Back to a social diagnosis of mental health conditions

“在杂音系列专栏里，我们收集各种各样有关精神疾病的声音。尽量去呈现更多的观点，打造一个多元化声音的集散地。”

杂音系列

第21篇

关键词：社会 社工 抑郁症 精神健康

翻译计划启动！

刺鸟推文翻译计划启动！该翻译计划由刺鸟志愿者自行认领喜欢且适合推广的刺鸟原创文章进行翻译，方便信息共享和行业交流，欢迎读者将我们的思考和实践分享给更多国家和地区的伙伴。若您对该计划感兴趣，欢迎报名我们的志愿者志愿者招募 | 温柔的勇士请来此栖息。

这篇文章节选自2017年的论文结尾，正好看到外卖骑手系统性困境的那篇文章。其实在精神健康领域又何尝不是如此。不管是对于助人者还是服务使用者来说，困境的后面都有着深层的结构性原因。

This article is adapted from the ending of a 2017 paper on depression-related social work. The paper presented several case studies from field research. Its original publication here was inspired by another article dealing with the systemic difficulties faced by delivery people. In fact, the observation about systemic difficulties also applies to the mental health field. Be it for the helper or the helped, deep-rooted structural problems underlie all surface issues.

在这篇文章里面，你可以了解到为什么我们称呼自己为非主流公共团体，你也能看到，精神疾病的干预不是治疗或解放二选一那么简单。

In this article, we hope to illustrate the reasons why we call ourself an "atypical NGO". We will also explain why intervention for mental illnesses is not a simple matter of treatment or liberation. Treatment in the clinical sense, and liberation in the Foucauldian sense.

生活的多重真理

Life's multiple truths

福柯——田野里至少有三位患者和我夸赞过他——将人文科学（包括社会工作）描述为“真理游戏（truth games）”，通过这种游戏，人类主体渴望去了解自身的真相，并且积极参与到通过护理实践寻找这一真理的过程。

Foucault — praised by at least three patients in my field research — called human sciences (including social work) truth games. Through these games, human subjects attempt to learn about their own truth. At the same time, they also actively participate in the discovery of truth. In the social work field, the latter is achieved by means of caring practice.

在这次的田野调查中，游戏的玩家不止患者一方。本文更多关注了患者，因此看到的更多是患者视角下的互动。妙妙选择了和中医完成关于自我真理的生产，火火们则在游戏中扮演了被医生和咨询师指挥的角色。我们也可以预测，越来越多的人会加入到这场游戏里来。对于个体来说这是一场艰难的重新发现自我之旅，对于社会整体来说，这是关于生命看法的大型游戏。

In our field research, patients were not the only "game players". However, since our focus was on them, we were more disposed to see things from their perspective. In this game, one interviewee Miaomiao chose to partner with traditional Chinese medicine to produce their own self-truths, whereas Huohuo assumed a role that took commands from doctors and therapists. We can safely predict that more and more people will partake in this game. For individuals, it will be a hard journey of self-rediscovery. At the societal level, it will be some kind of a massively multiplayer game about different life views.

实际上，人们不仅仅在寻找真理，也在再造真理。对于社会工作者又何尝不是？是治疗还是治理？是做病人的朋友还是做病人的敌人？

We don't just look for truths. We also create them. This also applies to social workers. Treatment or management? Be patients' enemy or friend? These types of questions may all contribute to the construction of our truth.

我想起小王对我说的话，“只要有一个反例你就不能下结论”，想起越陌对我说的话，“大家的想法可能是相反的。”

I'm reminded of what my friend Wang's statement: "With a single counter-example, you lose the privilege of reaching a conclusion." I remember equally well what Yuemo said: "People might have opposite views."

在一个不存在终极知识的世界中，社会工作要何去何从？我没有办法给出答案。但是这篇文章的写作本身或许就是答案。把各种各样的生活真理都讲述出来，尽管这样的讲述是局部的和片刻的，或许只有这样，社会工作才有可能“在现代性的尽头，承受动摇我们灵魂的凛冽狂风(Chambon, Irving, & Epstein,1999)”。

In a world where the ultimate knowledge is absent, where should social work go? I don't have an answer. But this article itself might hold a key to it. Narrate all kinds of life truths, even if the narration is partial and momentary. This is perhaps the only way through which social work can bear the winds that shake our soul at the end of modernity (paraphrased from Chambon, Irving, & Epstein,1999).

拍摄于安定医院附近

Photo shot near Anding Hospital, one of the most reputable psychiatric hospitals in China

The banner reads: "No Shots No Medications Completely Eradicate Depression Obsession Fear Anxiety Paranoia Insomnia"

面向社会的社工

Social workers for the society

我们要谨记，社会工作的名字有包含“社会”一词，所以，一定有其社会涵义。社会工作要同样重视关怀个人和改变社会的两个重要目标。社工专业不可以只着重改变个人的目标，而忽略了其“社会”目标。社工应该相信，个人治疗与实践社会公义不应该互相排斥，推动社会改变及社会公义并不等同忽略个人治疗工作的重要；热衷临床治疗工作也不表示要摒弃社会公义的使命。——甘炳光
"We must bear in mind that 'society' is in the name of 'social work'. Therefore, it has its social implications. Social work must tend equally to its two major goals: caring for individuals and promoting social changes. The social work professional cannot only focus on the former whiling ignoring the 'social' goal. They should believe that personal treatment and the practice of social justice are not mutually exclusive. Promoting social changes and social justice is not equivalent to ignoring the treatment of actual people. Nor does being passionate about clinical treatment imply the abandonment of the social justice mission. "
——Dr. KAM Ping Kwong 

在本文所呈现的抑郁图景里，抑郁症在充当临床定义之外还包含着复杂的社会意义。而这种社会意义，和社会工作所包含“社会”意义，能够以哪些方式契合从而指导实践呢？

In this article, we have chosen to depict depression not as a mere clinical diagnosis, but also as the carrier of a myriad of social meanings. This begs some further questions. First, in which ways can the social meanings of depression converge with the social meanings of social work? And once converged, how can they together guide our practice?

把服务对象看作是有着个人背景、经历和感受的完整的人，而非只看到病症和困难。这样的说法社会工作者已经十分熟悉，在第三章的讨论里面，我们已经看到了那些非常具体的心结，和患者一起面对这些痛苦，是长期以来社会工作的职责所在。第四章里面抑郁者对于学校应对机制的不满和期盼权益得到倡导的需求，要求社会工作者为患者制造和培养良好的环境。第五章里我们看到威权医学模式（paternalistic-medical）对患者的压迫，患者需要更多的权利，呼唤着促进自主的治疗模式（autonomy-promoting）。

Viewing the helped as complete human subjects with their own background, experience, and feelings, rather than just seeing diseases and difficulties — this is an idea that social workers are already fairly familiar with. In Chapter 3, we looked at some concrete difficulties that patients experienced. Facing these pains together with them has always been one of social workers' responsibilities. In Chapter 4, we looked at the dissatisfaction of students with depression towards the response system of their schools. We saw how badly they wanted their rights and interests to be advocated. This requires social workers to create and maintain a hospitable environment for them. In Chapter 5, we saw the oppression that the paternalistic-medical model imposed on patients. This calls for more patient rights as well as autonomy-promoting models.

以上的内容围绕着长期以来社会工作的两大目标，其一是关注个人转变与治疗；其二是推动社会改革并实现社会正义。

The above is in alignment with both of the previously-cited goals: treating and changing individuals on one hand, social reform and social justice on the other.

但这只是一部分。本文认为，社工还可以在“社会”层面做更为丰富的理解。

But this is not all. In our view, social workers can understand the “social” as carrying even more layers of senses.

首先是社会工作者面对抑郁症个体要如何理解其状况。个体的抑郁症情况在多大程度上是病理性的障碍又在多大程度上是文化的形塑？抑郁症是被当事人作为困境而试图摆脱还是作为策略而主动拥抱？不了解这些社会意义而只关心临床定义的话，就有可能忽略复杂的现实情况而陷入武断分类的陷阱中。在抑郁症诊断增长和人们对于抑郁症的意识突出的当下，社工的社会视角不仅仅是带着“社会背景”视角去评估服务对象，更需要“社会建构”视角来考察抑郁者本人对于自身抑郁症的看法是如何形成的。

The first layer concerns the way in which social workers should understand the sufferers' condition. To which extent can their depression be seen as pathological? And to which extent can it be attributed to culture’s shaping force? Does the sufferer view depression as an affliction to get rid of? Or, do they actively embrace the label as some sort of strategy? If we only see clinical definitions with no regard to the social layers, we might ignore the complexity of the reality and fall into the trap of dogmatic categorization. Diagnosis of depression is on the rise. Awareness of depression is in the spotlight. In this context, the "social" perspective for social workers is not simply a matter of evaluating service users based on their social background. We also need a "social construction" perspective, one that accounts for the ways the sufferers formed their own opinion about their depression.

再者是社会工作的服务范围和服务手法。回到本文所涉及到的抑郁者，他们多数没有住院经历，尽管站在医生的角度，他们中有的人“应该”住院。现有的精神健康社工实践多集中在极少数的医院和社区，这些人可能一直都不会去住院，也没有固定居住的社区，那么社会工作者如何能够为之提供服务？特别是在民间心理咨询如火如荼的当下，社工如何差别化发展？

The second layer concerns the range of social work services and its methods. Most mental health social workers are concentrated in a tiny number of hospitals and communities. Most of the patients interviewed in this article have never been hospitalized, although some of them "should" be so from a clinician’s view. And they are likely never going to get hospitalized. They might not even stay in one community for long. How can social workers bring services to them? Furthermore, with private counselling gaining more and more popularity, how can social workers find a differential way towards development?

拍摄于日本“自杀森林”

Photo shot in the "suicide forest" in Japan

长期以来我们的目光都聚焦于那些得了抑郁症的个人，把他们作为有病痛的、在特定意义的环境中融合了社会、历史和身体经验的主体，而如今这种主体性正在被以风险追踪为核心的现代防治手段所瓦解（Rabinow，1996）。到这里，在抑郁症这个话题上，社会工作的服务对象从个案走向了社群（society）。

We have, since long, focused on individuals with depression. We regard them as subjects with disease or pain and who integrate social, historical, and body experiences in specific contexts. However, this subjectivity is getting dismantled by the modern prevention method with risk tracking at its core (Rabinow, 1996). When it comes to depression, social service users are transitioning from individual cases to the communities.

这种服务范围的微妙变化也对服务手法做出了要求。

This subtle adjustment of service range poses new requirements on work approaches.

在服务手法上，社工需要融合微观和宏观的手法。在刺鸟栖息地的实践经验里面，结合社会工作专业所长，既尝试过组织线下讨论，也尝试过线上直播、撰写网络文章，在鼓励分享和倾听的同时也提供关于抑郁症现象的不同见解，和人们分享抑郁症不局限于医学视角的多重含义，用时下流行的方式来达到发出声音产生影响的目的。

In terms of service approach, social works should combine the macro with the micro. As an "atypical NGO", A Perch for the Thorn Birds tries to integrate the strengths of the social work profession. For example, we have organized offline discussions, online live-streaming sessions, and written online articles. We encourage sharing and listening. We offer different views on the phenomenon of depression as well as definitions of depression that are not restricted to the medical. We speak up to create impact, using diverse methods like filming, theatre, and others.

在这些实践里面，受众是某一类人而非某一个人。这样的从外围提供支持的方式，既呼应了抑郁者对于舆论环境改变的需求，呼应了普通民众的求知需求，也能够给微观层面的社工实务以辅助，能够将社工从固化的专业角色中解放出来，进行更加灵活的尝试，从而为社会工作的专业性提供更加丰富的内涵。同时我也看到，精神病学和心理学工作者同样正做一些并非老本行的事情，前文所提到的一些颇具影响力的自媒体就是他们工作的成果。我们姑且不说精神医学和心理学所主导的健康传播是否预示着更加乐观的前景，但这至少为缺位的社会工作者提供一种借鉴的可能。社会工作者有没有可能找到契合自己的实践形式，有没有可能提供差别化的内容，有没有可能发出不同视角的声音，从而在为抑郁者打开出路的同时也树立自己的专业独特性。

In these practices, the audience is not a specific person, but rather a type of people. These types of support in a more public sphere respond not only to depression sufferers' needs for changes in public opinions, but also to the general population's thirst for knowledge. They can thus assist the concrete social work done at the micro level. What's more, they liberate social workers from our fixed professional role, and give us the flexibility to venture out and try more things. This can enrich our profession.At the same time, psychiatric and other mental health professionals are stepping out of their niches. Some have created influential social media accounts. We social workers are by and large absent in this regard and can learn from them. We may try to find forms of practice that suits us, provide differential services, and speak up from different angles. This can not only help those with depression, but also contribute to our uniqueness as a profession.

甘炳光（2010）呼吁社工应当重拾社会本质，指出社会工作正在迈向个人辅导而忽略社会本分，指出社会工作专业在走向专业化的同时也走向了“去社会化”。他呼吁突破微观与宏观介入实务的界限，认为倡导工作是每个专业社工都要兼负的任务。在精神健康社会工作在内地作为一个行当尚未成型的时候，讨论太多细节有纸上谈兵的嫌疑。只是有一点很明确，对于香港社工来说，回归社会是要重新捡起来的东西，对于内地社工来说，这是当下就可以走的新路。

Dr. KAM Ping Kwong (2010) called on social workers to regain social nature of social work, noting that social work was moving towards individual counselling at the expense of its social callings. He argued that what came with the specialization within the field was its "desocialization". He also suggested that we break the boundary between macro and micro interventions, and considered advocacy and promotion to be every social worker's responsibility. One might say that addressing these detailed issues might be too early for Chinese mainland, where the profession is still in its formative stages. I beg to differ. For our Hong Konger counterpart, regaining social nature of social work is a rejustment. While for social workers in Chinese mainland, it is a direction that we can choose right now.

摄于2017年刺鸟栖息地办的展览现场

Photo shot at an exhibition organized by A Perch for the Thorn Birds

回到社会诊断

Back to a social diagnosis

一位三十岁不到的金融行业从业者曾经来参加我的活动。在我们一对一聊天的时候，他说他并不是抑郁症，就是觉得心里烦压力大，聊了被老家父母逼婚的烦恼。在某一天的深夜，他发消息问我：

“怎么摆脱原生家庭的阴影？”

我并没有开启倾听的模式扮演一个知心人，而是反问他，

“你从哪儿听来原生家庭这个词的。”毕竟这个词汇是一个心理学的术语。

他告诉我他从从一些公众号里了解到了这个说法，说着说着他表示：

“好像也是。如果他们不这么说我也不会老想我父母的事情。”

A finance professional once came to our event. When we were talking in private, he confided in me that he was not depressed, just angry and stressed. He talked about how his parents in his hometown were pressuring him to get married. One day, deep at night, he messaged me a question:

"How do you outgrow your family of origin's shadow? "

Instead of turning on my empathetic listener mode, I asked a question:

"Where did you learn about the expression, 'family of origin?'" It is a psychology term after all.

He told me how he learnt the expression from social media, and said:

"It seems about right. If they didn't use this expression, I wouldn't be always thinking about my parents and whatnot."

这之后，他开始长篇大论地说同事作为北京人可以不用像他那么辛苦，开始说贫穷出身所带来的阶层逾越的困难。他想表达的其实是社会不公平，但是说出口就变成了原生家庭对于自己的影响。伴随着心理健康概念流行的是那些侧重个人的说法和解释，这些东西让人们重新解释自己的生活经验并理解自己所处的现实。而抑郁症这种在界定方面模糊不清的东西，很容易就成为了承载意义的容器。

Then he started to elaborate on how his colleague, being a Beijing-native, didn’t have to work as hard as him and the difficulty of escaping the social class that came with his humble origins. He wanted to express how unjust the society was, but phrased it as family of origin's influence. Indeed, the popularization of mental health concepts resulted in personal interpretations based on one's life experience and understating of one’s own reality. Depression, with its ambiguous definition, can turn into a container of different meanings.

我不知道当下这些时髦的说辞会让人们达成和自己的和解还是会让人活得更加拧巴。同样，我也不知道反思和怀疑的话语会让人们豁然开朗还是变得义愤填膺。但有一点可以肯定，流传最广泛的那些话语正在形塑大多数人的观念。

I’m not sure if these pop psychology terms will help people reconcile with themselves or aggravate their inner conflicts. I’m equally unsure whether reflection and questioning will bring about more closure or more cynicism. In any event, the most widely used words are shaping the majority's perceptions.

小组活动中让大家对抑郁症这个词做开放式联想的结果

Free association about "depression" in a group work

国家卫计委在最近的新闻发布会上说，我国精神卫生工作内容正在逐步拓展，医疗机构积极探索开展心理健康服务。精神卫生似乎和心理健康是等价的存在，预防性的管理和直接的诊疗被认为同样重要。医生把心理咨询当作辅助治疗，咨询师则把医生当作定海神针。那社工要站在哪里呢？是做直接治疗的辅助者？是做强调风险的管理者？还是其他？在香港，先行者们已经体会到了类似的矛盾：社会工作者只得以“院舍化（institutionalization）”“社会控制（social control）”和“职事化（task oriented）”的模式推行实务，但对外宣传和机构服务承诺上又以“参与”“溶入”“社区照顾”作为包装（叶锦成，2012）。对于大陆的社工来说，情况可能更加复杂。

In a recent press release, authority from China’s National Health and Family Planning Commission said psychiatric work was expanding in the country and medical institutions were actively carrying out mental health services." Mental health and psychiatry were seen as equivalent, with proactive prevention and diagnosis and treatment put on an equal footing. In reality, doctors regard therapies as auxiliary treatment. Therapists also see doctors as a source of reassurance. But where do social workers stand? Treatment assistants? Risk managers? Or something else? Social workers in Hong Kong have already experienced a similar conundrum (Ye, 2012): social workers carried out their practices in the form of "institutionalization" and "social control" in a "task-oriented" manner. However, when it came to publicity and service promises, they had to use expressions in the style of "participation", "integration" and "community care". In Chinese mainland, the situation may be even more complex.

进入田野之前，我的脑海里总是出现规训、权力这样的词，也多多少少带着这些想法开始了探索，私以为抑郁者会更加想被“解放”而非“治疗”，但在实际接触后，我却发觉大多数人在大多数时候都在围绕着治疗、围绕着自我管理在和我讨论，尽管带着抱怨和不满，但那有别于反抗。实际上，越来越多的抑郁者积极的投入了围绕抑郁症的自我实践和社会实践，并且这样的实践也在重塑着抑郁症的意义；越来越多的普通人用精神病学和心理学的知识凝视自我，评估自己情绪与认知，并自觉地联合这方面的专业人士来调整自己的生活。谴责生物医学的傲慢、给还原论和个人主义定罪并不能帮助我们更好的理解当下，我们已经进入了一个医学、人类生命和生物技术普遍政治化的时代（Rose，2001）。在关怀生命本身成为人类生活主题的今天，我们面临的问题不再是治疗和解放的二选一。

Before starting the field research, words like "power" and "discipline" often came to my mind. I started my journey more or less with similar thoughts in mind, believing that people with depression might prefer being "liberated" rather than being "treated". After actually interacting with them, I discovered that most of them would focus on the topics of treatment and self-management when they discussed with me. With complaints and dissatisfaction indeed, but still a far cry from resistance. As a matter of fact, more and more patients have actively engaged themselves in depression-related personal and social initiatives. These initiatives in turn reshape the meaning of the illness. More ordinary people are examining themselves with knowledge from the psychiatric and psychological fields. They assess their emotions and cognitions, and willingly team with mental health professionals to help themselves make adjustments in life. To better understand the present, neither condemning biomedicine of arrogance nor blaming reductionism or individualism is of any use. We have entered an era where the medicine, human life and bio-tech have become political in a generalized way (Rose, 2001). With caring for lives being the theme of human life today, we are no longer faced with a simple question of treatment or liberation.

在本文即将收笔的2017年5月，我收到了来自田野调查对象双黄酮的信。她对我说，“去年的这个时候，大概是病情稍微好转一点，面对每天没有什么起伏的心情既然会感到惶恐。当时最喜欢的一句歌词是‘Everything is in order in the black hole’，是的，万物有序。但是感觉有什么东西在暗处蛰伏。”她的话放到我写作本文的初衷上也意外地合适。作为一个在现有的精神卫生实践中不得劲儿的社会工作学生，我总觉得在看起来是那么回事儿的事情下还蛰伏着许多不是那么回事儿的东西。

While finalizing this article in May 2017, I received a letter from an interviewee nicknamed Shuanguangtong. She wrote: "Around the same time last year, I was maybe feeling a bit better, but I'd still feel panic when faced with my bland mood with no swing. At that time, my favorite song lyrics was 'everything is in order in the black hole'. Yes, everything was in order. But something felt lurking in the dark." Oddly enough, her words also apply to the purpose of my writing. As a social worker student that still has much to learn from practice, I feel that behind a lot of things that look quite in order, lurk many others that are not.

这一幅抑郁图景里，有的地方曝光不足——抑郁者身处黑暗的痛苦；有的地方亮到刺眼——基因序列研究的进展。亮的、暗的、灰蒙蒙的，交织在一起，散发出诡谲的奇异光芒。我们一边重新阐释着生命，一边重新塑造着生命。

In this picture of depression, some areas are underexposed, like the darkness submerging the depressed; some are so bright that they become blinding, like the advancements in genome sequencing. The bright, the dark, and the foggy gray, all woven together, an odd light display. We reinterpret life and we reshape it.

一个世纪之前，在《社会诊断》这本社工经典著作中，Richmond（1917）认为 “诊断”概念的使用就像其他科学领域一样，特指对具体某个服务对象或受助者的社会状况（或社会情境）和人格进行精确的界定。对今天的社工来说，这样的事情变得越来越复杂。依附在其他学科的诊断上闷头做事搞不好会让社工离需要帮助的人越来越远，社工给出自己的诊断仍然充满必要。

A century ago, in her classic on social work Social Diagnosis, Richmond (1917) defined the concept of “diagnosis” in a way consistent with typical definitions in scientific fields as an accurate characterization of the social conditions (or social circumstances) and personality of a specific service user or attendee. For social workers today, things like diagnosis are more complicated than ever. If we, social workers, continue to rely on diagnoses from other disciplines and bury ourselves in task execution without any second-thoughts, it will probably divert us from the people in need. It is fully necessary for us to have the ability to issue diagnoses of our own.

END

翻译丨魏琦梦

校对 丨团子

原文作者 丨小卡

排版 丨小 i 

精神健康艺术团体。以超越学科的视角看待精神健康议题，身体力行促进知识和经验的生产， 秉持社会正义的理念， 探索多元介入的可能。开展同伴教育、 互助团体、 讲座沙龙等经典项目， 也通过影像研习、 影像制作、 戏剧演出、艺术展览等各种艺术创新方式进行精神健康大众传播。连续五年举办精神健康艺术展览。与多所高校合作， 组织教学和培训。曾获北京尚善公益基金会、 706空间青年基金、 银杏基金会、 爱德基金会支持。