憂鬱污名探究：病因歸因與面子顧慮之影響

Abstract

精神疾病污名問題，近年來愈來愈受到心理衛生專業人員、精神醫療消費者、非政府組織與立法機關的重視。污名概念涵蓋三個層次，即負向標籤、負向認知情緒、與負向行為反應。文獻回顧指出憂鬱污名對憂鬱者求助意願、自尊、自我效能、治療持續性、服藥遵從性、健康保險、友誼、婚姻、求職與工作等層面造成負面影響。過去研究指出，憂鬱症狀較嚴重者與亞裔或華人族群有較高的憂鬱自我污名。此外，華人較傾向將憂鬱病因歸諸心理層面，且面子顧慮傾向也較強。綜合以上，本論文目的共有兩個層面：一、探索病因歸因與面子顧慮對憂鬱污名的效果；二、嘗試尋求降低憂鬱污名的有效方法。本論文包含三個探討病因歸因效果的實證研究，並在第四個研究同時探究面子顧慮與病因歸因對自我污名的影響。 研究一以實驗的設計，將這兩種書面教育短文--1）強調憂鬱症屬於生理疾病的生理訊息，與/或2）強調憂鬱症並非患者過錯的去污名訊息，隨機分派給受試者閱讀，檢驗生理訊息、去污名訊息對專業求助意願的效果。結果發現接受生理訊息者有較高的求助意願，但去污名訊息則沒有顯著效果。顯示生理歸因可能可使憂鬱處境正當化，進而增進求助意願；但去污名訊息僅能降低公眾污名，無法提升求助意願。 研究二旨在探究生理歸因對公眾污名與自我污名的影響，採用團體講授方式提供憂鬱症之神經生理教育，進一步探討生理訊息是否影響社會距離與污名容忍度。結果發現：當與控制組相較時，接受生理訊息者對憂鬱者的社會距離較短，但兩組的污名容忍度無顯著差異。顯示生理訊息在降低公眾污名上有所助益，但卻無法影響自我污名。 研究三旨在探究憂鬱症病因歸因對污名相關變項的影響，採用各種情境短文給予受試者閱讀，以探討生理或心理的病因歸因訊息，是否透過責任歸因或可控性歸因來影響憂鬱污名之相關變項，包括對憂鬱者的態度、主觀預後評估、求助意願、污名感受等。結果發現不論是病人樣本或是大學生樣本，接受生理訊息皆可降低對憂鬱者的責任歸因，但責任歸因的中介效果並不存在，且心理歸因訊息並沒有任何顯著效果。顯示歸諸生理可使人們較不認為憂鬱為當事人的責任，但是否進一步提升求助意願仍需未來研究探討。 研究四以面子顧慮與命定、心理、人際、身體等病因歸因來預測門診憂鬱患者的自我污名。透過多元階層迴歸分析後發現，面子顧慮與身體、心理歸因等「向內歸因」的方式，對憂鬱自我污名具有顯著預測效果；其中，面子顧慮可解釋7.2%的總變異量，高於其他預測變項，顯示面子顧慮是華人社會中影響憂鬱患者自我污名非常重要的變項。 在綜合討論部分，本論文說明主要發現、研究限制、貢獻與未來方向。綜整所有發現，本論文認為在降低公眾污名的部分，採取歸諸生理的策略具有顯著改善效果，但在降低自我污名的部分，則可能要採取降低面子顧慮或歸諸命定的策略。然而，由於本論文大部分測量皆為僅評估態度層面的自填問卷，因此類化到實際行為時須十分謹慎。此外，取樣未必具有充分的代表性，故仍須以較保守的方式解釋研究結果。整體而言，本論文僅在生理/心理病因解釋的優劣論戰得到初步結論，不過也為未來心理衛生工作提供了些許的本土資訊。本論文也建議對一般人與憂鬱者的實務處遇上，可先透過生理訊息增進專業求助意願，減少責任歸因，待醫病關係較為穩定後，才探討心理、人際，甚至是靈性方面問題，以有效提供預防性、治療性的心理協助。在台灣文化的脈絡下，未來研究方向與臨床應用可能需要留意患者的面子問題，並將生理-心理-社會-靈性模式的整體觀納入考量。

Issues concerning the stigma of mental illnesses are getting more and more attention to mental health professionals, psychiatric consumers, non-governmental organizations, and legislative bodies in recent years. The conception of stigma consists of three levels: negative labeling, negative cognitions or emotions, and negative behavioral reactions. Literature review showed that stigma of depression have negative impacts on willingness to seek help, self-esteem, self-efficacy, treatment continuity, medication compliance, health insurance, friendship, marriage, and job-seeking to depressed patients. Previous studies also suggested that depressed people with severer symptoms and Asian or Chinese groups have higher self-stigma of depression. Furthermore, Chinese people were found to be more likely to attribute the cause of depression to psychological aspects and to have stronger face concern tendencies. Taking together, the aims of this dissertation research are twofold: first, to explore the effects of causal attribution and face concern on stigma of depression, and second, to search for effective methods to reduce stigma of depression. This dissertation includes three empirical studies on the effects of causal attribution, and the fourth study investigated the influences of face concern and causal attribution on self-stigma. In Study 1, an experimental design was used to examine the effect of psycho-education information about depression on help-seeking willingness. Two types of written education vignettes were employed, including: 1) biological information emphasizing that depressive disorder belongs to biological diseases, and/or 2) destigmatization information emphasizing that depressive disorder is not due to patients’ faults. The vignettes were given to randomly assigned participants. The effects of biological or destigmatization information on the willingness to seek professional help were examined. Results showed that participants receiving biological information had greater willingness to seek help, but destigmatization information did not have significant effect. It suggested that biological information might make depressive condition legitimized, and further increase willingness to seek help. However, destigmatization information may just decrease public stigma, rather than promote willingness to seek help. The purpose of Study 2 was to explore the effects of biological attribution on public stigma and self-stigma. A collective lecture of neurobiological education on depressive disorder was implemented to examine if biological information influenced social distances and stigma tolerance. The results showed that, when compared with the control group, participants who received biological information displayed shorter social distances to the depressed. However, two groups did not have any significant differences in stigma tolerances. It revealed that biological information may benefit the reduction of public stigma, whereas it may have no influences on self-stigma. The purpose of Study 3 was to explore the effects of causal attribution of depression on stigma-related variables. Various contents of scenarios were given to explore whether biological and/or psychological information influenced stigma-related variables including attitudes towards the depressed, subjective evaluation of prognosis, help-seeking willingness, and perceived stigma through responsibility and controllability attribution. The results showed that receiving biological information reduced responsibility attribution in both patient and college student samples, however, the mediating effect of responsibility attribution did not exist, and psychological attribution information did not have any significant effects. It suggested that biological attribution may make people believe that it is not the depressed individual’s responsibility to become depressed. Nevertheless, whether this can further influence help-seeking willingness still needs future research. In Study 4, face concern as well as fatalistic, psychological, interpersonal, and somatic causal attributions were employed to predict self-stigma of outpatients with depressive disorders. Through hierarchical multiple regression analyses, the results showed that face concern and “inward attribution” such as somatic attribution and psychological attribution had significant effects on predicting self-stigma of depression. Outnumbering other predictors, face concern explained 7.2% of the total variance. It suggested that face concern may be a very important variable which influences the self-stigma of the depressed in Chinese society. In the general discussion of this dissertation, main findings, limitations, contributions, and future directions were described. Taking all findings together, it is suggested that adopting the strategy of biological attribution may have positive effects on reducing public stigma, and adopting the strategy of face concern reduction or the strategy of fatalistic attribution could lessen self-stigma. However, most measurements in this dissertation are self-report questionnaires and only assess attitudes. Thus, it should be very cautious to generalize the results to actual behaviors. In addition, the samples were not fully representative. It should be take a conservative way to explain these results. Generally speaking, this dissertation can only reach a preliminary conclusion of the debates on the pros and cons of biological/psychological causal attribution. Nevertheless, it may provide some indigenous information for mental health promotion in the future. It is also suggested that, in order to provide preventive and/or remedial psychological help to ordinary people and patients with depressive disorders, biological information could be present first to increase help-seeking willingness, reduce responsibility attribution, and then talk over psychological, interpersonal, even spiritual problems after the relationship between the patient and the therapist become steady. Under the context of Taiwan culture, future directions of research and clinical applications are suggested to pay more attention to patients’ face issues and to take the holistic view of the bio-psycho-social-spiritual model into consideration.