的同时,能够促进当事人的改变。其主要效果体现为减轻症状,增加自尊和希望感以及促进参与治疗的动机等。和传统咨询技术相比,它还具有时间短、效率高以及能与其他治疗技术联合使用等优势。其主要局限为缺乏足够多的大样本研究,在跨国别、跨文化情境中的适用性及其作用机制还需进一步探讨。治疗性评估在中国文化情境下的发展,则受到测验工具的汉化修订、专业人员心理评估胜任力不足等挑战。     

工作同盟的结构：基于两种测量工具的检验

以大学心理咨询中心的当事人为样本,对国外两种广泛使用的工作同盟测量工具WAI-S和WAI-SR的结构和测量学指标进行检验。结果发现,WAI-S和WAI-SR的任务一致与目标一致两个维度的相关较高,分别为0.71和0.74;WAI-S和WAI-SR的一因素、二因素和三因素结构均没有得到充分支持;WAI-SR与咨询效果的相关不显著。WAI-S和WAI-SR的结构不能很好反映其所依据的理论假设,提示在对测量工具进行改进的同时,还需要对工作同盟的理论结构进行思考。     

表情符号:网络空间中的非言语线

网络表情符号是网络交往中用于交流情绪情感的从属性符号,起到了非言语线索的作用。本研究从网络表情符号的界定、使用的理论基础、使用动机、传递过程中的影响因素、信息接收者对表情符号的解释等方面进行梳理,提出未来研究应深入关注的四点内容:揭示网络表情符号的情绪表达规律及机制;关注网络表情符号使用的文化适应性;重视网络表情符号应用对青少年的影响;完善表情符号使用的测量工具,推进研究方法多元化。     

The Partners for Change Outcome Management System: A Both/And System for Collaborative Practice

Systematic client feedback (SCF) is increasingly employed in mental health services worldwide. While research supports its efficacy over treatment as usual, clinicians, especially those who highly value relational practices, may be concerned that routine data collection detracts from clinical process. This article describes one SCF system, the Partners for Change Outcome Management System (PCOMS), along a normative (standardized measurement) to communicative (conversational) continuum, highlighting PCOMS’ origins in everyday clinical practice. The authors contend that PCOMS represents “both/and,” providing a valid signal of client progress while facilitating communicative process particularly prized by family therapists steeped in relational traditions. The article discusses application of PCOMS in systemic practice and describes how it actualizes time‐honored family therapy approaches. The importance of giving voice to individualized client experience is emphasized.     

A discourse analysis of power in relation to PSYCHLOPS (Psychological outcome profiles) in the context of CBT for psychosis

Aims: Outcome measures (OMs) and routine change measurement have developed dramatically in psychological therapies over the last two decades and some therapists have expressed concerns that this, depending on how it is handled by the parties involved, can markedly affect the therapy. However, little research has investigated this. It therefore seemed timely to explore discourses of OMs drawn upon by both parties in the therapy room. Method: PSYCHLOPS (Psychological Outcome Profiles) is a client‐centred measure which offered an opportunity to explore how therapists and clients receiving CBT for psychosis talked about OMs. A useful contrast was provided by the CORE‐OM (Clinical Outcomes in Routine Evaluation‐Outcome Measure). The discourses drawn upon by clients (n=4) and therapists (n=4) were analysed, informed by a Foucaultian framework. Results: OMs were constructed as empowering or disempowering of clients, as being able to do therapeutic work of engagement and containment, and as part of the apparatus of service power, positioning therapists as relatively powerless to question their use. Discussion: It is suggested that client‐centred measures like PSYCHLOPS, although partly aligned with a recovery framework, may become part of top‐down state and service power, and there is a need for more research into the different ways in which OMs are used in therapy and the impacts on therapists, clients and their relationships.     

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.     

Feedback in Couple and Family Therapy: A Randomized Clinical Trial

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC (“treatment as usual” or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire–45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

Therapist Perceptions of Client Reactions

This study examined therapist ability to identify client-reported reactions. Sixteen therapists each saw two volunteer clients for single counseling sessions. In postsession reviews, clients rated the helpfulness of, and indicated their reactions to, each therapist intervention. Therapists also rated the helpfulness of, and indicated their perceptions of client reactions to, each therapist intervention. In 50% of the instances therapists matched clients, that is, reported the same reaction cluster as the clients did. There were higher match rates on the reaction clusters of therapeutic work (62%), supported (54%), and no reaction (46%) than negative reaction (27%) and challenged (14%). When therapists matched on therapeutic work, helpfulness ratings for the following intervention were higher than when therapists did not match. In contrast, when therapists matched on negative reactions and no reaction, helpfulness ratings for the following intervention were lower than when they had not matched. Thus, therapists' ability to match client reactions was related to their ability to generate helpful interventions. Implications for practice and future research are discussed.     

Using REBT in the Treatment of Restless Leg Syndrome: A Case-Study

This paper describes a case study of a middle-aged woman with restless leg syndrome (RLS) and the course of her treatment using rational emotive behavior therapy (REBT). Although the empirical support is somewhat limited, published literature suggests the potential effectiveness of cognitive-behavioral therapy in treating clients with RLS. This client sought treatment for chronic pain consistent with RLS which had affected her quality of life and daily functioning. She was assessed using a battery of quantitative measures. Conceptualization and treatment from an REBT perspective is discussed. The client was seen for six sessions. Treatment involved a combination of REBT disputing and cognitive restructuring techniques and behavioral interventions. Homework was given after each session. Between-meeting progress was assessed at each session using the Outcome Questionnaire and a scale measuring the client’s rational and irrational beliefs. The client reported a steady reduction in symptoms with associated improvements in sleep and daily functioning over the course of the six-session intervention. Therapeutic gains were maintained at 8-months follow-up.     

The Effect of Therapist–Client Racial Similarity on Client Satisfaction and Therapist Evaluation of Treatment

Client satisfaction with therapy services and therapists' perspectives of treatment evaluation were examined in relation to therapist and client racial similarity. Secondary data from a university marriage and family therapy clinic located in the southeast was used to pair therapists and clients on racial similarity or difference. Statistical analyses revealed no major differences in clients' perceptions of satisfaction based on similarity to therapists' race. Therapists indicated some differences in their perceptions of the success of services provided to clients based on similarity to client's race. Implications for researchers, clinicians, and educators are included.