臺灣精神病患成為父母者之家庭復原力與親職功能研究—以雙相情緒障礙症與重鬱症為例

Abstract

精神疾病對病患本身和家庭是具有長期深遠的影響，然而，過去多從缺陷、高風險取向來看待精神病患成為父母者(Parental mental illness; PMI)的家庭及親職功能。而本論文的研究，以優勢取向護理觀點，從精神病患的家庭，研究對象有兩群，一是由成年子女回顧童年的成長經驗，二是關注病患本身親職行為隨病程的動態變化與影響因子、父母雙方親職功能的變化對於子女的影響。希冀幫助PMI病患及家庭成員在因應疾病的困境中，找到家庭發展的優勢與復原力的立基點。 本論文包括兩個研究。研究主題一為：「雙相情緒障礙症病患成年子女之家庭復原力到個人復原力之經驗研究」。以質性的詮釋現象學(Interpretative Phenomenological Analysis; IPA)研究方法，研究目的是從雙相情緒障礙症病患的成年子女回顧成長經驗，瞭解子女在面對父母罹患雙相情緒障礙症的家庭困境中，如何覺察到家庭復原力或阻力，進而發展出個體復原力。結果部分，20位成年子女呈現出六個家庭復原力的主題，包括：罹病父母努力扮演好父母、父母的堅毅、父母正向看待罹病者、彈性的家庭角色、家庭成員的凝聚關係、家庭的對外社會連結；家庭復原力的阻力有三個主題：家庭/親職功能不彰、父母關係衝突、心理健康素養不夠。個體復原力有六個主題，包括：家庭逆境增加了面對壓力的勇氣、增強情緒調節能力、家庭逆境能提高人的自律性、促進對生活意義的反思、將逆境正常化為正常生活的一部分、有信心控制病情。而從家庭到個體復原力，兩者之間連結的樞紐，主要是子女與家庭情感連結，以及子女本身的認知情緒調控能力。 研究主題二為：「探討雙相情緒障礙症與重鬱症病患與配偶的親職功能與其子女社會心理適應之影響因素—縱貫性研究」，以量性的前瞻性縱貫研究方法。研究目的有兩個：1.探討雙相情緒障礙症與重鬱症病患成為父母者的臨床症狀與自覺社會支持，於急性精神病房出院前到出院後六個月期間，對病患親職功能之影響。2.探討病患的親職行為和配偶的親職行為和病人社會支持，從準備出院到出院後六個月，對其子女的社會心理適應之影響。此研究從病患急性住院階段，於出院前一周(T1)，同時間收集平日基準值(T0)，之後於出院後一個月(T2)、出院後三個月(T3)、出院後六個月(T4)進行四次重覆測量，採用病患自評的阿拉巴馬親職問卷，探討33位病患從急性住院階段到出院後六個月之親職功能的動態變化與影響因素。以及同樣時間點，採用由病患的配偶填寫之長處與困難量表，評估18個家庭的學齡期(7-14歲)子女社會心理適應方面之影響。以廣義估計方程式的統計方法分析資料，病患資料的結果發現，病患住院後其親職功能下降，從出院前到出院後追蹤6個月期間，其兩個正向親職行為面相並未恢復到基準值狀態。此外，憂鬱症狀和較低的社會支持與正向親職行為面向的變化有關，而躁症狀沒有顯示出這種關聯性。而憂鬱症狀對其親職功能是危險因子，而社會支持是保護因子。而由病患的配偶評估子女的資料，其結果與過去研究及親職理論，有一致與不一致之處，是未來需要進一步分析與探討的。尤其是病患和配偶之間在親職功能上的填補作用。這是未來需進一步透過更多樣本數、進階統計方法，從夫妻對偶來分析的親職功能對子女社會心理適應的影響。 本論文從實證到對臨床應用的貢獻，根據研究主題一，在父母罹患精神雙相情緒障礙症對成年子女的敘說中，雖然子女常以家庭的疾病負面經驗取代了正面經驗，但經過訪談的抽絲剝繭，仍然可以發現家庭是可以提供個體復原力基礎的。護理專業可引導子女從優勢觀點去體會，雖然家庭處於困境，但個人也可因此獲得好處，包括堅毅、及早規劃生涯等，並跳脫負面觀點，即早開始去尋找如何仍可做自己的平衡點上。根據研究主題二，本研究提供了初步的實證研究，瞭解精神病患本身的親職功能，從出院前到出院六個月來看，病患的親職功能主要是受到憂鬱症狀和低社會支持所影響，而子女的社會心理適應則是受病患症狀、社會支持，以及配偶的親職功能所影響，且住院確實可以提供子女保護。而病患本身對子女提供關愛的親職行為，是可以增加子女的長處行為。而當配偶的親職功能也不佳，無法填補病患不足的親職功能時，對子女的社會心理適應是確實會有負面影響的。本論文研究成果未來可以提供護理人員發展家庭護理能力，針對精神病患及其家庭，發展親職教育的評估與介入計畫，即早協助家庭建構其優勢能力。

Parental mental illness (PMI) profoundly impacts the patient and the family. In the past, PMI has often been viewed from a deficit or high-risk perspective, neglecting the opportunity for families and members to have positive experiences in coping with illness. In this thesis, we focus on the dynamic changes in parenting behaviors over the course of the illness in families with PMI and understand the impact of changes in parenting functions on children, as well as adult children's retrospective experiences of growing up with the illness, with the hope of helping PMI patients and family members find the family resilience and strength. Two studies are included in this paper. The first is 'A Narrative Study of Family Resilience to Individual Resilience in Adult Children with Parental Bipolar Disorder'. A qualitative Interpretative Phenomenological Analysis (IPA) study was conducted to understand how the children perceived family resilience or barriers to individual resilience in the face of their parents with bipolar disorder. 20 adult children with parental bipolar disorder were recruited. The result of this study shows the themes of family resilience included: good enough parenting, parental perseverance, positive attitude toward illness, flexible family roles, cohesive family relationships, and external social connections of the family; the themes of resistance to family resilience were: poor family/parental functioning, marital conflict relationship and low mental health literacy. Themes of individual resilience include: family adversity increases courage to face stress, enhances emotional regulation, increases self-discipline, promotes reflection on the meaning of life, normalizing adversity as part of normal life, and confidence in managing the illness. The pivotal link between family resilience to individual resilience is the children's emotional bonding to family and their emotional regulation ability. The 1st study suggests adult children experience family resilience because their parents prioritize their family responsibilities and overall family stability, while individual resilience is achieved through cognitive-emotional regulation as the primary coping strategy in the face of adversity. In terms of coping strategies, some children put aside their own needs and learn the role models of their non-ill parents role modeling, and develop family-centered strategies to cope well with the family. While some children lack attachment to their parents or too tangled, have become detached from their families early, and they choose to leave their families psychologically, i.e., to start their personal career planning early and develop their individual resilience. These two strategies have shown the two sides of the coin. However, both strategies may result in the neglect of the individual psychological needs of the children and indicate that the psychosocial needs of adult children with PMI still require the attention of the nursing profession. The 2nd study is 'A longitudinal study to examine the factors influencing parenting and psychosocial adjustment of children with bipolar disorder and depression since discharging from the hospital,' which is a prospective longitudinal study. The study was conducted to examine the dynamic changes and influences on the parenting function of 33 patients from the acute hospitalization stage to six months after discharge using the Alabama Parenting Questionnaire, which was self-rated by the patients. At the same time, the strengths and difficulties scale completed by the patients' partners was used to assess the impact of psychosocial adjustment on school-age (7-14 years old) children in 18 families. The data were analyzed using a statistical method with a generalized estimating equation. The aims of the study: 1. To examine the impact of clinical symptoms and social support on parenting functions of patients with bipolar disorder or major depressive disorder from discharge from the acute ward to six months after discharge; 2. To examine the impact of parenting behaviors of patients and partners and social support of patients on the psychosocial adjustment of their children from the time of preparation for discharge to six months after discharge. According 1st study, the nursing profession can guide children to appreciate the benefits of family hardship from a strengths-based perspective, including perseverance, early career planning, and the ability to look from a positive view. The 2nd study provides a preliminary empirical study to understand the parenting function of PMI. Patients' positive parenting domains did not fully return to the usual situation during 6-months post-discharge. A parenting functioning recovery program targeting the impacts of depressive symptoms on parenting functioning and insufficient social support is needed from hospitalization to post-discharge. This thesis allows the nursing profession to develop strength-based nursing to care for the whole PMI family and early foster family resilience.