健康生活:心理治療究竟靠譜嗎?大綱

Mental—health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release "evil spirits." Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.

古人們一度認爲，心理問題是“邪靈”作祟，需要使用鑽孔術，即在顱骨上鑽孔來釋放這些“邪靈”。如今，心理保健領域已經獲得了長足的進步。研究顯示，在過去的30年裏，認知行爲療法、辯證行爲療法和家庭療法均可有效地治療從焦慮症、抑鬱症到創傷後應激障礙、進食紊亂等一系列疾患。

The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.

問題是，幾乎沒有多少患者在接受診察後真正獲得了這些循證治療，尤其是認知行爲療法。2009年，一項由一流的心理健康研究人員進行的薈萃分析發現，儘管認知行爲療法治療常見疾病的有效性已經過大量試驗證實，但美國和英國的精神病患者卻很少接受這一療法。此外，研究人員在調查了近2300名美國的心理醫生後發現，在抑鬱症和焦慮症的治療中，有69%的患者僅在部分時間裏使用認知行爲療法，或將其與其他療法結合使用。

C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient's feelings and that often include exposure therapy and other activities.

認知行爲療法泛指多種結構化的指導型心理治療，通常包括暴露療法等。這些療法側重於探討潛藏於患者感覺背後的思想和觀點。

Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist's biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called "therapist drift."

相反，許多患者接受了東拼西揍的“大雜燴式”治療。該方法並非基於最新的研究成果，反而更多地受到治療師自身的偏見和培訓的影響。更有甚者，那些聲稱採用循證治療的專業人員也很少堅持他們所承諾的治療方法。這一問題稱爲“治療師偏移”(therapist drift)。

"A large number of people with mental health problems that could be straightforwardly addressed are getting therapies that have very little chance of being effective," said Glenn Waller, chairman of the psychology department at the University of Sheffield and one of the authors of the meta-analysis.

上述薈萃分析的作者之一，英國謝菲爾德大學(University of Sheffield)心理學系主席格倫·沃勒(Glenn Waller)指出：“許多患者本可以直截了當地解決自己的心理健康問題，卻把大量時間浪費在幾乎沒可能奏效的療法上。”

A survey of 200 psychologists published in 2005 found that only 17 percent of them used exposure therapy (a form of C.B.T.) with patients with post-traumatic stress disorder, despite evidence of its effectiveness. In a 2009 Columbia University study, research findings had little influence on whether mental-health providers learned and used new treatments. Far more important was whether a new treatment could be integrated with the therapy the providers were already offering.

一項發表於2005年的調查發現，雖然現有證據表明了暴露療法（一種形式的認知行爲療法）對創傷後應激障礙的有效性，但該調查所涉及的200名心理醫生中只有17%對其患者使用了該療法。2009年哥倫比亞大學(Columbia University)的一項研究則顯示，研究結果對心理保健服務提供者是否會學習和採用新的治療方法影響甚微。他們更加重視的是，新的治療方法能否整合入他們目前提供的治療之中。

The problem is not confined to the United States. Two years ago, Dr. Waller studied C.B.T. therapists in Britain treating adults with eating disorders to see what specific techniques they used. Dr. Waller found that fewer than half did anything remotely like evidence-based C.B.T.

這一問題並不侷限於美國。兩年前，沃勒博士對英國的一些認知行爲療法治療師進行了研究，並考察了他們在治療患有進食紊亂症的成年患者時使用了哪些特定的技術。沃勒博士發現，只有不到半數的治療師的工作帶有些循證認知行爲療法的影子。

"About 30 percent did something like motivational work, and 25 percent did something like mindfulness," said Dr. Waller. "You wouldn't buy a car under those conditions."

“約30%的治療師只是簡單地給患者來一番勵志，25%則引導患者進行正念之類的修習，”沃勒博士說，“在這種情況下，你怎麼可能放心地將健康託付給他們？”

Why the gap? According to Dianne Chambless, a professor of psychology at the University of Pennsylvania, some therapists see their work as an art, a delicate and individualized process that works (or doesn't) based on a therapist's personality and relationship with a patient. Others see therapy as a more structured process rooted in science and proven effective in both research and clinical trials.

在研究與實踐之間爲何會存在這樣的鴻溝？據賓夕法尼亞大學(University of Pennsylvania)的心理學教授黛安娜·錢布利斯(Dianne Chambless)稱，某些治療師把治療當成了藝術創作，一種以（或不以）其自身個性及其與患者之間的情感關聯爲基礎進行的微妙的個體化過程。而其他人則認爲這項工作是一項條理化的程序，它植根於科學，且其有效性在研究和臨牀試驗中均得到了證實。

"The idea of therapy as an art is a very powerful one,” she said. "Many psychologists believe they have skills that allow them to tailor a treatment to a client that's better than any scientist can come up with with all their data.”

“視治療爲藝術這一觀念的力量相當強大，”錢布利斯教授說，“許多心理學家都相信自己掌握的技能足以爲客戶量身打造治療方案，且其效果甚至比任何科學家憑藉數據所能提出的方案還要更勝一籌。”

The research suggests otherwise. A study by Kristin von Ranson, a clinical psychologist at the University of Calgary, and colleagues published last year concluded that when eating-disorder clinicians did not use an evidence-based treatment or blended it with other techniques for a more eclectic approach, patients fared worse, compared with those who received a more standardized treatment.

然而，研究表明，事實恰恰相反。加拿大卡爾加里大學的臨牀心理學家克里斯廷·馮·蘭森(Kristin von Ranson)和他的同事在去年發表的一項研究中總結道，在進食障礙的治療中，與接受規範化治療的患者相比，當臨牀醫生未採用循證治療或將其與別的技術一起攪和成折衷治療法時，患者的情況就不那麼樂觀。

Therapists who skew toward the "artistic" side say that so-called manualized treatment devalues crucial aspects of therapy like empathy, warmth and communication — the "therapeutic alliance."

傾向於“藝術性”的治療師們宣稱，所謂的“程式化治療”(manualized treatment)貶低了共情、溝通以及溫情這些“治療聯盟”的價值。

"If you want a patient to be using a treatment that works, what's most likely to get them there is the relationship you build with them," said Bonnie Spring, a professor of psychiatry at Northwestern's Feinberg School of Medicine.

“如果你希望患者採用有效的治療方法，與他們建立起感情聯繫很可能令你事半功倍，”西北大學(Northwestern)費恩柏格醫學院的精神病學教授邦尼·斯普林(Bonnie Spring)表示。

But some experts believe this is a false choice. "No one believes it's a good idea to have a bad relationship with your client," said Dr. Chambless. "The argument is really more, ‘Is a good relationship all we need to help a patient?' "

但其他的一些專家則認爲，這是一個錯誤的選擇。“誠然誰也不會以爲跟客戶交惡會是個好主意，”錢布利斯博士說，“爭論的真正焦點在於：‘僅僅靠跟患者搞好關係就足以幫助他們了嗎？'”

Besides, evidence-based treatments like C.B.T. still require expertise, clinical judgment and skill from practitioners, noted Terry Wilson, a professor of psychology at Rutgers University. "A stereotype of manualized treatment is: you go buy a book and it's a rigid, lock step thing," he said. "But when done competently, it's anything but."

羅格斯大學(Rutgers University)的心理學教授特里·威爾遜(Terry Wilson)指出，此外，認知行爲療法等循證治療還需要從業者擁有專業知識、臨牀判斷和技能。“程式化治療往往給人一種刻板印象，讓人誤以爲這是一種單純照章辦事的因循僵化的過程，”他說，“但如果你能恰如其分地進行這項治療，你會發現它完全不是這麼一回事。”

Differences in background and education play a role in a therapist's perspective on evidence-based treatment. "You can become a therapist with very little training in how to think scientifically," said Carolyn Becker, a professor of psychology at Trinity University in San Antonio. Psychiatrists, clinical psychologists, social workers and other mental-health professionals complete years of rigorous schooling and apprenticeships, but it is possible to practice therapy without such a foundation.

出身背景和教育程度的差異均可影響治療師對循證治療的觀點。“即使你幾乎從未接受過科學思維的訓練也可以成爲一名治療師，”聖安東尼奧三一大學(Trinity University)的心理學教授卡羅琳·貝克爾(Carolyn Becker)指出。精神科醫生、臨牀心理學家、社會工作者和其他心理健康專業人員都需要完成數年嚴格的學校教育和見習，但治療師們未必都具備上述基礎。

"A lot of students come in and say, ‘I hate science, but I'm good with people. I like to listen and help them,' " said Dr. Becker. There is little incentive for therapists to change what they are doing if they believe it works. But "every clinician overestimates how well they're doing," said Dr. Spring. Often patients simply feel they can't tell a therapist when things aren't going well.

“有不少學生說：‘我討厭科學，但我擅長與人交往。我樂於聆聽患者們的傾訴，並給予他們所需的幫助，'”貝克爾博士補充道。只要治療師們認定自己的工作行之有效，他們就不大情願做出改變。不過，“每名臨牀醫生都會高估自己的工作成效，”斯普林博士說，實際上，在很多情況下，患者只不過是覺得自己無法告訴治療師“進展並不順利”而已。

"A lot of times, therapists just don't know," Dr. Chambless said. "People will say, ‘Thank you, I'm fine now, goodbye,' and go into a different therapy."

“很多時候治療師們只是被蒙在了鼓裏，”錢布利斯博士說，“患者對他們說，‘謝謝你，我現在覺得好多了，再見'，然後又跑去接受另一套不同的治療。”

Despite the gap between research and practice, some experts are cautiously optimistic. Dr. Wilson believes mental health practitioners, especially younger clinicians, are slowly moving toward more evidence-based treatments. He pointed to a parallel shift among physicians that took place, he said, when medicine committed itself to science rather than to producing medical artists or gurus.

儘管存在着這些差距，專家們對未來仍然抱持着謹慎樂觀的態度。威爾遜博士認爲，心理保健行業的從業者，特別是年輕的臨牀醫生，正慢慢地向循證治療的陣營邁進。他指出，當醫學界更專注於科學而非生產所謂的“醫療藝術家”或“大師”時，在醫生之中也會發生相應的偏移。

"As a field, clinical psychology needs to do the same thing," he said. "We need to commit ourselves to science."

“在臨牀心理學領域內也亟需發生同樣的轉型，”威爾遜博士說，“我們需要更加致力於科學研究和實踐。”

Need to find a therapist well-grounded in the latest research? Experts recommend interviewing prospective providers before starting therapy, especially if you are looking for a specific type of treatment. Useful questions include:

你需要尋找一名深諳最新研究的治療師嗎？專家建議在開始治療前先對他們進行一場面試，當你所尋求的是某種特定類型的治療時尤其應該如此。有意義的問題包括：

What kind of trainings have you done, and with whom?

你完成了何種類型的培訓，同儕都有哪些人？

What professional associations do you belong to? (If you're looking for a C.B.T. therapist, for instance, ask whether the therapist belongs to the Association for Behavioral and Cognitive Therapies, where most top C.B.T. researchers are members.)

你屬於哪個專業協會？（例如，當你的目標是尋找一名 CBT治療師時，你可以詢問他是否隸屬“行爲和認知療法協會”，因爲大多數頂尖的認知行爲療法研究人員都是該協會的成員。）

What do you do to keep up on the research for treating my condition?

爲了更好地治療我的病情，你將如何跟進最新的研究進展？

How do you know that what you do in treatment works?

你如何確知應進行哪些治療？

Do you consider yourself and your approach eclectic? (Therapists who subscribe to an eclectic approach are less likely to adhere to evidence-based treatments.)

你是否認爲你所採用的方法具有折衷主義傾向？（贊同折衷治療法的治療師不大可能會堅持循證治療。）

What manuals do you use?

你使用的是何種治療手冊？

What data can you show me about your own outcomes?

你可以通過哪些數據來證實自己的成果？

"A clinician who can't tell you how many patients get well isn't going to care that much if you get well," said Dr. Waller.

“如果一名臨牀醫生無法告訴你有多少患者經過他的治療後得到好轉，那麼他同樣不會把你的病情放在心上，”沃勒博士如是說。