循证心理治疗解析

心理治疗服务的有效性得到研究证据支持,但在临床中采用循证实践很难。本文简介心理治疗循证实践的模式、研究成果和现状,分析工作中推行循证实践困难的原因,介绍一种新循证方式——循效施治。该方式能被整合到心理治疗中,以一种临床治疗师不感到胁迫的方式使其积极参与收集和反思证据的过程,并且允许其以创新方式将证据运用到实践中。     

心理治疗循证实践中“证据”的四个基本问题

循证实践正在成为西方心理治疗发展的主流方向。但如何理解循证实践的"证据"仍是见仁见智。部分社会大众甚至心理学专家仅将"循证"当作一种"修辞"或"时尚",顾名思义地界定"证据",或按主观信仰随意地选择与应用"证据"。文章以"证据"为研究焦点,试图建构系统理解"证据"的全面图景,探讨了心理治疗循证实践中关于"证据"的4个基本问题:(1)从历史考察与理论分析的视角出发,探讨了"心理治疗为什么需要证据";(2)从证据的类型范围、生产者及存在形式三个视角,描述了"心理治疗存在哪些证据";(3)从证据的科学程度、研究设计的严谨程度及解决实践问题的契合程度出发,阐述了"哪些证据才是好的证据";(4)从6个步骤推广证据及创新研究设计两个方面展开,分析了"在现实世界中如何推广与应用证据"。     

心理治疗的循证实践与循效施治

循证实践与循效施治是当前国外心理治疗的两种相互补充的模式,二者在理论假设、获取证据的来源、操作流程等方面存在着明显不同。从影响来看,循证实践的影响力超过了循效施治,它被美国提升推广为一种心理学运动,它的倡导昭示着目前临床心理治疗的一个关键性改革。然而,在心理治疗中要真正实施循证实践存在着很多困难和挑战,循效施治是解决这些困难和问题的方法之一。我国心理治疗的专业化水平不高,藉美国心理治疗循证实践提供的理念和方法去思考中国心理治疗的问题,我们亦可获得有益于中国心理治疗发展的思路。     

循证医学与心理治疗

随着循证医学在医学领域逐步普及 ,许多医学诊断方法和治疗措施面临科学检验和评价的今天 ,作为具有医学性质的心理治疗 ,笔者认为 ,也应借鉴循证医学的方法。1　以循证医学的方法 ,用现有最好的证据来制定诊断的依据和为每一个患者作出心理治疗方法的选择心理治疗的步骤 ,首先是建立良好的医患关系 ,为取得患者的配合 ,以便进行心理测验 ,使治疗师能根据个人临床经验和心理测验结果对症状作出正确评估和诊断。循证医学不排除个人临床经验 ,心理治疗也不例外。心理治疗中 ,有许多个案病例报道。尽管从学术的立场上讲 ,任何个案报导 ,都不能…     

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。     

后现代视野中的心理治疗及其思考

现代心理治疗与后现代心理治疗在关于认识论、知识的性质、标准、构造以及语言的作用等方面存在诸多差异。前者是对客观与理性的探寻．后者是对主观建构的追求。尽管人们对后现代心理治疗尚有诸多争论,但却能引发人们在扩展对心理治疗性质之认识、推进心理治疗本土化、克服心理治疗中的非人格化倾向等方面的有益思考。     

“心理咨询和治疗”方法的13年回顾分析及其循证思考

信息化、网络化使学科日益交叉与渗透。在网络化基础上 ,2 0世纪 90年代下半期兴起的循证医学[1] (ＥｖｉｄｅｎｃｅＢａｃｅｄＭｅｄｉｃｉｎｅ,ＥＢＭ )正在迅速推动医学的发展 ,使大量的临床诊断方法和治疗措施面临科学的评价。那么 ,具有一定医学性质的心理咨询和治疗业有无循证的可能和必要 ?笔者以《中国心理卫生杂志》“心理咨询和治疗”栏目自创刊到本世纪末 13年来的内容 (主要是心理和治疗的方法 )进行了分析 ,并提出“心理咨询和治疗也应循证”的观点 ,以期与同行商榷。1　材料与方法1 1　材料《中国心理卫生杂志》“心理咨询和…     

传统心理治疗的困境与释义学对心理治疗的影响

传统心理治疗追求自然科学模式,接受经验主义科学观,方法论上表现出本质主义、个体主义、普适主义、量化方法和还原论等特征.但是心理治疗更多的是一种人文关怀领域,因而传统心理治疗面临着种种困境.释义学强调了人文社会科学同自然科学的不同.释义学是一种意义的追寻,而不是一种因果关系的说明.它强调的是理解及其理解的文化背景.这些特征使得释义学与心理治疗具有明显的契合性,给心理治疗提供了一种新的理论基础.     

循证医学的哲学思考--科学实质、理论体系与实践意义

经历了一定时期的发展 ,循证医学正在走向成熟 ,其理论和观点引起了全球医学界越来越广泛的重视 ,对于医学教育、临床实践和医学科研正在产生深远的影响。然而 ,对循证医学的理论认识和实践意义仍然有不少争论[1～ 3] 。循证医学在中国的研究和应用远远落后于美英等发达国家水平。从哲学高度来考察循证医学的科学实质、理论体系及其实践意义 ,不仅有助于深入认识和理解循证医学这一新的观念和理论 ,也将进一步推动循证医学在医学实践中的广泛应用 ,对提高我国医疗卫生和科研水平具有重要意义。1　循证医学的科学实质1991年 ,加拿大学者Ｇ .…     

Evidence-Based Psychotherapy and Counselling in the UK: Critique and Alternatives

Developments in empirically supported therapy or evidence-based practice in the UK are outlined and critically examined. Perceived advantages and disadvantages are set out, with a commentary. It is asserted that the evidence-based ethos is seriously flawed and that psychotherapy is essentially a faith-based craft, not a thoroughly researchable scientific enterprise. Some alternatives to evidence-based practice are briefly outlined, before turning to an exploration of the wider context of anthropathology in which therapy takes place and against which it must acknowledge its limitations. Broad-brush conclusions are drawn.     

THE ‘OTHER 23 HOURS’: SPECIAL PROBLEMS OF PSYCHOTHERAPY IN A ‘SPECIAL’ HOSPITAL

In this paper, I describe and discuss the complexities of being a therapist in a maximum security forensic psychiatric hospital, working with patients who have committed acts of serious violence, and who also suffer from severe mental illness and personality disorders. I suggest that profound disturbances in the patient's inner world get played out in triangular disputes between the patient, the therapist and other professionals working in the hospital. I also describe how real events in the life of the institution impact on the therapeutic process, and the importance for the therapist of reflection on the ‘other 23 hours’ that the patient lives outside of therapy. Finally, I raise some ethical dilemmas that arise for therapists working in such settings, where the stated therapeutic aim is not only treatment but also the containment and prevention of future violence.     

Rules Versus Principles in Psychotherapy: Implications of the Quest for Universal Guidelines in the Movement for Empirically Supported Treatments

In this article we briefly review the mission and criteria of the EST movement and several of its criticisms. We question an often-unacknowledged feature of the EST initiative—its foundation in a rule-governed approach to the regulation of psychotherapy—and argue that this approach encounters significant problems that are better resolved through an alternative, principle-based approach. The contrast between these perspectives is illustrated by presenting results of a qualitative research project identifying the implicit principles actually used by expert therapists across psychotherapy orientations to regulate values and interventions within their practice.     

A Broader Perspective: Counseling Psychology’s Emphasis on Evidence

The process of identifying empirically supported treatments developed by the Division 12 of the American Psychological Association has been criticized from various perspectives. However, there are a number of alternative evidence-based models for using research findings to increase the efficacy of mental health services. In this article, the principles of empirically supported interventions developed and adopted by Division 17 (Society of Counseling Psychology) are presented. These principles (a) utilize a broad perspective of evidence, (b) consider a range of psychological interventions, (c) emphasize the quantitative aggregate of research evidence, (d) consider various levels of specificity, and (e) recognize philosophy of science issues that impinge on the types of conclusions that can be made.     

Evidence-Based Psychotherapy Means Evidence-Informed,Not Evidence-Driven

Some advocates of empirically-supported treatments (ESTs) argue that practitioners who do not use them are practicing unethically. I argue that it is unethical to try to impose EST criteria on the field of psychotherapy practice when (a) there is considerable controversy over these criteria, (b) there are alternative ways to construe evidence-based practice, and (c) by other criteria many approaches are evidence-based. I consider views of the relationship of science to practice, and other bases for practice such as practical knowledge and ethics. I conclude with a case history of client-centered therapy.     

存在主义心理治疗的两个哲学教条

作为基本信念的两个哲学教条,即“存在先于本质”和“人是绝对自由”,导致存在主义心理治疗遭受各种诟病。前者造成人的存在与本质分裂,过分夸大个体选择意义和忽略人的现实性等问题;后者造成自由与必然关系的割裂,忽略自由的条件性和抽掉人的社会历史性等问题。基于对两个哲学教条的反思,存在主义心理治疗要求“抽象人”与“具体人”,“个体性”与“社会性”,“此在性”与“历史性”的辩证统一,从根本上实现对人的科学理解,进而提升实效性。

     

三种方法论与心理治疗

心理治疗不仅作为心理学的一个分支与心理学密切相关,而且因其实践性强又与社会科学有着密切的联系。故在一般意义上,分别阐述社会科学领域中的三种方法论,即客观主义、后结构主义和一般系统论对心理治疗的影响,及其各自的优点和局限。     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.