難治型憂鬱症患者接受認知行為團體治療之歷程分析

A process analysis of the group-based cognitive behavioral therapy for patients with treatment-resistant depression

程靖容(Jing-Rong Cheng)

指導教授 ： 吳佳儀

國立臺灣大學/醫學院/護理學研究所/碩士(2022年)

https://doi.org/10.6342/NTU202203171

摘要

研究背景：憂鬱症（depressive disorders）是一個常見的精神疾病，盛行率為4.4％，現階段憂鬱症治療以藥物處置為主，然而臨床上有近三分之一的個案服藥治療後仍無法痊癒，被稱之為難治型憂鬱症（treatment-resistant depression, TRD）。已有許多針對憂鬱症與TRD個案的認知行為團體研究證實認知行為治療與藥物治療併行可有效減少憂鬱症狀，但關於認知行為治療合併以團體做為介入的方式，應用於難治型憂鬱症個案的研究卻付之闕如，質性相關的內容探討更是未見。研究目的：本研究目的在探討運用認知行為治療技巧於支持性團體中，幫助TRD個案穩定病情之可行性與成效，研究者同時分析影響個案復元的社會心理因素、觀察TRD個案的人際關係與互動特色，並運用亞隆團體概念分析TRD團體產生的團體療效因子。研究方法：本研究採質性研究法，研究者參與指導教授研究團隊已發展之八週認知行為治療為基礎的TRD團體架構，每周進行兩小時的團體討論及一小時會後會討論，同時取得個案同意於現場錄音錄影，作為逐字稿資料分析來源，並輔以簡式健康量表(即心情溫度計, Brief Symptom Rating Scale, BSRS-5) 監測個案的心理困擾程度、並以亞隆(Yalom)中文版療效因素量表追蹤團員對團體療效因子之感受。研究結果：共有23位個案參與認知行為團體治療，經過三梯次的八週團體分析，共得出22個次主題，歸納整理後得出五大主題，分別是團體互動特色與歷程、疾病因應與治療經驗、心理社會行為表現、壓力感受暨管理技巧及社區再融入等五項，團體互動特色與歷程，指在團體進行時，團體成員於此時此刻所發生的人際互動，以及亞隆團體療效因子的分析；疾病因應與治療經驗，主要了解成員的疾病治療過程與就醫經驗，自覺服藥遵從性的狀況，遇到不適症狀與疾病污名時如何自我因應面對；心理社會行為表現，涵蓋了自我反思、孤獨、自殺議題、酒精物質等社會心理議題；壓力感受暨管理技巧，包含回家作業實作討論與成員主觀對於壓力事件的感受分享；支持來源與社區生活規劃，涵蓋成員的社區支持系統來源以及種類。研究者分別於團體第三週、第八週及團體結束後一個月進行亞隆中文版療效因素量表追蹤分析，三梯次團體追蹤分數皆顯示，在團體第三週成員們對療效因子的感受性最低，而在團體結束後一個月成員們對療效因子的感受性最強，但三個時間點的追蹤分數並未達顯著差異，並發現情緒宣洩、資訊傳遞、普同感為最常出現之團體療效因子，另外，BSRS-5分數曲線顯示認知行為團體互動過程可維持成員的情緒狀態在穩定的水平，不至於因議論負面議題而導致顯著的負向心理困擾，三梯次的團體成員們於參加八週團體期間，每週心情溫度曲線圖皆未有明顯下降。結論與建議：團體治療能穩定TRD個案之憂鬱症狀及心理困擾，社區再融入之生活規劃搭配壓力管理技巧、心理社會議題因應與提升治療遵從等．有助於復元，未來可針對TRD團體進行更多研究與實務經驗之累積，以提供政策及學術未來之參考。

關鍵字

難治型憂鬱症 ； 認知行為團體 ； 歷程分析 ； 亞隆療效因子

並列摘要

Background: Depression disorder is a common mental disorder with a prevalence rate of 4.4% in general population. At present, the treatment of depression is mainly medication treatment, but nearly one-third of clinical cases are still difficult to treat and therefore known as treatment-resistant depression (TRD). The efficacy of combining gCBT and medication on TRD and depression patients is confirmed by previous studies. However, research on TRD patients is lacking especially the qualitative research.Purposes: The purpose of this research is to explore the feasibility of using gCBT in TRD by analyzing the social and psychological factors that affect the recovery and observe the interpersonal、interactive characteristics of TRD. The concept of Yalom group was applicated to analyze the group therapeutic factors in this study.Methods: The qualitative research method was used in this study. The researchers participated in an eight-week cognitive-behavioral therapy-based TRD group structure developed by the supervisory research team. Two hours of group discussions and one-hour post-meeting discussions were held each week. After the consents of the participants were obtained. Video and verbatim transcripts were recorded as the source of data analysis. The BSRS-5 scale was to monitor the psychological distress, the Yalom Chinese version of the therapeutic factor scale was to track the group members' response to the group therapeutic factors.Results: A total of 23 clients participated in the gCBT. After three stages of eight-week group analysis, a total of 22 sub-themes were obtained. Five major themes were summarized as: group interaction characteristics and process, disease coping and treatment experience, psychosocial behavioral performance, stress perception and management skills, and community reintegration. The follow-up analysis of the Chinese version of the therapeutic factor scale of Yalom was carried out in the third week, eighth week and one month after the group, respectively. The results of follow up scores showed that, the sensitivity to the therapeutic factor were lowest in the third week otherwise showed highest on one month after the end of the group. The tracking scores at the three time points did not reach a significant difference. Catharsis, imparting of information, and universality were the most frequently group therapeutic factors. The BSRS-5 score curve shows that the cognitive behavioral group interaction process can maintain the emotional state of members at a stable level, without causing significant negative psychological distress. The weekly score curve did not show a significant decrease during the study period.Conclusion and implications: gCBT can stabilize depressive symptoms and psychological distress in TRD. It is helpful for recovery, such as life planning for community reintegration, stress management skills, coping with psychosocial issues and improving treatment compliance. For research and practical experience is needed in gCBT for the TRD patients to provide a reference for policy and academic future.

並列關鍵字

treatment-resistant depression ； cognitive-behavioral therapy group ； process analysis ； therapeutic factors

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