團體終結之歷程、介入與反思

The Process, Intervention and Reflection of Group Termination

周勵志(Lih-Chih Jou) ； 林星翔(Xing-Xiang Lin)

《中華團體心理治療》 25卷1期 (2019/03) Pp. 31-39

摘要

目的：心理治療的結束可能代表病人已達成預設目標，或因其它因素需要結案。基於倫理責任，治療師有義務確保結案的過程符合專業倫理的規範和病人的最佳利益。被診斷為邊緣型人格的病人，常常是心理治療團體中的「問題病人」（Problem Patient），有較高的流失率，或對團體造成不良影響，甚至團體終結。回顧文獻多以負向觀點描述成員流失對團體與成員的影響。本報告以一個十七年之長期門診團體為基礎，描述團體成員與治療師共同面對團體的終結；除描述治療師的介入方式，及回顧成員的參與歷程，也賦予團體終結的正向觀點。研究團隊也追蹤團體成員以瞭解預後，並提供相關轉銜服務。方法：始於2001年三月，此長期的門診團體以客體關係理論與心智化導向為基礎，並以異質性的設計來舒緩邊緣型人格障礙病人對團體造成的張力，團體中也有其他的維持在較高的發展階段的團體成員，以促進邊緣型人格障礙病人的探索與解析。研究者使用質化分析來檢驗團體歷程，由2017年10月至2017年12月共九次；所有團體歷程以錄音檔保存，轉錄為逐字稿，並且以個案研究法進行分析。結果：新成員之流失者較多是以解決危機為參與團體目的，容易在團體中引發張力或產生人際衝突；舊成員之流失者則多因團體無法滿足需求，或團體外無法避免的因素。在建立穩定的團體基礎後，團體的終結原因並非一定是因「問題病人」；團體於衝突後進入工作階段，聚焦於討論此時此地之議題，可使團體以正向的「涵容環境」涵容團體成員。歷經團體在穩定治療聯盟下的工作期，部分團體成員能在結束團體後內化團體的治療關係、與治療師建立良好安全依附，對團體終結多有正向觀點，並進入下一個人之發展階段，對生活品質、人際關係與工作狀況也皆自陳有所改善。結論：團體終結與成員流失可適時、適當地因應，團體治療師可於事前篩選成員參考，也可依照不同類型成員提供不同介入。而團體非預期的終結或成員的流失若建立在穩定的團體關係與涵容環境中，應有利於病人病情的改善。

關鍵字

團體終結 ； 邊緣型人格障礙 ； 團體心理治療

並列摘要

Background/Objectives: Psychotherapy termination may be conceptualized as an intentional process that occurs over time when a patient has achieved most of the goals of treatment, and/or when it becomes reasonably clear that the patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. Psychotherapists maintain an obligation to ensure that this process is handled in an ethical manner consistent with each patient's best interests. Patients with Borderline personality disorder are notoriously to have high dropout rate in mental health services, which would delay the solutions of personal problems and the development of group process. In this presentation, the authors discuss how the group members and therapist faced group termination together; In addition to therapist's interventions, members' participating process were reviewed, and members' follow up and aftercare were also described. Method: Commenced in March 2001, this long-term outpatient group was based on Psychodynamic model, and lastly taken a Mentalization-informed approach. This group was designed to be heterogeneous to buffer the tension evoked by BPD patients. Besides old members, new members were recruited every 3 months to enrich the development & vitality of this group. The study period is from July to December 2017. All group sessions were recorded, verbatim transcribed, and analyzed by method of case study research. Results: I. Dropout and termination: 1. Dropout: The dropout new members usually characterized as higher functioning, more narcissistic trait, or pseudo-normality. The dropout old members were due to inevitable extra-group obligations, did not have adequate treatment adherence, or anxious attachment style. 2. Termination: Successfully terminated long-term participants often because of extra-group changes, such as go back to work, participate new pre-occupational training etc. Also, they maintained good therapeutic alliance, group cohesiveness, internalized and generalized group gains, and had positive progress in personal development. II. Aftercare: Individualized aftercare was provided unless dropout completely from treatment program, continuous OPD follow up, individual psychotherapy, or/and monthly community 2. Termination: Successfully terminated long-term participants often because of extra-group changes, such as go back to work, participate new pre-occupational training etc. Also, they maintained good therapeutic alliance, group cohesiveness, internalized and generalized group gains, and had positive progress in personal development. II. Aftercare: Individualized aftercare was provided unless dropout completely from treatment program, continuous OPD follow up, individual psychotherapy, or/and monthly community group program were arranged as needed. Conclusion: Psychotherapists terminate therapy when it becomes reasonably clear that the patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. Before group termination, therapist provided pre-termination counseling within the group, such as reviewing gains made in treatment, considering potential relapse risks and how to handle them, addressing future challenges to be dealt with either outside of psychotherapy or when returns to psychotherapy. This long-term outpatient group was ended not totally as expected; before the ending of this long-term outpatient group, the research team responded contingently to the developmental process of group, and the short-term follow up revealed as not inappropriately.

參考文獻

方紫薇&馬宗潔，( 1995)。團體心理治療的理論與實務(原作者：ID Yalom) ，台北：桂冠。

周勵志、林星翔&郁海琨，(2018) 。一長期門診心智化導向團體中的依附模式初探。中華團體心理治療，24(3), 34-41。

Barnett, J. E., MacGlashan, S. G., & Clarke, A. J. (2000). Risk management and ethical issues regarding termination and abandonment.

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: a test of a four-category model. Journal of personality and social psychology. 67(2), 226.

Gamache, D., Savard, C., Lemelin, S., Côté, A., & Villeneuve, É. (2018). Premature Termination of Psychotherapy in Patients With Borderline Personality Disorder: A Cluster-analytic Study. The Journal of nervous and mental disease, 206(4), 231-238.