『病人角色』的抗拒與接受：接受血液透析治療患者的心理調適歷程

From Resisting to Accepting Sick Role: the Psychological Rehabilitation Processes of End-Stage Renal Disease Patients with Hemodialysis

本研究目的在以腎病末期接受血液透析治療患者為例，探究失能性慢性病患者由抗拒疾病轉變至接受疾病的心理調適歷程。本研究以質性追蹤式佐以回溯式訪談，採用紮根理論（grounded theory）研究法進行資料的蒐集、分析與解釋。研究結果顯示，患者的心理調適過程是存在於個體與社會不斷對話互動的脈絡之中，表現於外的是置身病痛折磨並嘗試因應的努力，是經過「奮力抵抗」、「無奈受困」到「接受新自我」的一連串循環路圈，而此一循環路圈是為患者內在心理建構－「疾病表徵」與「自我價值感」各自轉化與交織互動的外顯結果。第一個循環路圈是從「奮力抵抗」到「無奈受困」的對立循環，在「疾病表徵」部分是病可以治好與病治不好的對立；在「自我價值感」部分是有價值的『健康人』與沒有價值的『病人』的對立，此等對立狀態充滿無法共存的衝突張力。而此等對立的消弭，代表患者逐漸意識到病治不好、自己已成為沒有價值的『病人』，而正式進入「無奈受困」階段。這是最憂鬱痛苦的時期，同時也開啟第二個循環，即是從「無奈受困」到「接受新自我」的辯證循環，是不斷映照辯證而統整轉化的過程，在「疾病表徵」部分是無法忍受的病痛與可以忍受的痛苦經驗的反覆映照辯證，而轉化沉澱成患者生命經驗的一環；在「自我價值感」部分是沒有價值且受社會歧視的『病人』與具有功能與價值的『健康人』的反覆映照辯證，而轉化出對『人』之本然的洞見，進而能夠接納新（生了病）的自我狀態。本研究進而探討觸發此二建構產生轉化的有利先前條件為，患者使用正向認知調適策略，以及社會支持網絡的正向回饋。而有關本研究所得結果之臨床建議，在文中亦一併探討。

Chronically disabled patients with acute onset suffer from dysfunction, low self-esteem, and psychological distress. With the use of prospective and retrospective interviews, this study explores patients' psychological rehabilitation process of moving from resisting the sick role to accepting it as a part of their self-concepts. We apply grounded theory procedures and techniques to collect, analyze and interpret the qualitative data. The results indicate that the psychological rehabilitation process presents in the continuous interaction between the individual and the society, and the patients express in the way of suffering and trying to cope with it. They pass through the cycles of 'making great efforts in resistance', 'being stranded helplessly', and 'accepting the new self', and the core psychological constructs that transformed underlying this process are illness representation and self-esteem. These two underlying psychological constructs go through two transformation cycles, and determinate the coping behavior and emotional reactions of the patients. The first is the opposing cycle: patients move from 'making great efforts in resistance' to 'being stranded helplessly', and the second is the dialectical cycle: patients move from 'being stranded helplessly' to 'accepting the new self'. When patients go through the two psychological transformation cycles, their illness representation will merge new and positive viewpoints instead of being totally negative, and their self-esteem will be repaired from being crumbling. Then we go a step further to explore the facilitating conditions for those transformation processes. The results indicate that positive cognitive strategies and social support are important factors for the psychological rehabilitation process.