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。     

Outdoor Behavioral Health Care: A Longitudinal Assessment of Young Adult Outcomes

This article details a 3‐year outdoor behavioral health care outcome study. Hierarchical linear modeling was used to analyze data from 186 young adults in a wilderness therapy program. Participants completed the Outcome Questionnaire–45.2 (Lambert et al., 2004 ) 6 times from Week 1 to 18‐month postdischarge follow‐up. Results indicated that clinically and statistically significant change occurred in treatment. Rates of change varied, and posttreatment scores remained stable, thus demonstrating that in‐treatment gains were maintained. Implications and recommendations for future research are discussed.     

Combining Patient Utility with Health Status Assessment to Improve Medical Decision Making

Physicians often use health status assessment tools to evaluate a patient's condition, then apply established guidelines to determine the most medically effective treatment. Yet additional criteria, such as the appropriateness of the treatment given the particular patient's preferences and attitude toward risk, are also highly relevant to quality care. While such preferences could be addressed via patient utility functions, their use in actual practice is somewhat limited because elicitation is often considered too burdensome for patients, unreliable, or redundant given other measures. For a small group of real patients who have suffered a stroke, we measure both traditional health status and patient utility for the current state to determine whether limited, focused utility assessment is a practical means of obtaining additional and relevant patient information. We find that utility assessment is perceived as reasonable and useful by patients, even when quite ill, and that utilities and health status are not redundant. In fact, investigating apparent inconsistencies between patient utility and observed health status can alert the physician to patient concerns and criteria not captured by more traditional measures. We propose an approach to medical decision making that uses both measures to improve patient–physician communication.     

Social cues and verbal framing in risky choice

We examined how people use social and verbal cues of differing priorities in making social decisions. In Experiment 1, formally identical life – death choice problems were presented in different hypothetical group contexts and were phrased in either a positive or negative frame. The risk‐seeking choice became more dominant as the number of kin in an endangered group increased. Framing effects occurred only in a heterogeneous group context where the lives at risk were a mixture of kin and strangers. No framing effect was found when the same problem was presented in the context of a homogeneous group consisting of either all kin or all strangers. We viewed the framing effects to be a sign of indecisive risk preference due to the differential effects of a kinship cue and a stranger cue on choice. In Experiment 2, we presented the life – death problem in two artificial group contexts involving either 6 billion human lives or 6 billion extraterrestrial lives. A framing effect was found only in the human context. Two pre‐conditions of framing effects appear to be social unfamiliarity of a decision problem and aspiration level of a decision maker. In Experiment 3, we analyzed the direction of the framing effect by balancing the framing. The direction of the framing effect depended on the baseline level of risk preference determined by a specific decision context. Copyright © 2001 John Wiley & Sons, Ltd.     

Insult,then Injury: Interpersonal and Institutional Betrayal Linked to Health and Dissociation

Psychological trauma, particularly trauma involving betrayal, has been linked to health problems. Betrayal trauma is also characterized by dissociation and difficulty remembering as victims face conflicting demands presented by a harmful but important relationship. Institutional betrayal is related to, but distinct from, interpersonal betrayal and in need of research on its unique effects. The current study has two related goals. First, the association between institutional betrayal and health problems is examined. Second, the previously documented association between institutional betrayal and dissociative symptoms is re-examined, while controlling for betrayal trauma. This study utilizes a sample of 302 college students (70% female, 63% Caucasian) who reported their trauma history (Brief Betrayal Trauma Survey), institutional betrayal history (Institutional Betrayal Questionnaire), distress related to health problems (Patient Health Questionnaire), and dissociative symptoms (Wessex Dissociation Scale). We found that institutional betrayal is uniquely associated with both health problems and dissociative symptoms even when controlling for betrayal trauma exposure. Findings add to the understanding of how institutional betrayal is uniquely associated to trauma-related physical and mental health outcomes. Small effect sizes, likely due to low base rates of health problems and dissociative symptoms in college students, and problems generalizing these results to clinical samples are discussed.     

Mental health measurement among women veterans receiving co-located,collaborative care services

Routine use of measurement to identify patient concerns and track treatment progress is critical to high quality patient care. This is particularly relevant to the Primary Care Behavioral Health model, where rapid symptom assessment and effective referral management are critical to sustaining population-based care. However, research suggests that women who receive treatment in co-located collaborative care settings utilizing the PCBH model are less likely to be assessed with standard measures than men in these settings. The current study utilized regional retrospective data obtained from the Veterans Health Administration’s electronic medical record system to: (1) explore rates of mental health measurement for women receiving co-located collaborative care services (N = 1008); and (2) to identify predictors of mental health measurement in women veterans in these settings. Overall, only 8% of women had documentation of standard mental health measures. Measurement was predicted by diagnosis, facility size, length of care episode and care setting. Specifically, women diagnosed with depression were less likely than those with anxiety disorders to have standard mental health measurement documented. Several suggestions are offered to increase the quality of mental health care for women through regular use of measurement in integrated care settings.     

Stories of family caregivers of people with dementia in Greece: Implications for counselling

A substantial body of literature has identified high rates of burden, psychological morbidity, social isolation, health and financial difficulties among dementia caregivers. The present qualitative study adopted an Interpretive Phenomenological Analysis approach in order to explore the lived experiences of dementia family caregivers within the Greek sociocultural context. The sample was purposive and consisted of 10 women dementia family caregivers from Athens and Thessaloniki. Individual in-depth interviews were conducted and analysed according to IPA. The participants’ personal accounts included themes related to ethical/existential and cultural aspects of family caregiving; changes in family relationships; impact of the caregiving experiences; sources of support and help seeking; positive and meaningful aspects of the care experience. The research findings are discussed in the context of Gilligan’s moral psychological theory, and cultural dimensions of family caregivers. Implications for counselling interventions aiming at supporting caregivers are presented.     

Manualised health support interventions: Their efficacy in a South African primary healthcare setting

The study examined the implementation efficacy of a stress-reduction intervention for people living with HIV/AIDS by health care workers in the Eastern Cape Province, South Africa. Informants were 20 health care workers drawn from two health facilities. There were 17 females (85%) and 3 males (15%). Participants engaged in a focus group discussion on their experiences using a theory-based manualised stress-reduction support intervention in primary care settings. Thematic content analysis of the data yielded the following themes characterising costs to faithful implementation: departure from manualised instructions and ad hoc improvisation of theoretical concepts; disruptive power dynamics; lack of grounding in community values; and implementation resource limitations. Manualised intervention implementation efficacy by health workers needs customisation to local culture and health service support services.     

Authentic leadership influences on organisational commitment in a South African state hospital

This study investigated the influence of authentic leadership (AL) on employee organisational commitment (OC) in a South African state hospital. A convenience sample of 222 employees (female = 81%; black = 82%) completed the Authentic Leadership Questionnaire on their perceptions of AL behaviours among their leaders; namely self-awareness, relational transparency, internalised moral perspective, and balanced processing. The employees also completed the Organisational Commitment Questionnaire to self-report on their own OC; namely affective, continuance, and normative commitment. Data were analysed utilising regression analysis to predict employees’ self-reported OC from perceived AL behaviours. Findings suggest AL scores to predict OC scores as well as the OC dimensions of continuance and normative commitment. AL scores did not predict affective commitment. Employees whose leaders apply AL may be able to retain employees through increased OC.     

Disparities in access to family physicians among transgender people in Ontario,Canada

Background: Informed by the Gelberg-Andersen behavioral model for vulnerable populations, this study examined the prevalence of and factors associated with not having a family physician among transgender (trans) people in Ontario, Canada.

Methods: Data were drawn from a respondent-driven sampling (RDS) survey of trans Ontarians age 16 and above (n = 433) conducted between 2009 and 2010. All analyses were weighted using RDS II methods. Prevalence ratios were estimated using average marginal predictions from logistic regression models.

Results: An estimated 17.2% (95% CI, 11.0 to 22.9) of trans Ontarians (median age = 28.7, 77.3% White) did not have a regular family physician. In multivariable analyses accounting for other predisposing and need-related factors, transfeminine persons (trans women and non-binary persons assigned a male sex at birth) who were Indigenous and/or persons of color were less likely than other transfeminine persons to have a family doctor. In addition, trans persons who were homeless or had unstable housing were less likely to have a family doctor than those who were adequately housed.

Conclusions: These results provide the first quantitative evidence of health disparities by race and gender within a Canadian transgender population and suggest a social gradient in access to care within Ontario's “universal health insurance” system.