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  • 學位論文

社會變遷下蘭嶼達悟人精神失序之分析 —現代醫療、文化建構與受苦的社會根源

A Study of Mental Illness of the Tao Minority and Social Change: Modern Menicine, Cultural Construction, and the Social Origins of Suffering

指導教授 : 張苙雲
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摘要


這篇論文從「社會受苦」的概念出發,反省基因論、建構論、環境論三個對精神失序現象的研究取徑,釐清其各自的貢獻與限制。筆者延續環境論的基本洞見,並將它進一步與社會受苦的概念結合,以探究達悟人所面對快速顯著的社會變遷與其精神失序的關係。論文的主要分析對象,則為晚近達悟人精神失序發病所集中的大約25到60歲之間,第一代接受現代教育的壯年世代。 在論文的第一部份,筆者指出,蘭嶼高比率精神病現象,反映出來一個不易察覺而卻影響深遠的問題,亦即處在快速社會變遷的過程中,一個傳統原住民社會結構瀕臨解組、導致迷亂的現象。當達悟人的獨特的社會組織型態、制度、規範逐漸被外來的力量所侵蝕,遷移求生、家庭解組、個人與集體認同的改變都帶來挫折與壓力,而個人無法回應如此巨大的挫折與壓力時,酗酒、精神失序、自殺等現象便不斷出現。筆者認為,要理解達悟人晚近廣泛而獨特的精神失序現象,不能簡單地訴諸單一因素,譬如生物醫學方面的基因解釋。我們必須深入田野,接近他們當代的生活世界與日常經驗,同時也有必要輔以各種文獻資料,釐清其長久的歷史處境與其當代命運的關連。 在論文的第二部分,筆者針對既有文獻對精神失序醫療化的限制,以及傳統文化與現代醫療的適當定位及可能的出路,帶入社會變遷的視野,反省文化「本質性」與文化「同質性」的假設。從時間縱向的角度來看,目前交錯影響達悟精神失序者的三個典範,亦即達悟傳統、基督宗教、與現代精神醫療,從古老的時代到晚近的時期,漸次對達悟人產生影響。「達悟傳統文化→基督宗教→現代醫療」,這樣的進展,大致相當於Max Weber所說的一種現代社會逐漸解除魔咒的理性化過程。晚近達悟人如何理解與處置精神失序者,受到這個變化過程的影響。從不同世代面對的社會變遷而言,他們的老、中、青三個世代,分別經歷主要世界觀的轉換。 蘭嶼的達悟部落,彷彿是一個去機構化的天然社區。其中大自然與非工業化的環境、尚存的生計經濟活動、以及緊密的家族連帶等,都有助於精神失序者精神狀態的穩定與康復。達悟精神失序者極少步入嚴重退化性的程度,原因還有待進一步研究。但是上述的條件,無疑對他們有相當正面的作用。對照那些推行去機構化運動而遭遇許多困難的高度現代化社會,達悟部落尚未充分現代化、或者說其相對的「落後」,卻恰是有利於這些社會邊緣者的地方,提供他們在那些較為現代化的社會已經難以覓得的庇護。但是在分析中,筆者也指出,對於年輕世代、甚至對那些中年的青壯世代而言,已經愈來愈不能浪漫地倚賴這種庇護。除了由於部落中緊密人際連帶關係所伴隨的歧視、偏見、與剝削之外,生計經濟勞動與所得,已經無法滿足年輕一代的生活價值與自我期許。被捲入現代社會變遷的過程,既改變蘭嶼自然環境與達悟傳統文化,也改變了達悟人本身,尤其是他們年輕世代的自我認同,使他們趨向強調個人獨立自主、薪資勞動的現代價值與生活想像。這些顯現在精神失序個案身上,也顯現在那些照顧者的身上。在年輕世代逐漸遠離傳統、進而趨向現代性的過程中,上述那些去機構化的天然社區有利於精神失序者的條件,對那些年輕個案而言,反而轉化成有所限制的不利條件。 一般而言,那些較為現代化社會中的精神失序者,往往缺乏社區的支援。對照之下,達悟部落做為去機構化的天然社區的特質,更為突出。如果我們面對達悟精神失序者與其親人的多重受苦,考慮到如何有助於舒解其磨難,而如果部落生活對精神病人有利的條件,尤其是對那些面對未來的年輕世代,卻也正逐漸削弱與瓦解,使他們可以處在自由放任的部落條件已改變,那麼屬於達悟人的「社區復健模式」究竟是什麼,可以說是未來本地的精神醫學與醫療社會學值得深思研究的問題。

並列摘要


A total of 3,000 Taos inhabit Lan-yu(蘭嶼), an isle to the southeast of Taiwan. An isolated minority isle, Lan-yu is a typical low-income and medically under-served community, with a small district health center as the only institution providing medical care. According to an important research conducted by a professor at the Kaohsiung Medical University, the rate of mental disorder among the Taos has been increasing in recent three decades. The proportion of the Han Taiwanese who have mental illness is typically 0.3%, while that of the Taos is 1.2%. It is assumed that there is a significant correlation between the Taos’ genetic background and the high rate. Why do Tao aboriginal people have a high rate of mental disorder in the last three decades? In this dissertation, my first hypothesis is that the high rate of mental illness among the Taos has to be partly explained in terms of social/economic/cultural influences that are highly related to their ethnic background. In order to answer this question, I review three theoretical approaches to mental illness: genetic medicine, constructionism, and socio-environmental theory. I made a criticism that either genetic medicine or social constructionism downplays the subjective experience of suffering from mental illness. Thus I draw on the concept of “social suffering” to address the issue of mental patients’ subjective experience. Also I improve the socio -environmental theory by integrating the analyses of the effects of social change on the Taos’ mental illness and of their mental patients’ subjective experience. The possibility that the biological, genetic factor plays a significant role in causing the Taos’ mental illness probably cannot be excluded. A great many of studies in Medical Sociology and Medical Anthropology have shown that diseases have its social roots, however. Social Inequalities based on social class, race, ethnicity, gender, and global relations contribute to inequalities in health conditions and access to care. In the Taos case, how the prevalence of mental illness has been related to the socially/economically/culturally marginalized condition of their isle community must be examined. The fact that almost all those who unfortunately have mental disorder are people with the experience of migrating to Taiwan and of suffering from the difficult adjustment to a predominantly Han Taiwanese society speaks volume to the mutual relationship between the prevalence of mental illness and their socially marginal situation due to their ethnic background. The analysis of this relationship constitutes the major part of this dissertation research. Moreover, I suggest a hypothesis that how the Taos have accommodated themselves to the prevalence of mental illness in their community is highly related to their particular culture. Empirical studies in Medical Sociology and Medical Anthropology have also contributed to understanding of how cultural, ethnic, class, and gender differences shape the experience of illness and responses to care. They describe and analyze how local forms of suffering are culturally and socially constructed, pointing out that illness is typically an interpersonal experience created out of cultural values and social practices. In this dissertation research, I analyze Tao mental patients’ illness narratives, the cultural aspects of their suffering, and their social course of disease in order to understand how the social institutions, dynamics of social power, and collective meanings in their community has shaped the experience of mental illness. This dissertation also studies how the Tao community has accommodated itself to the prevalence of metal disorder and makes a criticism of the recent promotion of “de-instutionalized” and “de-medicalized” care of mental patients in contemporary psychiatry. As a case study of the complicated relationship between modern medicine and a low-income community with a unique minority culture, the dissertation further examines the moral aspects of modern medical practice and medical technologies to obtain a more sophisticated understanding of some questions and dilemmas in contemporary medicine, especially psychiatry.

並列關鍵字

Tao minority social change social suffering disorder psychiatry gene

參考文獻


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