精神障礙者主體經驗下的社會融合：社區精神復健服務使用者的觀點

The Subjective Experiences of Social Inclusion of People with Mental Disabilities: The Perspective of Psychiatric Rehabilitation Service Users

本研究從精神障礙者（以下簡稱精障者）的個人經驗與主體立場出發， 探討精障者個人日常生活遭遇的各項社會融合經驗，及其對於社區精神 復健服務的主觀評價，並藉此描述精障者的主體性如何受到精神復健機 構的形塑。透過深度訪談八位使用社區精神復健服務的精障者，本研究 歸納發現：（一）精障者對社會融合的想法乃是回歸社區自立生活，並 期待透過工作所得賺取獨立生活費用，精障者願意為生活增添其他可能 性而努力，也藉由信仰產生自然的人際交流；（二）精障者的主體性源 自於對生活步調的掌控、對生活安排的自主權，並獲得他人的尊重與平 等對待；反之，當精障者被迫接受機構的權威管理與過度生活規範，其主體性將受到傷害；（三）對精障者而言，機構安排豐富多元的日常活 動與工作訓練，以及提供社會融合的橋樑等，都是符合其需求的精神復 健服務，而長期留置復健機構從事一成不變且低薪的勞力工作，則是精 障者最期待有所改善的服務層面。基於上述研究發現，本研究最後提出 相關政策與服務建議。

Research purpose Empirical studies on the social inclusion of people with mental disabilities in Taiwan are limited. This study aims to fill this gap. As social inclusion emphasizes the subjective feelings, willingness, and motivation levels of people with mental disabilities, this study explores the issue of social inclusion faced by people with mental disabilities from their individual perspectives and experiences. It also examines how psychiatric rehabilitation services shape the subjectivity of people with mental disabilities, reviewing the pros and cons of psychiatric rehabilitation services in fulfilling the needs of service users. There are three research questions to be answered in this study. First, what are the viewpoints and subjective experiences regarding social inclusion of people with mental disabilities? Second, how is the subjectivity of people with mental disabilities shaped by psychiatric rehabilitation services? Third, what services meet these needs, and what improvements in services need to be made for people with mental disabilities in psychiatric rehabilitation institutions? Method This study follows a qualitative research approach to delineate the social inclusion of people with mental disabilities in Taiwan. Since psychiatric rehabilitation institutions are set up to help people with mental disabilities recover, the research participants in this study were people with mental disabilities in these institutions. Considering the various degrees of autonomy and opportunities for social interaction among people with mental disabilities, the interviewees recruited in this study included residents of halfway houses, members of community rehabilitation centers, clubhouse members, and residents of community houses. Ethical approval was obtained before conducting the research interviews in 2022. Six participants recorded face-to-face semi-structured qualitative interviews and two participated in online interviews because of the pandemic breakout. In total, eight interviews were conducted. After transcribing the interview recordings, thematic analysis was used to analyze the interview transcripts, and thematic findings were derived in accordance with the repetitive analytical procedures of “whole-part-whole.”Results The findings are summarized as follows. People with mental disabilities think social inclusion is to live independently in the community. They hope to work and earn a living, and strive for other possibilities. They may also engage in interpersonal interactions through religious affiliations. In addition, rights of choice and autonomy, equal interaction and treatment, and respect for individual needs in psychiatric rehabilitation units are supportive factors of the subjectivity of people with mental disabilities. However, some adverse conditions such as class differences, inappropriate authoritarian management, and incomplete autonomy jeopardize the subjectivity of people with mental disabilities. Rehabilitation services that meet the needs of people with mental disabilities include various daily activities, multiple job training programs, and bridges for social inclusion. In contrast, rehabilitation services that need to be improved are mainly concerned with low wages, a limited variety of job opportunities, and reverse service effects. Conclusion Based on the research findings, some implications for government policy reform and service improvement in community mental health and social care are proposed. First, it emphasizes the subjectivity of people with mental disabilities. Training courses for rehabilitation institutions’ staff should emphasize the subjectivity of people with mental disabilities, help them achieve social inclusion and avoid the negative effects of institutionalization. Meanwhile, staff in rehabilitation institutions should return the choice and autonomy to people with mental disabilities and play the role of assistants with the belief that people with mental disabilities can be experts on their own lives. Second, they should provide employment opportunities for people with mental disabilities. Owing to the stigma of mental illness, poor educational backgrounds, aging problems, and other physical illnesses, people with mental disabilities are susceptible to social exclusion. Consequently, it is necessary to ensure that people with mental disabilities acquire various employment opportunities and job redesigning in response to functional impairment. To increase employment opportunities and income for people with mental disabilities, government sectors should work with rehabilitation institutions to expand employment resources, subsidize social enterprises, and establish shelter shops. Third, community support resources should be increased for individuals with mental disabilities. In the opinion of people with mental disabilities, financial problems are the most challenging for independent living. If government subsidies or residential services such as community houses are offered to people with mental disabilities to maintain a minimum quality of life, more people can return to community life. Additionally, people with mental disabilities require supportive community services to help them adjust to independent living and organize their daily lives. It is believed that by providing the abovementioned services, not only can the independent living and social inclusion advocated by the CRPD be fulfilled, but family caregivers’ stress and burden can also be reduced.