直面受苦：人文臨床心理學的心理病理學芻議

Coming Face-to-face with Suffering: Toward a Psychopathology for the Human-science Oriented Clinical Psychology

研究目的：在台灣，心理病理學被視為臨床心理學的三大專業領域之一，不過在教育訓練中，幾乎等同於DSM（Diagnostic and Statistical Manual of Mental Disorders）這個精神疾病診斷系統。然而從歷史上來看，DSM做為心理病理學的近乎同義詞，也不過是相當晚近的事情。因此DSM不是一個不能被挑戰的知識系統，也不應該被臨床心理學視為唯一的心理病理學。研究方法：本文是以批判—歷史取向（critical-historical approach）和傅柯式論述分析（Foucauldian discourse analysis）為方法，進行文獻反思與典範對話。研究結果：本文首先從批判歷史的角度描述DSM的發展，並且以Foucault（1980）的「部署」（dispositif）概念，檢視DSM如何在短時間內成為佔據精神醫學核心位置的重要實務手冊，並討論這個歷史轉變對精神醫學臨床工作造成的影響。在這個基礎上，本文接著討論臨床心理學在精神疾病診斷及治療的後DSM-III部署中的位置，並提出以「直面受苦」為核心的心理病理學為回應。研究結論：本文主張：（1）一個「直面受苦」的心理病理學承認受苦經驗在本體論上的不可化約性和屬己性，因此在知識論上會是「人文科學取向」的心理病理學；（2）一個「直面受苦」的心理病理學也涉及了知識與倫理關係的逆轉，它不是一套關於精神疾病的普遍性知識，而是在治療關係中展開、對受苦經驗的殊異性理解；（3）一個「直面受苦」的心理病理學，是向「心理病理學」原初意義的回歸：它是來自精神受苦者的「我說」，於其中他／她的「靈魂」如何「受苦」，得以向我們展現。

Purpose: In Taiwan, psychopathology is considered to be 1 of the 3 professional domains in clinical psychology. However, in educational training it is almost always equated with the DSM (Diagnostic and Statistical Manual of Mental Disorder). Equation of psychopathology with the DSM is recent. However, the DSM is not an unchallengeable system of knowledge, nor should it be treated as completely encompassing all forms of psychopathology in clinical psychology. Methods: We applied a critical-historical approach with a Foucauldian discourse analysis in order to critically reflect on the current status of psychopathology. Results: We first supplied a critical-historical description of the development of the DSM, and then used Foucault’s (1980) concept of dispositif to examine how the DSM quickly occupied a core position in the practice of psychiatry, thereby affecting clinical work. On this foundation, we then discussed how clinical psychology should be positioned in the post DSM-III era with regard to the diagnosis and treatment of mental illness. We proposed a form of psychopathology that situates coming face-to-face with suffering at the core. Conclusions: We propose that a human-science oriented psychopathology is: (1) a psychopathology that comes face-to-face with suffering. It recognizes the ontological status of the suffering experience, its irreducibility and its personal uniqueness. Therefore, it is inherently human science oriented; (2) a psychopathology that also involves reversal of the priority of ethics and knowledge. It is therefore not a system of universal knowledge about mental illness, but a singular understanding of the suffering experience unfolded in the therapeutic relationship; (3) a return to the original meaning of the word psychopathology. It comes from the “I say” of the sufferer, in which the suffering of the soul is unfolded to the therapist.