應用動機再促進方案於精神分裂症患者之成效研究

Abstract

背景及目的： 精神分裂症患者常存在著動機問題，而使其降低職能參與動機，導致較差的功能結果，但職能治療臨床實務上卻缺乏有效且系統性的動機再促進方案。本研究的目的是，根據職能治療學者De las Heras 與Gary Kielhofner等人發展之動機再促進策略，編寫動機再促進團體介入手冊，以應用於精神分裂症患者執行治療性介入，並驗證此動機再促進方案之成效。 方法： 研究者們首先將英文版動機再促進過程手冊翻譯成中文版，並由具精神科職能治療臨床經驗及量表中文化經驗的資深職能治療師協助校稿，以確保中文版之手冊與原版內容相符。作者們依此中文版手冊內之原則，參考臨床精神分裂症患者之活動參與及活動種類，編寫動機再促進團體介入手冊，之後邀請診斷為精神分裂症之個案接受此治療性介入。治療介入前後，受試者填寫自填量表，包括：職能自我評估量表、貝克憂鬱量表第二版中文版、簡式症狀量表，精神科專科醫師評估正性與負性症狀量表，職能治療師評估意志量表、職能治療綜合評量表之工作行為次量表。研究者比較前後測分數，並執行無母數統計法之符號檢定與威克森符號等級檢定及母數統計法之成對樣本t檢定。 結果： 動機再促進團體治療介入手冊在臨床預試及修正後完成，並應用於本研究中，以手冊式方式介入(manualized approach)。共有10位精神分裂症患者參與研究，年齡介於23到56歲。受試者共接受分別有2次個別操作式活動及6次團體活動的治療性介入，每次50分鐘。受試者的前後測表現，除簡式症狀量表外，在各量表的分數皆有進步。在符號檢定方面，意志量表的進步達統計上之顯著差異。在威克森符號等級檢定方面，意志量表、正性與負性症狀量表之負性量尺及量表總分之進步皆達統計上之顯著差異。在成對樣本t檢定方面，意志量表、正性與負性症狀量表之負性量尺及量表總分、職能自我評估量表之自我能力感部分之進步皆達統計上之顯著差異。 結論： 精神分裂症患者普遍存在有動機問題，但卻缺少以職能治療理論發展的治療介入策略。研究者透過設計具有理論基礎的動機再促進方案，並以手冊式方式進行介入，可促進職能治療介入的標準化，提昇精神職能治療的實證基礎。而研究結果顯示，此方案確實可增加個案的意志表現，增加個案參與職能表現的動機，並改善個案的負性症狀，值得後續進一步研究驗證其在不同族群的適用性。

Background and Purpose Persons with schizophrenia often have difficulty with motivation. This reduction in motivation can result in poor functional outcomes due to a lack of occupational participation. Despite this knowledge, within occupational therapy clinical practice there remains a lack of effective and systematic intervention programs to better serve these individuals. The purpose of this study is to develop a remotivation group intervention manual and to verify the effectiveness of remotivation protocol for persons with schizophrenia based on remotivation strategies developed by occupational therapy scholars De las Heras and Gary Kielhofner. Methods The researchers translated the English edition of the remotivation process manual into Mandarin. In order to ensure the Mandarin version of the manual was consistent with the English version, the manuscript was corrected by a senior psychiatric occupational therapist experienced in scale translation. The researchers wrote a remotivation group manual based on the principle of the Chinese version of the manual, and referred to activities and types of activities that clients of schizophrenia participated in prior to the clinical trials. The researchers then invited persons with schizophrenia to engage in this therapeutic intervention. Pre-assessment protocol had subjects filling out self-report scales, including the Occupational Self-Assessment (OSA), Beck Depression Inventory Chinese Version of the second edition (BDI-Ⅱ), the Brief Symptom Rating Scale (BSRS-50). Psychiatrists then assessed patients using the Positive and Negative Syndrome Scale (PANSS), followed by an occupational therapist who further assessed patients through the Volitional Questionnaire (VQ) and the work behavior subscale of Comprehensive Occupational Therapy Evaluation Scale (COTES). The researchers compared pre- and post-test scores using both nonparametric and parametric statistical methods, including Sign Test and Wilcoxon Signed-Rank Test (nonparametric) and a Paired-Sample t Test (parametric). Results The remotivation group intervention manual was written and revised after completion of a clinical pretest trial. The revised manual was applied to the current study and used to engage individuals with schizophrenia in manualized intervention. A total of 10 schizophrenic patients participated in the study, ranging from 23-56 years old. Subjects received two individual operating activities and six group therapeutic interventions. Each session was 50 minutes. The pretest and posttest scores of subjects in each scaled score all progressed except BSRS-50. The scores of Volitional Questionnaire were statistically significant in the Sign Test, Wilcoxon Signed-Rank Test and the Paired-Sample t Test. The negative scale, total scores of the Positive and Negative Syndrome Scale were statistically significant in the Wilcoxon Signed-Rank Test and the Paired-Sample t Test. The scores of the own competence of the Occupational Self-Assessment were statistically significant in the Paired-Sample t Test. Conclusion In general, patients with schizophrenia display motivation problems, however, a lack of theory driven occupational therapy intervention strategies hinders them from receiving the treatment they need. Through the design of theoretical basis remotivation protocol and a manualized approach the standardization of occupational therapy intervention to enhance evidence-based mental occupational therapy can be promoted. The results from this study show that utilization of a remotivation protocol helps to increase the patient's volitional performance, increase motivation to participate in occupational performance, and improves negative symptoms. Therefore, it is worth further study to verify its applicability in different diagnosis groups.