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# <i class="fa fa-file-text"></i> Disability, impairment or illness?
### The relevance of the social model of disability to the study of mental disorder
**Tree Zi @ 2021.03.25 DS-Course**
---
```graphviz
graph G {
node [color="blue" fontname="bold" fontsize=15 shape="cube"]
edge [fontsize=11 fontname="bold"]
dis [label="障礙研究"]
dis_1 [label="障礙\ndisability"]
imp [label="受損狀態\nimpairment"]
soc [label="社會學研究"]
label [label="標籤理論\nlabelling theory"]
# goffman [label="高夫"]
em_imp [label="體現的障礙性\n Embodied Impairment"]
em_ir [label="體現的非理性\n Embodied Irrationality"]
med [label="醫療化\nmedicalization"]
sim [label="處置相似性"]
risk [label="忽略障礙的結構因素"]
body_med [label="身體解釋權\n仍在醫學上"]
sk_med [label="有病看醫生，拿藥"]
adv [shape="Mrecord" label="{<f0>醫療仍是優先選項|<f1>醫療意識型態對政策的影響|疾病觀點與個人經驗的詮釋平衡}" fontsize=15 color="pink"]
#--------------
{dis_1, imp} -- dis [dir="back"]
dis -- soc [style="dashed" width="20" color="red"]
{rank="same";dis, soc}
label -- soc [dir="back"]
em_imp -- dis [dir="back"]
{rank="same";em_imp, soc}
em_imp -- em_ir [dir="forward"]
{dis, soc} -- med [dir="both"]
med -- {sim,body_med}
sim -- risk
body_med -- sk_med
{rank="same";med, adv}
}
```
---
## 缺乏社會學研究的精神障礙者處境
- 社會學研究並不重視精神障礙者的處境：
- <font color="skyblue"> *Sociological theory and research has not provided either a much-needed analysis and critique of the major changes taking place in mental health policy or fostered any recent social policy directed towards improving the quality of life for people diagnosed as suffering from sever mental illness who live the community.* </font>
---
- 本文的研究前提：精神障礙者的處境與其社會、心裡、以及身體上的限制有關。
- <font color="skyblue"> *......people with serious mental disorders is based on the assumption that for a small, but significant category of people, mental disorder is associated with **sever restrictions on social, psychological and physical well-being**.* </font>
---
## 障礙理論的回顧
- 障礙與受損狀態（Disability and Impairment）
- 障礙是「由於社會組織的活動並未考慮到個別成員的受損狀態，從而造成排除」
- 受損狀態則是「身體上的缺陷」
---
- 障礙的社會取徑（social approach to disability）
- <font color="skyblue"> *.....This location of the conceptualisation and analysis of disability within a social framework redirects analysis **from the individual to processes of social oppression, discrimination and exclusion**. The disadvantage experienced by disabled people is seen to be ‘institutionalized throughout society’.* </font>
---
- 「精神障礙」的社會取徑（social approach to psychiatric disability）
- <font color="skyblue"> *......the application of the social approach to disability to the study of mental ill health orients research and theoretical development towards an analysis of the complexity and multiplicity of the social restrictions faced by people diagnosed as ‘mentally ill’, and the social disadvantage and oppression they face..* </font>
---
- 醫療政策上，主要認為精神障礙者是困於他個人的「病徵」，而與社會結構的因素無關。
- 因此，狹隘的政策觀點影響了障礙者的需求，而對於障礙者的社會狀況，相關的社會學討論甚少。
---
## 既有的社會學討論：標籤理論
---
- 既有的社會學研究批判了醫療取徑的觀點，卻也同時強化了醫療取徑隱藏的問題
- 首先，社會學研究迴避「精神障礙」（及其經驗）本身，只強調「社會互動」的部份
---
- 而對於精神疾病患者，他們的情況則被視為是一種「社會互動下的產物」，這樣的觀點限制了社會學對於精神疾病的研究。
- <font color="skyblue"> *......Although the portrayal of mental disorders as social constructions has provided a much-needed challenge to the essentialist view of the body portrayed in medical science, it has placed major limitations on sociological inquiry.* </font>
---
- 社會學分析傾向將精神障礙的處境至於「社會互動」中，換言之，只分析那些「跟社會互動、以及建構自我認同有關」的現象
---
- 並不關心障礙者「主觀經驗」，也忽略了障礙者的主體感受：
- <font color="skyblue"> *Sociologists [....] have been loath to confront the possibility that a range of mental impairments exists which make the performance of certain activities difficult for people who suffer from these impairments. [...] This makes their work increasingly irrelevant for many people experiencing serious mental distress.* </font>
---
- 總而言之，社會學在精神障礙的研究上缺乏可用的解釋理論，可以既解釋受苦經驗的根源，同時也能發揮賦權的功能。
---
## 體現的障礙性與鑲嵌的非理性
- 體現的障礙性延續著「社會取徑」的討論，認為人的障礙是由於社會因素所導致。
---
- 體現的障礙性認為人對於自身的感受是建立在社會與身體的複雜互動：
- <font color="skyblue"> *One’s experience of the embodiment […] is the result of a complex relationship between society and corporeality. As the body is both a corporeal and a social construction, so our experience of embodiment is both sensory and ‘shaped by social relation and ideas’ about normal bodily form* </font>
---
- 但如果我們接受這個觀點，也就得同意自我認同以及對於障礙／受損經驗的感知是不能脫離於身體的。
- <font color="skyblue"> *…If we accept these arguements we are led to acknowledge that ‘selves’, identity and ==agency== cannot **be studied independently of bodies**, whether impaired or otherwise.* </font>
---
- 與之相反，體現的非理性（Embodied irrationality）試圖消解身－心二元論：
- <font color="skyblue"> *…it [...] eliminates the need to distinguish between **physical and mental impairment**. As Seymour points out: 'If sociology is the interpretative understanding of social action, **then embodied human beings, human personality and consciousness embodied in human material, are engaged in that action***'(1998: 9). </font>
---
- 體現的受損性與體現的非理性研究，整合了受損狀態、障礙以及環境因素，用以評估障礙者的處境
- 案例一：視障者與公共空間 (Butler & Bowl, 1997)
- 案例二：慢性關節炎勞動者如何調適(Pinder, 1995)
- 案例三：精神障礙學生的學習情況（(National Centre for Vocational Education Research, 1999）
- 在精神障礙研究中，體現的非理性研究較少
---
- 結合社會結構、agency(能動性)、意義，透過探討受損情境來為障礙者賦權。
- <font color="skyblue"> *These disability theorists [...] argue that the focus on individuals' understandings of how impairment and disability is experienced **restores a focus on agency and identity**. ...... [More important is that] how positive self-identity can be established and how the experience of impairment can lead to empowerment rather than disempowerment.*</font>
---
## 小結：醫療化取徑與障礙的社會取徑研究
- 受損狀態、障礙與慢性病的情況有所相似，但過度的「醫療化」會對障礙研究帶來不利的後果。
- 忽略社會結構所帶來的影響（也就是社會結構如何塑造對「障礙／受損狀態」的意義）。
- 障礙的社會取徑仍把「身體」的討論權歸還給醫學。
---
- 事實上，障礙者的確會尋求醫療途徑來解決自身問題（不管這個是障礙的、是受損狀態、還是真的是疾病），這個事實並未被重視。
- 重點仍然是要看見複雜的結構脈絡
---
- 障礙研究對社會學的啟示：
1. 重新省視「後去機構化」時代下醫療的社會控制
- 醫療行為：住院
- 吃藥
2. 醫療意識型態如何影響精神醫療政策制定以及其實行
- 因為被認為是病，才會有後續的事情
- 即便考量了社會福利制度，仍無法消除「病狀」帶來的歧視
3. 在「承認疾病會帶來不利」與「個人受損狀態的經驗」中取得解釋的平衡
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