SFBT目标设定在临终关怀中的创新应用

英文原文

Journal of Systemic Therapies, Vol. 33, No. 2, 2014, pp. 35–49

A SOLUTION-FOCUSED THERAPY GROUP DESIGNED FOR CAREGIVERS OF STROKE SURVIVORS

Rhea Plosker and Jeff Chang

In 2006, 44 million Americans acted as informal caregivers for other adults. In Canada, in 2007, this number was 2.75 million. Stroke is the leading cause of disability in North America, so there is strong economic and social value in supporting stroke caregivers. Moving Forward, a group for stroke caregivers, builds on a Solution-Focused Therapy foundation. The group uses a modular, flexible structure easily learned, used, and modified for application to different settings. Positive feedback resulted in the group now offered as an ongoing service. The greatest challenge is recruitment. Many interested caregivers have too many demands on their time to commit to regular attendance. Work is underway to explore formats best suited to caregiver availability constraints.

The Moving Forward group for caregivers of stroke survivors was born from the commitment of social workers at a Toronto rehabilitation hospital. Stroke rehabilitation focuses on the patient, but those working in the field know that family caregivers play a critical role in success. The first 3–6 months post-stroke are the most difficult as caregivers navigate many life changes. This same period is also crucial for the stroke survivor’s rehabilitation, with survivors doing better if their caregivers are well supported. In developing the group, our goal was to create a meaningful intervention for caregivers who have to reorganize their lives post-stroke as well as to make it easy for facilitators to learn, use, and adapt to a variety of caregivers and settings.

Solution-Focused Therapy (SFT) is a brief therapy focusing on goal setting and maximizing personal resources. It encourages hope by examining "what’s working," contrasting with the focus on deficits found in the medical model. The future focus supports caregivers to plan their post-stroke lives, and the emphasis on maximizing resources integrates well with the transactional model of stress. A brief therapy, SFT also aligns with the current environment of limited funding for caregiver services.

SFT emphasizes the importance of language. While acknowledging and validating a client’s problem, SFT primarily focuses on asking questions to elicit exceptions to the problem, or times when the problem is less severe. The SFT process of constructing exceptions to the problem, rather than the problem itself, generates hope by drawing clients’ attention toward their already proven ability to master challenges—what works. This naturally leads to conversations about constructing future solutions.

There are no recent published studies evaluating SFT applied to work with stroke survivors and their caregivers. However, there is support for the use of SFT applied to health care and to working with ill adults. Simon (2010) noted the importance of a hope-oriented therapy in the health care sector, where it is easy for complex clinical problems to overwhelm patients and families. Quick and Gizzo (2007) discussed the benefits from using SFT with patients of the Kaiser Health Maintenance Organization in California. Several recently published papers describe applications of SFT to Emergency Room suicide assessment, patients with HIV/AIDS, and Crohn’s disease, suggesting SFT reduces hopelessness and increases quality of life and ability to cope.

SFT is also a good fit for group work. Gingerich, Kim, Stams, and Macdonald (2011), reviewing SFT outcome research, found SFT group interventions had a medium outcome effect size, compared to the small effect size found in individual interventions.

The Moving Forward group uses a consistent solution-focused process flow throughout all sessions, a common practice in solution-focused groups. The Moving Forward process flow uses three key solution-focused practices:
1. Setting goals. Setting goals facilitates solution building. Movement toward goals can be described even when goal attainment is not complete.
2. Look for "what’s working" or times when the problem is less severe. Focusing on times when we cope better permits strengths, skills, and resources to become more visible and future possibilities to emerge.
3. Take small steps toward change. Small changes lead to bigger ones. If something works, keep doing it. If something does not work, try something else.

Six solution-focused techniques are embedded in Moving Forward group sessions: Pre-session Change, Goal-Setting Questions and the Miracle Question, Scaling Questions, Highlighting Exceptions and Building Solutions, Relationship Questions, and Compliments and a Task.

At the time of writing, the group has run four times, including one single-session focus group and three planned four-week groups. The group continues to evolve based on attendee feedback. Evidence gathered so far suggests that the group has been effective. Facilitators have observed examples where solution-focused conversations highlighted caregiver strengths that surprised other professionals working closely with the caregiver. The modular group structure has proven to be easy to learn, adapt, and use by the five facilitators involved to date.

The biggest challenge for Moving Forward has been caregiver recruitment and attendance. Hospital staff are already overworked and recruitment is very time-consuming. Caregivers acknowledge the need for support and there is interest in the group, but timing, logistics, and conflicting demands have posed multiple challenges.

Moving Forward uses a modular design intended to support multiple formats and applications. We believe the group format to be adaptable for caregivers of those suffering from other problems, particularly for caregivers of adults requiring rehabilitation services due to the sudden onset of illness or disability. The group design also supports a transition out of the hospital environment to supporting caregivers in the community.

Multiple research opportunities exist. The need for stroke caregiver support is large, but there is little intervention research. SFT has proven successful in multiple health care applications and our experience is that SFT is an excellent fit for working with stroke caregivers. Both caregivers and the SFT literature would benefit from systematic research in this area.

There is also value in assessing the impact of interventions like Moving Forward on indirect outcomes such as emergency room visits, readmission rates, and nursing home admissions of the stroke survivor. In our current cost-cutting environment, demonstrating that a caregiver intervention reduces health care costs might help make a case for funding services.

Informal caregivers deserve recognition and support both because of their needs and because of the significant amounts of unpaid labor contributed by them to our economy. Caregiver support will grow in importance as our population ages. The Moving Forward group, with its solution-focused approach and modular design, seems to fit well with the needs of caregivers across multiple settings, while also supporting the needs of busy group facilitators.

中文翻译

《系统治疗杂志》第33卷第2期，2014年，第35-49页

为中风幸存者照顾者设计的焦点解决治疗小组

Rhea Plosker 和 Jeff Chang

2006年，4400万美国人作为非正式照顾者照顾其他成年人。在加拿大，2007年这一数字为275万。中风是北美致残的主要原因，因此支持中风照顾者具有重要的经济和社会价值。“向前迈进”是一个为中风照顾者设立的小组，建立在焦点解决治疗的基础上。该小组采用模块化、灵活的结构，易于学习、使用和修改，适用于不同环境。积极的反馈使该小组现在作为一项持续服务提供。最大的挑战是招募。许多感兴趣的照顾者时间需求太多，无法承诺定期参加。目前正在探索最适合照顾者时间限制的形式。

为中风幸存者照顾者设立的“向前迈进”小组源于多伦多康复医院社会工作者的承诺。中风康复侧重于患者，但该领域的工作者知道家庭照顾者在成功中起着关键作用。中风后的前3-6个月是最困难的，因为照顾者要应对许多生活变化。这一时期对中风幸存者的康复也至关重要，如果照顾者得到良好支持，幸存者会恢复得更好。在开发该小组时，我们的目标是为那些必须在中风后重新组织生活的照顾者创造有意义的干预措施，同时使促进者易于学习、使用和适应各种照顾者和环境。

焦点解决治疗是一种专注于目标设定和最大化个人资源的简短疗法。它通过检查“什么在起作用”来鼓励希望，与医学模型中关注缺陷的做法形成对比。未来导向支持照顾者规划他们中风后的生活，而最大化资源的重点与压力交易模型很好地结合。作为一种简短疗法，焦点解决治疗也符合当前照顾者服务资金有限的环境。

焦点解决治疗强调语言的重要性。在承认和验证客户问题的同时，焦点解决治疗主要侧重于提出问题以引出问题的例外，或问题不那么严重的时刻。焦点解决治疗构建问题例外而非问题本身的过程，通过将客户的注意力引向他们已经证明的应对挑战的能力——什么在起作用，从而产生希望。这自然导致关于构建未来解决方案的对话。

目前没有近期发表的研究评估焦点解决治疗应用于中风幸存者及其照顾者的工作。然而，有支持将焦点解决治疗应用于医疗保健和与患病成年人工作的证据。Simon（2010）指出，在医疗保健领域，希望导向疗法的重要性，因为复杂的临床问题很容易压倒患者和家庭。Quick和Gizzo（2007）讨论了在加州凯撒健康维护组织患者中使用焦点解决治疗的好处。最近发表的几篇论文描述了焦点解决治疗在急诊室自杀评估、HIV/AIDS患者和克罗恩病中的应用，表明焦点解决治疗减少了绝望感，提高了生活质量和应对能力。

焦点解决治疗也适合小组工作。Gingerich、Kim、Stams和Macdonald（2011）在回顾焦点解决治疗结果研究时发现，焦点解决治疗小组干预具有中等效果大小，而个体干预的效果较小。

“向前迈进”小组在所有会话中使用一致的焦点解决流程，这是焦点解决小组的常见做法。“向前迈进”流程使用三个关键的焦点解决实践：
1. 设定目标。设定目标促进解决方案构建。即使目标未完全实现，也可以描述向目标的进展。
2. 寻找“什么在起作用”或问题不那么严重的时刻。关注我们应对更好的时刻，使优势、技能和资源更加可见，未来可能性得以显现。
3. 采取小步骤改变。小变化导致大变化。如果某事有效，继续做。如果无效，尝试其他方法。

六种焦点解决技术嵌入“向前迈进”小组会话中：会话前变化、目标设定问题和奇迹问题、量表问题、突出例外和构建解决方案、关系问题、以及赞美和任务。

在撰写本文时，该小组已运行四次，包括一次单次焦点小组和三次计划的四周小组。该小组继续根据参与者反馈发展。迄今为止收集的证据表明该小组有效。促进者观察到焦点解决对话突出照顾者优势的例子，这些优势让与照顾者密切合作的其他专业人员感到惊讶。模块化小组结构已被证明易于学习、适应和使用，迄今为止涉及的五位促进者都证实了这一点。

“向前迈进”最大的挑战是照顾者招募和出席。医院工作人员已经超负荷工作，招募非常耗时。照顾者承认需要支持，并对小组感兴趣，但时间安排、后勤和冲突需求带来了多重挑战。

“向前迈进”采用模块化设计，旨在支持多种形式和应用。我们相信该小组形式可适应其他问题患者的照顾者，特别是因突发疾病或残疾需要康复服务的成年人的照顾者。该小组设计还支持从医院环境过渡到社区支持照顾者。

存在多个研究机会。中风照顾者支持需求很大，但干预研究很少。焦点解决治疗在多个医疗保健应用中已证明成功，我们的经验是焦点解决治疗非常适合与中风照顾者工作。照顾者和焦点解决治疗文献都将受益于该领域的系统研究。

评估像“向前迈进”这样的干预措施对间接结果的影响也有价值，例如急诊室就诊、再入院率和中风幸存者的养老院入住。在当前成本削减的环境中，证明照顾者干预降低医疗成本可能有助于为服务资金提供理由。

非正式照顾者值得认可和支持，既因为他们的需求，也因为他们为我们经济贡献的大量无偿劳动。随着人口老龄化，照顾者支持将变得越来越重要。“向前迈进”小组以其焦点解决方法论和模块化设计，似乎很好地适应了多种环境下照顾者的需求，同时也支持了忙碌小组促进者的需求。

文章概要

本文介绍了为中风幸存者照顾者设计的焦点解决治疗小组“向前迈进”。文章基于2014年《系统治疗杂志》的研究，探讨了焦点解决治疗在支持照顾者中的应用。文章指出，中风是北美致残的主要原因，照顾者面临巨大压力，而焦点解决治疗通过目标设定、寻找“什么在起作用”和小步骤改变，帮助照顾者规划未来、最大化资源。小组采用模块化设计，易于适应不同环境，但招募和出席是主要挑战。研究显示，焦点解决治疗在医疗保健中有效，能减少绝望感、提高生活质量。文章强调，照顾者支持具有经济和社会价值，未来可扩展至其他疾病照顾者，并需要更多研究评估其效果。

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