【作者】 秦旻；

【导师】 郑涌；

【作者基本信息】 西南大学 ， 基础心理学， 2010， 博士

【摘要】 门诊心理治疗是我国心理健康服务体系的一个重要组成部分,对治疗和缓解非精神病性心理障碍具有重要作用。我国门诊心理治疗的效果究竟如何,已有这方面的研究大多集中在门诊调查报告中,由治疗师单方面做简单有效或无效评价；研究内容单一,通常是与药物治疗作比较,缺乏对个体心理治疗效果的研究。本研究采用心理治疗研究中的效果设计取向,在自然状态下对医院个体形式的心理治疗效果进行研究。研究内容包括结果研究和过程研究两部分。本研究采用问卷法、访谈法和单个案方法等多种方法,对门诊心理治疗的效果、治疗因素和作用机制进行探讨。在修订与编制了两个治疗效果问卷与三个心理治疗会谈成分问卷后,结果研究部分利用问卷调查门诊患者心理治疗满意度及其影响因素,以及对门诊多次治疗患者心理治疗效果进行连续监测,采用生存分析建构门诊心理治疗的剂量效果模型：过程研究部分放在一次会谈中进行考察,根据Lambert(1992)提出的心理治疗效果四因素模型设计泛理论会谈效果模型,并采用结构方程模型探讨和验证一次会谈中四因素如何作用产生治疗效果。最后通过单个案研究对该模型进行验证和诠释。全文旨在对门诊心理治疗效果现状进行调查研究,并为心理治疗理论本土化提供依据。主要的研究结果如下：1.结合国内外相关资料自编门诊心理治疗满意度问卷,探索性因素分析表明满意度问卷形成一个因素,即满意度。经检验,问卷具有较好的同质信度和结构效度,临床实用性良好,可作为评估患者对心理治疗是否满意的有效工具。2.结合国内外相关资料自编门诊心理治疗结果问卷,经检验具有较好的同质信度和重测信度；实证效度佳,能区分正常人群和门诊患者,对治疗改变敏感,与常用诊断量表中度显著相关,患者咨询前后问卷测得的即时效果与患者满意度间相关显著,且三个维度与满意度相关的差异性间接证实问卷具有良好的结构效度；相关程度分析和验证性因素分析也说明问卷具有较好结构效度,可以作为医院门诊心理治疗效果评价的工具。3.修订期望问卷(CEQ和PEI-R),探索性因素分析表明期望问卷形成三个因素：效果期望、建议-关系期望和听众-赞成期望。问卷信效度经检测显示良好,可以作为评估患者对心理治疗期望的有效工具。4.修订治疗联盟问卷(WAI-S台湾版),经检验,较好的同质信度、结构效度和实证效度,可以作为评估心理治疗中治疗联盟质量的有效工具。5.修订会谈评价问卷(SEQ-V台湾版),经检验,较好的同质信度、结构效度和实证效度,可以用来评估患者心理治疗会谈感受。6.本研究中大多数患者对门诊心理治疗满意。患者的性别、就业状况、诊断情况、既往咨询经历史和是否用药对满意度没有显著影响。患者的年龄、文化程度、家庭状况和收入水平对满意度有显著影响,表现为随年龄增长对心理治疗满意度下降,文化程度为初中及以下患者、家庭状况为独居者和收入水平最低者对心理治疗满意度最低。7.剂量效果研究生存分析显示本研究中门诊心理治疗效率：5次会谈治疗后有1/4患者达到临床显著效果,9次会谈后半数患者可以获得临床显著效果,17次会谈后将会有3/4患者达到临床显著效果。该数据可供门诊心理治疗师与患者协商会谈次数时作借鉴参考。8.本研究中患者对心理治疗效果抱有正向期望。在角色期望方面,患者更倾向于寻求建议-关系而不是寻求听众-赞成。性别对期望没有显著影响；年龄越小越渴望寻求建议-关系；教育程度越高,效果期望有增加趋势,而寻求建议-关系期望增加更显著；独居者最倾向于寻求听众-赞成,与配偶和父母居住者最倾向于寻求建议-关系,抱有最大的效果期望；休学者最愿意寻求建议-关系；收入越低越倾向于寻求建议-关系,收入越高越倾向于寻求听众-赞同。神经症更多寻求建议-关系,人格障碍更多寻求听众-赞同；心理障碍越严重,效果期望和寻求建议-关系期望越低；既往没有咨询经历的人抱有更高效果期望,而有咨询经历的人抱有更高角色期望；对既往咨询效果评价越高,所持效果期望越高；没有接受药物治疗患者的效果期望更高,而接受药物治疗者更倾向于寻求建议-关系。9.本研究中患者评价的治疗联盟总体正向,但与台湾和美国相比仍有差距,有待提高。性别对治疗联盟没有显著影响；年龄越小、教育程度越高、以及收入越低者对联盟评价越高；家庭结构越完整对治疗联盟评价越高,与父母和配偶居住者最高,独居者评价最低；上班上学者对治疗联盟评价好于待业者。神经症评价的治疗联盟最高,而人格障碍评价的治疗联盟最低；心理病理越严重,治疗联盟评价越差；咨询经历有无不影响患者对治疗联盟的评价,但对既往咨询效果评价越高,治疗联盟评价越高；是否用药不影响患者评价的治疗联盟。10.本研究中患者的会谈评价总体正向,顺畅性评价稍高于深度性。性别和收入对会谈评价没有显著影响；年龄越小会谈评价越高；教育程度越高会谈评价也越高；与父母配偶居住者会谈评价最高,独居者评价最低；休学者对会谈评价最高,而待业者最低。诊断类型对会谈评价无影响；心理病理越严重对会谈顺畅性评价越低；既往没有接受过心理咨询者会谈评价高于有咨询经历者,对既往咨询效果评价越高,对本次会谈评价越高；药物使用对会谈评价无显著影响。11.本研究证实效果期望是通过治疗联盟为中介对会谈评价产生作用,中介效应大于直接效应。建议-关系期望是通过治疗联盟的完全中介作用对会谈评价产生作用。12.本研究显示会谈效果模型有较好的拟合度,模型可以接受。根据会谈效果模型得出心理治疗的总效果为单次会谈效果累积,会谈前心理健康状态好的患者通过治疗后获益更多,获益部分是通过期望→治疗联盟→会谈评价中介。期望是通过治疗联盟→会谈评价促进治疗效果,其作用为间接效应。治疗联盟对治疗效果的正效应是通过会谈评价完全中介。会谈评价作为治疗效果的即时指标对其有正预测力。13.单个案研究中结合定量分析和质性研究,发现对患者治疗改善有帮助的因素是4个：患者资源、治疗关系、干预技术和期望,患者资源通过影响期望,期望影响治疗关系,而治疗关系决定干预技术的使用,它们联合在一起协调一致共同导致治疗改变发生,验证前文提出的会谈效果模型。更多还原

【Abstract】 Outpatients psychotherapy is an important constituent of the mental health service system in China, which can cure and relieve nonpsychotic mental disorders. However, most of the studies about effectiveness of outpatients psychotherapy in China concentrate in survey design, are evaluated success or not by therapists only, and compare psychotherapy with drug treatment which leading to short of individual psychotherapy. Taking the treatment effectiveness research orientation, the present study use methods of questionnaire, interview and single-case methology to comprehensively and thoroughly discuss the outcome and process of individual psychotherapy for outpatients in naturalistic state.Firstly, we developed two outcome questionnaires, named Client Satisfaction Questionnaire for Outpatients Psychotherapy and Psychotherapy Outcome Questionnaire for outpatients. Also we revised three processes questionnaires, named Psychotherapy Expectancy Scale, Working Alliance Inventory-Short, and Session Evaluation Questionnaire. Secondly, using outcome questionnaires, the outcome research investigate and evaluate the effect of outpatients psychotherapy from client satisfaction and dose-effect model. Thirdly, using outcome questionnaire and processes questionnaires, the process research construct session effect model by Lambert’s four therapeutic factors model(1992).Finally, in order to verify and interpretation session effect model, we use single-case methodology to study favorable factors during counseling. The aim of the study is to investigate psychotherapy effect in naturalistic state, which can provide reference for theory localization.Then main finding are summarized as follows:1.According to related data at home and abroad, we developed ourselves client satisfaction questionnaire. Exploratory factor analysis of client satisfaction questionnaire resulted in construction of one factors:satisfaction. It was tested that client satisfaction questionnaire had good internal reliability, content validity, structure validity, and clinical utility, and could be an effective tool evaluating client’s satisfaction.2.According to related data at home and abroad, we developed ourselves psychotherapy outcome questionnaire.It was tested that psychotherapy outcome questionnaire had good internal and test-retest reliability, could distinguish patients from the normal, was sensitive for change, and had convergent validity with common diagnostic instruments. The difference between the score tested before and after one session correlated significantly with the score of client satisfaction questionnaire, which show its good empirical validity. The sub factors’ correlation with the score of client satisfaction questionnaire are different which show its good structure validity. Correlation analysis and confirmatory factor analysis of psychotherapy outcome questionnaire also show it good structure validity. It could be an effective tool evaluating psychotherapy outcome.3.We combine Client expectation questionnaire with Psychotherapy Expectancy Inventory-Revised and revised them as our psychotherapy expectancy questionnaire. Exploratory factor analysis of expectancy questionnaire resulted in construction of three sub factors:outcome expectation, advice-relationship expectation, and audience-approval expectation. It was tested that psychotherapy expectancy questionnaire was reliable and valid, can be an effective tool evaluating client expectancy of psychotherapy.4.We revised Working Alliance Inventory-Short (WAI-S). Confirmatory factor analysis of WAI-S resulted in construction of one sub factors:alliance. It was tested that WAI-S had good internal reliability, structure validity, and empirical validity, could be an effective tool evaluating psychotherapy alliance for patients.5.We revised Session Evaluation Questionnaire-V(SEQ-V). Confirmatory factor analysis of SEQ-V resulted in construction of two sub factors:depth and smooth. It was tested that SEQ-V had good internal reliability, structure validity, and empirical validity, could be an effective tool for patients evaluating session experience.6. We use client satisfaction questionnaire to evaluate the effect of outpatients psychotherapy. Most patients are satisfied with their psychotherapy. Patient’s variables, such as gender, employment, diagnosis, the history of previous psychotherapy, and meditation have no statistically significant difference on client satisfaction. In terms of the patients age, it shows the younger the better. In terms of education, it shows the lowest the worst. In terms of family status, the satisfaction of the patients living on their own are worst. In terms of income, the lowest the worst.7.Using dose-effect design, survival analysis indicated that 25% patients attain clinical significant change(CS) was 5 sessions,50% patients attain CS was 9 sessions, and 75% patients attain CS was 17 sessions. Psychotherapists who negotiates with patients about the length of treatment can refer to these data.8.We use psychotherapy expectancy questionnaire to evaluate the expectation of patients. Most patients have positive outcome expectation, and patients are more likely to seek advice-relationship than audience-approval.Patient’s variables, such as gender, has no statistically significant difference on patients expectation. In terms of age, it shows the younger the more seeking advice-relationship. In terms of education, it shows the higher the education the higher the outcome expectation, and the more seeking advice-relationship. The patients living on their own are more likely to seek audience-approval, and also lower outcome expectation. The patients living with their parents and spouses are more likely to seek advice-relationship, and also higher outcome expectation. The patients who dropout of school are more likely to seek advice-relationship.The higher income the more seeking audience-approval, and the lower income the more seeking advice-relationship. The patients diagnosed as neurosis are more seeking advice-relationship, and the patients diagnosed as personality disorder are more seeking audience-approval. The higher score of psychotherapy outcome questionnaire, the worse of mental status, and the lower of outcome expectation and the less seeking advice-relationship. The patients with no experience of psychotherapy have higher outcome expectation, and the patients with experience of psychotherapy has high role expectation. The patients who valued their previous psychotherapy have higher outcome expectation. The patients without meditation have higher outcome expectation, and the patients with meditation are more likely to seeking advice-relationship.9.We use WAI-S to evaluate the patients’ relationship with their therapists. Most patients have positive relationship with their therapists, but the score are lower than that of Chinese Taiwan and USA.Patient’s variables, such as gender, previous psychotherapy experience, and meditation or not has no statistically significant difference on the score of WAI-S.The patients who are younger, higher education, lower income, and living with their parents and spouses give higher score of their WAI-S.The patients who are living on their own, unemployment give lower score of their WAI-S. The patients diagnosed as neurosis give higher score of their WAI-S than personality disorders. The higher score of psychotherapy outcome questionnaire, the worse of mental status, and the lower of the score of WAI-S.The patients who valued their previous psychotherapy have high score of WAI-S.10. We use SEQ-V to evaluate the session experience of patients. Most patients have positive experience with their session, and give higher score on smooth factor than depth factor. Patient’s variables, such as gender, income, diagnosis, and meditation or not have no statistically significant difference on their score of SEQ-V. In terms of the patients age, it shows the younger the better. In terms of education, it shows the higher the better. In terms of family status, the score of SEQ-V of the patients living on their own are worse than that of the patients living with their parents and spouse. In terms of employment, the score of the dropout of school are higher than that of unemployment. The higher score of psychotherapy outcome questionnaire, the worse of mental status, and the lower of the score.The patients without previous psychotherapy experience give higher score than the patients with previous psychotherapy experience, and the patients who valued their previous psychotherapy have high score of SEQ-V.11.Amos7.0 software was applied to explore the relationships of expectancy, working alliance, and session evaluation. We find that the working alliance mediates the relationship between outcome expectation and session evaluation, and mediation effect is larger than direct effect; the working alliance mediated the relationship between advice-relationship expectation and session evaluation, and it is complete mediation.12.Amos7.0 software was applied to explore the session effect model.After modifying original model, many fit indices indicated the model fit was satisfactory. The session effect model show us psychotherapy outcome are added by every session effect. The treatment gains(the mental health status before the session) promote expectancy, and expectancy in turn fosters working alliance. Working alliance leads to high session evaluation, and productive sessions are linked to augmentation in mental health status. Positive influences for expectancy, working alliance, and session evaluation were observed, and expectancy and working alliance have no direct effect on mental health status after the session.13.The single-case methodology combined quantitative and qualitative research, proved four therapeutic factors on the patient:patient resources, working alliance, specific techniques and expectancy. Patient resources influence patient expectancy, and expectancy influence working alliance, and working alliance govern the use of specific techniques. All the four factors linkup and lead to change aligned.更多还原