精神障礙者在就業服務中的復原與復健

Recovery and Rehabilitation of People with Mental Disability in Employment Services

沈詩涵(Shih-Han Shen)

指導教授 ： 林萬億

國立臺灣大學/社會科學院/社會工作學研究所/碩士(2008年)

https://doi.org/10.6342/NTU.2008.01100

摘要

從瘋狂到以障礙被看待，精神疾病的社會處置從監禁轉變為跨越醫療、注重復健與精神障礙者的復原。綜觀現有的精神復健體系，院內到院外的服務不脫職能復健和就業服務的範疇。據此，本研究從精神障礙者在就業服務體系中或自行就業的經驗，深思就業服務對精神障礙者復健的意義與功能展現，並藉此描繪帶著疾病就業的精神障礙者獨特的工作圖像，以澄清精神障礙者於服務系統裡的感受和期待，試圖提出適切的復健服務策略建議。
本研究以設籍北縣/市的7位精神障礙者為受訪對象，以及北市某精神障礙者服務組織專業人員6名的服務經驗為輔助參考，採用深度訪談法。研究發現分為四點：第一，現行服務在院內到社區、方案內到競爭性職場的場域分佈上呈現不連貫，服務對於精神障礙者雖有「整裝待發」、「前進就業的踏階」、「職場闖蕩的後盾」及「避風港/安身立命的處所」等意涵，但體系內的分工不易令方案異動不停，且服務功能容易分散、失焦。此外，就業服務受到醫療為依據、服務資格條件的門檻限制，以及高度依賴勞動市場帶來的限制，使專業人員即使力求創新、多樣化，仍難以形成完整的服務網絡。
第二，精神障礙者工作的圖像受個人擁有的社會資源影響極深，個人或家庭社經條件不佳者，工作猶如「肩頭的重擔」，而疾病與個人特質高度重疊、不易融入一般社群者，工作則往往流於工具性手段，彷彿「機構收容的替代」；另一部分擁有較佳環境條件者，則可將工作的定義擴展至學業、志願服務，發展個人生涯，工作可作為「資本累積」的介面，與藉此重塑「多樣的自我輪廓」。
第三，精神障礙者罹病後的社會關係，多半圍繞在家庭、醫療院所與社區方案內，及就業場所，實務上接觸的高情緒表達（HEE）家庭轉移至精神障礙者身上的壓力，實則來自現實生活的困境；院內及方案內的同儕，則可成為精神障礙者復健、復原歷程裡的楷模、借鏡；而精神障礙者與其他障別的同儕，因身分的相仿，在職場中形成小型的競爭圈；一般職場同事方面，無論是友善或壓力源的人際，疾病顯然將精神障礙者在社群中的位置區隔，形成一座「玻璃牢籠」。
最後，綜合7位受訪者的經驗，因工作相關及其他生命階段的任務受阻，而帶來的疾病歸因，使「復原」隱隱指向恢復就業的目標邁進；此外，工作在配合醫療、幫助他們遠離醫療的層面上，確實被視為一種療效；再者，就業提供再社會化、成人形象與未來願景的媒介，是返回社會「複合式」的復原管道；然而最重要的，「復原」的時間軸向不只包含疾病狀態的逆轉，尚且應考量到復原為一個存在於時代脈絡下的概念，精神障礙者不只需符合當代的「成人」規模，還需將復原的時間面向延伸至未來。
依據上述發現與分析，本研究建議如下：
1)在服務體制面，其一為「政策為依歸的服務輸送」，將資源提供者提升至政府層級，免除服務更動、變換不定的窘境；其二，則是「多元價值的精神障礙者就業服務」，解除銜接醫療的唯一途徑，在社區方案裡收納更多樣需求型態的精神障礙者，並將服務方案視為「復健」甚於「就業」，創造精神障礙者與社區之間的橋樑；其三則是設計「使用者參與的服務方案」，以精神障礙者自身的經驗作為服務的媒介；
2)在專業人員的價值基礎上，則應立足於「心理衛生」、「精神復健」的服務定位，聚焦在服務中的「復原」標的，著重過程性目標甚於侷限的任務性目標；
3)最後，有鑑於現有服務功能切割的不易，後續研究可更深入於各類精神復健服務的內涵與功能差異性，及其對於精神障礙者復健、復原的影響。

關鍵字

精神障礙者 ； 復原 ； 復健 ； 就業服務

並列摘要

From “nut” to “people with mental disability”, the way modern society treats mental illness has gradually changed, people with mental illness was released from jail/hospital to community. At the same time, social services for people with mental disability has moved their focus to rehabilitation and recovery, instead of the framework based-on medical point of view. After scanning the existing psychiatric rehabilitation services in Taiwan, researcher found out that occupational therapy and employment counseling dominate the main market. Hence, this study took deepth interview as data-collecting method, sampling 7 persons with mental illness reside in Taipei City or Taipei County, have received employment services. Besides, according 6 professionals affiliated with a union organized by folk of people with mental disability in Taipei City, drawing the comprenensive picture of service presently. Attempt to delve into the 7 interviewees experience and clarity the functions of services to them. Further, pondering the meanings of employment to people with mental illness on their way to recovery.
After analyzing the data collecting from 7 interviewees and 6 professionals, the result points out that:
First of all, the programs have four meanings for interviewees, “equipping”, “stepping-stone”, “supporter” and “shelter/settlement”. But the service system has not come into a network, since the same functions appear in several types of programs, and these programs vary constantly. Mover over, there are a number of barriers about service admissibility, such as taking medicine regularly or holding certificate of disability.
Secondly, the work image of people with mental disability is highly influenced by individual’s social and economic resource. Families which possess few social capital couldn’t support individuals with mental illness develop their own career, they “work for life” so the image of work just like their “Burden”; for those who symptoms overlap with individual’s traits, they often have serious difficulties to integrate into normal interpersonal relationship in workplace, work becomes the “substitute for institutionalization”; oppositely, individuals who obtain better conditions could expand the framework of their “work” to more matters, for instance, pursuing their education or participating voluntary service, they “work for accumulating-assets”; in addition, they “work for themselves” as work provides a new chance for them to “modeling a multiple self-image”.
Third, once a person fall into mental illness, his/her social contact would usually block in family, hospital, service program and workplace. Interviewees show that families which have been referred to HEE clinically, often have a lot of issues and troubles between members, so the sicked member would lose the patient role in his/her family; about the peer in hospitals or community programs, they could become a good pattern or counter example for each other; then talking of the colleagues who have other categories of disability, because of the same position in workplace, they would apt to becoming competitions; as for the rest people they encounter in workplace, like the managers, partners or customers, more often than not treat them specially, no matter in nice or awful manner.
Finally, about the time axis of “recovery”, the concept should be placed in the context of contemporary society, and carries a continuous implication of their future vision.
In accordance with above, this study bring up certain suggestions:
1)Regarding service system, researcher claims to design a “policy-based”, “multiple values” and “customer-participating” model of service.
2)About the service providers, it will be a better perspective viewing service as “mental health” and “psychiatric rehabilitation” programs focus on the process than limited goals.
3)At last, following researches could explore different kinds of psychiatric rehabilitation service thorough, in view of the confused situation of present services.

並列關鍵字

People with mental disability ； Recovery ； Rehabilitation ； Employment services

參考文獻

王增勇（2005）。活泉之家。國立陽明大學衛生福利研究所上課講義。

鄭若瑟、高家常（2005）。精神疾病患者生活品質及其測量。台灣精神醫學，19:3，179-191。

宋麗玉（2005）。精神障礙者之復健與復元—一個積極正向的觀點。社會政策與社會工作學刊，18:4，1-29。

潘美玲、張維安（2003）。經濟行動與社會關係：社會自我保護機制的研究。台灣社會學刊，30，51-88。

林金環（2003）。慢性精神病患社區職能復健與自我概念之相關性探討。慈濟大學護理學研究所碩士論文。