精神疾病「病識感」（insight）的社會分析：一個民族誌的觀察

The Social Analysis of Psychiatric Insight: An Ethnographic Observation

病識感是區隔正常與精神病的主要臨床特徵之一，但是長久以來在臨床上對於病識感的普遍使用，卻是建築在對於病識感的模糊、直覺以及常識性界定上。晚近有關病識感的理論探討則有了長足的進展，包括像是Anthony S. David的三面向病識感模型，以及Ivana Markova´的符號學式病識感模型。然而臨床病識感的重新概念化，仍然忽略了病識感現象所蘊含的重大社會文化面向與意義。本研究彙整概念史、文化精神醫學、心理學、語言學與醫療人類學等領域對於病識感議題的批判性研究，藉此對於這種新興的病識感構念，提出社會文化觀點上的補正。透過民族誌資料的呈現及分析，本研究指出：精神疾病病識感的臨床認定，必須放在其發生的臨床脈絡當中來進行瞭解，而臨床互動則又必須考量它與更廣大社會文化及歷史脈絡之間的關聯。本研究認為，唯有透過這種多層次的脈絡化方式，並輔以病識感的社會文化觀點，才能夠超越目前有關病識感判定的爭議與困境，並對於臨床病識感現象的豐富意涵有更深入的掌握與瞭解。同時透過民族誌視框來予以重新脈絡化的臨床病識感現象，將可以作為進一步考察臨床現象背後更寬廣社會及歷史過程的窗口。

Clinical insight has been one of the main features differentiating the normal from the psychiatric abnormal. However, the common and pervasive usage of this concept has been built upon some ambiguous, intuitive and commonsense definitions. Not until recently have some theoretical elaborations of this concept been successfully made, such as Anthony David's tri-dimensions model or Ivana Markova's semiotic model of insight. Nonetheless, these re-conceptualizations of clinical insight have still ignored the greater socio-cultural dimensions and meanings contained in the phenomenon of clinical insight. This study integrates critical perspectives from conceptual history, cultural psychiatry, psychology, linguistics and medical anthropology, and brings the complementary emphasis of socio-cultural concerns into the new conceptual development of clinical insight. Through the ethnographic presentation and analysis, this study points to the fact that the understanding of the clinical judgment of psychiatric insight has to be achieved by re-embedding it into the clinical context where it occurs, and that this clinical context is deeply embedded within and connected to the much broader multi-layered socio-cultural and historical contexts. This study suggests that only through this sort of multiple re-contextualization, with an emphasis on socio-cultural dimensions, can the current debate and obstacles to the conceptualization of clinical insight be surpassed, and a deeper understanding of the complex phenomenon of clinical insight be arrived at. It is also suggested that the ethnographic re-contextualization of the phenomenon of clinical insight can serve as a window to the better awareness and investigation of the broader social and historical process behind the phenomenon of clinical insight.