職能治療中治療關係與治療成效之探討

Abstract

前言：以個案為中心的服務模式不只是被健康相關專業越來越重視，與職能治療的核心哲理一直就是將個案視為全人看待並尊重的臨床科學相互呼應。在衡定職能治療的服務品質時，治療師與個案的接觸過程是否有具備足夠的專業知識、以及治療性地運用自我在臨床推理中、形成與個案良好且適當的治療關係，往往影響療效。治療師透過與個案的治療關係，誘發並促進個案的參與度，並且增加自我察覺、提高改變的動機，因為增進參與活動的頻率與程度，進而改善了個案的功能狀態。本研究目的是藉由系列研究，探討治療師與個案兩方對於治療關係的觀點、並且進行治療關係評估工具的心理計量驗證，探討治療關係與治療成效的關聯性。方法：所有程序皆在台大醫院倫理委員會審核及監督下執行。研究一共有33位治療師與他們正在治療中的個案共18位填寫本土發展的治療關係問卷，根據無母數統計方法分析他們對於治療關係重要性的看法與感受到的治療關係好壞之相關性與差異性；研究二共有202位於精神衛生領域執業的職能治療師、以及229位正在接受職能治療的精神病友填寫治療關係問卷及工作同盟量表，所收集的資料用以檢視治療關係問卷的心理計量特性；研究三則為研究二的參與者，治療師及精神病友除了上述兩份問卷之外，治療師需額外填寫在治療關係中用來建立治療關係的治療策略、而病友額外填寫個人因子相關問卷(包括症狀嚴重度、性格、功能程度等)以及療效指標(包括治療滿意度及治療參與度)，探討個人因子、治療關係、及治療成效之間的關聯性。結果：從研究一的結果發現治療師與個案對治療關係都同等看重，但對於感受到的治療關係好壞卻有顯著差異，在多項題目上個案都顯著評價比治療師高；研究二驗證了從研究一修正而來的個案版與治療師版問卷，表現出適當的心理計量特性；而研究三則指出個案的診斷、性格與治療關係、以及治療關係與治療成效之間有著顯著正相關。討論與結論：研究結果得知，治療師和個案的觀點有著顯著差異，指出治療關係需要由個案自陳與治療師填寫才能夠得到較完整的訊息。治療關係當中個案容易感受到及較難感受到的元素與治療師有明顯不同，且治療師所使用的策略、個案的診斷及性格與治療關係有顯著相關。這也提醒了治療師在建立或維持良好的治療關係時所需要關注的地方。良好的治療關係中存在較理想的治療滿意度與參與度，支持了治療關係與治療成效有著顯著正相關。

Background: The client-centered service is more and more emphasized by health-related professions, which echoes the central philosophy of occupational therapy (OT) always view the individual as holistic exist and with respect. During the contact process between therapists and clients, enough knowledge base, therapeutic use of self in the clinical reasoning, and establishing positive relationship will determine the treatment effectiveness. An OT practitioner develop the relationship with his/her client, to improve the self-awareness and the motivation to change, to enhance the frequency and intensity of participation, and to manifest the client’s functional status accordingly. The purposes of the series of study are to investigate the perspectives of therapeutic relationship in OTs and their clients, the psychometric of culture- and rehabilitation-specific therapeutic relationship questionnaire, and the association with therapeutic effectiveness. Methods: All procedures were approved by the Institutional Review Board of NTUH. We recruited the practicing OTs (N=33) and their clients (N=18) to respond the therapeutic relationship questionnaires in study 1. To probe the perspectives of them, non-parametric statistical analysis was conducted for correlation and difference comparison. In study 2, the practicing OTs in mental health settings (N=202) and individual with mental illness who were receiving OT (N=229) were recruited. All of them had to fill-out the therapeutic relationship questionnaires (TRQs) and the Working Alliance Inventory for examining the psychometric properties of the TRQs. In study 3, all participants in study 2 extra filled out related questionnaires about personal factors, such therapeutic strategies for therapists, and symptom severity, personality, functional status, and therapeutic effectiveness (including satisfaction and participation) for clients. The data was examined for the correlation among personal factors, therapeutic relationship, and therapeutic effectiveness. Results: Therapist and client participants in study 1 valued the importance of therapeutic relationship equally. However, clients rated their relationship significantly differently from their therapists on several items (such as ‘good motivation’, ‘trust the therapist’, ‘the therapist could give professional knowledge and suggestion’, and so on). The refined therapeutic relationship questionnaires from study 2 demonstrated adequate psychometric properties. The findings of study 3 indicated the positive correlation between therapeutic relationship and therapeutic effectiveness. Discussion and conclusion: There is significant perspectives between therapists and their clients indicating the need of two versions of therapeutic relationship questionnaire for clinical use. The item difficulty and association with therapist’s strategy and client’s diagnosis and personality suggests practitioners to pay more attention on these variables to establish or maintain their relationship. Furthermore, therapeutic relationship correlates positively with treatment satisfaction and participation which echoes to previous literatures.