國立臺北護理健康大學生死與健康心理諮商系

國立臺北護理健康大學生死與健康心理諮商系

Department of Thanatology and Health Counseling National Taipei University of Nursing and Health Sciences

碩士論文

指導教授：李玉嬋 博士 Advisor: Yu-Chan Li, Ph.D.

焦點解決短期諮商取向多元減痛技巧對脊髓損傷者 改善中樞神經痛症候群的經驗探討

Study of Reducing Central Pain Syndrome for Patients with Spinal Cord Injury by Using Solution-focused Brief Therapy and Multiple Techniques

研究生:戴孝芸 Hsiao-yun Dai

中華民國 104 年 7 月

July, 2015

致謝

絕對不可能完成的。

感恩指導教授李玉嬋老師，您的「明天再想」讓我對每個明天都抱著希望，

也就熬了兩個學期的明天，都未曾絕望。也要感謝論文口委:吳淑芳研發處處長， 在百忙之中，千辛萬苦的認真指導。梁淑媛老師在炎炎夏日，犧牲假期，耐心指 導孝芸，深深感恩老師們的辛勞與用心。

要感恩曾煥棠老師、吳庶深老師、林綺雲老師、李佩怡老師、黃傳永老師。

感謝你們的包容，讓我學分都通過了。感恩李克翰心理師，讓我學習團體諮商專 業技巧，也感恩給我機會見習脊髓損傷團體。要感恩家人，尤其是父親和兩位姊 姊、外甥女和外甥。感恩同學，珮響、翠珍、曉聞、律惠、卉湄、茲涵、蔚琪、

家民、振賦、金麟、清文、碧珠、嘉吟、玉汝、珮娟、郁茹、書蓉、雪鳳、如萍、

克柔、承蘭，都是忘年之交。

尤其要感恩本研究中的兩位先導個案和 9 位參與研究的個案，你們用生命經 驗分享對傷友的重要訊息，也包容我的”不知道”真實的疼痛和明確的協助路 徑，過程好像就依靠你們的大氣度，就度過困境。期待你們善良的力量分享給更 多傷友，使更多傷友度過難關! 也期待醫學和工業技術上的進展，使你們的狀況 也能越來越好。

祝福大家，明天一定會更好!

摘要

本研究探討焦點解決短期諮商取向多元減痛技巧對 7 位脊髓損傷者建構適 宜之工作流程與重要步驟，並且由憂鬱、失志、自我效能與減痛之改善情形，以 及四種量表前測和後測結果，做為對照參考。

研究方法包含兩部分:質性部分是以行動研究法建構工作流程。結果發現:

焦點解決短期諮商取向多元減痛技巧對此 7 位脊髓損傷者建構出本研究之減痛 工作流程，並且找出十個重要步驟: 1.建立關係、2.確定目標與疼痛量尺評估、

3.發大願、4 處遇創傷事件的自責與寬恕(用 EFTA 敲穴道技巧將負面情緒下降，

目的為了創造身體正向「例外」經驗)、5.建立正向身體經驗、6.負向量尺減為 零(聯想出現其他創傷經驗之處遇)、7.正向認知輸入(用 EFTA 動眼技巧。目的為 了建立自我正向認知:「例外」)、8.量尺分數再評估、9.讚美(隨時有機會即作，

不限制依照此排序)、10.回家作業。其中重要步驟 1、9 與 10 無法得到個案口頭 肯定回應，但是研究者觀察認為個案會在心中思考，對雙方關係和後續改善仍有 正向影響，所以仍列為要做之重要步驟。本工作流程，重要步驟 4 至重要步驟 6 之間有來回進出、如迴圈重複的部分，可能隨時因為聯想到的事件而應用，插入 正常流程當中。

量性部分是以實地實驗法比較兩組前後測的減痛效果。研究結果:14 位脊髓 損傷者，依照能否有時間諮詢分為兩組。實驗組經介入後，以 SPSS 20.0 統計分 析，量性研究之結果如下:以 7 位參與介入之實驗組成員與 7 位控制組成員，以 卡方檢定，兩組在工作狀態、受傷部位，達顯著差異。其餘未顯著。實驗組僅一 位有工作，控制組七位全有工作。實驗組 7 位全是頸髓損傷，控制組傷勢較輕，

6 位胸髓、一位腰髓損傷。根據 Mann-Whitney U，發現:實驗組在年齡顯著大於 控制組。實驗組平均年齡 47.1 歲，控制組平均年齡 33.1 歲。實驗組此三項都顯 著居於劣勢。另根據 Wilcoxon matched-pairs signed-rank test 檢定，發現實 驗組前、後測之簡式麥吉爾疼痛量表現在痛量尺、失志量表分數有顯著下降，其 他在 PHQ、失志、麥吉爾痛感受、總痛量尺、自我效能沒有差異。根據無母數之 Mann–Whitney U 檢定，發現受試者在介入後的實驗組與控制組的改變量，在 PHQ、失志、麥吉爾痛感受、現在痛量尺、總痛量尺、自我效能皆無顯著差異。

簡式麥吉爾疼痛量表，兩組前後測差異比，「總痛」為(z=-1.8，p=0.075)。以 無母數雙尾檢定:研究假設時，如果設方向性，即實驗組之減痛會比控制組下降 更多，若其方向與假設相同時，p 值可以除以 2(z=-1.8，p=0.038)，因此簡式麥 吉爾疼痛量表「總痛」下降達顯著。

關鍵字:中樞神經痛、脊髓損傷者、焦點解決短期諮商取向多元減痛技巧、憂鬱、

失志、自我效能

Abstract

Background/Objectives: It is common for Patients with spinal cord injury to have Central Pain Syndrome. This study was aimed at establishing a working flow and finding out the working flow, important issues, steps, and techniques for patients with spinal cord injury by using Solution-Focused Brief Therapy and multiple

techniques to reduce pain, depression, demoralization, and to increase self-efficacy.

Methods: The research used the mixed method. In the aspect of qualitative research, Action Research was used. In the other aspect, Field Experiment was used as a

quantitative research method. Demoralization Scale-Mandarin version, Self-Efficacy Scale-Mandarin version, Patient Health Questionnaire-Mandarin version, and Short-form of McGill Pain Questionnaire-Mandarin version were also used.

Results: The important steps of the working flow were as follows. There were 10 steps: 1. Make a cooperative relationship 2. Make sure the goal and evaluate the scale of pain 3. Make a resolution 4. Deal with the blame related to the traumatic events on themselves or others and try to resolve the hurt and forgive themselves and others 5. Establish a positive physical experience 6. Make the scale of the negative emotions and negative beliefs go down to a zero 7. Put in positive beliefs about themselves 8. Evaluate the scale of pain again 9. Praise 10. Assign homework.

Although steps 1,9,10 got no response from clients and could not be proved to be effective, according to researcher’s observation, clients will ponder them in their mind and will still have good effect for them later in the future. Furthermore, the data of four standard questionnaires were analyzed with SPSS 20.0, the results were as follows: First, Compared 7 subjects in the experimental group with 7 subjects in the control group, with Chi-square test, working and the place of injury were

significant; with Mann-Whitney U, the age was significant. Secondly, With Wilcoxon matched-pairs signed-rank test, compared the differences of scores of 7 subjects in the experimental group only with themselves, pain of now of short form McGill Pain Questionnaire-Mandarin version and demoralization Scale-Mandarin version were lessened significantly. Thirdly, with Mann-Whitney U to compare the differences between two groups, nothing was significant. But in the previous hypothesis, the direction was set that the total pain of the subjects in the experimental group will lower than that of the subjects in the control group. Since the direction of the result was consistent with the hypothesis , the p value can be divided by 2 and become z=-1.8，p=0.038. Therefore, the total pain of short form McGill Pain

Questionnaire-Mandarin version, was lowered significantly.

Conclusions: Ten important steps were found in the working flow. The effect of using Solution-Focused Brief Therapy and multiple techniques to reduce pain was

significant statistically.

Key words: Central Pain Syndrome, patients with spinal cord injury, self-efficacy, depression, demoralization, Solution-Focused Brief Therapy and multiple

techniques to reduce pain