基于循证心理实践的高校新生适应障碍筛查和干预研究
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摘要
鉴于国内高校新生适应障碍的流行性和严重性、适应障碍临床研究的匮乏性以及当前高校对新生适应问题干预工作的随意性,本研究试图建立高校心理健康工作中对新生适应障碍进行筛查和干预的有效模式。
研究一：基于系统评价、访谈法与试验法的高校新生适应障碍筛查研究
研究目的：以适应障碍自身特征为核心,在关注症状的同时,更兼顾病因学的考量,从“应激事件”、“易感素质”、“症状表现”三者入手,制定更客观、准确的大一新生适应障碍筛查工具。
研究步骤：
(1)首先分析了适应障碍传统诊断模式的不足,及由此带来的科研与实务上的问题,采用系统评价方法对相关文献进行筛选,对纳入文献采取质性分析,最终以“自身需求”为分类核心,制定新生适应障碍“应激源与应激表现”的编码及类属图表,并据此制定访谈提纲。
(2)选取214名高校新生,通过焦点访谈小组获得每个个案“应激原因与表现”的记录,根据中国精神疾病分类与诊断标准第三版(以下简称CCMD-3)对适应障碍的界定,初筛出新生适应障碍疑似患者54名。进一步采用深度访谈法对该群体进行筛查,最后获得37名适应不良或适应障碍新生。整理访谈资料,比较适应不良组(含适应障碍)与正常组的不适描述,提取特征描述,并在此基础上制定高校新生适应障碍半定式筛查量表。
(3)设计独立、“盲法”的诊断性试验,将CCMD-3适应障碍诊断标准作为参照,比较半定式筛查量表的有效性和可靠性。
研究发现：
(1)高校新生适应障碍有效筛查角度应为对改变的适应度。从入学后“期待的变化是否发生”、“未预料到的变化是否发生”、及“是否丧失目标感/意义感”引入,了解是否采取措施应对改变、什么措施、效果如何、及自己对此结果是否满意等。对易感素质和精神症状的评估贯穿其中。
(2)高校新生适应障碍核心筛查内容应涉及人际关系、学业成就、日常生活、价值观念等四个方面。其中人际关系包括宿舍关系、同学关系、家庭关系、恋爱关系、师生关系等,且需比较个体对入学前后人际关系的依赖程度差异。学业成就与日常生活内容的筛查,主要考量个体的自主安排能力,包括目标设定与执行力。
(3)高校新生适应障碍半定式筛查量表有良好的评分者信度,优于CCMD-3适应障碍诊断标准；较CCMD-3对新生心理问题的判断更为灵敏,对适应不良和适应障碍的界定更为明确。
研究二：基于系统评价和实验法的高校新生适应障碍干预研究
研究目的：探索、验证高校新生适应障碍有效可行的心理干预策略。
研究步骤：(1)回顾心理治疗研究的常见问题,以提高临床效力为目标进行研究设计。(2)采用系统评价法对国外适应障碍的心理干预随机对照试验进行筛选,分析纳入文献,最终提取出有效干预策略：强调行动导向的认知行为策略、简明动力性心理治疗策略。并据此设计各实验组团体干预方案。(3)纳入研究一筛查所得被试,随机分为四组,其中三组同时接受为期7周的团体心理干预,一组为对照组。
研究发现：
一、症状变化特点
(1)高校新生适应障碍具备一定的随时间自我治愈的能力,其特征为：不适基线水平越低、初始症状越轻,改善速度越快。
(2)设计合理的心理干预不仅能显著增加不适症状随时间改善的幅度,也能缩短症状改善所需时长。
(3)治疗初期自评结果较前测结果的轻度恶化现象为被试对治疗师防御性降低的表现,反应了更真实的自评水平。
(4)治疗结束时改善幅度越大,治疗结束后症状反复的程度相对越明显；但反弹程度与基础水平相比极其轻微,为疗效显著后的回归效应,属于可接受范围。
二、有效治疗成分
(1)良好的同盟关系能降低组员的防御性,从而在疗效自评体系上提供更加真实的信息；
(2)认知行为团体心理干预对治疗高校新生适应障碍、抑制症状恶化有最良好的疗效；
(3)动力分析治疗成分对平衡情感体验的改善效果更为显著；
(4)认知行为治疗成分对提升焦虑、抑郁情绪调控能力的效果更加显著；
(5)自我暗示和人际脱敏治疗方法能有效提升高校新生适应障碍患者的自尊水平；
(6)良好的治疗小组同盟关系、以及频繁的组内人际反馈练习,能更有效降低新生的社会孤立感。
三、适应人群
(1)对来自农村地区与异地大城市地区的适应不良新生进行干预时,应关注改善其社会孤立感。农村地区的新生对团体治疗的接受性优于大城市地区新生,针对后者宜考虑采取个体干预。
(2)焦虑情绪是女性适应不良新生的主要症状之一,以“提高情绪唤起阈限、改善情绪调节能力”为目标的干预策略对该群体疗效显著。
(3)针对存在适应问题的贫困新生进行心理干预时,有的放矢地开展提高自尊水平的团体辅导,是改善其适应问题的较为高效的干预措施。
创新点：
1、在心理治疗领域采用循证思维,既分析已有研究、搜集证据、又通过临床实践提供新证据,在国内心理治疗研究领域尚属首次；
2、从应激源、易感素质及症状三个角度制定适应障碍的半定式筛查量表是对传统单一症状学诊断思维的创新；
3、将医学研究中独立、“盲法”的诊断性试验设计扩展至心理障碍研究领域,有利于提高心理障碍筛查方法的客观性。
4、将干预策略划分为诸个治疗成分,以此对不同症状的有效性进行程度划分,同时考量不同人群的接受性,并在此基础上提出高校新生适应障碍的干预指南,为国内高校新生适应障碍心理干预工作的突破。
Based on the concerns of the popularity and severity of adjustment disorder (AD) among college freshmen, the insufficiency of clinical researches on AD, and the lack of objectivity in current college psychotherapy practices, the purpose of this research is to establish an effective model for diagnosis and intervention among college freshmen with AD.
Study I:The screening study with the methods of the systematic review (SR), the interview, and the random controlled trial.
Purpose:Based on the dimensions of stressors, vulnerabilities, and symptoms, develop an objective and effective tool for screening AD among college freshmen
Steps:
(1) The problems lying in the symptomatology diagnosis of AD were first analyzed.Then A SR was done to determine the stressors which college freshmen might have experienced and this work also provided an interview outline which focused on "individual needs".
(2) 214 college freshmen took part in the focus group interview, among which 54 students were choosen as AD suspects and joined in the in-depth interview for the next round.37 AD individuals were selceted out through the interview by means of CCMD-3. By comparing the information from AD group with normal freshman group, specific descriptions which present the features of stressors of AD group were proposed and therefore a semi-structure screening scale for AD among college freshmen was invented.
(3) An independent and blind diagnosis trial was conducted to test both reliability and validity of this scale.
Results and conclusions:
(1) Effective perspective of screening AD among college freshmen is to evaluate the adaption to change, including "the expectation to change has realized or not", "unexpected change has occurred or not", and"whether the sense of meaning is lost or not". From this perspective, coping strategies and their effects, as well as satisfaction could be interviewed. The vulnerabilities and symptoms should be evaluated through the observation and conversation process.
(2) Effective points of screening AD among college freshmen involve interpersonal relationships, performance and achievement, life routines, and values. The interpersonal relationships include dorm relationships, classmate relationships, family relationships, romantic relationships, etc. The dependent level on relationships established before and after college entrance should be compared and evaluated. The ability to set goals and conduct the schedule is the basic consideration in appraising life routines and performance and achievement.
(3) The semi-structure screening scale for AD among college freshmen has better inter-rater reliability and sensitivity to freshmen's psychological problems than CCMD-3.
StudyⅡ:The psychological intervention research for AD freshmen with the methods of SR and experiments.
Purpose:Explore and test the efficiency of psychological intervention strategies for college freshmen with AD.
Steps:
(1) The common problems in clinical researches were reviewed, and the study was designed in an efficiency-improving manner. (2) An SR was conducted on AD psychological intervention experiments researches. On the basis of the SR results, intervention strategies were made.
(3) Group intervention therapies were carried out, including three experimental groups with different psychotherapy programs and one matched group.
Results and conclusions:
(1) AD among freshmen has a mechanism of self-cure. The less severe the symtoms is, the faster the improvement is.
(2) The intervention strategies from SR can enhance the improvement.
(3) With the denfense of group members going down, the symptoms may deteriorate a little after the first session.
(4) After intervention programs finished and great improvement has been made, fluctuations may occur and stay at an acceptable range.
(5) Therapy alliance could lower down defense level of members and therefore produce more credible self-evaluated information.
(6) Cognitive-behavioral therapy shows the best efficiency in curing AD and restraining the symptoms fluctuations.
(7) Brief dynamic therapy shows the best effect in enhance mood symptoms.
(8) Cognitive-behavioral strategies raise the ablitily more significantly of emotion regulation in both anxiety and depression.
(9) The component of autogenic training and systematic desensitization could promote self-esteem higely efficiently.
(10) Therapy relationship with high quality and frequent interpersonal fedback practices reduce social isolation experience in the largest scale.
(11) Group therapies are effective to bring down social isolation experience of AD freshmen who come from peseant families.
(12) Intervention strategies aimed on "raising emotion arousal level and improving emotion regulation" are especially effective to female AD freshmen.
(13) To enhance the self-esteem level proves the best way of psychological intervention with AD freshmen who have economic difficulties.
Points of innovation:
(1) Testing and providing clinical data on the basis of the relevant proof collection and analysis under an evidence-based framwork is the first try in psychotherapy research field at board.
(2) screening AD among college freshmen on the dimensions of stressors, vulnerabilities, and symptoms is an innovation and enlargement of diagnosis of AD under traditional one-dimension symptomatology conceptuation.
(3) Broadening the design of independent and blind diagosis trial from medical research into the psychological disorder research can increase the objectivity of screening tools used for mental disorders.
(4) Proposing an intervention guide for college freshmen with AD based on dividing intervention strategies into components, evaluating each component's efficacy, and taking the populaton diversity into consideration, is a breakthrough of psychological intervention work in current college at board.
研究一：基于系统评价、访谈法与试验法的高校新生适应障碍筛查研究
研究目的：以适应障碍自身特征为核心,在关注症状的同时,更兼顾病因学的考量,从“应激事件”、“易感素质”、“症状表现”三者入手,制定更客观、准确的大一新生适应障碍筛查工具。
研究步骤：
(1)首先分析了适应障碍传统诊断模式的不足,及由此带来的科研与实务上的问题,采用系统评价方法对相关文献进行筛选,对纳入文献采取质性分析,最终以“自身需求”为分类核心,制定新生适应障碍“应激源与应激表现”的编码及类属图表,并据此制定访谈提纲。
(2)选取214名高校新生,通过焦点访谈小组获得每个个案“应激原因与表现”的记录,根据中国精神疾病分类与诊断标准第三版(以下简称CCMD-3)对适应障碍的界定,初筛出新生适应障碍疑似患者54名。进一步采用深度访谈法对该群体进行筛查,最后获得37名适应不良或适应障碍新生。整理访谈资料,比较适应不良组(含适应障碍)与正常组的不适描述,提取特征描述,并在此基础上制定高校新生适应障碍半定式筛查量表。
(3)设计独立、“盲法”的诊断性试验,将CCMD-3适应障碍诊断标准作为参照,比较半定式筛查量表的有效性和可靠性。
研究发现：
(1)高校新生适应障碍有效筛查角度应为对改变的适应度。从入学后“期待的变化是否发生”、“未预料到的变化是否发生”、及“是否丧失目标感/意义感”引入,了解是否采取措施应对改变、什么措施、效果如何、及自己对此结果是否满意等。对易感素质和精神症状的评估贯穿其中。
(2)高校新生适应障碍核心筛查内容应涉及人际关系、学业成就、日常生活、价值观念等四个方面。其中人际关系包括宿舍关系、同学关系、家庭关系、恋爱关系、师生关系等,且需比较个体对入学前后人际关系的依赖程度差异。学业成就与日常生活内容的筛查,主要考量个体的自主安排能力,包括目标设定与执行力。
(3)高校新生适应障碍半定式筛查量表有良好的评分者信度,优于CCMD-3适应障碍诊断标准；较CCMD-3对新生心理问题的判断更为灵敏,对适应不良和适应障碍的界定更为明确。
研究二：基于系统评价和实验法的高校新生适应障碍干预研究
研究目的：探索、验证高校新生适应障碍有效可行的心理干预策略。
研究步骤：(1)回顾心理治疗研究的常见问题,以提高临床效力为目标进行研究设计。(2)采用系统评价法对国外适应障碍的心理干预随机对照试验进行筛选,分析纳入文献,最终提取出有效干预策略：强调行动导向的认知行为策略、简明动力性心理治疗策略。并据此设计各实验组团体干预方案。(3)纳入研究一筛查所得被试,随机分为四组,其中三组同时接受为期7周的团体心理干预,一组为对照组。
研究发现：
一、症状变化特点
(1)高校新生适应障碍具备一定的随时间自我治愈的能力,其特征为：不适基线水平越低、初始症状越轻,改善速度越快。
(2)设计合理的心理干预不仅能显著增加不适症状随时间改善的幅度,也能缩短症状改善所需时长。
(3)治疗初期自评结果较前测结果的轻度恶化现象为被试对治疗师防御性降低的表现,反应了更真实的自评水平。
(4)治疗结束时改善幅度越大,治疗结束后症状反复的程度相对越明显；但反弹程度与基础水平相比极其轻微,为疗效显著后的回归效应,属于可接受范围。
二、有效治疗成分
(1)良好的同盟关系能降低组员的防御性,从而在疗效自评体系上提供更加真实的信息；
(2)认知行为团体心理干预对治疗高校新生适应障碍、抑制症状恶化有最良好的疗效；
(3)动力分析治疗成分对平衡情感体验的改善效果更为显著；
(4)认知行为治疗成分对提升焦虑、抑郁情绪调控能力的效果更加显著；
(5)自我暗示和人际脱敏治疗方法能有效提升高校新生适应障碍患者的自尊水平；
(6)良好的治疗小组同盟关系、以及频繁的组内人际反馈练习,能更有效降低新生的社会孤立感。
三、适应人群
(1)对来自农村地区与异地大城市地区的适应不良新生进行干预时,应关注改善其社会孤立感。农村地区的新生对团体治疗的接受性优于大城市地区新生,针对后者宜考虑采取个体干预。
(2)焦虑情绪是女性适应不良新生的主要症状之一,以“提高情绪唤起阈限、改善情绪调节能力”为目标的干预策略对该群体疗效显著。
(3)针对存在适应问题的贫困新生进行心理干预时,有的放矢地开展提高自尊水平的团体辅导,是改善其适应问题的较为高效的干预措施。
创新点：
1、在心理治疗领域采用循证思维,既分析已有研究、搜集证据、又通过临床实践提供新证据,在国内心理治疗研究领域尚属首次；
2、从应激源、易感素质及症状三个角度制定适应障碍的半定式筛查量表是对传统单一症状学诊断思维的创新；
3、将医学研究中独立、“盲法”的诊断性试验设计扩展至心理障碍研究领域,有利于提高心理障碍筛查方法的客观性。
4、将干预策略划分为诸个治疗成分,以此对不同症状的有效性进行程度划分,同时考量不同人群的接受性,并在此基础上提出高校新生适应障碍的干预指南,为国内高校新生适应障碍心理干预工作的突破。
Based on the concerns of the popularity and severity of adjustment disorder (AD) among college freshmen, the insufficiency of clinical researches on AD, and the lack of objectivity in current college psychotherapy practices, the purpose of this research is to establish an effective model for diagnosis and intervention among college freshmen with AD.
Study I:The screening study with the methods of the systematic review (SR), the interview, and the random controlled trial.
Purpose:Based on the dimensions of stressors, vulnerabilities, and symptoms, develop an objective and effective tool for screening AD among college freshmen
Steps:
(1) The problems lying in the symptomatology diagnosis of AD were first analyzed.Then A SR was done to determine the stressors which college freshmen might have experienced and this work also provided an interview outline which focused on "individual needs".
(2) 214 college freshmen took part in the focus group interview, among which 54 students were choosen as AD suspects and joined in the in-depth interview for the next round.37 AD individuals were selceted out through the interview by means of CCMD-3. By comparing the information from AD group with normal freshman group, specific descriptions which present the features of stressors of AD group were proposed and therefore a semi-structure screening scale for AD among college freshmen was invented.
(3) An independent and blind diagnosis trial was conducted to test both reliability and validity of this scale.
Results and conclusions:
(1) Effective perspective of screening AD among college freshmen is to evaluate the adaption to change, including "the expectation to change has realized or not", "unexpected change has occurred or not", and"whether the sense of meaning is lost or not". From this perspective, coping strategies and their effects, as well as satisfaction could be interviewed. The vulnerabilities and symptoms should be evaluated through the observation and conversation process.
(2) Effective points of screening AD among college freshmen involve interpersonal relationships, performance and achievement, life routines, and values. The interpersonal relationships include dorm relationships, classmate relationships, family relationships, romantic relationships, etc. The dependent level on relationships established before and after college entrance should be compared and evaluated. The ability to set goals and conduct the schedule is the basic consideration in appraising life routines and performance and achievement.
(3) The semi-structure screening scale for AD among college freshmen has better inter-rater reliability and sensitivity to freshmen's psychological problems than CCMD-3.
StudyⅡ:The psychological intervention research for AD freshmen with the methods of SR and experiments.
Purpose:Explore and test the efficiency of psychological intervention strategies for college freshmen with AD.
Steps:
(1) The common problems in clinical researches were reviewed, and the study was designed in an efficiency-improving manner. (2) An SR was conducted on AD psychological intervention experiments researches. On the basis of the SR results, intervention strategies were made.
(3) Group intervention therapies were carried out, including three experimental groups with different psychotherapy programs and one matched group.
Results and conclusions:
(1) AD among freshmen has a mechanism of self-cure. The less severe the symtoms is, the faster the improvement is.
(2) The intervention strategies from SR can enhance the improvement.
(3) With the denfense of group members going down, the symptoms may deteriorate a little after the first session.
(4) After intervention programs finished and great improvement has been made, fluctuations may occur and stay at an acceptable range.
(5) Therapy alliance could lower down defense level of members and therefore produce more credible self-evaluated information.
(6) Cognitive-behavioral therapy shows the best efficiency in curing AD and restraining the symptoms fluctuations.
(7) Brief dynamic therapy shows the best effect in enhance mood symptoms.
(8) Cognitive-behavioral strategies raise the ablitily more significantly of emotion regulation in both anxiety and depression.
(9) The component of autogenic training and systematic desensitization could promote self-esteem higely efficiently.
(10) Therapy relationship with high quality and frequent interpersonal fedback practices reduce social isolation experience in the largest scale.
(11) Group therapies are effective to bring down social isolation experience of AD freshmen who come from peseant families.
(12) Intervention strategies aimed on "raising emotion arousal level and improving emotion regulation" are especially effective to female AD freshmen.
(13) To enhance the self-esteem level proves the best way of psychological intervention with AD freshmen who have economic difficulties.
Points of innovation:
(1) Testing and providing clinical data on the basis of the relevant proof collection and analysis under an evidence-based framwork is the first try in psychotherapy research field at board.
(2) screening AD among college freshmen on the dimensions of stressors, vulnerabilities, and symptoms is an innovation and enlargement of diagnosis of AD under traditional one-dimension symptomatology conceptuation.
(3) Broadening the design of independent and blind diagosis trial from medical research into the psychological disorder research can increase the objectivity of screening tools used for mental disorders.
(4) Proposing an intervention guide for college freshmen with AD based on dividing intervention strategies into components, evaluating each component's efficacy, and taking the populaton diversity into consideration, is a breakthrough of psychological intervention work in current college at board.
引文
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