精神復健機構的評鑑制度與專業實踐：建制民族誌之分析

Abstract

本研究旨在探究精神復健人員在權力體制規範之下的工作樣貌，並嘗試分析評鑑制度與實際工作經驗之間的斷裂經驗，發掘體制背後的意識型態是如何運作，以及精神復健人員在實務工作中所展現的工作樣貌及對專業的實踐。

透過建制民族誌作為探索問題的角度，以國家透過評鑑制度與精神復健機構、精神復健人員和精神障礙者之間所形成的權力結構作為研究場域，並訪談五位精神復健機構資深的管理者或專業人員，藉由對在地經驗的描述，理解精神復健機構如何回應評鑑制度的要求，以及法規、文本對精神復健工作的擠壓，並沿著評鑑制度建制的脈絡描繪出精神復健體系的權力運作。研究發現如下：

一、精神復健的專業在建制化過程中，延續了精神醫療的意識型態，國家運用評鑑制度管控精神復健機構的服務品質，設置辦法、評鑑基準和評鑑委員帶有醫療比社區更專業的邏輯，進而對機構進行審視並達到管控的目的，評鑑的結果主導著健保給付資源的分配。

二、機構為因應評鑑制度生產各式的文本紀錄以佐證服務績效，機構運用各種工作知識滿足了國家的要求，但機構服務的主體—精神障礙者，卻也在這個過程中不斷被消費，上下權力來回拉扯的結果，犧牲精神障礙者的需求和主體性。

三、復元的觀點帶給精神復健人員重新詮釋專業的機會。在精神復健發展的歷程中，精神復健的工作人員應擺脫醫療觀點和評鑑的限制，適時的丟掉專業的角色，又該在什麼時候穿上專業的外衣，從精障者的生活中去了解其能力及限制，以精神障礙者的本質做為主體，看見的是個人的發展，而不再只是著重在病情控制與管理，並以社區為基礎並貼近精神障礙者的生活，充分展現精神復健工作的多元樣貌。

建議未來評鑑制度應將服務品質回歸到精障者的需求，並理解精神復健人員在地性經驗，考量精神復健機構在社區化的多元樣貌，使評鑑制度更加完善。

This research was generated from the day-to-day work experience and problems of the researcher who serves as a psychiatric practitioner and an executive manager of a psychiatric rehabilitation agency, and intended to explore work experiences under the accreditation system and to analyze the disjuncture between accreditation system and practical fieldwork, as well as to discover the operation of ideology behind the power system which strongly impact the profession of psychiatric rehabilitation.

The methodology of institutional ethnography was adopted. The research focus was the power structure between the government, agencies, professionals, and persons with psychiatric disabilities behind the accreditation system in the field of psychiatric rehabilitation. The texts generated by the fieldwork, and regulations and documents related to the operation of accreditation system were examined. Five senior supervisors and professionals also participated in-depth interviews to describe their experiences to meet the demands from the accreditation process. The results are below:

1. The institutionalization of the profession of psychiatric rehabilitation retains the ideology of psychiatry as a medical system. The government uses the accreditation system to control the service quality of psychiatric rehabilitation agencies. Also, the establishment and management measures of psychiatric rehabilitation agency and the appointment process of accreditation surveyors convey the ideology that the medical system is more professional than the filed of psychiatric rehabilitation professionals and agencies in the communities. Furthermore, the government censors and controls the psychiatric rehabilitation agencies by the results of accreditation which leading to the redistribution of reimbursement form the National Health Insurance system.

2. To prove the service outcomes, the psychiatric rehabilitation agencies use various records to meet the standard of accreditation. In other words, the psychiatric rehabilitation agencies implant a kind of working knowledge to satisfy the government. However, the subjectivity of psychiatric rehabilitation service, i.e., the voices, needs, and the lives of persons with psychiatric disabilities, would disappear in the process of operation of power.

3. The notion of recovery brings opportunity for psychiatric rehabilitation professionals to reinterpret their profession. The psychiatric rehabilitation professionals should extricate themselves from the ideology of medicalization and the limitations from accreditation system in the professional development. They should be able to adjust their professional positions and structure according to multiple faces of the subjectivity and lives of the people with psychiatric disabilities living in the communities, rather than to emphasize symptoms control and management.

This study discovered the fact of the disjuncture between the work experiences and subjectivity of psychiatric rehabilitation under current accreditation standards and process. It is recommended that the future accreditation system should focus on service qualities which reflect the needs of persons with psychiatric disabilities who live in community, and should take diverse perspectives of local experience of psychiatric rehabilitation professional into account.