自殺企圖通報個案的受助經驗：南投區心理衛生服務中心的田野觀察

Help-receiving Experiences of Reported Suicide Attempters: Field Observation of Nantou Regional Mental Health Service Center

江弘基(Hung-Chi Chiang)

指導教授 ： 張玨

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2013年)

https://doi.org/10.6342/NTU.2013.01920

摘要

研究目的：本研究的目的，在於瞭解自殺企圖者經由防治體系通報後，在被動情況下接觸社區外展關懷服務的經驗；透過深入觀察自殺企圖者與服務人員之間的互動過程及現象，進一步理解相關自殺防治措施規劃與執行的理念脈絡，以期能夠提供未來政策參考。研究方法：本研究以「南投區心理衛生服務中心」為研究範圍，蒐集其計畫緣起、組織架構、人力配置及服務內容等資料，做為背景分析。田野觀察包括前半年的機構見習準備，與後續四年期間在中心服務人員的陪同與協助下，與30位自殺企圖通報個案及家屬進行深度訪談。研究結果：經由訪談逐字稿分析，比對受訪者基本資料及服務紀錄，本研究發現自殺企圖者在成為通報個案後，排斥�接受後續關懷服務的因素與「對自殺行為的看法」及「服務人員所屬單位屬性」有關；從抗拒轉而接受服務的過程，則與個案對於服務人員「本身特質」及「服務風格」的反應與適應程度有關；從輕生到重新找到支撐生活的支點關懷服務對於個案帶來的幫助，包括心理調適及實質轉介服務層面，對於個案與家屬及重要他人之間關係也有改善的效果。一般民眾「求（醫）助行為」的理論架構多以專業助人者角度出發，假設受助者應該主動求助，將尋求與持續接受服務的責任歸諸於被服務者，並無法適切反映自殺企圖通報個案的被動「受助」經驗。由於自殺議題與精神醫療的敏感性與汙名化影響，通報個案對於關懷服務的信任與接受度，非但無法因服務人員的機構屬性或專業身分順理成章地成形，甚或造成提供服務的障礙；傳統用來預測民眾醫療服務利用的健康信念模式中，情緒困擾的嚴重度與不接受精神醫療服務的後果，也未能解釋通報個案態度轉變的原因。對於已經就醫的通報個案來說，能夠清楚說出精神醫療團隊不同領域的專業人員可以滿足自己的不同需要，乃符合心理衛生服務使用的entry point模型所說，民眾會因不同的心理問題尋求不同的專業人員；至於在尋求服務的時機點上，通報個案的經驗指出自殺防治服務體系在lay delay與system delay方面的諸多盲點。結論：「南投區心理衛生服務中心」在本研究期間所執行的通報後續關懷服務，從防治策略、規劃管理者、服務人員及專業取向來說，均帶有濃厚的精神醫療模式色彩。然而，從本研究受訪個案的「受助」經驗可知，精神疾病相關概念對於服務社區中的企圖通報個案並無法直接助益；通報個案在被迫接觸社區外展服務所產生的不適應反應，反而促使中心採取主動出擊的外展策略，工作人員嘗試跨越機構化的服務提供模式、專業角色本為，以及行政僵化的藩籬，在面臨生命危機的自殺企圖個案與嘗試開創自殺防治工作的精神醫療專業人員之間，成功地示範了一個可行的互動模式。對於目前只重視死亡率及再企圖率的降低、過度倚賴自殺風險評估及精神醫療服務轉介，且受限於無法充分解釋指標數據變異原因的主流自殺防治策略推動者來說，具有相當的參考價值。此外，本研究的結果提供自殺防治工作者文化能力培養的一個重要面向：如何不受制並跨出助人者的專業本位，而得以走近自殺企圖者、進入並同理其自殺思維。這是自殺企圖通報個案的經驗帶給我們最大的啟示。

關鍵字

自殺企圖 ； 通報 ； 受助經驗 ； 文化能力 ； 自殺防治 ； 外展後續關懷服務 ； 社區心理衛生服務中心

並列摘要

Purpose: This doctoral dissertation aimed at understanding the help-receiving experiences of reported suicide attempters while passively facing community outreach postvention services. It is the researcher’s hope that, by looking deeply into the interaction between involuntary suicide attempters and service providers, the social context behind the suicide prevention strategy be further clarified. Methods and materials: In-depth interviews with 30 reported suicide attempters, including their families were carried out, between 2003 and 2005, with the assistance of community outreach nurses in the Nantou Regional Mental Health Service Center. Before the interviews began, the researcher spent six months on participation observation in outpatient clinics and outreach visits to familiarize with suicidal patients and clients. Details regarding the operation of the center were also collected as background information. Results: According to the analysis of transcripts of interviews and the comparison with case records, the researcher found that after the suicide attempters were reported and outreached, they became the involuntary clients. The rejection/acceptance of the postvention services were related to the ways they looked at their suicide attempts and the affiliation of the outreach helpers. The turning point of attitude change was determined by the personality and helping style of the helpers. Traditional models of help-seeking behaviors, which are based on the concept of active help-seeking and compliance to professional advises, do not apply in the case of the passive, help-receiving suicidal attempters. Due to the stigma attached to both suicidal behaviors and mental illness/health services, the reported suicide attempters’ trust and acceptance towards community outreach services cannot be guaranteed by the professional/institutional identity of the psychiatric outreach nurses; most of the time, it became barriers to receiving assistance. The severity of emotional distress and the negative consequences of not seeking help, as emphasized in healthcare utilization studies, also cannot explain why the involuntary helpees changed their minds. For those who finally accepted referral mental health care, looking for specific professionals for different needs is crucial during their journey of receiving help for recovery. This finding fits the model of entry point in healthcare research. As for the issue of timing to seek help, this study points out many blind-spots related to lay delay and system delay of the suicide prevention system. Conclusions: Psychiatry/medical model dominated the strategy development and services provision of suicide prevention efforts made by the Nantou Regional Mental Health Service Center. From the help-receiving experiences of the suicide attempters, it is clear that the mental illness perception cannot facilitate help-seeking/receiving behaviors, especially in the initial stage of outreach intervention. The mal-adaption responses to this setback triggered the pro-action approach adopted later by the center. The psychiatric nurses step forward and further and went beyond psychiatric wards, professional identities, and rigid administrative procedures. The result was a successful interaction model between involuntary suicide attempters and innovative outreach helper. It shows an alternative to risk-approach, which over-relies on unexplainable, and often frustrating, mortality and morbidity.

並列關鍵字

suicide attempt ； help-receiving ； help-seeking ； suicide prevention ； outreach ； involuntary client ； cultural competency ； community mental health center

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