旁門左道？「道」亦有道─ 跳脫醫療觀點的另類精神障礙社區復健模式

Abstract

台灣自1990年代爆發龍發堂違法收容精神障礙者事件後，逐漸走向以西方現代精神醫療專業權威模式為主流的時代；但不同於醫療觀點的另類模式，卻也持續的以另一股力量多元化的發展著。不同的組織社群以自身不同的社會處境脈絡，嘗試著各種另類的可能性，追尋著對待精神障礙者處遇上不同的價值理念。本研究試圖更細緻的探究台灣這幾十年來，一些跳脫病理觀點的另類模式究竟走出了什麼樣的豐富性。研究者透過Burawoy所提出利用參與觀察的方法選取特殊情境的個案，進行巨觀分析的延伸個案法，選取三個跳脫病理觀的異例場域，分別為不具專業背景，自行發展本土化模式的家屬自助團體；以美國活泉之家所發展出的會所模式做為參照的社福機構；以及資深社工自行開業的社區復健中心。研究者在研究過程中利用實習生的身分，實際進入三個研究田野，深入了解各機構最真實第一現場的工作模式與實踐路徑。分析上針對三間機構各自主要推動者的背景脈絡；在此背景脈絡下對於精神障礙者的理解視角、所創造出新的社區復健論述與工作模式的設計與具體操作；以及在發展出另類的工作模式之下，究竟創造了精神障礙者病人之外什麼樣的新主體，而這樣的新主體又是鑲嵌在什麼樣新的助人互動關係之中，藉此分析比較不同場域的實踐路徑。研究發現，由家屬自組的自助團體，依據創會會長自身的經驗發展了十分具有本土文化特色的工作模式，嘗試在都會生活中複製台灣五、六0年代閩南農村宗族聚落的社群文化。精神障礙者在家屬為主體的努力與庇護下，成功以這種十分具有華人特色的類宗親親友的互動關係，以一種「攀親帶故的自己人」之姿，成功在主流社會中卡位。相較於完全來自本土經驗所發展出來的工作模式，一群新生代的助人工作者，各自帶著自己對於精神醫療的懷疑與批判，嘗試操作一個源自國外的會所模式。過程中，打破了專業人員與精神病患間舊有的權威互動模式，與精神障礙者發展出一種類似同事的平權夥伴關係，共同肩負機構組織的運作，一起與精神障礙者學習對於公共事務發表自己的看法，長出對於體制的批判性；學習如何做一個公民，發揮公民精神，展開從社群內擴展到外部社會的對話。然而，實際在台操作會所模式，過程中面臨的是台灣體制的框限、與個案互動關係的失衡，檢討與調整之下，第一代操作會所模式的資深工作者，決心出走，另闢道路，自行開辦社區復健中心，選擇有限度的倚賴政府資源，期待換來更多的自主性。與個案的關係也從平權夥伴的營造，轉向發展更為真實的貼身搏鬥互動，期待帶領精神障礙者不只是身分主體的轉換，更進一步的對於個人與體制產生根本性的變革。三間機構依著對於精神障礙者不同的處遇信念，發展出不同的處遇模式，承接了不同階層、不同狀態的精神障礙者與其家庭，影響了社會不同的層面，也對當前的體制反映了不同的批判性。三間機構在實踐道路上都不斷的在進行思辯與革命，思辯與革命著身為一個助人工作者最終的使命─「如何善待生命；生命應長的什麼樣？」，使得三間機構在行動過程中更趨本土化與貼近個案的發展。有趣的是，三個機構位處不同的社會處境，受到不同主流體制的壓迫，為求認同與解放，在實踐的路徑上卻朝彼端前進與發展，形成一種具有相互辯證性的關係，也讓我們得以以更多元立體的視角去看待現今精神障礙社區復健服務的整體樣貌。

Since Long Far Temple`s illegal admission of patients with psychiatric disability broke out during the 1990`s, the professional authority model of modern Western psychiatric has gradually become the mainstream in Taiwan. While different from the alternative model from medical perspective, it still continues to develop diversely as another force. Basing on their own different social situated contexts, different communities are testing various alternative possibilities as well as pursuing different values and beliefs in terms of treatments of persons with psychiatric disability. This study attempts to explore about the diversity of alternative models that are outside of the pathological point of view developed in Taiwan during the past decades. Selecting cases of particular circumstances using the participant observation method proposed by Burawoy, this study proceeded with the extended case method using macro analysis, picking three anomaly fields outside of pathological point of view: a self-developed self-help group, formed by family members of patients, with no professional background; a social welfare organization that adopted the Clubhouse Model developed by Fountain House of USA, and a community rehabilitation center opened by senior social workers, respectively. During the process, the researchers of this study used their identity of interns to actually enter into the three research fields and thereby understand the truest front line work models and practice approach in-depth. This study analyzed the background contexts of main promoters for the three aforementioned institutions, the angle for understanding for persons with psychiatric disability under these background contexts, the new community rehabilitation discourses they created, and the designs of these work models as well as the concrete operation. This study also analyzed what kind of new subjects were created outside of the persons with psychiatric disability under these developed alternative work models, and what kind of new helping relationship these new subjects were embedded in, so as to compare the different practice approaches of different fields. This study found that self-help group formed by the family members, basing on the experience of the founder himself, developed a work model that is highly local cultural characteristic, trying to copy the community cultural of Hokkien rural clans and tribes in the 1950`s and 1960`s into the city life. Under the efforts and shelter mainly from their family members, and in a relatives-friends type of interaction that was full of Chinese characteristics, persons with psychiatric disability, acting as a buddy by relation, successfully claimed a place in the mainstream society. Different from the above mentioned work model entirely developed from the local experiences, a group of new generation helpers, each with their own suspicions and criticisms of psychiatric, attempted to operate a Clubhouse Model derived from overseas. In the process, they broke the old authority interaction model between the healthcare professionals and the patients with psychiatric disability, but instead formed an equal partnership similar to that of the colleagues with the patients and jointly operated the organizational operation of the institution. They learned together with the persons with psychiatric disability to express their views on public affairs and develop their critical thinking toward the system. They learned how to be a citizen, act with a civic spirit, and expanding their dialogues from the internal community to an external society. However, during their actual practices of Clubhouse Model in Taiwan, they faced with the frames and limits of Taiwan`s system as well as the imbalance of interactive relationship with the patients. After some reviews and adjustments, the first generation of senior social workers who operated the Clubhouse Model decided to leave and went for a new path. They opened a community rehabilitation center by themselves, choosing to depend on government resources limitedly in hope of obtaining more autonomy. Their relationship with the patients also turned from equal partners to a more realistic close-fighting interaction, hoping not only to lead the persons with psychiatric disability to transform their identities and subjects, but further produce fundamental changes for the individuals and the system. The three institutions developed different models of treatment basing on their different treatment belief toward persons with psychiatric disability. They took on persons with psychiatric disability and their families of different social strata and conditions, making an impact on different levels of the society and reflecting different critical thinking toward the current system. On the road of their practices, they kept on thinking and evolving, trying to figure out the ultimate missions as a professional helper - "How to treat life with kindness, and how life is supposed to be like?" That made the action processes of the three institutions more localized and closer to the development of the cases. Interestingly, the three institutions were under different society situations and subjected to different oppressions from the mainstream system. To obtain recognition and emancipation, however, they moved and developed toward the each other in their path of practice, forming an inter-dialectical relationship between them. That also allows us to look at the overall situation of community rehabilitation for psychiatric disability with a multi- dimensional perspective.