心理保健联盟：概念化、证据和临床应用

The alliance in mental health care: conceptualization, evidence and clinical applications

——原载《世界精神医学》杂志2023年第22卷第1期——

<World Psychiatry> 2023, Volume 22, Issue 1

【摘要】联盟的概念反映了临床医生和患者之间的协作关系，定义为由三个要素组成： a) 就治疗目标达成一致； b) 一项任务或一系列任务的协议； c) 纽带的发展。 尽管关于联盟的大部分理论和研究都来自心理治疗领域，但该概念适用于涉及寻求帮助的人和社会认可的治疗师的任何实践。广泛的研究证据表明，联盟（通常在第三次或第四次治疗时的测量）是各种形式心理治疗结果的有力预测指标，即使考虑到先前的症状改善和其他因素也是如此。临床医生和患者都将不同的能力带到治疗情境中以形成联盟。与患者有关的因素包括，除其他外，诊断、依恋历史和类型、动机以及对归属感的需求。然而，联盟的好处被发现主要是由于治疗师的贡献，特别是他/她的促进人际交往能力，包括口头流利、希望和积极期望的沟通、说服力、情绪表达；温暖、接受和理解；同理心和联盟破裂修复反应。安慰剂研究允许在非心理治疗环境中实验性地操纵治疗师和患者之间关系的各个方面。在这些情况下，出现了关系的两个组成部分：情感部分（包括被临床医生照顾和理解）和认知部分（包括相信治疗师有能力选择和实施有效治疗）。在这里，我们提出了一个模型，该模型描述了联盟创造利益的三种途径，名为CARE（关怀、专心、真实和同理心）、EXPECTANCY和SPECIFIC。 尽管研究和临床关注主要集中在临床医生和患者面对面互动中的联盟，但有初步证据表明患者与其他诊所工作人员、护理系统或互联网介导的项目之间的联盟服务。这些新的研究领域显然需要进一步发展。

【关键词】联盟、关系、纽带、期望、治疗目标、能力、温暖、同理心、安慰剂、信任

[Abstract] The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

[Key words] Alliance, relationship, bond, expectations, treatment goals, competence, warmth, empathy, placebos, trust

论文原文：Bruce E. Wampold, Christoph Flückiger (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22 (1): 25-41.

https://doi.org/10.1002/wps.21035

（需要英文原文的朋友，请联系微信：millerdeng95）