短程心理咨询的会谈间体验对咨询效果的影响——来自纵向测量的证据
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摘要
采用多层线性分析方法,在短程心理咨询的连续会谈中检验来访者的会谈间体验对咨询效果的影响。以36名个案、151次会谈为样本,结果发现,来访者的症状总体呈线性下降趋势;不同来访者症状变化的速率存在个体差异,会谈间体验的情绪因子能解释症状变化速率总变异的40.79%。结论:在短程心理咨询中,来访者想起咨询会谈或/和咨询师时的情绪体验能显著预测咨询效果。
Psychotherapy process includes insession process and intersession process,occurring in and outside the counseling room respectively,and the latter has been neglected for a long time in psychotherapy research history. Intersession process refers to the thoughts,memories,and feelings about therapists or therapy sessions that clients experience during the intervals between sessions. Intersession process is a joint product of actual in- session therapeutic interaction and the client's prior personality,in particular,the client's conscious and unconscious transference potentials. It connects the therapeutic process and client's actual life,and has repaired functions for clients in therapy. The present study aimed to identify the effects of intersession processes on treatment outcome over successive sessions in short- term therapy.12 male and 24 female student visitors of a college counseling center,with a mean age of 22. 47( SD = 2. 60) and without personality disorder or other psychiatric symptoms,participated in the study. Intersession process was measured by the Chinese version of the Intersession Experience Questionnaire( IEQ),which consisted of eight factors of four dimensions( intensity,context,content and emotion). The treatmentoutcome was measured by the Outcome Questionnaire- 45( OQ- 45) and higher scores meant more severe symptoms. Participants were asked to complete IEQ and OQ before each session from sessions 2 to 9. Finally,151 sessions /36 cases were collected,and the mean measures of each case was 4. 19( SD = 1. 26).A two- level hierarchical linear model was built to investigate the effects of time and time- depended predictor IEQ on OQ. Results indicated that,generally,in the short- term psychotherapy the symptoms of clients significantly declined in linear tendency,while OQ decreased by 1. 27 point after each session. The proportion of total variance between the cases of the regression equation was 79.76%,which meant the necessity to use multilevel analysis. The initial symptoms and the change rates of OQ over time differed significantly among different cases. The different change rates could be well predicted by the positive and negative factors of emotion dimensions of IEQ,with contributions of 40. 79% to total rate variance. When IEQ positive or negative emotion factors increased by 1 point,the OQ scores decreased by 7. 398 or increased by 6. 433,respectively. However,other three dimensions of IEQ had no significant effects on outcome.The results suggested that the intersession processes could well predict the different change rates of symptoms among individuals in short- term therapy( less than 9 sessions),and intersession emotions may reflect the client's transference potentials to the therapist,which can be acknowledged and used to facilitate treatment. As mentioned above,intersession experience about therapists or / and sessions is a joint product of actual in- session therapeutic interaction and the client's prior personality,therefore,the positive and negative emotion may not be a causation,but a reflection of treatment outcome,which means that the intersession experience and outcome may be a covariant relationship. There are two limitations of this research,one is the small sample size,and the other is not considering nonlinear tendency of outcome change.
Psychotherapy process includes insession process and intersession process,occurring in and outside the counseling room respectively,and the latter has been neglected for a long time in psychotherapy research history. Intersession process refers to the thoughts,memories,and feelings about therapists or therapy sessions that clients experience during the intervals between sessions. Intersession process is a joint product of actual in- session therapeutic interaction and the client's prior personality,in particular,the client's conscious and unconscious transference potentials. It connects the therapeutic process and client's actual life,and has repaired functions for clients in therapy. The present study aimed to identify the effects of intersession processes on treatment outcome over successive sessions in short- term therapy.12 male and 24 female student visitors of a college counseling center,with a mean age of 22. 47( SD = 2. 60) and without personality disorder or other psychiatric symptoms,participated in the study. Intersession process was measured by the Chinese version of the Intersession Experience Questionnaire( IEQ),which consisted of eight factors of four dimensions( intensity,context,content and emotion). The treatmentoutcome was measured by the Outcome Questionnaire- 45( OQ- 45) and higher scores meant more severe symptoms. Participants were asked to complete IEQ and OQ before each session from sessions 2 to 9. Finally,151 sessions /36 cases were collected,and the mean measures of each case was 4. 19( SD = 1. 26).A two- level hierarchical linear model was built to investigate the effects of time and time- depended predictor IEQ on OQ. Results indicated that,generally,in the short- term psychotherapy the symptoms of clients significantly declined in linear tendency,while OQ decreased by 1. 27 point after each session. The proportion of total variance between the cases of the regression equation was 79.76%,which meant the necessity to use multilevel analysis. The initial symptoms and the change rates of OQ over time differed significantly among different cases. The different change rates could be well predicted by the positive and negative factors of emotion dimensions of IEQ,with contributions of 40. 79% to total rate variance. When IEQ positive or negative emotion factors increased by 1 point,the OQ scores decreased by 7. 398 or increased by 6. 433,respectively. However,other three dimensions of IEQ had no significant effects on outcome.The results suggested that the intersession processes could well predict the different change rates of symptoms among individuals in short- term therapy( less than 9 sessions),and intersession emotions may reflect the client's transference potentials to the therapist,which can be acknowledged and used to facilitate treatment. As mentioned above,intersession experience about therapists or / and sessions is a joint product of actual in- session therapeutic interaction and the client's prior personality,therefore,the positive and negative emotion may not be a causation,but a reflection of treatment outcome,which means that the intersession experience and outcome may be a covariant relationship. There are two limitations of this research,one is the small sample size,and the other is not considering nonlinear tendency of outcome change.
引文
江光荣.(2012).心理咨询的理论与实务.北京:高等教育出版社.
柯纳斯,詹姆斯.(2001/2008).内化(王丽颖译).北京:北京大学医学出版社.
李钰静,骆宏.(2009).心理咨询效果评估量表中文版的信度和效度.中国心理卫生杂志,23(2),105-107.
刘红云.(2007).如何描述发展趋势的差异:潜变量混合增长模型.心理科学进展,15(3),539-544.
刘红云,张雷.(2007).追踪数据分析方法及其应用.北京:教育科学技术出版社.
秦佑凤,胡姝婧.(2008).心理咨询效果问卷OQ45在中国部分人群的试用报告.中国临床心理学,16(2),138-140.
张雷,雷雳,郭伯良.(2003).多层线性模型应用.北京:教育科学出版社.
朱文臻,江光荣,朱旭,陶嵘.(2011).心理咨询中的突然获益:工作同盟及初始症状的影响.心理科学,34(6),1502-1507.
Beail,N.,Kellett,S.,Newman,D.W.,&Warden,S.(2007).The dose–effect relationship in psychodynamic psychotherapy with people with intellectual disabilities.Journal of Applied Research in Intellectual Disabilities,20(5),448-454.
Birmaher,B.,Brent,D.A.,Kolko,D.,Baugher,M.,Bridge,J.,Holder,D.,&Ulloa,R.E.(2000).Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder.Archives of General Psychiatry,57(1),29-36.
Bowlby,J.(1988).A secure base:Clinical applications of attachment theory.London:Routledge.
Diguer,L.(2005).Mentalisation et psychothérapie chez le patient limite.L'Evolution psychiatrique,70(3),649-661.
Farber,B.A.,Lippert,R.A.,&Nevas,D.B.(1995).The therapist as attachment figure.Psychotherapy:Theory,Research,Practice,Training,32(2),204-212.
Geller,J.,&Farber,B.(1993).Factors influencing the process of internalization in psychotherapy.Psychotherapy Research,3(3),166-180.
Gingerich,W.J.,&Eisengart,S.(2000).Solution‐focused brief therapy:A review of the outcome research.Family process,39(4),477-498.
Hartmann,A.,Orlinsky,D.,Weber,S.,Sandholz,A.,&Zeeck,A.(2010).Session and intersession experience related to treatment outcome in bulimia nervosa.Psychotherapy:Theory,Research,Practice,Training,47(3),355-370.
Hartmann,A.,Orlinsky,D.,&Zeeck,A.(2011).The structure of intersession experience in psychotherapy and its relation to the therapeutic alliance.Journal of Clinical Psychology,67(10),1-20.
Hartmann,A.,Orlinsky,D.E.,Geller,J.D.,&Zeeck,A.(2003).Der Inter-Session-Fragebogen(ISF)—Ein Instrument zur Erfassung von psychotherapierelevanten Prozessen zwischen Sitzungen[The Intersession Questionnaire—An inventory for the measurement of patients'processing of psychotherapy between sessions].Psychotherapie,Psychosomatik und Medizinische Psychologie,53,464-468.
Hayes,A.M.,Laurenceau,J.P.,Feldman,G.,Strauss,J.L.,&Cardaciotto,L.A.(2007).Change is not always linear:The study of nonlinear and discontinuous patterns of change in psychotherapy.Clinical Psychology Review,27(6),715-723.
Hill,C.E.(2005).Therapist techniques,client involvement,and the therapeutic relationship:Inextricably intertwined in the therapy process.Psychotherapy:Theory,Research,Practice,Training,42(4),431-422.
Hill,C.E.,Corbett,M.M.,Kanitz,B.,Rios,P.,Lightsey,R.,&Gomez,M.(1992).Client behavior in counseling and therapy sessions:Development of a pantheoretical measure.Journal of Counseling Psychology,39(4),539-549.
Horvath,A.O.,&Symonds,B.D.(1991).Relation between working alliance and outcome in psychotherapy:A meta-analysis.Journal of Counseling Psychology,38(2),139-149.
Howard,K.I.,Kopta,S.M.,Krause,M.S.,&Orlinsky,D.E.(1986).The dose–effect relationship in psychotherapy.American Psychologist,41(2),159-164.
Knox,S.(2003).I sensed you with me the other day:A review of the theoretical and empirical literature on clients'internal representations of therapists.Psychotherapy,38,5-8.
Knox,S.,Goldberg,J.L.,Woodhouse,S.S.,&Hill,C.E.(1999).Clients'internal representations of their therapists.Journal of Counseling Psychology,46(2),244-256.
Lambert,M.J.,Burlingame,G.M.,Umphress,V.,Hansen,N.B.,Vermeersch,D.A.,Clouse,G.C.,&Yanchar,S.C.(1996).The reliability and validity of the Outcome Questionnaire.Clinical Psychology&Psychotherapy,3(4),249-258.
Lock,J.,Agras,W.S.,Bryson,S.,&Kraemer,H.C.(2005).A comparison of short-and long-term family therapy for adolescent anorexia nervosa.Journal of the American Academy of Child&Adolescent Psychiatry,44(7),632-639.
Maas,C.J.M.,&Hox,J.J.(2005).Sufficient sample sizes for multilevel modeling.Methodology:European Journal of Research Methods for the Behavioral and Social Sciences,1(3),86-92.
Martin,D.J.,Garske,J.P.,&Davis,M.K.(2000).Relation of the therapeutic alliance with outcome and other variables:a metaanalytic review.Journal of consulting and clinical psychology,68(3),438-450.
Orlinsky,D.E.,&Geller,J.D.(1994).Patients'representations of their therapists and therapy:New measures.In J.P.D.N.E.Miller,L.Luborsky,&J.P.Barber(Ed.),Psychodynamic treatment research:A handbook for clinical practice(pp.423-466).New York:Basic Books.
Orlinsky,D.E.,Geller,J.D.,Tarragona,M.,&Farber,B.(1993).Patients'representations of psychotherapy:A new focus for psychodynamic research.Journal of consulting and clinical psychology,61(4),596-610.
Orlinsky,D.E.,Ronnestad,M.H.,&Willutzki,U.(2004).Fifty years of psychotherapy process-outcome research:Continuity and change.Bergin and Garfield’s handbook of psychotherapy and behavior change,5,307-390.
Quintana,S.M.,&Meara,N.M.(1990).Internalization of therapeutic relationships in short-term psychotherapy.Journal of Counseling Psychology;Journal of Counseling Psychology,37(2),123-130.
Strupp,H.H.(1978).The therapist's theoretical orientation:An overrated variable.Psychotherapy:Theory,Research&Practice,15(4),314-317.
Tang,T.Z.,&DeRubeis,R.J.(1999).Sudden gains and critical sessions in cognitive-behavioral therapy for depression.Journal of consulting and clinical psychology,67(6),894-904.
Vermeersch,D.A.,Lambert,M.J.,&Burlingame,G.M.(2000).Outcome questionnaire:Item sensitivity to change.Journal of Personality Assessment,74(2),242-261.
Vermeersch,D.A.,Whipple,J.L.,Lambert,M.J.,Hawkins,E.J.,Burchfield,C.M.,&Okiishi,J.C.(2004).Outcome questionnaire:Is it sensitive to changes in counseling center clients?Journal of Counseling Psychology,51(1),38-49.
Wzontek,N.,Farber,B.,&Geller,J.D.(1995).Patients'posttermination representations of their psychotherapists.Journal of the American Academy of Psychoanalysis(23),395-410.
Zeeck,A.,Hartmann,A.,&Orlinsky,D.E.(2006).Internalization of the therapeutic process:Differences between borderline and neurotic patients.Journal of personality disorders,20(1),22-41.
Zhong,J.,Wang,A.,Qian,M.,Zhang,L.,Gao,J.,Yang,J.,&Chen,P.(2008).Shame,personality,and social anxiety symptoms in Chinese and American nonclinical samples:a cross‐cultural study.Depression and anxiety,25(5),449-460.
从所收集的所有数据中取130个随机样本。
柯纳斯,詹姆斯.(2001/2008).内化(王丽颖译).北京:北京大学医学出版社.
李钰静,骆宏.(2009).心理咨询效果评估量表中文版的信度和效度.中国心理卫生杂志,23(2),105-107.
刘红云.(2007).如何描述发展趋势的差异:潜变量混合增长模型.心理科学进展,15(3),539-544.
刘红云,张雷.(2007).追踪数据分析方法及其应用.北京:教育科学技术出版社.
秦佑凤,胡姝婧.(2008).心理咨询效果问卷OQ45在中国部分人群的试用报告.中国临床心理学,16(2),138-140.
张雷,雷雳,郭伯良.(2003).多层线性模型应用.北京:教育科学出版社.
朱文臻,江光荣,朱旭,陶嵘.(2011).心理咨询中的突然获益:工作同盟及初始症状的影响.心理科学,34(6),1502-1507.
Beail,N.,Kellett,S.,Newman,D.W.,&Warden,S.(2007).The dose–effect relationship in psychodynamic psychotherapy with people with intellectual disabilities.Journal of Applied Research in Intellectual Disabilities,20(5),448-454.
Birmaher,B.,Brent,D.A.,Kolko,D.,Baugher,M.,Bridge,J.,Holder,D.,&Ulloa,R.E.(2000).Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder.Archives of General Psychiatry,57(1),29-36.
Bowlby,J.(1988).A secure base:Clinical applications of attachment theory.London:Routledge.
Diguer,L.(2005).Mentalisation et psychothérapie chez le patient limite.L'Evolution psychiatrique,70(3),649-661.
Farber,B.A.,Lippert,R.A.,&Nevas,D.B.(1995).The therapist as attachment figure.Psychotherapy:Theory,Research,Practice,Training,32(2),204-212.
Geller,J.,&Farber,B.(1993).Factors influencing the process of internalization in psychotherapy.Psychotherapy Research,3(3),166-180.
Gingerich,W.J.,&Eisengart,S.(2000).Solution‐focused brief therapy:A review of the outcome research.Family process,39(4),477-498.
Hartmann,A.,Orlinsky,D.,Weber,S.,Sandholz,A.,&Zeeck,A.(2010).Session and intersession experience related to treatment outcome in bulimia nervosa.Psychotherapy:Theory,Research,Practice,Training,47(3),355-370.
Hartmann,A.,Orlinsky,D.,&Zeeck,A.(2011).The structure of intersession experience in psychotherapy and its relation to the therapeutic alliance.Journal of Clinical Psychology,67(10),1-20.
Hartmann,A.,Orlinsky,D.E.,Geller,J.D.,&Zeeck,A.(2003).Der Inter-Session-Fragebogen(ISF)—Ein Instrument zur Erfassung von psychotherapierelevanten Prozessen zwischen Sitzungen[The Intersession Questionnaire—An inventory for the measurement of patients'processing of psychotherapy between sessions].Psychotherapie,Psychosomatik und Medizinische Psychologie,53,464-468.
Hayes,A.M.,Laurenceau,J.P.,Feldman,G.,Strauss,J.L.,&Cardaciotto,L.A.(2007).Change is not always linear:The study of nonlinear and discontinuous patterns of change in psychotherapy.Clinical Psychology Review,27(6),715-723.
Hill,C.E.(2005).Therapist techniques,client involvement,and the therapeutic relationship:Inextricably intertwined in the therapy process.Psychotherapy:Theory,Research,Practice,Training,42(4),431-422.
Hill,C.E.,Corbett,M.M.,Kanitz,B.,Rios,P.,Lightsey,R.,&Gomez,M.(1992).Client behavior in counseling and therapy sessions:Development of a pantheoretical measure.Journal of Counseling Psychology,39(4),539-549.
Horvath,A.O.,&Symonds,B.D.(1991).Relation between working alliance and outcome in psychotherapy:A meta-analysis.Journal of Counseling Psychology,38(2),139-149.
Howard,K.I.,Kopta,S.M.,Krause,M.S.,&Orlinsky,D.E.(1986).The dose–effect relationship in psychotherapy.American Psychologist,41(2),159-164.
Knox,S.(2003).I sensed you with me the other day:A review of the theoretical and empirical literature on clients'internal representations of therapists.Psychotherapy,38,5-8.
Knox,S.,Goldberg,J.L.,Woodhouse,S.S.,&Hill,C.E.(1999).Clients'internal representations of their therapists.Journal of Counseling Psychology,46(2),244-256.
Lambert,M.J.,Burlingame,G.M.,Umphress,V.,Hansen,N.B.,Vermeersch,D.A.,Clouse,G.C.,&Yanchar,S.C.(1996).The reliability and validity of the Outcome Questionnaire.Clinical Psychology&Psychotherapy,3(4),249-258.
Lock,J.,Agras,W.S.,Bryson,S.,&Kraemer,H.C.(2005).A comparison of short-and long-term family therapy for adolescent anorexia nervosa.Journal of the American Academy of Child&Adolescent Psychiatry,44(7),632-639.
Maas,C.J.M.,&Hox,J.J.(2005).Sufficient sample sizes for multilevel modeling.Methodology:European Journal of Research Methods for the Behavioral and Social Sciences,1(3),86-92.
Martin,D.J.,Garske,J.P.,&Davis,M.K.(2000).Relation of the therapeutic alliance with outcome and other variables:a metaanalytic review.Journal of consulting and clinical psychology,68(3),438-450.
Orlinsky,D.E.,&Geller,J.D.(1994).Patients'representations of their therapists and therapy:New measures.In J.P.D.N.E.Miller,L.Luborsky,&J.P.Barber(Ed.),Psychodynamic treatment research:A handbook for clinical practice(pp.423-466).New York:Basic Books.
Orlinsky,D.E.,Geller,J.D.,Tarragona,M.,&Farber,B.(1993).Patients'representations of psychotherapy:A new focus for psychodynamic research.Journal of consulting and clinical psychology,61(4),596-610.
Orlinsky,D.E.,Ronnestad,M.H.,&Willutzki,U.(2004).Fifty years of psychotherapy process-outcome research:Continuity and change.Bergin and Garfield’s handbook of psychotherapy and behavior change,5,307-390.
Quintana,S.M.,&Meara,N.M.(1990).Internalization of therapeutic relationships in short-term psychotherapy.Journal of Counseling Psychology;Journal of Counseling Psychology,37(2),123-130.
Strupp,H.H.(1978).The therapist's theoretical orientation:An overrated variable.Psychotherapy:Theory,Research&Practice,15(4),314-317.
Tang,T.Z.,&DeRubeis,R.J.(1999).Sudden gains and critical sessions in cognitive-behavioral therapy for depression.Journal of consulting and clinical psychology,67(6),894-904.
Vermeersch,D.A.,Lambert,M.J.,&Burlingame,G.M.(2000).Outcome questionnaire:Item sensitivity to change.Journal of Personality Assessment,74(2),242-261.
Vermeersch,D.A.,Whipple,J.L.,Lambert,M.J.,Hawkins,E.J.,Burchfield,C.M.,&Okiishi,J.C.(2004).Outcome questionnaire:Is it sensitive to changes in counseling center clients?Journal of Counseling Psychology,51(1),38-49.
Wzontek,N.,Farber,B.,&Geller,J.D.(1995).Patients'posttermination representations of their psychotherapists.Journal of the American Academy of Psychoanalysis(23),395-410.
Zeeck,A.,Hartmann,A.,&Orlinsky,D.E.(2006).Internalization of the therapeutic process:Differences between borderline and neurotic patients.Journal of personality disorders,20(1),22-41.
Zhong,J.,Wang,A.,Qian,M.,Zhang,L.,Gao,J.,Yang,J.,&Chen,P.(2008).Shame,personality,and social anxiety symptoms in Chinese and American nonclinical samples:a cross‐cultural study.Depression and anxiety,25(5),449-460.
从所收集的所有数据中取130个随机样本。