心理治疗循证实践中“证据”的四个基本问题

Four questions on “evidence” in evidence-based practice in psychotherapy

循证实践正在成为西方心理治疗发展的主流方向。但如何理解循证实践的"证据"仍是见仁见智。部分社会大众甚至心理学专家仅将"循证"当作一种"修辞"或"时尚",顾名思义地界定"证据",或按主观信仰随意地选择与应用"证据"。文章以"证据"为研究焦点,试图建构系统理解"证据"的全面图景,探讨了心理治疗循证实践中关于"证据"的4个基本问题:(1)从历史考察与理论分析的视角出发,探讨了"心理治疗为什么需要证据";(2)从证据的类型范围、生产者及存在形式三个视角,描述了"心理治疗存在哪些证据";(3)从证据的科学程度、研究设计的严谨程度及解决实践问题的契合程度出发,阐述了"哪些证据才是好的证据";(4)从6个步骤推广证据及创新研究设计两个方面展开,分析了"在现实世界中如何推广与应用证据"。

Few topics in psychotherapy are as controversial as evidence-based practices （EBP）. Certain members of the general public and sometimes even professionals use the term ＂evidence-based＂ as a form of rhetoric. They reframe the definition of ＂evidence＂ in favor of their particular understanding of psychotherapy. This paper focuses on four fundamental questions about the evidence obtained in EBP in psychotherapy, trying to show the multiple framings of ＂evidence＂. 1. Why does psychotherapy have to be based on evidence？ This challenges have been present throughout the development of psychotherapyinitially in the Royal Commission＇s investigation of Franz Mesmer＇s animal magnetism in 1874; then Hans Eysenck＇s doubts about the efficacy of psychotherapy in 1952; and in the 1980 s, the requirement of accountability and managed care in health care and the competition between psychotherapy and psychotropic drugs. With the emergence of empirically supported treatment and EBP, the challenges for psychotherapy continue. Psychotherapy must be shown to be based on evidence, and is often compared to pharmacotherapy implicitly or explicitly. Evidence for efficacy is one of the most important contributions to support and boost the development of psychotherapy. Theoretically, the role of EBP in the social sciences is similar to that of ＂engineering practice＂ in the natural sciences. Contemporary risk, audit and information strategies add to the weight of the importance of evidence. 2. What types of evidence are there？ EBP＇s evidence can be classified into different types, including research-based evidence and practice-based evidence; scientific evidence and local evidence; impact evidence, implementation evidence, attitudinal evidence, economic evidence, and ethical evidence; research-based, manualized, guidelines, standards, principles, databases, and so on. All researchers, practitioners, managers, and even patients are qualified to produce different kinds of evidence. 3. Which type of evidence is the best？ EBP does presume that, for a given question, some available evidence may be of better quality than other evidence. Research evidence is one critical -- yet not the only -- contributor to EBP. Other situational information, stakeholder＇s concerns, and practitioner＇s experiences are also beneficial to EBP. There is no single criterion for evaluating all forms of evidence. Different types of evidence are meant to solve different questions. The best standard of assessing the quality of evidence is the degree to which the evidence can solve the real problems in real contexts. 4. How is evidence used？ EBP consists of mature implementation strategies such as ＂AAA TIE＂ （Asking, Accessing, Appraising, Translating, Integrating and Evaluating）. It provides an accessible way to apply the evidence to clinical situations. However, some factors, including representativeness of samples, sources of funding, and researchers＇ theoretical allegiance create limitations to the process of evidence dissemination. New research designs such as practice-oriented research, trans-diagnostic and trans-treatment research, as well as cultural benchmarking research are all important means to producing more evidence that would suit the needs of practitioners.