社安網心衛社工服務精神疾病合併家暴加害者處遇經驗初探-以臺灣東部為例

Abstract

本研究旨在探討臺灣東部地區心衛社工對於精神疾病合併家暴加害者及其家庭的處遇經驗。研究目的在於瞭解心衛社工服務對象面臨哪些生活議題，心衛社工又如何採取處遇策略。本研究採質性研究方法，以標準取樣法與滾雪球取樣法，運用半結構式訪談大綱，與7位花蓮縣、臺東縣以及宜蘭縣具有1年以上心衛社工工作經驗者，進行一對一深度訪談，將訪談錄音轉為逐字稿，以主題分析法進行研究資料分析，得到研究結果如下：一、如何走上心衛社工之路：從事心衛工的原因包含職涯考量、願意接受挑戰、受薪資吸引。二、心衛社工服務對象生活議題與服務考驗：心衛社工服務對象及其家庭的生活議題包含藥酒癮及不規則服藥、家庭對個案有愛也有礙、就業資源匱乏、個案對家庭經濟依賴，處在社會邊緣及面對精神疾病的污名。也發現心衛社工是家庭的浮木，要承擔家屬期待未實現的情緒反應，更直面個案的抗拒情緒，專業關係建立不易，家庭與個案的改變意願低，因此動機促進是心衛社工的課題，也發現個案是自己醫療處遇的專家，所以心衛社工的衛教要個別化。三、心衛社工的價值信念及處遇方法：心衛社工透過以人為本的助人信念，發展以關係為基調的工作取向，建立關係後聚焦在提升個案對所處生態的適應性，所運用的策略包含連結醫療系統穩定精神疾病、鬆動家庭系統、鼓勵個案自立以及輔助資源運用等。心衛社工發現合併藥酒癮議題的個案存在高風險時，會將工作重心轉移到加強被害者人身安全，並以減害原則進行處遇。心衛社工運用強制力是一把雙面刃，有其優勢也有受限之處。四、心衛社工與網絡成員的合作：保護性社工與心衛社工因為看待案件的視角不同而帶來工作差異，包含：強調快而有力的危機介入VS重視生態環境相互適應；保護被害人安全導向VS關心加害者情緒需求；期待醫療介入緩解危機VS瞭解醫療限制考量社會環境因素。兩造社工雖有各自作為之時，但關係已逐漸鬆動，可依案家需求分工合作。五、心衛社工角色的挑戰、成就以及盼望：心衛社工的挑戰包含需要面對無解的困境、服務成效無法立即彰顯、面對精神症狀的不穩定、可用資源薄弱、訪視頻率未能呈現服務品質。而能促成有效的網絡合作並共同改善風險，以及服務對象的正向反饋，能使心衛社工獲得成就感。心衛社工在重重的挑戰中，仍然期待自身能夠強化專業知能，但也盼望政府避免多元服務議題削弱心衛社工核心量能，以及整合社會安全網專業人員，達到優化心衛社工角色的目標。針對研究發現，本研究提出相關議題討論：從研究、理論與政策看東部心衛社工處遇；隱藏在家庭暴力與精神疾病背後的難題；心衛社工資源運用的限制；強制性處遇的灰色地帶；共案共訪機制執行概況。最後針對實務面、政策面以及研究各面向提出建議。This study aims to examine how mental health social workers in the Eastern Taiwan area handle cases involving domestic violence perpetrators who have mental illnesses, as well as their interventional experience with the perpetrators' families. The purpose of the research is to understand the life issues encountered by individuals served by mental health social workers and how these social workers apply intervention strategies to address those issues. This study employs a qualitative research method using both standard sampling and snowball sampling techniques. Semi-structured interviews were conducted with seven mental health social workers from Hualien County, Taitung County, and Yilan County, each with over one year of experience. The interviews were recorded, transcribed, and examined using thematic analysis. The research findings were as follows:1. How to Pursue a Career as a Mental Health Social Worker: The reasons for becoming a mental health social worker include career considerations, willingness to accept challenges, and salary attraction.2. Life Issues and Service Challenges Encountered by Individuals Served by Mental Health Social Workers: The life issues faced by these individuals and their families include drug and alcohol addiction, irregular medication adherence, family dynamics that both support and create obstacles, a lack of employment resources, financial dependency on the family, social marginalization, and stigma associated with mental illness. It was also noted that mental health social workers often act as a last resort or"grasp at straws" for families, dealing with unmet expectations and addressing resistance and emotional reactions from individuals. Building professional relationships is challenging, with low willingness for change from families and individuals, making motivational enhancement a key focus. Additionally, individuals often manage their treatment, so health education provided by mental health social workers needs to be individualized. 3. Value Orientations and Intervention Methods of Mental Health Social Workers: Mental health social workers adopt a person-centered philosophy as their guiding principle. They develop a relationship-based approach to their work, focusing on enhancing individuals' adaptability to their environment once a relationship is established. Their strategies include linking individuals to medical systems to stabilize mental illness, easing family dynamics, encouraging self-reliance, and assisting with the utilization of resources. When mental health social workers identify high-risk cases involving both drug and alcohol addiction, they shift their focus to enhancing the victims' personal safety and apply harm reduction principles in their interventions. They recognize that using compelling force is a double-edged sword: it has its advantages but also its limitations.4. Collaboration Between Mental Health Social Workers and Network Members: The collaboration between protective social workers and mental health social workers is shaped by their different perspectives on cases, leading to differences in their approaches. These differences include: focusing on rapid and effective crisis intervention versus emphasizing ecological and environmental adaptation; prioritizing victim safety versus addressing the emotional needs of perpetrators; expecting medical interventions to alleviate crises versus understanding medical limitations and considering social environmental factors. Although each type of social worker has a distinct role, their collaboration has become more flexible, allowing for division of labor based on the specific needs of each case.5. Challenges, Achievements, and Aspirations of Mental Health Social Workers: Mental health social workers face several challenges, including dealing with unresolved dilemmas, the inability to display immediate service effectiveness, managing unstable psychosis symptoms, limited available resources, and the frequency of visits is mistakenly viewed as a measure of service quality. Despite these challenges, effective network collaboration and positive feedback from those served contribute to a sense of achievement for social workers. They hope to strengthen their professional expertise while also wishing for the government to avoid crippling their core capacities through diverse service issues. Additionally, they look forward to better integration of social safety net professionals to enhance and optimize their roles.Based on the research findings, this study discusses relevant issues, including: examining mental health social work practices in Eastern Taiwan from research, theoretical, and policy perspectives; the hidden challenges behind domestic violence and mental illness; limitations in resource utilization by mental health social workers; the gray areas of compulsory interventions; and the implementation of joint case and visit mechanisms. Finally, recommendations are provided for practical applications, policy adjustments, and future research directions.