本文旨在研究臺北市樟新社區與一壽重殘照顧中心之互動，關於一個都市社區與精神障礙照顧機構之互動情形。分析主要分為兩部分，第一部份回溯一壽重殘照顧中心進入樟新社區之過程與情形，第二部分則分析樟新社區與一壽重殘照顧中心現階段之互動情形與未來建議。此外，本文也特別引用了「鄰避情結」（即「不要在我家後院」，”Not-In-My-Backyard syndrome”，簡稱NIMBY）作為論述基礎，試圖去檢視社區居民對於照顧中心的觀感，找出居民排斥或接納照顧中心之情形與原因等，並以衝突歷程的概念去剖析互動現狀。本研究目的則是希望透過個案研究，探討一個社區如何與精神障礙照顧服務機構互動，以從中找出能使社區居民與照顧服務機構二者共生、互助、融合之社區工作精隨。 本研究採質性研究之個案研究法，運用多重資料來源，並藉由觀察互動及深度訪談法來蒐集資料。其中深度訪談選取參與或了解本研究議題者作為訪談對象，包括規劃或承辦照顧中心進入社區的政府人員、來自照顧中心承辦單位及在照顧中心服務的管理者或工作者、對議題了解或熟悉社區事務的社區居民，藉此先行了解一壽重殘照顧中心進入社區之過程，包括照顧中心設立的過程與決策考量、照顧中心設立時與社區之衝突對立情形，以及政府單位、民間團體、社區居民三方對於衝突對立的認知、處理方式或行動。再者，也深度探究社區與機構過去至今的互動樣貌，包括社區與照顧中心的互動現況、社區居民對照顧中心設立觀感與鄰避情結、社區居民排斥或接納照顧中心之情形與原因，進而找出促進照顧中心融合社區或其他可能作法。 最後，根據本研究，提出相關政策建議如下： 一、檢討我國公有土地政策，以避免社福資源被稀釋； 二、讓障礙者參與決策過程，以落實真正的社區照顧； 三、在各地廣設心理衛生中心，讓障礙者能在原本的社區居住； 四、透過立法保障與教育倡導，以維護障礙者之居住權； 五、組織經營照顧中心志工團，並促進機構與社區的互惠及共生關係； 六、社區或機構相關工作者可採低姿態、柔性、創意方式，長期經營社區關係。 　　 關鍵字：社區、精神障礙、照顧機構、鄰避情結 / This research aims to study the interaction between the Zhangxin Community in Taipei City, an ordinary community in a big city, and the Taipei Yi-Shou Care Center, an institution for the psychiatric disabled. In the first part of the study, the researcher reviews the process of how the Taipei Yi-Shou Care Center moved into the Zhangxin community, whereas the second part analyzes the interaction between them and further provides suggestions for future cooperation. Besides, the researcher specifically adopts the concept of “Not-in-my-backyard syndrome” (NIMBY) as the theoretical background to survey the perceptions of the community residents toward the care center. Moreover, this study identifies the reasoning behind the acceptance or refuse of the move-in of the care center. Finally, this paper analyzes current status of interactions through the lens of conflict process. In summary, the aim of the research is to identify how community residents interact with an institution for the psychiatric disabled; furthermore, this study concludes the essence of community work in helping community residents and health care institution to cohabit, achieve mutual help, and integrate with each other. This research adopts case study method and collects data from multiple sources, such as onsite observation of the interaction and in-depth interview. For the in-depth interview, this study recruited key persons who have participated in and are aware of the issue. Therefore, the interviewees range from the government officials who have planned or taken charge of the move-in, the managers or workers of the care center or higher level of administration, to the Zhangxin community residents who are aware of the issue or general community affair. Accordingly, this paper first strives to investigate the move-in process, from the decision-making processes of the establishment of the Taipei Yi-Shou Care Center and the conflicts between the supporters and critiques during construction, to the perceptions, solutions, and actions toward the problem from the government, non-government organizations, and the residents. Second, the study thoroughly reviews the history of the interaction pattern between the residents and the institution, including the status quo of the interaction, the perception and the NIMBY of the residents toward the care center, and the situation and reasons of acceptance or refuse of the care center. In the end, this paper proposes possible means to help the care center better integrate with the community. This research proposes six suggestions for policy below: 1. Review the policy of public lands to avoid diluting the resources of social welfare. 2. Invite the disabled to participate in policy making to realize essential community care. 3. Set up community mental health centers to render the opportunities for the disabled to live in the original community. 4. Safeguard the right of residence of the disabled through legislation and education. 5. Organize volunteer groups of the care center, and improve the mutual benefit and cohabitation relationship between the institution and the community. 6. Community and institution workers manage long-term relationship with the community through modest attitude and in flexible, creative ways. Key words: community, psychiatric disability, care institution, Not-In-My-Backyard syndrome(NIMBY).

本研究主要目的在於瞭解(一)精神障礙者成功適應工作的情形、(二)適應工作期間的權能感受，以及(三)就業服務人員協助其適應工作與增強其權能之策略運用。藉由受訪者回顧參與過渡性就業期間的經驗以瞭解工作適應狀況和權能感受間的關係和影響。研究中以質化之深度訪談法進行資料蒐集，研究參與者的選取主要是來自中華民國康復之友聯盟「台北交誼中心」和「高雄交誼中心」，涵蓋十位精神障礙會員與兩位就業服務人員，並以半結構式的訪談方式進行資料蒐集。本研究結果歸納為以下重點: 一、影響精神障礙者工作適應的因素，主要分為三大層面:個人(就業動機、個人特質與能力、面臨的工作困難、採取的因應方法)、人際(家庭系統與職場系統)、社會環境(會所模式與醫療院所)，而三者間具有循環且交互影響的作用。 二、精神障礙者的工作適應情況，則可區分為以下三個指標:外在滿意度(出席狀況、準時、工作主動性、工作專注力、工作配合度、工作效率及雇主評價)、內在滿足(正向感受與負向感受)、以及工作任期，其中他們的外在工作表現多能達到雇主要求，內在滿足則是正向感受遠多於負向感受，而工作任期是綜合外在滿意度與內在滿足的工作適應表現，他們皆能穩定就業，達到工作期滿。 三、精神障礙者的權能感受與工作適應狀況息息相關，而多半展現在個人(能夠接納自己與肯定自我、覺察自我效能、建立正向自我形象、激發正向內在動力、自我增權、能夠自我選擇與決定、覺得與所處的環境有良好的適配度)與人際層面(具備與人溝通的知識和技巧、與他人互動時能肯定自我、能夠與他人形成夥伴關係、得到他人的尊重)。 四、就業服務員是精神障礙者的適應工作職場的支持主力，主要是扮演「先鋒」、「支持」與「後盾」等重要角色；亦是運用多元的增強權能策略提升其權能感受之關鍵人物。 五、依據精神障礙者的工作適應與權能感受型態區分為四大取向，分別為「內外權能展現取向」、「內在權能增強取向」、「外在支持調適取向」、「懷才不遇取向」。依循四取向之脈絡，筆者延伸發展出最為理想之核心類屬，即「內外權能實現取向」。 依據研究發現，筆者針對工作適應之關鍵角色--就業服務員提出下列幾點建議(一)對精神障礙者之個人處遇策略:增加精神障礙會員的社交能力、運用更多元的增強權能策略來激發復元因子；(二)催化雇主對精神障礙會員之認識與接納；(三)強化會所過渡性就業與就業職場間的連結；(四)建立友善且接納的社會環境。本研究結果分析與研究限制皆於文中提出說明，提供未來相關研究與實務之參考。 / The study explored the states of persons with psychiatric disability succeeding in work adjustment and empowerment during the Transitional Employment service, and the strategy that employment service staffs adopted to help psychiatric disabilities to adapt their jobs and empower them. Through the survey participants’experiences during the period of participating in the transitional employment service, the study attempted to find out the relationship between work adjustment and empowerment. Qualitative method of the profound experiences was utilized to collect data. The survey participants included 10 persons with psychiatric disability and 2 employment service staffs. All of them were selected from TAMI (The Alliance for the Mentally Ill of R.O.C.,Taiwan) and interviewed by using semi-structured interviewing method. The major findings of this study were as follows: 1.The factors that affected the work adjustment of persons with psychiatric disability were divided into three perspectives：individual (employment motivations, personal characteristic and capability, difficulties encountered at work, and the coping strategies), interpersonal (family and workplaces system) and social environment (the clubhouse and hospitals). Moreover, the three levels of factors had interactive impact on the subjects. 2.The state of psychiatric disability’s work adjustment was divided into three aspects：satisfactoriness (attendance, punctuality, positiveness, concentration, cooperation, working efficiency, and evaluation from the employers), satisfaction (positive and negative feelings),and tenure. For the most part, their performance at work could fulfill the employer’s requests, they have much more positive feelings than negative ones, and as the tenure, which was an integrated performance of both satisfactoriness and satisfaction, they were able to work steadily until the tenure expired. 3.To extend the psychiatric disability’s work adjustment and performance above, the empowerment of persons with psychiatric disability almost revealed itself at both individual (their capabilities to accept and approve of themselves, to perceive self-efficacy, to establish positive image, to stir positive internal motivation, to empower themselves, to make choices and decisions, and to fit the environment) and interpersonal (to possess the knowledge and techniques to communicate with others , to approve themselves while interacting with others, to build up partnership, and to obtain others’ respect) aspect. 4.Employment service staffs played an important role in supporting the psychiatric disability’s work adjustment at workspaces. For the most part, they served as pioneers, supporters, and backing; meanwhile, they were the key persons that adopted multiple strategies to empower the subjects. 5.Based on the states of work adjustment and empowerment, the subjects were categorized into four major types of orientation. Overall, the core category of the subjects extracted was “demonstration of internal and external power”. According to the findings, the investigator brought up some suggestions: 1.The treatment of psychiatric disability’s individual situation：improve psychiatric disability members’ ability to establish interpersonal relationship and adopt multiple empowerment strategies to stimulate resilience. 2.Encourage employers to understand and accept the psychiatric disability members. 3.Strengthen the connection between the Transitional Employment service of the clubhouse and workspaces. 4.Establish a friendly and acceptable social environment. The analysis and restriction of the study was brought up in the article, providing references to future related study and practice.

目前國內針對精神障礙者就業相關文獻，主要著重於就業影響因素。因此，本研究以復元統合模式為架構，探究精神障礙者在職業抉擇歷程裡有哪些影響因子以及其與復元之關係。本研究為理解精神障礙者如何解讀自己曾經歷的職業抉擇歷程，採半結構訪談之方式訪談七位具有多年就業經驗的精神障礙者，研究結果如下： 1.精神障礙者職業抉擇影響因素包含： (1)個人因素：清楚身體現況、過去就業經驗、職業倦怠。 (2)家庭因素：家人促進職涯發展情況與家人阻礙職涯發展情況。 (3)非正式支持因素：朋友與宗教組織提供就業資訊與建議。 (4)工作環境因素：交通、工作穩定性、職場友善度、工作機會。 (5)正式支持因素：就業服務單位協助轉介、就業服務員之協助。 (6)社會大眾汙名化：雇主對於精神障礙者的不友善、民眾對於精神障礙者的偏見與歧視、疾病自我汙名化。 2.職業抉擇歷程與復元：從受訪者的生命故事裡得知精神障礙者的求職之路蜿蜒迂迴，呼應復元是一個來來回回的過程。而本研究發現雖然工作動機並不一定影響精神障礙者的職業選擇，但在復元過程裡是重要激發強健心理能量的來源。本研究亦看到生涯成熟度對於精神障礙者職業選擇的影響。 3.精神障礙者就業與復元：精神障礙者在參與工作的過程裡，會發展個人策略及尋求相關資源協助，從而增強工作效能。而穩定就業讓精神障礙者得以提高生涯自主性、開始關注生活品質，及具有回饋社會的能力，這都是一種復元的展現。 最後，研究者結合上述研究結果與復元統合模式，嘗試繪製出精神障礙者職業抉擇與復元統合模式之關係，並提出本研究限制與建議，提供精神障礙者、精神障礙者之家屬、服務提供者和政策制定者。 / This research has based on the unity model of recovery to explore the factors affecting career choice of people with mental disorder, as well as to illustrate the relations between these factors and one’s recovery. Departing from domestic correlational literature that mostly underlines the factors impacting employment of people with mental illness, this study aims to shed new light on this research area by employing the framework above. Thereupon, semi-structured interviews are conducted with 7 interlocutors of multi-year working experiences to establish elaborated understandings of their self-narratives on the career choice process. The findings are: 1.Factors influencing the career choice of people with mental illness are as follows: (1)Personal factor: including clear understanding of personal health condition, past employment experiences, and occupational burnout. (2)Family factor: varied conditions where family members may be encouraging or discouraging in one’s career development. (3)Informal supporting factor: such as employment information and advices from friends or religious organizations. (4)Work environment factor: including transportation convenience, job stability, workplace friendliness, and job opportunities. (5)Formal supporting factor: referral from employment service providers, assistance from employment service officers. (6)Public stigma: such as antagonistic attitudes received from employers, prejudice and discrimination from the public, and even more, self-stigma one experiencing. 2.Career choice process and recovery: From the life stories disclosed by the interlocutors, their twist-and-turn paths toward employment could clearly be seen, echoing that of the recovery “is not a perfectly linear process”. Although work motivation might not be the determining cause of their career choice, it is crucial for inciting mental strength during recovery process. Furthermore, this research has also demonstrated the influence of career maturity towards career choice of people with mental disorder. 3.Employment and recovery: During their participation in employment, people with mental illness would develop personal strategies and seek for assistance from related resources in order to thrive at work environment. Moreover, stable employment aids one’s recovery in many ways, such as promoting one’s career autonomy, instilling life qualities, and also strengthening one’s potential to give back to the society. In accordance with the findings mentioned above, this study has made an attempt to depict the relations between career choices of people with mental illness and the unity model of recovery. Lastly, research limitations along with suggestions for further research are subsequently raised, in the hope of serving as a reference for them with mental illness, their families, mental health services providers, and policy makers.

精神障礙者的服務深受現代精神醫學的影響，「診斷」會先於「人」作為看待精神障礙者的框架。隨著對精神疾病的詮釋更加多元，開始出現一些以重視精神障礙者主體性、社會結構取向、優勢正向思考為特點的另類工作方法。本研究所探討的繪畫團體和展覽行動也是基於以上理念的工作方法。 本研究透過與五位精神障礙者的深度訪談，以及對他們繪畫作品的視覺評估，來瞭解他們參與繪畫團體和展覽行動中的轉化歷程。本研究以精神障礙者的生命故事和作品作為開啟，去走進每一個人的生命經驗，去瞭解每一個人的個性、想法，藉此放下視他們為精神障礙者的視框，逐漸展現每一個獨特的個體。基於對每一個個體的深入理解，從而瞭解到他們如何在繪畫團體中感受當下的平靜專注、運用創作練習自我表達、透過自我覺察促成改變的契機、彼此被看見、被傾聽，並獲得人對人之影響力的過程。繪畫也成為了一種非結構化的工作方式，去幫助工作者更貼近每個精神障礙者的內心世界。隨著繪畫團體的「自我探索」面向不斷加深，個人生命背後共有的社會處境被看見，該團體開始有意識地以展覽行動來朝向「社會參與」的面向發展。該團體運用展覽為精神障礙者建立一個真實社會互動的空間、獲得新的身份以及人際磨合和情緒控制的學習，並透過情感共鳴的方式達到去污名的效果。 / The service for people with psychosocial disability is deeply influenced by the modern psychiatry, which tends to see the person as a diagnosis rather than a man / women. As the interpretation of mental illness is becoming more diverse, there comes some alternative treatment methods, which emphasize the individuality of people with psychosocial disability, using social structure orientation and strength-based thinking. The art group and art exhibition studied in this paper are also based on above philosophy. Through in-depth interviews with five people with psychosocial disability and visual assessment on their artworks, this study aims to understand their changing experience in the art group and art exhibition. This study starts with the life stories and artworks of the five interviewees, stressing them as unique individuals with own personality then thoughts rather than those imposed stereotypes of people with psychosocial disability. Based on the depth understanding of every interviewees, the study described their experience in the art group allowing them to feel peaceful and focused, and through art making they were able to express and develop awareness of self, hence promoting changes in self and relationships. The art group described in this study used nonstructural working method, which allowed the group leader and social workers to become closer to the inner world of people with psychosocial disability. With time, shared self-experiences emerged among the art group members, and the group started to evolve towards more social participation in ways of art exhibition. The art exhibition provided them a platform for real interaction with the society, for formulation of new identity, for opportunities to learn interpersonal skills and emotion control, and for diminishing stigmatization through emotional empathy. Keywords: people with psychosocial disability, personal stories, art group, art exhibition

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.