Away From Psychiatrization: Towards Socio-Ecological Wellbeing in the Community
By Gill Batty -August 11, 2022
你知道《從前有一個女人吞了一隻蒼蠅》這首兒歌嗎？ 它描述了以越來越多的荒謬累積來應對問題。 押韻中的女人吞下一隻蜘蛛來捉蒼蠅，然後是一隻鳥來捉蜘蛛，以此類推。 這種韻律可以被理解為一個隱喻，代表了現代流行的心理健康狀況不佳的觀念以及如何應對它：一系列不斷升級的生物醫學干預措施，實際上並沒有解決根本問題。
Do you know the nursery rhyme called “There once was a woman who swallowed a fly”? It describes responding to a problem with more and more cumulative absurdity. The woman in the rhyme swallows a spider to catch the fly, then a bird to catch the spider, and so on. This rhyme could be understood as a metaphor representing the prevailing modern notions of poor mental health and how to respond to it: an escalating series of biomedical interventions that don’t actually solve the underlying problem.
//譯者備註:從前有一個女人吞了一隻蒼蠅影片
精神病學很少質疑他們治療的假設。（“蜘蛛會捉蒼蠅，所以治療會有效。”）但是，就像押韻一樣，這種簡單化的理解無法考慮到問題的背景。
Psychiatry rarely questions the assumptions of their treatment. (“Spiders catch flies, so therefore the treatment will be effective.”) But, as in the rhyme, this simplistic understanding fails to take in the context of the problem.
精神病學假設存在一個尚未發現的生物學問題，導致人們感到痛苦。因此，基於這種假設，他們的治療是生物學的——通常是一種藥物，它會產生有害的影響，需要用進一步的藥物治療；當藥物沒有達到預期的效果時，會開出不同的藥物，有時還會伴隨新的診斷，產生更多的副作用；當症狀持續存在時，治療有時會升級為電擊或深部腦刺激，或氯胺酮等實驗性藥物。
Psychiatry assumes that there is a biological problem—yet undiscovered—causing people to experience distress. So, their treatments, based on this assumption, are biological—usually a drug, which can cause harmful effects that need to be treated with further drugs; when the drugs don’t have the desired effect, different drugs are prescribed, sometimes along with new diagnoses, with more adverse effects; when the symptoms persist, the treatments sometimes escalate to electroshock or deep brain stimulation, or experimental drugs like ketamine.
在某種程度上，精神病學甚至比童謠還要糟糕。至少故事中的角色正在試圖解決問題的原因——蒼蠅。但精神病學只關注症狀——從不問一開始是什麼原因造成的。
In a way, psychiatry is even worse than the nursery rhyme. At least the character in the story is trying to solve the cause of the problem—the fly. But psychiatry only focuses on the symptoms—never asking what caused them in the first place.
並非總是可以簡單地立即改善條件，因為原因是多方面的，並且會隨著時間的推移而演變。然而，通過診斷和症狀控制來定位個體內部的功能障礙，許多人生活中的惡劣條件更有可能被忽視和忽視，因為他們繼續忍受和管理其負面影響。
It is not always possible to simply improve conditions with immediate effect, for causes are multifactorial and tend to evolve over time. However, by locating the dysfunction within the individual through diagnoses and symptom control, there is a greater possibility that the inhospitable conditions in which many people live their lives will be overlooked and ignored, as they continue to endure and manage their negative impact.
我的專業工作涉及童年性虐待的成年倖存者，這告訴我將人類對痛苦的反應定位為精神上的“疾病、紊亂或殘疾”是值得懷疑的。倖存者的焦慮程度是可以理解的，這常常導致諮詢過程成為難以忍受的考驗。我與顧問和客戶一起工作，教授人類生存系統的功能及其運作，將焦慮重新定義為功能性和保護性，而不是功能失調和病態的起源。
My professional work involved adult survivors of childhood sexual abuse, which taught me that positioning human responses to distress as mental “illness, disorder, or disability” is questionable. Anxiety levels were understandably high for survivors, often leading to the counselling process being an unbearable ordeal. I worked alongside counsellors and clients, teaching both about the function of the human survival system and its operation, reframing anxiety as functional and protective, rather than dysfunctional and pathological in origin.
在此之前，許多倖存者被告知，他們的複雜需求源於精神病，即位於他們自己有缺陷的大腦化學中，而不是對虐待的可理解的痛苦表達及其對他們與自己和他人關係的更廣泛影響。
Until this point, many survivors had been told that their complex needs were psychiatric in origin, i.e., located in their own faulty brain chemistry, rather than understandable expressions of distress in response to abuse and its broader effects on their relationship with themselves and others.
與我一起工作的許多人都開了多種藥物，通常是針對醫生所說的“醫學上無法解釋的症狀”。疼痛、偏頭痛、行動不便、炎症性疾病、自身免疫症狀、體重增加、疲勞——所有這些通常都與醫源性症狀（副作用，或僅僅是藥物的影響）無法區分。很難準確地弄清楚這些藥物應該治療什麼。現在正在經歷藥物副作用的倖存者認為這些有害影響是器質性身體疾病。他們從未被告知這些是藥物的影響。並發的流行衝突被視為常態。
Many of the individuals I worked with were prescribed multiple medications, often for what doctors described as “medically unexplained symptoms.” Pain, migraines, mobility issues, inflammatory diseases, auto-immune symptoms, weight gain, fatigue—all were often indistinguishable from iatrogenic symptoms (side effects, or simply effects of medication). It was difficult to figure out precisely what the medicines were supposed to be treating. Survivors who were now experiencing medication side-effects believed these harmful effects were organic physical illness. They had never been told that these were effects of the drugs. Concurrent syndemic clashes were seen as the norm.
由此產生的猖獗的多藥問題讓我和我的同事感到震驚，他們大多是以人為本的顧問，與受到傷害並隨後被醫療系統註銷的客戶作鬥爭。
The resulting rampant polypharmacy issues came as a shock to my colleagues and I, who were mostly person-centred counsellors grappling with clients who had been harmed and subsequently written off by the medical system.
我和我的項目經理同事們開始收集這些數據，並於 2012 年 10 月 25 日召開了一次會議，讓蘇格蘭各地的 GP 讓他們意識到這個問題。
My fellow project managers and I began to collect this data and ran a conference on October 25th, 2012, for GPs across Scotland to make them aware of this issue.
所有參加我們服務的人都長期被困在精神病系統中，長期診斷出慢性心理疾病。這些人是兄弟姐妹、兒女、父母、音樂家、廚師、藝術家、學者。有些人在他們那個時代是運動員。一旦被貼上標籤和治療，通常以監禁和強制服藥的形式，它們就再也不會一樣了。這些人不只是為了捕捉蒼蠅而吞下一隻蜘蛛——他們被告知以診斷和藥物的形式吞下一匹馬，這正在摧毀他們。
All the individuals attending our services had been stuck in the psychiatric system for a long time with long-term diagnoses of chronic psychological conditions. These individuals were brothers, sisters, sons and daughters, parents, musicians, chefs, artists, academics. Some had been athletes in their day. Once labelled and treated, often in the form of incarceration and forced medication, they were never the same again. These people had not just swallowed a spider to catch the fly—they had been told to swallow a horse in the form of diagnosis and medication, and it was destroying them.
當我開始在愛丁堡大學攻讀全球心理健康與社會理學碩士學位時，我希望在全球層面找到新方法的證據。然而，很明顯，精神病學被驅使在世界範圍內傳播許多已在高收入環境中開發和實施的相同方法。這讓人感到震驚，因為在同樣的高收入環境中，接受治療的人數大幅增加，診斷率和痛苦率似乎也在逐年增加。這是否表明這種對不良心理健康的反應不起作用？
When I began an MSc in Global Mental Health and Society at the University of Edinburgh, I hoped to find evidence of new approaches at the global level. However, it became clear that psychiatry is driven to spread, world-wide, many of the same approaches that have been developed and implemented in high-income settings. This feels alarming, because in those same high-income settings, where the number of people receiving treatment has increased substantially, the rates of diagnosis and distress also appear to be increasing year on year. Doesn’t this indicate that something about this response to poor mental health is not working?
然而，還有其他令人驚嘆的項目不依賴於在世界各地出口相同的生物醫學模型。一個位於加爾各答的項目被稱為 Iswar Sankalpa。該項目幫助建立了一個基本的支持性和創造性結構，圍繞著生活在街頭的“心理障礙”個體。
However, there are other amazing projects taking place that don’t rely on exporting that same biomedical model around the world. One project, based in Kolkata, was called Iswar Sankalpa. The project helped to create a bare-bones supportive and creative structure around individuals with ”psychosocial disabilities” who live on the streets.
這個項目給我的啟發是“無議程”的精神：他們既沒有被推動去改革、改善或回家——他們得到了基本的醫療、牧靈和物質護理（淋浴、乾淨的衣服等）。 , 並被傾聽。如果個人需要，可以提供支持或改變的途徑，例如社區參與以及培訓和發展的機會。該項目還得到了更廣泛社區的自願成員的支持，並感到尊重、體貼和體貼。
What inspired me about the project was the “agenda-less” ethos: they were neither nudged to reform, to improve, or to go home—they were offered basic medical, pastoral, and material care (showers, clean clothing, etc.), and were listened to. Pathways to support or change, such as opportunities for community involvement and training and development, were available if it was desired by the individual. The project also engaged support from willing members of the wider community and felt respectful, thoughtful and considerate.
研究 項目
Research Project
這個例子鼓勵我通過社會生態框架來看待基層項目。
This example encouraged me to look at grassroots projects through a socioecological framework.
我查看了 位於印度 的Burans項目 、危地馬拉的 Buena Semilla項目以及位於英國的項目Camerados 。儘管這些項目中的每一個都採用不同的方法，但它們的共同點是每個項目都被有意地置於社區的社會和地理中心。為人們創造了身體和情感空間，讓他們聚集在一起進行聯繫和交流。每個人都採用最低等級的參與式方法，恢復議程是由參與服務的個人與組織中的工人合作共同創造的。
I looked at the projects Burans, based in India, Buena Semilla in Guatemala, and the Camerados, a UK based project. Although each of these projects was different in approach, what they had in common was that each was deliberately situated in the social and geographical heart of communities. Physical and emotional space was created for people to come together to connect and commune. Each had a participatory approach with minimal hierarchy, and recovery agendas were set co-creatively by individuals engaging with the service in collaboration with workers in the organisations.
方法是基於小組的，鼓勵通過同伴支持建立聯繫。來自社區的人們被邀請分享他們的經歷和鬥爭，並開始認識到邊緣化和歧視對心理健康的一些影響。促進小組選擇的廣泛主題的討論導致加強聯繫、關係以及對個人和小組素質和技能的識別，這通常會加強更廣泛社區內的關係。人們被邀請認識到他們的生活與他們的情緒和心理反應之間的聯繫。這些項目中的每一個都對社區中已經存在的資產進行了認可，例如公共空間、環境美、文化歷史和智慧、技能和能力，
Approaches were group-based, encouraging connection through peer support. People from the community were invited to share their experiences and struggles, and to begin to recognise some of the impacts of marginalisation and discrimination upon mental health. Facilitated discussions on a wide range of topics chosen by the group led to enhanced connection, relationships, and the identification of individual and group qualities and skills which often resulted in strengthening relationships within the broader community. People were invited to recognise the connections between their lives and their emotional and psychological responses. Each of these projects also placed recognition upon the assets already present in the community, such as common spaces, environmental beauty, cultural history and wisdom, skills and abilities, and how they belonged to and could be built upon within the community, by the community.
我在研究的項目中發現強調社區和聯繫。參與和共同生產體現在每個組織的精神中，並通過知識共享在個人和集體層面鼓勵賦權。鼓勵聽和說，讓人們感到被傾聽和理解。這對我來說代表了以人為本的行動。
What I found in the projects that I researched was an emphasis on community and connection. Participation and co-production were present in the ethos of each organisation, and empowerment was encouraged at the individual and collective level through knowledge sharing. Listening and speaking was encouraged and led to people feeling heard and understood. This for me represented person-centredness in action.
Buena Semilla 最初是一個項目，旨在應對危地馬拉偏遠地區的土著居民所遭受的高嬰兒和孕產婦死亡率。很快就顯而易見的是，社區遭受了極端程度的邊緣化和剝奪，這導致了貧困、剝奪和與更廣泛的社會生態環境的脫節。醫療保健也基本上無法獲得。壓力和緊張，以及與祖傳遺產和價值觀的脫節，助長了暴力和藥物濫用的大男子主義文化。
Buena Semilla began as a project in response to high levels of infant and maternal mortality being suffered by the indigenous population in hard-to-reach areas of Guatemala. What was quickly apparent were the extreme levels of marginalisation and dispossession being suffered by the community, which was leading to poverty, deprivation, and disconnection from the broader socioecological environment. Healthcare was also largely inaccessible. Stresses and strains, as well as a disconnect from ancestral heritage and values had contributed to a machismo culture of violence and substance abuse.
將社區的女性聚集在一起，在對話圈中坐在一起，談論和分享故事，認識技能和優勢，相互提供支持，從而開始了賦權。該組織促進和支持獲得醫療保健和其他社會產品的機會，逐漸地，女性開始重新獲得集體力量的感覺。社區的人，雖然起初很謹慎，但開始參加社區小組會議。對土著文化遺產的承認導致社區自豪感的恢復和對強加的殖民價值觀遺產的拒絕。人們開始意識到他們能夠做出的貢獻。從這些開始，小企業開始了，身份被收回了。這些變化導致家庭暴力和藥物濫用的減少，
Bringing together the women of the community to sit together in dialogue circles, talking and sharing stories, recognising skills and strengths, offering support to one another, led to the beginning of empowerment. Access to health care and other social goods was fostered and supported by the organisation, and gradually the women began to regain a sense of collective strength. The men of the community, though cautious at first, began to attend the community group meetings. Recognition of indigenous cultural heritage led to the regaining of community pride and the rejection of the legacy of imposed colonial values. People began to realise the contributions that they were able to make. From these beginnings, small enterprises were begun, and identities were reclaimed. These changes resulted in a decrease in domestic violence and substance abuse, while maternal health and infant mortality measurably improved.
Burans 項目還強調促進邊緣化社區的聯繫。將難以接受教育、處於社會心理困擾的年輕人聚集在一起，與同伴支持人員一起確定他們面臨的挑戰。該項目是聯合製作的縮影。小組成員在創建視覺交流工具方面發揮了重要作用，這些工具在他們的特定社區環境中對他們來說是有意義的和文化相關的。這使那些幾乎沒有受過教育的人能夠與該項目建立聯繫。標準的恢復模式被避開了，有利於獨立構建的目標設定，這得到了同行工作者的支持。這些團體就恢復、技能發展和未來目標制定了自己的議程。
Project Burans also emphasises facilitating connection in marginalised communities. Young people who had difficulty accessing education, who were in psychosocial distress, were brought together to identify their challenges with peer support workers. The project epitomised co-production. Group members were instrumental in creating visual communication tools which were meaningful and culturally relevant to them in their specific community settings. This enabled people who’d had little access to education to connect with the project. Standard recovery models were eschewed in favour of independently constructed goal-setting, which was supported by peer workers. The groups created their own agendas with regard to recovery, skills development, and future aims. Another arm of the project involved the development of peer support and skills for caregivers in the community, offering support to those who struggle with minimal resources.
Camerados 被描述為一個運動而不是一個組織。它的精神很簡單：創造人們可以聚集在一起交流、分享、提供支持、認識優勢和建立社區的空間。這被描述為人們“互相照顧”。他們在包括醫院和監獄在內的大量社交和工作空間中設立了這樣的空間，稱為“公共客廳”。這種空間的一個副產品是，參與其中的人報告說他們的心理健康和幸福感得到了改善，以及他們以前覺得不存在的聯繫感和歸屬感。
The Camerados is described as more of a movement than an organisation. Its ethos is simple: to create spaces in which people can come together to commune, share, offer support, recognise strengths, and build community. This is described as people “looking out for each other.” They have set up such spaces, called “public living rooms,” in a vast array of social and workspaces, including hospitals and prisons. A by-product of such spaces is that those involved report improved mental health and wellbeing, as well as a sense of connection and belonging that they felt was previously absent.
認識到社會生態條件的影響，而不是大腦疾病理論，似乎有助於人們理解他們在環境中的經歷，而不是認為自己在環境中功能失調。當我研究這些組織時，我的想法是關於正在創造的條件以及這些刻意培育的空間的積極影響。全球精神衛生運動和世界衛生組織承認此類項目的價值（因為他們同時試圖通過他們的建議對此類項目實施監管）。與此同時，儘管存在明顯的缺陷和失敗，但也有大型基礎設施正在建立，以生物醫學模式的形式提供較少基於社會的心理健康支持模式。
Recognition of the impact of socioecological conditions, as opposed to an illness of the brain theory, appears to help people to make meaning of their experience in the environment as opposed to considering themselves as dysfunctional in the environment. My thoughts as I researched these organisations were about the conditions that were being created and the positive impact of such deliberately cultivated spaces. There is recognition of the value of such projects by the movement for Global Mental Health and the World Health Organisation (as they simultaneously attempt to impose regulations upon such projects through their recommendations). At the same time, there are also large infrastructures being established to deliver less socially-based models of mental health support in the form of the biomedical model, despite its obvious flaws and failings.
預防
Prevention
儘管許多組織都在做著令人驚嘆的工作，但它們通常停留在人類體驗的治療端。幫助重建聯繫和社區以及改善環境往往發生在心理惡化之後，而不是預防它。
Although many organisations are doing amazing work, they often reside at the treatment end of the human experience. Help with rebuilding connection and community and fostering an improved environment tends to come after psychological deterioration rather than in prevention of it.
如果正如全球心理健康運動所承認的那樣，不良心理健康對全球經濟造成的成本負擔確實很高，並且難以獲得心理健康服務的資金，那麼為什麼全球心理健康在很大程度上缺少預防敘述？
If, as acknowledged by the movement for Global Mental Health, the burden of cost of poor mental health to the global economy is truly high, and funding for mental health services is hard to come by, why is prevention largely missing from the Global Mental Health narrative?
如果我們承認“恢復”條件的重要性，那麼我們也許還需要意識到，我們忽略了人們最初期望生活的原始條件。
If we acknowledge the importance of conditions for “recovery,” then we perhaps also need to be aware that we are overlooking the original conditions in which people are expected to live in the first place.
我越是探索全球心理健康干預措施（以診斷、醫學和短期解決問題療法的形式）的地理和社會生態學，就越清楚地以剝奪公民身份的形式歧視、邊緣化、無法獲得基本醫療保健、移民政策的影響以及導致物質和社會貧困的教育障礙，都是導致心理健康惡化的明顯原因。
The more I explored the geographies and socioecology’s of places where Global Mental Health interventions, in the form of diagnosis, medicine, and short-term problem-solving therapies, are being established, the clearer it became that deprivation of citizenship, in the form of discrimination, marginalisation, lack of access to basic health care, the impacts of migratory policies, and barriers to education leading to material and social poverty, were obvious causes of deteriorating mental health.
儘管承認痛苦的社會方面，全球心理健康運動和世界衛生組織使用的首選術語“心理社會殘疾”仍然將問題定位為個人內部的殘疾，而不是更廣泛的社會生態學。心理健康質量與物質和環境條件之間的聯繫仍然模糊不清。
Despite acknowledging the social aspects of distress, the preferred term used by the movement for Global Mental Health and the WHO,” psychosocial disability,” still locates the problem as a disability within the individual, rather than in the broader socioecology. The connection of the quality of mental health to material and environmental conditions remains obscured.
在研究預防方法時，誠實地對待不良社會生態學對心理健康的因果影響將是一個很好的起點。與其建立昂貴的基礎設施來治療症狀，不如讓人們了解這種聯繫，從而幫助人們理解他們的痛苦。人們至少可以開始認識到功能失調的真正原因，而不是被留在他們的反應功能失調的錯覺中。
Being honest about the causal effects of poor socioecologies upon mental health would be a good starting point when looking at preventative approaches. Instead of setting up expensive infrastructures to treat symptoms, empowering people with knowledge about such connections helps people to make sense and meaning of their suffering. Rather than being left under the illusion that their responses are dysfunctional, people can at least begin to recognise where the dysfunction really lays.
結論
Conclusion
我們知道，生活條件的質量對於人類茁壯成長的能力至關重要，因此首先需要更加註重創造體現人權、以人為本、以社區為中心、充分參與的環境的條件。由於繼續未能將痛苦視為惡劣條件的晴雨表，我們冒著輸出具有破壞性的症狀管理模型的風險，這將使處於這種條件下的人們增加了診斷出位於其人體內的故障的負擔。
We know that the quality of living conditions is vital to the ability of human beings to thrive, so there needs to be more focus on creating conditions that embody human rights, person-centred, community-focussed, fully participatory environments in the first place. By continuing to fail to recognise distress as a barometer of poor conditions, we risk exporting a destructive model of symptom management that will leave people in such conditions with the added burden of a diagnosis of malfunction located within their person.
到目前為止，我的研究已經證實，我們作為人類生活的條件在很大程度上決定了我們是否能夠在身體、情感和心理上茁壯成長。承認這一點使我得出結論，不良的心理健康是不良條件的副產品。這讓我與全球心理健康議程發生衝突，該議程的重點是提供更好的心理支持。我覺得雖然心理支持非常重要，但有證據表明，如果病因仍未解決，生物醫學治療會產生更多治療，但無濟於事。
My research so far has confirmed for me that the conditions in which we live our lives as human beings largely dictate whether or not we are able to thrive physically, emotionally, and psychologically. Acknowledging this leads me to conclude that poor mental health is a by-product of poor conditions. This leaves me in conflict with the Global Mental Health agenda, where the emphasis is on providing better access to psychological support. I feel that while psychological support is very important, the evidence is that biomedical treatments beget more treatments, to no avail, if causal factors remain unaddressed.
當我考慮我的研究博士的方向時，我意識到我的問題是：我們真的在這個星球上存在全球心理健康危機，還是我們有一個“我們期望人們在告訴他們的同時生活的惡劣條件”他們的反應是“心理疾病”危機嗎？這個問題與我開始在心理健康領域工作的旅程有關，我自己的診斷和治療經驗給康復造成了障礙，需要在康復發生之前將其拆除。我認為為了全球心理健康的利益，可能有必要對建立在大腦功能障礙的有缺陷前提下的精神系統進行類似的拆除。
As I contemplate the direction of my research PhD, I’m conscious that my question is: Do we really have a Global Mental Health crisis on this planet, or do we have a “poor conditions in which we expect people to live while telling them that their responses are psychological illness” crisis? This question ties in with the beginning of my journey into working in the field of mental health, where my own experience of diagnosis and treatment created a barrier to recovery which needed to be dismantled before recovery could take place. I feel that a similar dismantling of a psychiatric system built on the flawed premise of brain malfunction may be necessary for the benefit of Global Mental Health.
***
來源:
Mad in America 擁有不同作家群體的博客。這些帖子旨在作為一個公共論壇，廣泛地討論精神病學及其治療。所表達的意見是作者自己的。
吉爾巴蒂Gill Batty與全球各地正在經歷焦慮的客戶進行一對一的合作。她目前正在創建一個在線的、完整插圖的交互式課程，該課程將是一個數字版本——以便有更多的時間來研究診斷和焦慮的醫學化對個人和社會對焦慮的理解及其作為遇險信號和功能的作用的影響。回复。推特：@GillBatty
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.