Những cân nhắc đạo đức nghề liên quan đến việc áp dụng thực hành dựa trên bằng chứng trong tâm lý trị liệu

NHUNG C A N N H A C DAO DLfC NGHE LIEN QUAN DEN VIEC AP DUNG THL/C H A N H D U A TREN BANG C H O N G TRONG TAM LY TRI LIEU Nguyln Thj Minh Hang Khoa Tdm ly hoc, Trudng Dai hoc Khoa hoc Xd hdi vd Nhdn vdn, Dai hpc Quoc gia HdNpi \ TOM TAT Thuc hdnh dua tren bdng chung (Evidence-based practice) Id viec dp dung cdc bdng chung cua khoa hoc thuc nghiem vdo dieu tri da vd dang trd thdnh mot xu hudng manh me cdc khoa hpc sue khoe vd khoa hpc tdm ly Ddy la xu hudng tdt yiu, cd tdc dung thuc ddy tinh quy chudn cua tdm ly tri lieu Tuy nhien, cd mpt thuc ti id viec dp dung tri lieu dua tren bdng chimg cung dang Id vdn de gay tranh cai vd cd nhiiu quan diim khde Mot nhung chu de tranh ludn Id cdc khia canh dao due lien quan din viec dp dung tri lieu dua tren bdng chimg Nhifng tranh luan ndy la cdn ihiel de suy ngam, canh bdo, phdng ngiea nhirng riii ro cd the cd ddi vdi cd khdch hdng vd nhd tdm ly tri lieu Bdi viet ndy tap trung phdn tich mdt sd vdn de dao due nghe lien quan den viec dp dung thuc hdnh dua tren bdng chimg tdm ly tri lieu, dong thdi de xuat mot sd gidi phdp de ddm bdo dao due thuc hdnh dua tren hdng chimg bdi canh vdn hda Viet Nam Tit khoa: Bao due nghe torn ly; Thuc hdnh dua tren bdng chiing; Tri lieu dua tren bdng chung; Lieu phdp dupe hd tra thuc chung; Hieu luc vdn hda Ngdy nhdn bdi; 28/10/2019; Ngdy duyet ddng bdi: 25/1/2020 Dat v5n de Thuc hanh dira tren bang chiing (Evidence-based practice - EBP) bat nguon tir y hpc nhung da nhanh chong ducfc cong dong cac nganh cham soc sue khoe chap nhan (Christiansen va Lou, 2001) va dang nhan dugc su quan tam Ion cua ITnh vuc dich vu nguoi noi chung va cac ITnh vuc chuyen nganh noi rieng (Thyer, 2004) Ngay nay, co thS kk rat nhieu ITnh virc co ap dung thuc hanh dua tren bing chung nhu cac khoa hoc sue khoe, tam ly tri lieu, giao due, quan ly, luat phap, chinh sach cong Trong boi canh do, nhung nha tam ly tri lieu chuyen nghiep cung khong xa la gi voi khai niem thuc TAP CHI TAM LV HOC S6' (251), - 2020 hanh dira tren bang chiing hay khai niem gan han vdi linh -vuc eua minh la tri lieu dua trin bdng chimg (Evidence-based therapy - EBT) Thuc hanh dua tren bang churng lam gia tang uy tin nghe nghiep va cai thien ro ret hieu qua tri lieu Tuy nhien, nhitng Igi ich thuc hanh dua tren bang chiing thudng dupe nhdn manh ma cac nguyen tSc dao diic co ban lien quan khdng dupe chu y ddy du (Christiansen va Lou, 2001) Do vay, viec xem xet va danh gia mot each khach quan, khoa hpc cac van de dao dire lien quan la rat can thiet va khdng lam giam di tim quan trpng eua thuc hanh dira tren bang chirng Tham chi, cac can nhac ve dao dure cd tac dung thuc day su tien bp ciia thuc hanh dua tren bang chiing Imh virc cham sdc sure khoe cho ngudi theo hudng cang khoa hpc hon, tiet kiem ngudn luc hem va phit hgp hon vdi nhilu bdi canh va vdi mdi ngudi benh Khai niem thuc hanh du-a tren bang chirng Ve mat Ijch sil, nhiing ngudi dua sang kien thuc hanh dua trdn bang churng d My xuat phat tir dpng ca mudn ngan chan viec lang phi tien bac cho nhiing can thiep v6 gia trj va cd the quan ly cac cdng ty cham sdc siic khde Cac lieu phap dugc hd trg thirc chimg cho phep cac cdng ty bao hiem han che chi tra cho nhirng lieu phap da dupe chiing minh bang thuc nghiem la cd hieu qua nhat va tdt nhat (Pope va Wedding, 2011) Vay, thuc hanh dua tren bang chimg dugc hiSu nhu the nao? Theo nhiing ngudi di tien phong trpng llnh vuc nay, thuc hanh dua tren bang chiing la "sir dung mpt cdch co luong tdm, ro rdng vd hop ly nhimg bdng chimg lot nhat hien tql viec dua quyet dinh chdm soc cho tirng binh nhdn" (Sackett va cpng sir, 2000, trang 71) Xu hud'ng thilc day viec ap dung cac kSt qua nghien ciru vao linh vuc thuc hanh lam xuat hien khai niem cdc lieu phdp duac ho tro thuc chimg (Empirically supported therapies ESTs) Cac lieu phap dugc hd trg thuc chiing la mgt pham trii cua thuc hanh dua tren bang chiing, nhan manh den dp hieu luc ben so vdi dp hieu luc ben ngoai va sir dung lap luan khoa hpc la quy nap (Whaley va Davis, 2007) Cu the hem, thue hanh dua tren bang chirng cd nghia la ap dung cac ket qua thu nhan dugc tit cac nghien ciiu dupe thiet ke va thue hien tdt vd hieu qua eua cac phuong thurc, phuong phap didu trj Chung cho tdt ca cac ITnh vuc cham sdc ngudi thi thuc hanh dua tren bang chung dugc hilu la sir tich hgp tiru ciia ba nguonr cac bang chung tir cac nghien cuu tdt nhat, chuyen mdn lam sang va gia trj cua ngudi benh (Sackett va cdng sir, 2000; Thyer, 2004) Rieng ITnh luc tam ly trj lieu, Hiep hpi Tam ly hgc My tuyen bd thiic ddy thuc hanh tam ly co hieu qua va nang cao sire khde cdng ddng bang each ap dung cac nguyen tdc dupe hd trg thuc nghiem de lua chpn, hudng din va quyet djnh ca bdn ITnh vuc; thuc hanh danh gia tam ly (practice psychological assessment), djnh hinh trudng hgp (case formulation), TAPCHI TAM lyHOC, Sd2 (251), - 2020 19 quan he tri lieu (therapeutic relationship) va can thiep (intervention) (APA2006) Tri lieu dua tren bdng chiing ciing dugc ndi din nhu mgt cdng cu dieu tri^vdi ba tru cot la: i) cac bang chimg nghien ciru khoa hgc tdt nhit din thdi diem hien tai; ii) cac gia tri va sd thich cua than chu; iii) cac kinh nghiem lam sang cua nha trj lieu (Sackett va cdng sir, 2000) "Khi ba yiu to ndy duac^ lich hap^ thi nhd tri lieu yd binh nhdn trd thdnh mpt liin minh chdn dodn vd diiu tri nhdm toi uu hoa kit qua lam sdng vd chdt lirang cuoc sdng" (Scakett va cdng su, 2000, trang I) Ba tranh luan vl dao dire lien quan din thuc hanh dira tren bang chu-ng Nhirng ngudi ung hd tri lieu dua tren bdng chirng cho ring, bat ky lieu phap trj lieu nao cung can dupe nghien cim cdn than bdng cac nghien ciru thuc nghiem dupe thilt kl tdt Nha tam ly tri lieu cin sit dung cac lieu phap da dugc chiing minh la cd hieu qua tdt va uu tien la tdt nhdt ddi vdi tirng rdi loan cu the Muc tiSu cua viec sir dung cac lieu phap dupe hd trp thuc chung la loai bd cac lieu phap khdng cd can cir khoa hpc xac dang hoac loi thdi dl su dung cae phuong phap cd hieu qua hon thdng qua viec quyet dinh dura tren cac bang churng khoa hpc vung chdc thay vi each lam truyin thdng, phi he thdng va dua vao true giac Day la xu hudng tat yeu, cd tac dung thue day tinh quy chuan ciia tam ly tri lieu va tao mdt nen tang virng chac hon cho ITnh vuc cham sdc sire khde tam thdn (Norcross, Beutler va Levant, 2006) Tuy nhien, co mpt thuc te la viec ap dung cac lieu phap dupe hd trp thuc chirng ciing dang la vdn dl gay tranh cai va cd nhieu quan diim khac gidi chuyen mdn Mpt cac chu de tranh luan la cac vdn dl dao due lien quan din viec ap dung (hay khdng ap dung) va ap dung tihu thi nao nguyen tdc trj lieu dua tren thuc chung, Nhirng tranh luan la cdn thilt dl suy ngdm, canh bao, phdng ngira nhirng riii ro cd the cd ddi vdi khach hang va vdi ca nha tam ly tri lieu 3.1 Van di tranh luan thu nhSt Jien quan din phuong dien nghien ciiu Hang loat cau hdi thudng dupe dat a day la; Lieu cac nghien cuu vl ESTs cd the danh gia dung sir khac biet vl hieu qua tri lieu cua cac lieu phap khac hay khdng? Cac ngi dung va tieu chi danh gia nao cdn phai dugc xem xet cac nghien ciru thuc nghiem ludng tinh hieu qua cua cac lieu phap tam ly? Cac biln ddc lap dugc thilt kl du tot dl phat hien dugc su anli hudng cua chiing d mire dp nao va nhu thi nao din cac biln phu thugc (hieu qua dieu tri)? Cac dir lieu thu dugc tit nhirng nghien ciru cd dam bao tin cSy hay khdng? Cae nghien ciru lap lai (cac lin khac d cung mpt cap nha tri lieu va than chii va d cac cap nha trj lieu va than chu khac nhau) cd cho kit qua tuong tur hay khdng? 20 TAPCHI'TAMiy HOC, S6'2 (251), - 2020 Khong cd cau tra Idi nao do'n nghTa ma thda dang cho tdt ca cac cSu hdi tren Tdt nhien khdng cd gi dam bao 100% tdt ca cac nghidn ciiu dIu dugc thilt kl va thuc hien du tot nhu de cd the danh gia dugc sir khac biet vl hieu qua eiia cac lieu phap Vi vay, nhirng tieu chuan bat huge ma mot lieu phap dugc hd trg thuc nghiem can phai dat dugc la: Thii nhdt, (a) cac nhdm thuc nghiem cd hi$u qua vugt trgi ve mat thong ke so vdi sii dung thudc, gia dugc hoac cac dilu trj tam ly khac hoac (b) hieu qua tuong duong vdi dieu trj da dugc thilt ISp cac thi nghiem vdi cd mau phii hgp Thii hai, mdt loat cac thuc nghiem Idn ddi vdi cac ea lam sang don le phai cd ket qua nhu tieu chudn (a) Ngoai ra, (c) cac thue nghiem phai dugc thuc hien vdi hudng din dilu tri; (d) cac dac diem miu phai dugc xac djnh ro rang; (e) hieu qua cua lieu phap phai dugc danh gia bdi hai ngudi tham djnh dpc lap hoac cac nhdm tham djnh khac (Chambless va cpng su, 1998) Khi nghien ciru ve van de Barlow (2004) da thita nhan su phirc tap ciia cac bien so cac nghien ciru thirc nghiem, chang han, cac nha nghien curu thudng dua mgt bien sd phd bien la kinh nghiem lam sang cua nha trj lieu dl danh gia Theo ong, dieu dd cd nghTa la bien sd dugc nghien citu bdi canh da dugc sap dat Them vao do, mSi nghien citu dugc thue hien tren mpt nhdm miu co mgt roi loan hay hpi chung cu thi, vdi cac dac diim ca nhan va van hda - xa hdi rieng biet ma se khdng giong vdi bat ky than chu nao khac Vay ma, sau dd ket qud cua nghien cim thuc nghiem phan phdi ngau nhien (Radom assignment study - RAS) lai dugc khai quat len va tham chi cd the trd mgt miu thiet lap lam sang (clinical settings) Chinh vi vay, Sternberg (2006) canh bao can than trgng viec giai thich cac ket qua ciia RAS Sternberg (2006) cdng dong thdi dat hang loat cac cau hoi de cac nha nghien citu va nha thuc hanh tam ly tri lieu suy ngam: "Viec diiu tri se tien hdnh nhu thi ndo dp dung vdo nin vdn hoa khac? No se co hliu qud vdi nhung nguai CO chdn dodn kem theo? Lieu diiu tri co tdc dung vol moi ngudi neu cd su kit hap ddc Met vol thudc? Lieu phdp se van hdnh nhu thi ndo vat nhiing nguai CO miic khdng cu tri lieu tdm ly cao? Cuol ciing, chiing ta nen quan tdm den tinh tong qudt kit qud ciia nhirng nghien ciru bdt ky hay nhiing trudng hap cd bietT (trang 269) Nhiing cau hdi neu tren khd cd thi tim thiy cau tra Idi xac dang, chua noi den cau tra Idi dudi dang quy trinh ky thuat rd rang Mgt s6 tac gia khac ndi din mpt thach thirc khac lien quan den tinh ddc dao va linh hoat ciia tam ly tri lieu Tren thuc tl, tam ly trj lieu khdng chi la mgt khoa hgc ma cdn la qua d-inh tuong tac giOa hai ca nhan vdi cudc hai sdng khac nhau, vdi nIn van hda va ban sdc khac nhau, thi gidi nhan thitc va cam xiic khac Do vay, tucmg tac vdi mdi ngudi deu dua vao dd nhiing thii thudc vl minh va ct mpt mite nao dd, hp anh hudng va djnh hinh TAP CHI TAIVI ly HOC, Sd (251), - 2020 lin Goodheart (2006) da rit chinh xac cho rSng "Tdm ly tri lieu tri""i tien phdi Id vl ngudi Np v6 cimg la dang Tdm ly tri Itiu khong chi la "O lire khoa hpc, cUng khong thi tinh gian y nghia thdnh mot ITnh vuc ca hpc ky thudl Tdm ly tri liiu Id qud trinh tuang tdc vd co su llnh hoat ciia no "0 (nhd tri lieu vd nguai benh) sdng tap viec tim dudng ddn din su tlit" hliu vd kit noi su can thiip phu hap vat nhu cdu cua hp" (trang 42) Nhung dieu ham y khdng thi ap dung mpt each cung nhdc mdt lieu phap nao vdi khung lam vice va cac ky thuat don thudn, cd dinh vdi mpi than chu bat mdi than chu la ban the nhat va mdi nha tam ly trj lieu ciing vay Them vao dd, nhu d phdn ddu da dl cap, mac du tri lieu dua tren bang chirng dugc coi la mgt cdng cu cd ba tru cot (Sackett va cdng sir, 2000), vay, hdu hit tdt ca cac nghien ciru va thuc hanh ngudi ta thudng noi nhilu den bdng chung khoa hpc ma bd qua hpac ndi rat it den hai tru cdt lai la benh nhan va nha tri lieu Trong dd, tam ly tri lieu thi hai tru cgt sau cdng khdng kem phan quan trgng so vdi cac bang chung nghien ciru Vay ma, rdt it cac lieu phap dupe hd trp thuc chirng co hudng din nhung chi tiet thurc hanh cu thi lien quan din gia trj va sd thich cu the cua mdi than chd Trong khudn kho cua tru cot thu hai, cd mpt thach thuc khac ve dao dire lien quan din quyin dupe lira chpn lieu phap tri lieu cua than chii Cac tiha cung cdp djch vu sue khde tam thin cdng cd nghia vu dao dire de dam bao rang benh nhan hoac khach hang cua hp bilt nhirng Igi thi va bdt Igi cua cac lira chgn dilu tri khac danh cho hp, dl hp cd thi dua lira chgn sang suit (Chambless va Hollon, 1998; Chambless va cdng su, 1998) Tuy nhieii, d day ed mdt sir that rac rdi la thuc hanh dua tren bang chirng vdn dugc thiet ke de giup nha trj lieu dua quyet dinh dua tren bang churng khoa hgc Nhu vay, tu dau, Igi the thudc ve nha trj lieu Dieu dupe mpt sd nha phe binh md ta la chit nghia gia trudng dua trin bdng chimg (Evidence-based paternalism) (Rysavy, 2013; Slowther va cpng sir, 2004; Liberati va Vineis, 2004) Vay, trudng hgp khach hang lira chpn lieu phap ma minh cho la phii hpp hon vdi gia trj va sd thich cua ban than ma dd khdng phai la lieu phap ma nha trj lieu chgn dura tren bang chirng thi giai quyet van de nhu thi nao? Mpt sd nha phe binh khac ciing luu y rang, quan diem ve hieu qua cua mdt than chu cu the nao dd cd the khdng gidng vdi quan diem ve hieu qua cua nhirng ngudi da dugc cac bang chirng nghien ciru (Allmark, 2015) Cu the, cac nghien ciru thudng xac djnh tieu chi danh gia hieu qua cua dieu trj la tuong quan giQa ket qua dieu tri va chi phi bd ra, nhu vay, nhirng tieu chi danh gia khac cua benh nhan bj bd qua Ddi vdi tru cot thir ba, khdng chi kinh nghiem lam sang la quan trgng nhu Sackett va cdng sir (2000) da dl cap ma cac.biln sd khac nhu cae dac diim 22 TAP CHi TAM l y HOC, Sa' (251), - 2020 nhan each, cac van dl tam ly vk cac co che phdng ve cua ban than nha trj lieu cung vd cimg quan trpng bdi chiing anh hudng theo each hay each khac din than chu va cac yeu td khac tam ly tri lieu Tuy vay, cac nghien ciru vl vai trd ciia nha trj lieu chi mdi de cap den kinh nghiem lam sang ma it chu y den cac dac diem nhan each, cac van de tam ly va co che phdng ve cua nha trj lieu Chdng han, nha trj lieu gap rac rdi vi van de ciia than chu lam xudt hien d nha trj lieu nhirng cam xuc tieu cue lien quan den chinh cac vdn dl cupc sdng rieng cua than chu Trong tinh hudng nay, cac hudng din chung cua thuc hanh dua tren bang chiing hOu ich nhu the nao vdi vdn dl cu the cua nha trj lieu? Tam ly trj lieu la qua trinh tuo-ng tac giOa hai ca nhan, vay, cac dac diem nhan each, cac co che phong ve cua hai ben chac chdn anh hudng den viec thiet lap mdi quan he tri lieu giira nha trj lieu va than chu Van de cudi cung chit dS thii nhat la cac nghien ciru khdng ngiing phat trien, cung cd nghTa la cac bang chirng khoa hpc lien tuc dupe cap nhat va cd the thay ddi Dieu budc cac nha thuc hanh tam ly trj lieu phai lien tuc cap nhat va theo kjp cac ket qua nghien cim, ddng thdi cd mgt thai dp cdi md va san sang thay doi de hien thue hda cac ket qua nghien ciru mdi vao cong vice dieu trj hang cua minh 3.2 Van de tranh luan thii- hai lien quan den yeu td van hda cac nghien ciru ve thurc hanh dua tren bang chii-ng, cung cd nghTa la lien quan tdi cac lieu phap dupe hd trg thuc chung Thuc hanh dua tren bang chirng den tir cac nghien ciiu dugc thurc hien chu yeu d Hoa Ky va mgt vai nude chau Au cd phii hgp vdi tam ly trj lieu trpng bdi canh cua cac nen van hda khac? Lieu cac lieu phap dugc ho trp thuc chirng cd tinh het anh hudng cac yeu td van hda ca nhan tir nha tri lieu va than chil hay khdng? Cac lieu phap dugc hd trp thuc chirng cd phii hgp vdi than chii thugc cac van hda thilu sd hay khdng ma chung dugc hd trg bdi cac bang chiing tir cac nghien ciru tren cac nhdm mau da so? Ddi vdi cac nhdm tieu van hda khac thi viec ap dung cac lieu phap dupe hd trg thuc chirng nhu the nao? Cac nha thurc hanh chu y dieu gi hay can lam gi dl khac phuc nhirng han che neu tren ap dung cac lieu phap dugc hd trg thuc chirng vdi cac nhdm van hda khac? Dd la mdt sd cau hdi ma ngudi thuc hanh tam ly trj lieu can dat va can nhac sit dung bat ky lieu phap trj lieu nao Ve ban chat, nhirng cau hdi tren lien quan den hliu luc vdn hda (Cultural competence) cua cac lieu phap dupe hd trp thuc chirng va ciia nha tam ly trj liSu su dung cac lieu phap dd Van hda dupe xem la mgt qua trinh nang dpng, lien ket qua khir va hien tai va dugc djnh hinh mpt phan bdi boi canh xa hpi, lich sii va chinh trj bat cit nen van hda nao cung cd nhiing ylu td dpc lap (interconnection) mang tinh dong nhdt npi tai (internally homogeneous) va nhiing yeu td ngoai lai, giao TAP CHf TAM ly HOC, Sd (251), - 2020 23 thoa vdi cac nIn van hda khac hay cdn ggi la ylu t l phu thugc lin gW^ cac van hda khac (interdependence) (Whaley va Davis, 2007) Vay, h>?" lire van hda la gi? Hieu lire van hda dugc hilu hien nhu thi nao tam V^"lieu? Hliu luc vdn hoa la mite phti hgp cua mpt ly thuylt, mot quan diem hay mgt he thing nao dd doi vdi cac nIn van hda khac Trong tSm ly ^1 lidu, hi|u luc van hda cd thi dugc xem xet tir hai phuong dien; tir cac lieu phap dugc hd trg thuc chiing va tir ban than nha hi li$u Tir phuong didn lieu phap, hieu lire van hda dugc hilu la mire dp phu hpp cua cae lieu phap dugc ho trg thuc chimg ap dung cho than chu thugc mdt nIn van hda khac so vdi van hda gdc ma lieu phap dd dugc thilt lap va thu nghiem Tir phuong dien nha tam ly tri lieu, hieu lire van hda dupe xem xet d hai khia canh: thii nhat, nha tn heu cua mpt nen van hda khac (so vdi van hda gdc ma lieu phap dugc thiet I?p va thu nghiem) hoan toan ed thi sii dung (tdt nhien, nlu dugc dao tao) lieu phap nao dl danh gia va can thiep cho than chu; thir hai, nha ttj lieu phai "cd kien thirc vd ky ndng ciia mot nin vdn hoa cu thi di dua nhiing can thiep hliu qud cho nhung thdnh viin ihuoc nin vdn hda do" (Sue, 1998, trang 441) Vay, cac lieu phap dugc hd trg thue churng hien co dap irng tieu chuan vl hieu luc van hda nhu thi nao? Theo Kirmayer (2012), tdn tai it nhat bin han chi Idn lien quan din hieu luc van hda cac nghien ciiu ve thuc hanh dua tren bdng chung Thu nhdt, cac nghien ciru cho thdy cd it bdng churng lien quan din cac nhdm van hda thilu si, dilu din din cac kit qua thu dugc dua tren dii lieu tir cac nhdm mlu thupc da sd khdng chac chan phii hgp vdi cac nhdm van hda cu thi Thii hai, bdng chirng nghien citu ve kit qua can thiep cd xu hud'ng tap trung vao cac trieu chirng va hanh vi ca nhan ma khong xet den su anh hudng cua cac yeu td van hda len cac trieu chirng va hanh vi dd Thir ba, cac cdng ddng van hda khac cd the cd each hieu khac ve cac phuong phap va cdng cu ludng cac nghien ciiu ve thuc hanh dura tren bang chirng Thir tu, khung chan doan va khai niem dugc sti dung de dat cau hdi, dua cac bien phap can thiep va xac djnh kit qua thuc hanh dua tren bang chimg dugc xac djnh theo van hoa va dd cd kha nang sai lech hoac khdng phu hgp vdi nhdm van hda khac Mac du ve mat ly thuyet, cac nghien ciru ve thuc hanh dua tren bdng churng va cac nghien curu ve hieu lire van hda can bd sung cho nhau, nhien, hai ITnh vuc it gap tren thuc tl (Whaley va Davis, 2007) Tir day xudt hien khai niem cac lieu phap thich ling van hda Thich ling vdn hda la nhirng no lire lam cho cac lieu phap dugc hd trp thuc chiing phii hpp hon vdi cac dac diim van hda cua mpt nhdm cpng ddng, dan tpc thilu so, nhdm tin nguong/tdn giao cu thi nao dd Ndi each khac, "thich ung vdn hoa Id mot phuang phdp Idm cho cdc dich vu siic khoe tdm thdn tro nen co hiiu luc vi vdn hoa han" (Lopez va cong sir, 2002; Miinoz va Mendelson, 2005) Cu thi hon, "Thich img vdn hda Id bdt ky su diiu chinh ndo 24 TAP CHf TAM l y HOC, So' (251), - 2020 vi diiu tri dua trin bdng chiing bao gom su thay doi cdch tiip can dich vu, bdn chdt ciia moi quan hi tri lieu hoac cdc thdnh phdn cua bdn thdn viec diiu tri de phii hap vol niem tin vdn hoa, thdi dp va hdnh vi ciia nhdm muc tliu" (Whaley va Davis, 2007) Theo do, thich ling van hda ed thi dugc hilu rdt rdng, bao gdm, djch cac hudng dan dieu trj, thilt lap mdi quan he trj lieu theo each cua van hda cu the dang dugc thich ung, sil dung cac vi du phii hgp vdi niem tin van hoa cua khach hang, sir dung cac cau ngii, tuc ngii ban dja de giai nghla/minh hpa, (Miinoz va Mendelsoii, 2005) Mpt nd luc dang ke nham kiem chirng hieu luc van hda cua cac lieu phap dupe hd trg thiic chimg thugc ve Miranda va cong su (2005) Kit qua kilm djnh kha tich cue, tat ca cac lieu phap dugc hd trg thuc chiing nguyen ban va cac phien ban thich irng van hda deu cd hieu qua vdi cac nhdm dan tpc thieu sd Tuy vay, cac tac gia ciing khuyen cao rang cac phien ban thich img van hda chua dugc tham dinh bang cae nghien ciru thir nghiem lam sang ngau nhien (Randomized clinical trial) Ngay ca ddi vdi mdt sd lieu phap dugc thich irng van hda don le thi cac nghien ciru cQng chi dua bien si dan tgc/chung tpc nhu la mgt bien so nhan khau xa hpi (Iwamasa, 1996), vi vay, dp hieu lire van hda cd the chi dap ung tieu chuan be mat, cac sac thai van hda mang tinh npi dung vin chua dugc phat hien (Whaley va Davis, 2007) Mpt dieu dang quan tam khac la "tdc dpng ciia vdn hoa cd thi xdy qud trinh tri lieu han Id kit qud" (Kohn va cpng su, 2002; Whaley va Davis, 2007) Mdt sd tac gia da bao cao rang, benh nhan dan tdc thieu si d My bd dieu trj thudng xuyen han so vdi cac benh nhan khac (Organista, Miinoz, R.F va Gonzalez, 1994) Ciing cd nhirng khuyen nghj rang, neu de ngudi than tham gia vao qua trinh dieu trj nhu hudng dan tieu chuan cua Trj lieu nhan thurc hanh vi se khdng phii hpp vdi mgt so cdng ddng van hda Thay vao do, de ngudi benh tu chi dinh mpt ngudi ma hg cam thay gan giii va thoai mai tham gia ho trg dilu trj se phu hgp hon (Hatch, Friedman va Paradis, 1996) Lieu viec bd trj lieu cd lien quan den viec thiet lap mli quan he tri lieu va viec thiet lap mdi quan he trj lieu co khac biet nhu the nao giira cac van hda khac nhau? 3.3 Vin tranh luan thii ba lien quan din tinh cdng bang ddi vdi tat ca benh nhan trj lieu Cau hdi dat d day la: Tri lieu dua tren bdng chirng cd phu hgp vdi nhirng ngudi mac nhieu rdi loan ciing mpt luc, cd phii hgp vdi ngudi gia va tre em ma hau het cac nghieii cim chu yeu tap trung danh gia mgt lieu phap nao dd cd hieu qua vdi mpt rdi loan cu the va nhdm mau thudng cd ciing nhiing dac diim nhat dinh ve tudi (thudng la ngudi Idn trudng thanh)? Ben canh dd, tinh cdng bang cung dugc xem xet bdi carih cua van hda va ton giao, tam linh Ndi each khac, cac nghien cuu cd xet den cac dac diim xa hgi ridng biet ciia mpt sd nhdm ngudi cd cac tdn giao va niem TAP CHf TAM l y HOC, Sd' (251), - 2020 25 tin tam linh khac hay khdng? Hon nti-a, viec ap dung dO lieu dugc ngliie" CUT! tren nhditi cho ca nhan la rdt khd khan va xet d mgt mire dp nao '^ khdng cdng bdng, bdi cac dieu kien khdng bao gid gilng het d hai benh nhan bdt ky nao dd (Christiansen va Lou, 2001) De xem xet thdu dao va da ehilu ban cac van dl tranh luan hay cac cau hdi tren day, rdt dang tham khao y kiln cua Allmark (2015) dng sii dung lap luan cdn phan djnh rd rang giiia thuc tl va kiln thitc khoa hpc cua Aristotle de nhan djnh ring " Bdng chiing dual dang klin thirc khoa hpc, cho dii duac dinh nghia rpng rdi nhu thi ndo ciing khdng thi tao hinh mdu co sa cho thitc tiin vi np khong thi cung cdp cdc muc tliu md hdnh dpng thuc tiin yiu cau, thuc hdnh dua trin bdng chirng phdl duac cung cdp tit bin trang qua tnnh thirc hdnh" (trang 180) Mac du phat bilu cua Allmark (2015) dugc neu bdi canh cua y hpc nhung rat dang dl cac nha tam ly hgc suy ngam Mpt s8 de xuat cho tam ly tri lieu d Viet Nam Nhu tren da trinh bay, cac nghien cuu tren thi gidi chi cac bang chirng cho thdy, viec ap dung tri lieu dua tren bdng chung la mgt xu hudng tat ylu va khoa hgc, dam bao cho hieu qua cua tri lieu Tuy nhien, cac nha phe binh cho rdng, trj lieu dua tren bdng chirng dua tren dinh nghTa qua hep ve bang chimg va hilu bilt (Whaley va Davis, 2007; Allmark, 2015) Dilu dat cac vdn dl dao dure thuc hanh cac lieu phap dugc hd trg thuc chirng cac bli canh van hda - xa hdi va tinh hudng cu thi khac Cac khia canh dao due cdn can nhdc lien quan din ba van de Idn, bao gom hieu luc cua cac nghien ciiu ve cac lieu phap dugc hd trp thuc chirng, dp hieu lure van hda ciing nhu thich ung van hda cua cac lieu phap dugc hd trg thuc chimg va tinh cdng bang trj lieu Ci Viet Nam, bdi canh hien nay, ma chit de nghien ciru cdn gan nhu bj bd trdng, chiing tdi de nghj hai giai phap ca ban de dam bao cho trj lieu lieu dua tren bang chirng phu hgp hon vdi ngudi Viet Nam Thir nhdt, nha tam ly thyc hanh can: I) Tang cudng cap nhat thong tin, kien thiic ve cac lieu phap dugc hd trg thuc chimg Dieu phai dugc thyc hien mgt each sau sac ban bang viec tim hieu cac nghien cuu nguyen ban va cac nghien ciiu hieu lyc van hda ciing nhu thich drug van hda (neu ed) cua cae lieu phap dd, dac biet can chu y den ban chat cua bang chung lam sang; 2) Cdn danh gia can than cac bang chung hien cd trudc ap dung cho mgt benh nhan cu the, song song vdi dd can can nhac cac kinh nghiem lam sang va tinh din nguyen vpng cua benh nhan; 3) Khdng su dung cac nghien citu phi dao dire; 4) Cin ludng trudc cac vdn dl van hda tilm tang trj lieu de can nhdc viec sir dung lieu phap nhu thi nao la phu hgp va tdi uu nhat ddi vdi tirng benh nhan cu thi; 5) Khi nhan dien dugc nhirng ddu hieu va yeu td khdng phii hop 26 TAP CHf TAM ly HOC, So' (251), - 2020 van hda cua cac lieu phap ma minh dang thyc hien, nha tam ly thyc hanh cdn tham vdn vai ddng nghidp la cac tihalam sang va cac nha nghien ciiu cd kinh nghiem vl hudng giai quyet van de de ban che tac ddng cua su khdng phii hgp dd ddi vdi ngudi benh Thii hai, ddi vdi cac nha nghien ciru, can day manh cac nghien ciru thich ling van hda ddi vdi cac lieu phap dugc hd trg thyc chirng vao bdi canh van hda Viet Nam Ket qua cua cae nghien ciru tap dieu kien dl phat triln thuc hdnh dua trin bdng chiing cd hiiu luc vdn hoa (culturally competent evidence based practices) - dd mdi la mgt nen thyc hanh khoa hpc vdi day dii phuang dien va y nghTa Cac nghien ciru thich irng van hda can quan tam ddy dii din cdc dac diem tam ly - xa hpi khac cua cac nhdm mau, dac biet la lira tuli, dan tpc, tin nguSng/niem tin tSm linh va viing mien vdn la nhirng dac diim tao nen su khac biet van hda ciia ngudi Viet Nam ma cd anh hudng kha Idn din tam ly trj lieu Ket lu^n Cae vdn de dao dure lien quan den thyc hanh dua tren bang chiing bai vilt ddng vai trd quan trgng viec quyet djnh tam ly trj lieu NIU thieu cac can nhac dung mire ve cac van de co the se anh hudng khdng nho din hieu qua dieu trj, tao nhirng tin that vl chi phi, ve thdi gian va cd the ca tinh than cho ngudi benh Tuy nhien, thyc hanh thieu bang chirng ciing gay ton that khdng kem cho uy tin ngh6 nghiep va cho benh nhan, tham chi tdn that cdn nang ne hem nhieu Do vay, kim chi nam ciia nha tam ly trj lieu mpi trudng hpp vin la ba try cot ca ban: bang chung tdt nhat hien cd, kinh nghiem lam sang va gia trj/lya chpn cua ngudi benh Them vao do, su can trpng, lucmg tam nghe nghiep va tinh than ludn san sang tham van vdi ddng nghiep cd kinh nghiem la nhirng dieu kien khong thi thieu ddi vdi nha tam ly trj liSu Tai lieu tham khao Allmark P (2015) Ethics and evidence-based practice In: LIPSCOMB, Martin, (ed.) Exploring evidence-based practice: Debates and challenges in nursing Routledgc key themes in health and society London Routledge 180 - 194 Available for prepurchase here, http://www.roudegdge.coni/books/details/9781138789906 American Psychological Association Presidential Task Force on Evidence-Based Practice (2006) Evidence-based inpsychology American Psychologist (4) P 271 - 285 Barlow D.H (2004) Psychological treatments, /taierican Psychologist Vol 59 Iss P 869-878 TAP CHf TAM l y HOC, S6' (251), - 2020 27 Chambless D.L & Hollon S.D (1998) Defining empirically supported therapiesJournal of Consulting and Clinical Psychology Vol 66 P - IS, Chambless D.L., Baker M.J., Baucom D.H., Beuder L.E., Calhoun K.S., CritsChristophP., etal (1998) Update on empirically validaied therapies, II Clinical Psychologis Vol 51 P 3-16 Christiansen C, Lou J.Q (2001) Ethical considerations related to evidence base practice American Journal of Occupational Therapy 55 (3) 345 - 349 DOI: 10.5014/ ajot.55.3.345 Goodheart CD (2006) Evidence endeavor, and expertise in psychological practice In CD Goodheart, A.E Kazdin & R.J Stemberg (Eds.) Evidence-based psychotherapy: Where practice and research meet P 37-61 Washington DC American Psychological Association Hatch M.L., Friedman S & Paradis CM (1996) Behavioral treatment of obsessive disorder in African Americans Cognitive and Behavioral Practice Vol P 303 - 315 Iwamasa G.Y (1996) On being an ethnic minority cognitive behavioral therapist Cognitive and Behavioral Pracdce Vol P 235 - 254 10 Kirmayer L.J (2012) Cultural competence and evidence-based practice in mental health: Epislemic communities and the politics of pluralism Social Science & Medicine Vol 75 P 249 - 256 11 Kohn L.P., Oden T., Miinoz R.F., Robinson A & Leavitt D (2002) Adapted cognitive behavioral group therapy for depressed low-income African American women Community Mental Health Journal Vol 38 P 497 - 504 12 Liberati A., Vineis P (2004) Introduction to the symposium: What evidence based medicine is and what it is not Journal of Medical Ethics 30 (2) P 120 - 121 13 Lopez S.R., Kopelowicz A, & Canive J.M (2002) Strategies in developing culturally congruent family interventions for schizophrenia- The case of Hispanlcs In H.P Leiley 8c D.L Johnson (Eds.) Family interventions in mental illness: International perspectives P 61 - 90 Westport CT Praeger 14 Miranda J., Bernal 0., Lau A., Kohn L., Hwang W.C & LaFromboise T (2005) State of the science on psychosocial interventions for ethnic minorities Annual Review ofClinical Psychology Vol LP 113- 142 15 Mun'oz R.F & Mendelson T (2005) Toward evidence-based interventions far diverse populations: The San Francisco General Hospital prevention and treatment manuals Journal of Consulting and Clinical Psychology Vol 73 P 790 - 799 16 Norcross J.C, Beutler L.E & Levant R.F (2006) Evidence-based practice in mental health: Debate and dialogue on the fundamental questions Washington DC American Psychological Association 28 TAP CHf TAM ly HOC, Sd (251), - 2020 17 Organista K.C., Miinoz R.F & Gonzalez G (1994) Cognitive - behavioral therapy for depression in low-income and minority medical outpatients: Description of a progra and exploratory analyses Coffiiiive Therapy and Ressmch Vol 18 P 241 -259 18 Pope K., Wedding D (2011) Contemporary challenges and controversies In Corsini R.J & Wedding D (Editors) Current Psychotherapies 9"' Ed Belmont CA Book/Cole Cengage Leaming 19 Sackett D.L., SUauss S.E., Richardson W.S., Rosenberg W & Haynes R.B (2000) Evidence-based medicine London Churchill Livingston 20 Slowther A.M., Ford S & Schofield T (2004) Ethics of evidence based medicine in the primary care setting Journal of Medical Ethics 30 (2) P 151 - 155 21 Stemberg R.J (2006) Evidence-based practice: Gold standard, gold plated, or fool's gold? In CD Goodheart, A.E Kazdin & R.J Stemberg (eds.) Evidence-based psychotherapy: Where practice and research meet P 261 - 271 Washington DC American Psychological Association 22 Sue S (1998) In search of cultural competence In psychotherapy and counseling American Psychologist Vol 53 P 440 - 448 23 Thyer B.A (2004) What is the Evidence-based practice? Brief Treatment and Crisis Intervention (2) P 167 - 176 DOI: 10.1093/brief-treatment/mhh013 24 Rysavy M (2013) Evidence-based medicine: A science of uncertainty and an art of probability Virtual Mentor 15 (1) P - 25 Whaley A.L & Davis KE (2007) Cultural competence and evidence-based practice in mental health services: A complementary perspective American Psychologist 62 (6) P 563 - 574 DOI: 10.I037/0003-066X.62.6.563 TAP CHf TAM ly HOC, Sd (251), - 2020 29 ... lieu cd lien quan den viec thiet lap mli quan he tri lieu va viec thiet lap mdi quan he trj lieu co khac biet nhu the nao giira cac van hda khac nhau? 3.3 Vin tranh luan thii ba lien quan din tinh... chi tiet thurc hanh cu thi lien quan din gia trj va sd thich cu the cua mdi than chd Trong khudn kho cua tru cot thu hai, cd mpt thach thuc khac ve dao dire lien quan din quyin dupe lira chpn lieu... tSc dao diic co ban lien quan khdng dupe chu y ddy du (Christiansen va Lou, 2001) Do vay, viec xem xet va danh gia mot each khach quan, khoa hpc cac van de dao dire lien quan la rat can thiet va