我国心理健康服务方法的现状研究
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摘要
心理健康服务方法作为心理健康服务技术体系的一个重要组成部分,是实现心理健康服务目标的手段和途径,指心理健康服务从业者以某种心理健康理论为依据为各种人群提供服务时,所采用的促进和保持心理健康的一系列途径、策略或手段。心理健康服务方法不同于服务理论,同一理论背景下可能有多种服务方法,服务方法也不同于服务技术,一种方法中包含有多种具有不同功能的技术。目前我国最常用的心理健康服务方法包括精神分析疗法、认知疗法、行为疗法、认知行为疗法、家庭疗法等。由我国心理健康服务从业者原创的本土化方法包括钟友彬创立的认识领悟疗法、朱建军创立的意象对话技术等。目前我国缺少针对服务方法的系统研究以及从方法学角度开展的研究。本研究拟探讨三个问题：第一,我国心理健康从业者使用哪些服务方法?第二,我国心理健康从业者如何管理自己的方法(包括选择方法、改变方法、学习新方法以及整合使用)?第三,我国从业者为了适应本土文化,对自己的服务方法采取了哪些本土化适应策略?即对服务方法及其使用方式进行了哪些本土化的调整和改造?研究的目的在于通过对我国心理健康服务方法现状的了解,为我国未来开展心理健康服务培训、提高心理健康服务方法的有效性和科学性提供支持。
本研究由5个子研究组成。研究1和研究2用于探讨第一个问题,即我国心理健康从业者使用哪些服务方法。研究1通过对2000年1月到2010年12月发表的心理健康预防干预研究报告进行文献计量学分析,考察心理健康预防服务中服务方法的使用情况。研究2对全国30个省、市、自治区中,包括心理咨询师、心理辅导员、心理治疗师在内的2133位从业者的心理健康服务方法使用情况开展问卷调查,考察从业者各种服务方法的使用频率和相关因素。研究3探讨第二个问题,即从业者如何管理及使用自己的服务方法。研究3对22位心理健康服务从业者进行深度访谈,考察从业者对自己服务方法的管理(包括选择方法、改变方法、整合方法以及学习新方法)及其影响因素。研究4和研究5探讨第三个问题,即从业者的服务方法本土化适应策略。研究4通过对22位心理健康服务从业者的深度访谈,从从业者的角度了解其为了适应我国文化背景和服务对象特点而对服务方法采取的本土化适应策略。研究5选取了10次心理咨询面谈进行定性分析,从心理咨询服务实践的角度探索从业者所采取的服务方法本土化适应策略,并对咨询师中的知名咨询师与一般咨询师的本土化适应策略进行对比,以验证和拓展研究4中所得到的结论。
以上系列研究得出以下结论：
1、我国心理健康服务方法可分为单一方法和整合方法,在单一方法中,使用率最高的有认知疗法、认知行为疗法、行为疗法、理性情绪疗法、精神分析疗法、来访者中心疗法、家庭治疗。在整合方法中,最常整合使用的方法包括认知疗法、精神分析、来访者中心疗法及行为疗法。我国本土原创的意象对话疗法和认识领悟疗法的使用率低于所调查的其它14种西方引进的方法,但高于催眠疗法。
2、不同人口学特征(性别、年龄、专业、受教育程度、工作环境)的从业者使用的服务方法存在差异。在学校环境中从业、有心理学或医学专业背景,年龄小于30岁,学历为大本及以上的从业者使用认知、理性情绪、来访者中心疗法、行为疗法、森田疗法5种方法的比率最高。而在社会机构从业,有医学或心理学专业背景,年龄在30-45岁,学历为硕士及以上的从业者更偏好使用精神分析疗法。另外,在社会机构或医院环境工作,非心理学、非教育学或非医学专业背景,年龄在45岁以上,学历为大专的从业者则更多使用催眠疗法。整合法使用率最高的群体是有心理学专业背景,年龄大于45岁,学历为博士的从业者。不同专业特征(从业年限、有无资格证书和培训经历)的从业者使用的服务方法也有差异。没有专业资格证书的从业者更多地使用交互分析和音乐疗法这两种方法。音乐疗法的使用率与从业者所受的各类培训均不相关,仅与个体自我体验有关,显示出使用音乐疗法的从业者可能欠缺专业的基础理论培训和相关系统培训。
3、与国外研究中从业者首要考虑其自身因素不同,我国从业者在选择服务方法时首要考虑来访者因素,尤其重视来访者遇到的问题类型、其次是来访者的个性特征和年龄。在影响从业者选择服务方法的自身因素里,影响最大的是从业者自身的训练背景,之后是经验和个人喜好,这与国外从业者受自身临床经验影响最大也不同。反映出我国从业者在选择服务方法时,更多是对来访者的需求(问题)与自身的供给(受训多的方法)之间进行匹配。影响从业者选择服务方法的环境因素中,与来访者的关系是从业者首要考虑的问题。
4、从业者在学习新的服务方法时,最希望学习的前4类新方法包括：满足当前临床需要的新方法、满足个人成长和发展需要的新方法、容易纳入及扩展现有方法体系的新方法以及实操性强的新方法。而国外从业者则喜欢学习能整合到自己现有方法体系中的新方法。反映出目前我国从业者在方法上最大的需要是应对临床工作中遇到的具体困难,解决燃眉之急是从业者最急迫的需求。从业者学习新方法的最常见方式是参加短训班和看书自学。导致学习某种新方法失败的因素包括从业者自身因素、培训因素和方法因素。其中最主要的从业者因素包括从业者试图保持原有理论取向,以及学习动机不足。导致学习失败的培训因素中最主要的是系统训练不足(这与其学习方式主要是短训班和自学有关)。导致学习失败的方法因素中最主要的是新方法不能与从业者原有方法整合,以及新方法与本土文化不匹配。
5、从业者对服务方法如何适应本土文化的认识不统一,有的从业者没有意识到在使用服务方法时需要加以本土化。而对此有意识的从业者对服务方法本土化持不同态度,有的认同本土化适应的重要性。还有的从业者则认为本土化没有必要,无论从业者对服务方法本土化的态度和认知如何,研究四和五中反映出,从业者在提供服务时或多或少都采取了一些策略,以实现服务方法与本土文化的融合。
6、我国从业者所采取的本土化适应策略体现在建立咨询关系、个案概念化(指咨询师根据心理咨询的理论对来访者的问题进行理论假设的过程,包括获取信息,解释问题,以及形成咨询计划)以及干预方式3个方面。建立咨询关系的本土化适应策略包括：营造亲近感、建立权威感和对来访者进行咨询知识教育。个案概念化的本土化策略包括从文化背景诠释问题、从文化习俗了解家庭互动、以及用文化概念解释干预原理；干预方式的本土化策略包括指示性干预、契合文化的认知矫正、邀请家庭成员加入以及传统价值观干预。
7、与一般咨询师相比,知名咨询师采取的服务方法本土体适应策略具有以下特点：a.数量上更多。b.知名咨询师较少采用树立权威的策略,而更多地采用营造亲近感的策略,努力成为来访者的“自己人”。c.知名咨询师在个案概念化部分的策略更具深度,主要表现在收集信息的方式(从传统习俗来了解家庭互动)以及解释干预原理的方式(用文化相关的概念来解释干预原理)。d.知名咨询师给予来访者具体的行为指导,不拒绝指示性干预,更多地运用本土文化概念对来访者进行认知干预。
8、我国心理健康服务方法中存在的问题可分为两类,一类是服务方法本身的问题,体现为缺乏本土化方法和技术。另一类是从业者使用服务方法时的问题。包括：a.一些从业者缺乏本土化意识；b.部分从业者使用整合服务方法时有很大随意性,缺乏思考和总结。c.因服务方法培训缺乏系统性和连续性而导致一些方法使用起来徒有其名而无其神,还有些方法有被滥用、误用的风险。d.从业者服务方法的本土化适应策略存在问题,包括使用的策略少、深度不够以及因从业者将自身价值观投射到来访者问题中而产生的策略误用的问题。
9、针对研究中发现的问题,提出了我国心理健康服务方法的一些发展建议。从政府管理层面来看,应从建立相关管理职能部门,建立从业者职业资格审查、考核的相关管理制度、加强培训机构及培训者资质管理等方面实现规范化、法制化管理。从专业发展层面看,应从改革培训体系,将服务方法的本土化内容纳入培训体系中、增加对从业者的职业指导、建立专业行会来推进交流合作以及开展方法研究四个方面加以发展。
本研究在理论和方法上均有所创新。理论创新体现在：1、对我国心理健康服务方法使用的影响因素进行了系统的研究,探讨了其背后的原因,对这一领域的理论建构有所贡献,尤其是对从业者服务方法的整合方式的考察,以及对从业者学习新的服务方法进行的探讨是以往研究所未曾涉猎的。2、对我国从业者的服务方法本土化适应策略进行研究,以往这一领域的研究一直以理论探讨为主,在本研究中通过访谈及对心理咨询会谈的分析,得出了具有启发性的结论。在方法创新方面,本研究综合使用了定性研究和定量研究方法。本研究采用大样本调查,获得国内较新、较具代表性的服务方法现状信息。在服务方法的本土化适应策略的研究中,既有对从业者的深度访谈,也有对心理咨询会谈实践的质性分析,从不同角度对问题加以考察。此外,在质性研究中,混合使用了演绎法和归纳法。
在应用价值方面,本研究的结论对于心理健康服务人员的培训、考核及从业者的自我完善均具有参考价值。
本研究是对心理健康服务从业者服务方法使用状况的一点初步探索,在今后的研究中,可以从建立具有较好信效度的心理咨询会谈本土化适应策略编码系统入手,对较大样本量的心理咨询会谈录音或录像材料进行编码,并结合从业者和来访者的访谈和调查,以及会谈效果评价,进一步深化对服务方法本土化适应策略的研究。也可以通过开发本土化适应策略的测查工具和开展不同服务方法的跨文化个案研究来扩展和完善这一研究领域。
Mental health service approach system is an important part of mental health service system. It refers to the methods and strategies which mental health service providers apply to improve the mental health levels of their clients. The most common mental health theoretical approaches in China include psychodynamic therapy, cognitive therapy, behavioral therapy, CBT, family therapy, psychodrama, Morita therapy, Gestalt therapy, narrative therapy, cognitive insight therapy, imaging communication therapy, and so on. Most of those approaches were developed in western culture, and only a small part of them were developed by native therapists. The most influential native theoretical approaches included cognitive insight therapy developed by Zhong Youbing and imaging communication therapy developed by Zhu Jianjun. Comparing to the important roles which mental health theoretical approaches played in fulfilling the mental health service targets, researches on this aspect are obviously inadequate. More systematic researches and methodological researches are needed. The aim of this research was to investigate the present status of theoretical approaches in China. The better understanding of the mental health approaches would facilitate the development of mental health service training system and the optimization of resource distribution.
The dissertation consisted of5studies. Study1was aimed to investigate the present status of practice approaches in primary prevention service with a literature content analysis of primary prevention intervention reports published from January,2000to December,2010in China. In study2,2133mental health practitioners including counselors, therapists, clinical psychologist and so on from30provinces and districts in China were surveyed. Those practitioners were working in schools, hospitals and other social institutes. The survey was aimed to gather the information which was about the frequency of their usage of different theoretical approaches and the influential factors. In-depth interviews were conducted to22mental health practitioners in study3. Practitioners were asked about their choice on theoretical approaches at the beginning of their relationships with their clients, how they changed their choice and why. The purpose of this investigation was also to identify the influential factors which impacted the current clinical practices of a broad range of mental health providers, as well as the influential factors of their adoption and sustained use of new practices. The same22mental health providers were interviewed in study4to investigate their cultural adaptation strategies in their clinical practices. Cultural adaptation strategies refer to the adaptations practitioners made to make the western theoretical approaches suitable for Chinese clients and the cultural background. To make further investigation in those strategies,10counseling sessions were analyzed in study5with qualitative method. In conclusion, the purpose of the serial of researches was to answer3questions, that were, what approaches practitioners chose to use in their clinical practice and the reason for their choice, what influenced practitioners'adoption and sustained used of new approaches, and what adaptation strategies practitioners used to meet the special demands in their practice in Chinese cultural background.
The results of the above researches showed that:
1. The mental health practitioners in China mainly used theoretical approaches in two ways, separately or integratively. The most frequently used approaches in the separate way were cognitive therapy, CBT, behavioral therapy, rational emotional therapy, psychoanalysis therapy, client-centered therapy and family therapy. The most frequently used approaches in the integrative way were cognitive therapy, psychoanalysis therapy, client-centered therapy and behavioral therapy. The native approaches which were developed by Chinese therapists were used less frequently than the other14western approaches, but more frequently than hypnotherapy.
2. Demographic factors such as gender, age, educational background, major and professional factors such as practice years, professional certificates and training experience had influenced the practitioners'adoption of the theoretical approaches. It was found that practitioners who were working in schools, majored in psychology or medicine, younger than30, and had a bachelor degree were more likely to adopt cognitive therapy, rational-emotional therapy, client-centered therapy, behavioral therapy and Morita therapy. Practitioners who had a doctoral degree, older than45, and majored in psychology were more likely to use approaches in an integrative way. Practitioners who had no professional certificates were more inclined to adopt interaction analysis therapy and musical therapy. Besides, the use of musical therapy was significantly correlated to the practitioners'personal experience rather than professional training, which might infer that the practice of musical therapy in China was lack of systematic training.
3. Three categories of factors influenced the approach adoption process of practitioners, which were client factors, practitioner factors and environmental factors. Practitioners took the client factors as the top factors to be considered, especially the clients'problems and their personality characteristics.
4. Practitioner inclined to learn new theoretical approaches which were helpful for solving the clinical problems in their practice and which could help them with their personal growth. Most practitioners learned new approaches by attending short-term workshops or by self-teaching. The most common obstacles practitioners encountered in practice were inadequate training, complicated practice demands of the approach, and the mismatch between the new approach and the practitioners'theoretical orientation or cultural background.
5. Practitioners used cultural adaptation strategies intentionally or unintentionally in the process of providing mental health service to Chinese clients. Practitioners showed their awareness of cultural adaptation in the counseling sessions.
6. The results of the in-depth interviews in study4and the counseling session content analysis in study5showed that there were three aspects of the practitioners' cultural adaptation strategies, namely, counselor-client relationship, case conceptualization, and intervention ways. Practitioners in China inclined to employ more authoritative strategies to develop counselor-client relationships. In case conceptualization, practitioners used traditional culture, social phenomenon and psychosomatic bonding in Chinese traditional medical theories to conceptualize case, and taught the clients knowledge about psychotherapy and counseling. In the ways of intervention, practitioner in China used more instructive intervention.
7. Comparing to other psychotherapists, the famous therapists adopted more cultural adaptation strategies. They used strategies to close the distance between them and their client rather than to show their authority. Famous adopted cultural adaptation strategies in the case conceptualization process with depth, which were demonstrated by their ways of collecting information (by asking about how the family spent traditional festivals) and explaing the intervention ideas with culturally accepted concepts. The famous therapists also put emphasize on giving clients some specific behavioral advices to bring about some positive changes in the client's life.
8. The existing problems which were faced by Chinese mental health service system were classified into2kinds. The first kind was about the theoretical approach system itself, which involved the lack of approaches rooted in Chinese culture. The second kind was about the ways practitioners applied their theoretical approaches, which included that some practitiones lacked the awareness of the cultural adaptation of their approaches, some approaches were potentially abused due to the inadequate training, and cultural adaptation of the practitioners were inadequate and lack of depth.
9. The advices on the development of Chinese mental health practitioners' theoretical approaches were divided into two categories. The first category was on the policy level. The government should set up a specific administrative department for mental health practice, draw up rules and regulations on professional qualification, and emphasize on the quality control of training systems. The second category was about the professional development of mental health practice. Emphasis on cultural sensitivity should be added to the training systems. Professional guidance should be introduced to the mental health practitioners to help them gain more awareness of their professional development and personal growth. Industrial associations were also recommended to push the cooperation and communication in the industry. To improve the efficiency of the mental health service in China, more application researches on evidence-based interventions and cultural adaption would be needed.
There were innovations both in the theory and the methodology in this dissertation. In terms of theory, the result of the studies updated the existing knowledge of Chinese mental health theoretical approaches because the large scale survey had a better representativeness. The results of the systematic researches on the adoption of theoretical approaches and the influential factors renewed and expanded the theories of mental health services in China. The study on cultural adaptation strategies was the first attempt in empirical research in this domain, and the results were inspiring.
In terms of application value, the results of this study could provide reference for training and management on mental health service providers as well as for service providers'self-improvement.
This study was a preliminary exploration on theoretical approaches of mental health services providers. The future study should take a more comprehensive stratified sampling and develop a coding system on cultural adaptation strategies in counseling sessions to bring about improved and in-depth researches on cultural adaptation stategies of mental health services providers.
本研究由5个子研究组成。研究1和研究2用于探讨第一个问题,即我国心理健康从业者使用哪些服务方法。研究1通过对2000年1月到2010年12月发表的心理健康预防干预研究报告进行文献计量学分析,考察心理健康预防服务中服务方法的使用情况。研究2对全国30个省、市、自治区中,包括心理咨询师、心理辅导员、心理治疗师在内的2133位从业者的心理健康服务方法使用情况开展问卷调查,考察从业者各种服务方法的使用频率和相关因素。研究3探讨第二个问题,即从业者如何管理及使用自己的服务方法。研究3对22位心理健康服务从业者进行深度访谈,考察从业者对自己服务方法的管理(包括选择方法、改变方法、整合方法以及学习新方法)及其影响因素。研究4和研究5探讨第三个问题,即从业者的服务方法本土化适应策略。研究4通过对22位心理健康服务从业者的深度访谈,从从业者的角度了解其为了适应我国文化背景和服务对象特点而对服务方法采取的本土化适应策略。研究5选取了10次心理咨询面谈进行定性分析,从心理咨询服务实践的角度探索从业者所采取的服务方法本土化适应策略,并对咨询师中的知名咨询师与一般咨询师的本土化适应策略进行对比,以验证和拓展研究4中所得到的结论。
以上系列研究得出以下结论：
1、我国心理健康服务方法可分为单一方法和整合方法,在单一方法中,使用率最高的有认知疗法、认知行为疗法、行为疗法、理性情绪疗法、精神分析疗法、来访者中心疗法、家庭治疗。在整合方法中,最常整合使用的方法包括认知疗法、精神分析、来访者中心疗法及行为疗法。我国本土原创的意象对话疗法和认识领悟疗法的使用率低于所调查的其它14种西方引进的方法,但高于催眠疗法。
2、不同人口学特征(性别、年龄、专业、受教育程度、工作环境)的从业者使用的服务方法存在差异。在学校环境中从业、有心理学或医学专业背景,年龄小于30岁,学历为大本及以上的从业者使用认知、理性情绪、来访者中心疗法、行为疗法、森田疗法5种方法的比率最高。而在社会机构从业,有医学或心理学专业背景,年龄在30-45岁,学历为硕士及以上的从业者更偏好使用精神分析疗法。另外,在社会机构或医院环境工作,非心理学、非教育学或非医学专业背景,年龄在45岁以上,学历为大专的从业者则更多使用催眠疗法。整合法使用率最高的群体是有心理学专业背景,年龄大于45岁,学历为博士的从业者。不同专业特征(从业年限、有无资格证书和培训经历)的从业者使用的服务方法也有差异。没有专业资格证书的从业者更多地使用交互分析和音乐疗法这两种方法。音乐疗法的使用率与从业者所受的各类培训均不相关,仅与个体自我体验有关,显示出使用音乐疗法的从业者可能欠缺专业的基础理论培训和相关系统培训。
3、与国外研究中从业者首要考虑其自身因素不同,我国从业者在选择服务方法时首要考虑来访者因素,尤其重视来访者遇到的问题类型、其次是来访者的个性特征和年龄。在影响从业者选择服务方法的自身因素里,影响最大的是从业者自身的训练背景,之后是经验和个人喜好,这与国外从业者受自身临床经验影响最大也不同。反映出我国从业者在选择服务方法时,更多是对来访者的需求(问题)与自身的供给(受训多的方法)之间进行匹配。影响从业者选择服务方法的环境因素中,与来访者的关系是从业者首要考虑的问题。
4、从业者在学习新的服务方法时,最希望学习的前4类新方法包括：满足当前临床需要的新方法、满足个人成长和发展需要的新方法、容易纳入及扩展现有方法体系的新方法以及实操性强的新方法。而国外从业者则喜欢学习能整合到自己现有方法体系中的新方法。反映出目前我国从业者在方法上最大的需要是应对临床工作中遇到的具体困难,解决燃眉之急是从业者最急迫的需求。从业者学习新方法的最常见方式是参加短训班和看书自学。导致学习某种新方法失败的因素包括从业者自身因素、培训因素和方法因素。其中最主要的从业者因素包括从业者试图保持原有理论取向,以及学习动机不足。导致学习失败的培训因素中最主要的是系统训练不足(这与其学习方式主要是短训班和自学有关)。导致学习失败的方法因素中最主要的是新方法不能与从业者原有方法整合,以及新方法与本土文化不匹配。
5、从业者对服务方法如何适应本土文化的认识不统一,有的从业者没有意识到在使用服务方法时需要加以本土化。而对此有意识的从业者对服务方法本土化持不同态度,有的认同本土化适应的重要性。还有的从业者则认为本土化没有必要,无论从业者对服务方法本土化的态度和认知如何,研究四和五中反映出,从业者在提供服务时或多或少都采取了一些策略,以实现服务方法与本土文化的融合。
6、我国从业者所采取的本土化适应策略体现在建立咨询关系、个案概念化(指咨询师根据心理咨询的理论对来访者的问题进行理论假设的过程,包括获取信息,解释问题,以及形成咨询计划)以及干预方式3个方面。建立咨询关系的本土化适应策略包括：营造亲近感、建立权威感和对来访者进行咨询知识教育。个案概念化的本土化策略包括从文化背景诠释问题、从文化习俗了解家庭互动、以及用文化概念解释干预原理；干预方式的本土化策略包括指示性干预、契合文化的认知矫正、邀请家庭成员加入以及传统价值观干预。
7、与一般咨询师相比,知名咨询师采取的服务方法本土体适应策略具有以下特点：a.数量上更多。b.知名咨询师较少采用树立权威的策略,而更多地采用营造亲近感的策略,努力成为来访者的“自己人”。c.知名咨询师在个案概念化部分的策略更具深度,主要表现在收集信息的方式(从传统习俗来了解家庭互动)以及解释干预原理的方式(用文化相关的概念来解释干预原理)。d.知名咨询师给予来访者具体的行为指导,不拒绝指示性干预,更多地运用本土文化概念对来访者进行认知干预。
8、我国心理健康服务方法中存在的问题可分为两类,一类是服务方法本身的问题,体现为缺乏本土化方法和技术。另一类是从业者使用服务方法时的问题。包括：a.一些从业者缺乏本土化意识；b.部分从业者使用整合服务方法时有很大随意性,缺乏思考和总结。c.因服务方法培训缺乏系统性和连续性而导致一些方法使用起来徒有其名而无其神,还有些方法有被滥用、误用的风险。d.从业者服务方法的本土化适应策略存在问题,包括使用的策略少、深度不够以及因从业者将自身价值观投射到来访者问题中而产生的策略误用的问题。
9、针对研究中发现的问题,提出了我国心理健康服务方法的一些发展建议。从政府管理层面来看,应从建立相关管理职能部门,建立从业者职业资格审查、考核的相关管理制度、加强培训机构及培训者资质管理等方面实现规范化、法制化管理。从专业发展层面看,应从改革培训体系,将服务方法的本土化内容纳入培训体系中、增加对从业者的职业指导、建立专业行会来推进交流合作以及开展方法研究四个方面加以发展。
本研究在理论和方法上均有所创新。理论创新体现在：1、对我国心理健康服务方法使用的影响因素进行了系统的研究,探讨了其背后的原因,对这一领域的理论建构有所贡献,尤其是对从业者服务方法的整合方式的考察,以及对从业者学习新的服务方法进行的探讨是以往研究所未曾涉猎的。2、对我国从业者的服务方法本土化适应策略进行研究,以往这一领域的研究一直以理论探讨为主,在本研究中通过访谈及对心理咨询会谈的分析,得出了具有启发性的结论。在方法创新方面,本研究综合使用了定性研究和定量研究方法。本研究采用大样本调查,获得国内较新、较具代表性的服务方法现状信息。在服务方法的本土化适应策略的研究中,既有对从业者的深度访谈,也有对心理咨询会谈实践的质性分析,从不同角度对问题加以考察。此外,在质性研究中,混合使用了演绎法和归纳法。
在应用价值方面,本研究的结论对于心理健康服务人员的培训、考核及从业者的自我完善均具有参考价值。
本研究是对心理健康服务从业者服务方法使用状况的一点初步探索,在今后的研究中,可以从建立具有较好信效度的心理咨询会谈本土化适应策略编码系统入手,对较大样本量的心理咨询会谈录音或录像材料进行编码,并结合从业者和来访者的访谈和调查,以及会谈效果评价,进一步深化对服务方法本土化适应策略的研究。也可以通过开发本土化适应策略的测查工具和开展不同服务方法的跨文化个案研究来扩展和完善这一研究领域。
Mental health service approach system is an important part of mental health service system. It refers to the methods and strategies which mental health service providers apply to improve the mental health levels of their clients. The most common mental health theoretical approaches in China include psychodynamic therapy, cognitive therapy, behavioral therapy, CBT, family therapy, psychodrama, Morita therapy, Gestalt therapy, narrative therapy, cognitive insight therapy, imaging communication therapy, and so on. Most of those approaches were developed in western culture, and only a small part of them were developed by native therapists. The most influential native theoretical approaches included cognitive insight therapy developed by Zhong Youbing and imaging communication therapy developed by Zhu Jianjun. Comparing to the important roles which mental health theoretical approaches played in fulfilling the mental health service targets, researches on this aspect are obviously inadequate. More systematic researches and methodological researches are needed. The aim of this research was to investigate the present status of theoretical approaches in China. The better understanding of the mental health approaches would facilitate the development of mental health service training system and the optimization of resource distribution.
The dissertation consisted of5studies. Study1was aimed to investigate the present status of practice approaches in primary prevention service with a literature content analysis of primary prevention intervention reports published from January,2000to December,2010in China. In study2,2133mental health practitioners including counselors, therapists, clinical psychologist and so on from30provinces and districts in China were surveyed. Those practitioners were working in schools, hospitals and other social institutes. The survey was aimed to gather the information which was about the frequency of their usage of different theoretical approaches and the influential factors. In-depth interviews were conducted to22mental health practitioners in study3. Practitioners were asked about their choice on theoretical approaches at the beginning of their relationships with their clients, how they changed their choice and why. The purpose of this investigation was also to identify the influential factors which impacted the current clinical practices of a broad range of mental health providers, as well as the influential factors of their adoption and sustained use of new practices. The same22mental health providers were interviewed in study4to investigate their cultural adaptation strategies in their clinical practices. Cultural adaptation strategies refer to the adaptations practitioners made to make the western theoretical approaches suitable for Chinese clients and the cultural background. To make further investigation in those strategies,10counseling sessions were analyzed in study5with qualitative method. In conclusion, the purpose of the serial of researches was to answer3questions, that were, what approaches practitioners chose to use in their clinical practice and the reason for their choice, what influenced practitioners'adoption and sustained used of new approaches, and what adaptation strategies practitioners used to meet the special demands in their practice in Chinese cultural background.
The results of the above researches showed that:
1. The mental health practitioners in China mainly used theoretical approaches in two ways, separately or integratively. The most frequently used approaches in the separate way were cognitive therapy, CBT, behavioral therapy, rational emotional therapy, psychoanalysis therapy, client-centered therapy and family therapy. The most frequently used approaches in the integrative way were cognitive therapy, psychoanalysis therapy, client-centered therapy and behavioral therapy. The native approaches which were developed by Chinese therapists were used less frequently than the other14western approaches, but more frequently than hypnotherapy.
2. Demographic factors such as gender, age, educational background, major and professional factors such as practice years, professional certificates and training experience had influenced the practitioners'adoption of the theoretical approaches. It was found that practitioners who were working in schools, majored in psychology or medicine, younger than30, and had a bachelor degree were more likely to adopt cognitive therapy, rational-emotional therapy, client-centered therapy, behavioral therapy and Morita therapy. Practitioners who had a doctoral degree, older than45, and majored in psychology were more likely to use approaches in an integrative way. Practitioners who had no professional certificates were more inclined to adopt interaction analysis therapy and musical therapy. Besides, the use of musical therapy was significantly correlated to the practitioners'personal experience rather than professional training, which might infer that the practice of musical therapy in China was lack of systematic training.
3. Three categories of factors influenced the approach adoption process of practitioners, which were client factors, practitioner factors and environmental factors. Practitioners took the client factors as the top factors to be considered, especially the clients'problems and their personality characteristics.
4. Practitioner inclined to learn new theoretical approaches which were helpful for solving the clinical problems in their practice and which could help them with their personal growth. Most practitioners learned new approaches by attending short-term workshops or by self-teaching. The most common obstacles practitioners encountered in practice were inadequate training, complicated practice demands of the approach, and the mismatch between the new approach and the practitioners'theoretical orientation or cultural background.
5. Practitioners used cultural adaptation strategies intentionally or unintentionally in the process of providing mental health service to Chinese clients. Practitioners showed their awareness of cultural adaptation in the counseling sessions.
6. The results of the in-depth interviews in study4and the counseling session content analysis in study5showed that there were three aspects of the practitioners' cultural adaptation strategies, namely, counselor-client relationship, case conceptualization, and intervention ways. Practitioners in China inclined to employ more authoritative strategies to develop counselor-client relationships. In case conceptualization, practitioners used traditional culture, social phenomenon and psychosomatic bonding in Chinese traditional medical theories to conceptualize case, and taught the clients knowledge about psychotherapy and counseling. In the ways of intervention, practitioner in China used more instructive intervention.
7. Comparing to other psychotherapists, the famous therapists adopted more cultural adaptation strategies. They used strategies to close the distance between them and their client rather than to show their authority. Famous adopted cultural adaptation strategies in the case conceptualization process with depth, which were demonstrated by their ways of collecting information (by asking about how the family spent traditional festivals) and explaing the intervention ideas with culturally accepted concepts. The famous therapists also put emphasize on giving clients some specific behavioral advices to bring about some positive changes in the client's life.
8. The existing problems which were faced by Chinese mental health service system were classified into2kinds. The first kind was about the theoretical approach system itself, which involved the lack of approaches rooted in Chinese culture. The second kind was about the ways practitioners applied their theoretical approaches, which included that some practitiones lacked the awareness of the cultural adaptation of their approaches, some approaches were potentially abused due to the inadequate training, and cultural adaptation of the practitioners were inadequate and lack of depth.
9. The advices on the development of Chinese mental health practitioners' theoretical approaches were divided into two categories. The first category was on the policy level. The government should set up a specific administrative department for mental health practice, draw up rules and regulations on professional qualification, and emphasize on the quality control of training systems. The second category was about the professional development of mental health practice. Emphasis on cultural sensitivity should be added to the training systems. Professional guidance should be introduced to the mental health practitioners to help them gain more awareness of their professional development and personal growth. Industrial associations were also recommended to push the cooperation and communication in the industry. To improve the efficiency of the mental health service in China, more application researches on evidence-based interventions and cultural adaption would be needed.
There were innovations both in the theory and the methodology in this dissertation. In terms of theory, the result of the studies updated the existing knowledge of Chinese mental health theoretical approaches because the large scale survey had a better representativeness. The results of the systematic researches on the adoption of theoretical approaches and the influential factors renewed and expanded the theories of mental health services in China. The study on cultural adaptation strategies was the first attempt in empirical research in this domain, and the results were inspiring.
In terms of application value, the results of this study could provide reference for training and management on mental health service providers as well as for service providers'self-improvement.
This study was a preliminary exploration on theoretical approaches of mental health services providers. The future study should take a more comprehensive stratified sampling and develop a coding system on cultural adaptation strategies in counseling sessions to bring about improved and in-depth researches on cultural adaptation stategies of mental health services providers.
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