短期心理治療的中輟現象:病人臨床和心理動力特性的探討

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2016

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研究目的:1. 探討完成治療、中輟治療但事先告知、中輟治療但不告而別三類病人之比率,以及以三種不同方式定義中輟所產生的中輟率差異。2.探討前述三類病人實際參與心理治療的次數。3. 探討前述三類病人在人口學、臨床、出席狀況與治療關係初期和末期的心理動力特性等方面的差異。4.根據前述預測變項,建立可以區別前述三類病人的迴歸預測模式。5. 探討以心理治療歷程紀錄做為文本,進行Operationalized Psychodynamic Disgnosis-2(OPD-2)心理動力診斷的可能性、限制與突破方式。 研究方法:1.研究對象:1999年10月到2005年1月之間,在臺灣某精神科專科醫院門診接受某位精神分析取向心理治療師個別治療的成人病人,總計97人。2.研究工具:變項分析所根據的檔案資料為病歷紀錄與心理治療歷程紀錄,治療關係初期為病人最早出席的兩次治療,治療末期為病人最後出席的兩次治療。心理動力特性的分析工具為OPD-2與Heidelberg Structural Change Scale(HSCS)。 研究結果:1. 完成治療者、事先告知者、不告而別者的比率分別是34%、36.1%、29.9%,三者的比率沒有顯著差異。根據出席次數低於12次、未出席治療期最後約定談話、未約定最少12次以上的治療期談話並出席治療期最後談話三種方式來定義中輟,所產生的中輟率分別是63.9%、40.2%、66%,三者有顯著的差異。2. 本研究全體樣本參與治療的平均次數為8.76次,其中完成治療者、事先告知者、不告而別者參與治療次數的平均數分別是13.12、6.69、6.31次。3.完成治療者與不告而別者在人口學、臨床、出席狀況、治療關係初期與末期的心理動力等範圍,都有明顯的差異。提早告知者與完成治療者的差異多過於與不告而別者的差異,提早告知者—完成治療者的主要差異是在出席狀況與治療關係初期與末期的心理動力等範圍,在人口學與臨床變項方面則沒有明顯差異。提早告知者—不告而別者之間差異最小,主要差異是在人口學、臨床與出席狀況方面,在治療關係初期與末期的心理動力特性幾乎沒有差異,只是提早告知者比不告而別者呈現出更多的「個體化—依賴」衝突。4. 可以區別三類病人的最佳迴歸預測模式包括無故缺席比率、治療關係末期的內在交流與主要衝突類型三個變項,Nagelkerke R2為.74、McFadden R2為.50,整體正確預測率為76.8%,對於完成治療者、提早告知者與不告而別者的正確預測率分別為81.3%、64.3%與86.4%。5.以心理治療歷程紀錄做為文本,用來分析OPD-2的心理動力存在參考資訊不足或不相關、文字表徵具有歧義性等普遍性問題,在評定OPD-2各軸向時也存在一些特定性問題。本研究對於前述問題建議一些解決方式,以因應治療歷程紀錄資訊不足所帶來的挑戰,提供未來以心理治療談話內容進行OPD-2評分的參考。
Purposes: 1. Explore percentages of psychotherapy completers, dropouts with prior notice(DWN), dropouts without prior notice(DNN), and differences of dropout rates according to three difinitions. 2. Explore actual attending times of psychotherapy of these three patient groups. 3. Explore differences among these three groups in demorgraphic, clinical, attendance variables and psychodynamics during initial and terminal stages of psychotherapy. 4. Basing on these predicting variables, set up regression models to discriminate three groups. 5. Explore the possibilities and perils of evaluating Operationalized Psychodynamic Disgnosis-2(OPD-2) psychodynamics if use psychotherapy process notes as analysis text, and find out solutions to limitations of such evaluation. Methods: 1. Population: 97 Adult patients taking individual psychotherapy from a psychoanalytic psychotherapist in outpatient department of a special psychiatric hospital in Taiwan from October, 1999 to January, 2005. 2. Tools: Variables were analysed basing on documentations of medical chart and psychotherapy process notes. Inital stage of psychotherapy included first two participated sessions, terminal stage included last two participated sessions. OPD-2 and Heidelberg Structural Change Scale (HSCS) were used to analyse psychodynamic variables. Results: 1. Percentages of psychotherapy completers, DWN and DNN were 34%, 36.1% and 29.9%, no significant difference among groups. Dropout rates of three dropout definitons which were patients participated less than 12 sessions, patients didn't attend last appointed session, and condition combined these two criteria were 63.9%, 40.2%, 66% accordingly, there were significant differences among them. 2. The mean of participated therapy sessions of all patients was 8.76 sessions, 13.12, 6.69 and 6.31 sessions individually for completers, DWN, and DNN. 3. Completers and DNN shown significant differences in all domains of variables, including various demorgraphic, clinical, attendance variables and psychodynamic variables in initial and terminal stages. DWN-completers differences were greater than DWN-DNN differences. The main domains of DWN-completers differences exist in attendance variables and psychodynamic variables in initial and terminal stages, but no significant difference shown in demorgraphic and clinical variables. DWN-DNN differences were the least one among three between-group comparisons, where major differences were present in domains of demorgraphic, clinical and attendance, and there was almost no diffrence in terms of psychodynamic variables, no matter inital or terminal stage, except DWN shown more individuation-dependence conflicts in initial stage than DNN. 4. The best discirminating regression model included three variables: no show rate, internal communication and primary dysfunctional conflict in OPD-2 in terminal stage. Its Nagelkerke R2 is .74, McFadden R2 is .50, total correct prediction rate is 76.8%, with 81.3%, 64.3% and 86.4% correct rates for completers, DWN and DNN accordingly. 5. Evaluations of OPD-2 psychodyanmics basing on psychotherapy process notes shown general problems including insufficient or irrelevant information, various interpretations of the same description, and other specific problems while evaluating axes of OPD-2 and HCSC. This study provided some adaptive suggestions for future user to code OPD-2 and HCSC items basing on psychotherapy process notes to cope with these challenging situations due to insuffient information.

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治療中輟, 臨床變項, 出席狀況, 心理動力, OPD-2, HCSC, dropout, clinical variables, attendance variables, psychodynamics, OPD-2, HCSC

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