外展心理介入有心理症狀但未求助者的初探-以九二一災民為例

Abstract

回顧地震災難心理學的相關研究指出，災難創傷所引起的心理壓力反應具有長期、慢性化的影響，然而許多有心理壓力反應症狀的民眾可能會因為精神疾病的污名化、社會文化的漠視或忽視、應付接踵而至的生活事件、或症狀引起的退縮行為等種種因素，而不願或未求助心理專業的協助，因此相關的研究同時也指出發展外展心理介入計劃的必要性；然而不論在實務或在研究方面，對有心理症狀但未求助的災民實施外展心理介入卻是鮮而少見的。<br> 本篇研究採用已獲多數研究證實有效治療創傷壓力疾患（Posttraumatic Stress Disorder, PTSD）的認知行為治療（Cognitive-Behavioral Therapy, CBT），做為對有症狀但未求助的九二一災民外展心理介入的工作架構，再透過發現取向（discovery-oriented）的研究方法，整理分析介入訪談的資料，以獲得外展心理介入歷程的發現與探討。\n<br>整理、分析研究資料發現：災民容易因為災後接踵而至的生活變動或退縮而無法求助心理專業，災民因為地震後引發早期適應不良基模和外在聚焦的因應型態，以致無法覺察沒有求助或造成心理症狀慢性化，此與吳英璋（2000）所論及性格特質與災後處遇因素影響災後心理反應是一致的。外展心理介入以持續、密集的方式與災民建立適當的工作關係，改變災民對人負向的基本信念，讓災民有更深入的敘述與自我覺察，其次在貼近災民的日常生活脈絡中，從日常生活事件反覆地分析與練習，才足以動搖既有的信念與行為反應，使災民對事件產生內在聚焦的因應來增加自我效能和控制感，並且從災民置身所在的環境脈絡裡處理創傷個案的經驗迴避問題。以CBT做為外展心理介入的架構進行介入，比較無法使用家庭作業讓個案學習與練習，需透過個案所及能說的日常生活事件中，對其內在經驗聚焦、反覆辯證以致增加個案正向經驗、辨識刺激控制、以及思考的辨證，使個案增加自我效能、控制感、自我肯定等，以達到增加個人資源與賦權之目的。

There are lots of studies about disaster psychology related earthquakes presenting long-term chronically influence to psychological reactions, and implicating the importance of outreach intervention programs for non-seeking people with traumatic psychological reactions or posttraumatic stress disorder(PTSD). The people might not get help from professionals because stigmatization, apathy or ignore of society, business on going daily events, or withdrawal symptoms. So far as, neither even practicing nor research, there is few article about outreach intervention program for the people with psychological symptoms but non-seeking help. This study applies the framework of cognitive-behavioral therapy(CBT) verified by a lot of studies and practice for PTSD, and uses the discovery-oriented research, to discover and gain the understandings of outreach psychological intervention to non-seeking help people with psychological stress reactions in 921 earthquake. The result finds that people with psychological stress reactions mostly accompany with continuously daily event and withdrawal symptoms to seek help. The early maladaptive schemas invoked by earthquake and the external focus make people difficult to aware the need for help and chronically, and this finding is consistent with the discussion of the psychological reactions influenced by personality trait and disaster management in Wu (2000). Outreach psychological intervention established the working relationship through continuously, condensed schedule changing their negative belief to people, and having them deeper narrative and self-awareness. Secondary, by closed their contextual daily life and repeated exercises by daily event, such impacts are enough to shake their steadily believes and habituated behavioral reactions, then to have people internal focus and increase self-efficacy and controllability; further management is contextual analysis and treatment of experiential avoidance in the ecological context of daily life. The outreach psychological intervention by the framework of cognitive-behavioral therapy, it is difficult to apply homework assignment as review or exercise between sessions; and for regaining personal resource and empowerment, outreach psychological intervention mostly applies internal focus and repeated dialectical discussion to increase positive experience, discriminate of stimulus control, and dialectical thinking, and finally people have more self-efficacy, controllability, and self-assertiveness.