關於 mental health theory ，我們在網路上蒐集到這些相關的討論、資訊與評價

整理資料發現近兩年前去某國際研討會分享 #手天使 心得時的講稿，當時把我知道的議題面向都寫進去了。貼上來給有興趣的朋友。

[[slide page 1]]
Thank you for attending this part.
I'm from Hand Angel, a non-profit organization of Taiwan.

The title of my presentation is "As a sex worker and a sex volunteer",
since I'm both a sex worker, and also attending Hand Angel as a sex volunteer.

[[slide page 2]]
Allow me to introduce my organization more,
though you may know some from what Vincent has said in the morning.

Our main tenet is sexual rights to people with disabilities.

[[slide page 3]]
This includes not only orgasm, but also the right to control one's sexuality with autonomy and without discrimination.
People know us usually because we provide limited sexual service for servere physical or visual disabilities, including females.

Hand Angel is not a registered organization in Taiwan,
since we literally provide sexual service, which is considered against public order and morals.

However, we are still able to initiative our idea on the table
because our service are free, which means we actually do not violate any law.

[[slide page 4]]
In Taiwan, the definition of "sexual transaction" includes obscene acts in exchange for monetary,
which means it's considered transactional sex even there is no sexual intercourse.
And since transactional sex is technically illegal in Taiwan,
there's no legal way for us to charge anything by providing any service which may be considered obscenity.

This is much different in other countries.
In Japan, the law prohibiting sexual transaction only applies to intercourse between one male and one female. That's why White Hands and NOIR are able to provide paid handjob. The other reason is that they seem do not locate their service as sexual transaction. We can talk about this difference later.
And in Hong Kong, there's some way for sex workers not to be punished, which is called "one-woman brothel". So the difficulty for people with disabilities to satisfy their sexual desire would be different.

I, who has been a sex worker for years -- under the table, of course -- was invited to join Hand Angel at its very beginning.
[[slide page 5]]
People keep asking me that how a sex worker would think about a free sexual service.
But before that question, I think it's more important for us to know the difference other than money.
What's the difference between a classical transactional sex and our service?

As a sex worker, I hope my customers will come back to me more and more, as many times as they can pay.
But as a member of Hand Angel, I hope the servees would not need us anymore.
In fact, I hope they don't have to come to us at the very beginning.

The reason why people with disabilities may need sexual service, is the absence of sexual resource, the resource to fulfill one's sexual desire.

This is just like other issues of disabilities.
[[slide page 6]]
Just providing a service would not resolve the structural problem.

For example, if you give food to the poor without changing their situation, you would end up finding out that they're still poor.
Now change the "food" to "sex".
If we just give our own sex to those who barely have sexual resource, we'll end up exploiting ourselves, and their bad situation still remains.

The problem is, disabled people are considered abnormal, and they have been treated as no unnecessary needs.
But what is necessary for a person to live her own life instead of just survive?
In our issue, disabled people are usually considered asexual, and seldom sexy. That's the stigma we're going to break down.

[[slide page 7]]
There are some textures talking about disabled people in love and having sex, such as "Scarlet Road", "Sex on Wheels", and "The Sessions".
However, the narrative are usually based on ableism.
Viewers usually focus on how can the service provider "bear" to have sex with disabled people, instead of seeing the obstacles disabled people encounter.

[[slide page 8]]
A feminist has said that the relationship a disabled person has is considered depending on the compassion of the other person. People think their sexuality is disgusting and only saints are able to tolerate it.

So we can see the problem is not only physical obstacles, but also how we think about intimate relationship a disabled person deserves.

[[slide page 9]]
Does Hand Angel care about intimate issue? The answer is yes.
In our service, we provide not only sexual service. Our target is not the physical orgasm, but the infinite opportunity of their own lives.
Here are two examples.

[[slide page 10]] Little Prince
Since this servee can sense nothing below his waist, a classical handjob would be meaningless.
Fortunately, we have a BDSM queen in our team.
She thought of techniques in SM to check how pain it is to the slave, and use the same trick to check how the servee's body can feel.
I have to emphasize: that was not a medical treatment, that was about communication with each other.
They were talking about the feeling of two people, instead of the body of one person.
The whole process relies on the intimacy between the sex volunteer and the servee.

[[slide page 11]] ND
"Strolling" for him was from his room to the front door of his home.
Uh, I'm not talking about he lives in a big house.
Though using an electric wheelchair, ND's finger was not powerful enough to control the device for more than 10 minutes,
which means going out alone is not possible for him.
But after applying for our service, he trained himself to "walk" longer.
Even after our service, we were told that he kept trying to leave home and meet other friends.

Another servee has tried other entertainment such as snorkeling and paragliding after our service.
He's having a more plentiful life than before, and even than me.

[[slide page 12]]
In these cases, we can see that:
First, physical orgasm is not the only purpose of a sexual service.
Secondly, libido, or desire for sexual activity, is a strong energy for people to live.

There's a continuing question for us: People can still live without sex.
[[slide page 13]]
What's so important for disabled people to have sex?
Well, I think sex is probably not important for those who can have sex easily, but the impossibility to sex or intimacy may deny the self-esteem of a person.
Sex is an important reason for most people to make friends. So on the other hand, once a person is forced to abandon the opportunity to have sex, she (or he) might lose the energy to social activities. And that's not good for mental health.

[[slide page 14]] The 3 aspects we care about
First, physical orgasm. This is not only about sex organ, but also those come from your erogenous zone.
The problem is not only that people don't know how to interact with disabled people during sex,
but also that people do not want to know how the sex would be for people with different disabilities.

Second, intimacy. The right to have a satisfying date is also important.
Let's imagine, what if a couple of lovers want to kiss each other while seeing movie in a theater, but one of them is in wheelchair so their positions are actually separated?

Third, social integration. Many people with disabilities don't have enough opportunity to make close friends. One of the reasons is that other people usually don't know how to react with disabled people. Therefore, education is important.

[[slide page 15]] Gender Equity Education
In Taiwan, gender equity education comprises 3 parts: affective education, sex education, and gay and lesbian education.
Though I also want to introduce the situation that the conservative group is raising a proposal of referendum to forbid gay and lesbian education, but that's not the issue here so I have to skip that. I hope people who are interested in Taiwan may notice that same-sex marriage is not the only issue about gender equity.

Uh, back to disability rights movement.
As an organization which cares both gender issue and disability issue, we note that even open-minded gender activists may ignore the existence of people with disabilities.
Gender equity education is never designed or applied in the point of view of the disabled.
For example, there are some materials for teaching safe sex, but people seldom think about how a blind person should know before she (or he) masturbate or have sex.

We have a servee who once masturbated in the bathroom of his home, but couldn't clean up since not knowing where his semen reached during ejaculation, and therefore shocked his sister who later used the bathroom.
And another friend bought an artificial vagina in a sex toy store. But he didn't even know he have to erect before insertion.

[[slide page 16]] female servee
People caring about gender equity keep question us: why is there only one female servee during these 5 years after our foundation?
Well, we think the answer is complicated. But the most important one is: how difficult for a female to "confess" she has sexual desire?
We all know about "slut shaming", and those terms to humiliate females by their sexuality -- such as "bitch" and "whore".
It's difficult even for able-bodied females to state their sex experience and preference.
Then it's even more difficult for disabled females to think what she herself wants.

But before sexual activity with other people, disabled females don't even know their body well.
The only female servee we have, told us she has never seen or touched her own vagina.
So we also hosted some conferences and speeches to discuss about such situation of disabled females.

[[slide page 17]] Androcentrism
This is an important issue for us. And I think it's important for those who care about sexual health of disabled people.
Though there are some textures talking about sexual desires of disabled females. To provide sexual service or even sex education to them is barely seen.
I have to admit that, even though there are more and more female members joining us, androcentrism is still not easy to get over.

[[slide page 18]] limitations
Hand Angel provides service to those with servere physical or visual disabilities.
So here comes a frequently asked question: what about others?
The main difficulty for us is that we don't know enough about the situation of other disabilities.
Of course we know that people with other disabilities also don't have enough sexual resources,
but we ourselves do not have enough resources to share, either.
That's why we also hope other people to compose other similar organization.

Meanwhile, there are some people we cannot help because of law.
Adolescents are the ones I myself care about most,
since male teenagers have overwhelming sexual desire, and that would be hell for those with upper limb disability.

However, there are always laws prohibiting youths to have sex in every country.
[[slide page 19]]
In Taiwan, it is legal to have sexual activity after 16. No matter it's intercourse or not.
But even for an organization providing free service like us, the member who communicate with sex volunteer and the servee would be punished as a broker if the servee is younger than 18.
Actually, we do have an applier who mailed us about his desire when he was 15. What we can do is tell him to wait 3 more years.

Unfortunately, being an adult does not mean your right to sex is permitted.
[[slide page 20]]
People with intellectual disability or mental disorder are also infantilized, treated as babies or angels, and considered asexual.
The dilemma is similar to what teenagers have. Their consents are not considered valid.
That is frustrating. The law to protect them from sexual violence also tortures them.

[[slide page 21]] Acrotomophilia and devotees
While talking about disabled people in love or having sex, this is also an issue we should mention.
Some people worry about that devotees are just trying to dominate or take control of the disabled people.
This is similar to MacKinnon's dominance theory and male supremacy.
Devotees are considered to have more power in the relationship, and thus disabled people have a lack of autonomy.

I think that's a stigma, too.
The dominance theory does not deny free love. It focuses on the power issue.
Thus, the problem lies still on the absence of resources disabled people deserve.
Slanders on devotees are based on the prejudice that disabled people are never sexy,
and that denies the possibility for disabled people to have plentiful sexual activity.
The whole society shall support disabled people to have their own autonomy in their relationship.

[[slide page 22]] Difficulties
Usually, people would understand sexual desire of disabled people.
But to support it publicly is another story, especially for the organizations relying on donations.
There are some social workers and parents telling us that they want to do something to help their cases and family,
but it is still an issue which could not be spoken.
It's never been easy for us to talk about sex on the table, but it should be done.
Even for those who don't agree with the idea of sexual service, I do hope you could at least support disabled people to talk about their sex and romance.

[[slide page 23]]
This ends my report. Thank you for listening.
I'm Kong, a sex volunteer of Hand Angel from Taiwan.

【腦中小劇場　第53場　歷經腥風血雨後的記憶傷痕】
　　　　
「今早八點，本市北區一處工地突然發生氣爆，初步懷疑是下水道沼氣引發事故。據目擊民眾表示，氣爆當時人孔蓋瞬間噴飛，火勢隨即竄出，造成四名工人臉部四肢不等面積的灼傷，傷患三人意識清醒，另一人意識模糊，現場一片狼藉，由於爆炸威力強大，導致附近商家與診所均受波及，幸無其他民眾傷亡...」
　　
【事件發生之時】

這是三個多月前的新聞，我移開手機頁面，慢慢將視線轉向眼前的男子。阿良是這次意外的受害者，但他不是那些身負重傷的工人，也不是行經現場的路人或診所裡的患者，新聞沒給他版面，事發當時他甚至不在現場，而是在兩條街以外的地方。當時的他剛送完孩子上學，在路邊嗑光最愛的古早味蛋餅，突然間遠處傳來爆炸聲，他不知該望向何方，於是坐上車，關掉臨停號誌，繫上安全帶，然後──
　　
一塊人孔蓋筆直地插進擋風玻璃。
　　
如果能用數字呈現，他很確定自己跟死亡的距離大概是20公分，20公分比兒子的塑膠尺還長，感覺上卻比兩公分還短。等他回過神，才發現自己迎接死亡的動作有兩個，一個是把頭轉向車門，一個是用手護住副駕駛座。他的臉緊貼左側車窗，如果照平常的駕駛位置，他的天靈蓋應該跟擋風玻璃的下場一樣。他不知道他這姿勢維持了多久，只聽到有人用手機拍照的聲音，鏡頭裡的他被快門定格，現實中的他則被那20公分的距離定格。
　　
當時他的右臉還卡了些玻璃屑，下車後，他抖掉身上的碎玻璃，打給警方及保險公司，然後和老婆報平安，到目前為止，他覺得自己的每個動作都是被搖控完成的。他聽不見任何聲音，只感受到路面的震動，突然間他開始狂吐，然後抱頭痛哭，他一直以為是自己怕死，後來才發現，他是慶幸副駕駛座的兒子已經去上學。
　　
阿良說，人孔蓋飛進來那一刻，超像《不可能的任務》（Mission: Impossible）的最後一幕，一陣爆炸阿湯哥跳上車廂，直昇機墜落在軌道上，螺旋槳尖端慢慢停在他的面前。只是電影會暗幕，觀眾會離場，阿湯哥不會有任何創傷，整件事有明確的結束時間，但自己的記憶卻彷彿沒有終點。
　　
這就是電影與現實的距離，雖然同樣都是20公分。
　　
【回到事發現場】

如果可以，將時間倒轉回到事發當天，想像阿良的腦袋有個透明頭罩，然後再把時間調慢十倍，於是就會清楚地看到：
　　
在人孔蓋由遠而近，準備撞擊擋風玻璃前，阿良看見一顆不斷擴大的黑點，黑點透過視網膜傳向視覺神經，接著傳到視丘（thalamus）。視丘負責整合各類感官訊息，可以把它想成像一個不太會抱怨的行政秘書，它將不同單位的信息彙整完畢後，分別轉給杏仁核（amygdala）與大腦皮質（cerebral cortex），此時傳輸路徑一分為二。杏仁核路徑又稱「情緒路徑」，作用是感受情緒後做出即時反應；大腦皮質路徑則稱「認知路徑」，作用是對外界刺激進行細緻的分析與判斷，再傳給杏仁核，做出合宜的應對。
　　
杏仁核位於邊緣系統，是掌管情緒的重要單位，負責辨識與解釋。於是，當杏仁核辨識出人孔蓋是一個「威脅」之後，它會閃出紅光，立刻下達指令給下視丘（hypothalamus）。下視丘是人體的「軍備庫房」，儲存各種彈藥武器來保護人體，於是，當杏仁核的紅燈一閃，紅色電流通過下視丘，便會釋放壓力荷爾蒙，包括腎上腺素與皮質醇（cortisol），同時啟動交感神經作用。於是，心跳便會開始加速，像個救命的泵浦，把血液往重要器官傳送，接著用力吸進氧氣、肌肉瞬間緊繃、腸胃持續翻滾，而這場動員，全是為了抵抗外界的威脅。可以應戰，也可以棄逃，不管衝或縮（fight-or-flight response），身體都會幫你做好策應。
　　
這條路徑，通常會在一秒內完成傳輸。
　　
經過杏仁核辨識，確認威脅過強，阿良選擇棄逃，但他來不及解開安全帶，於是血液往上半身集中，以洪荒之力將頭撇向另一側，成功為自己續命。可惜的是，人一旦腦充血或面對突如其來的危機，通常會讓「情緒路徑」接管大腦，一切由杏仁核說了算，「認知路徑」只能退居二線。也因此，才會時常看到有人在電視螢幕前哭著說我太衝動、現在很後悔之類的話。於是，大腦皮質雖然幫阿良處理後續流程，卻無法幫他在日後面臨威脅之際恢復理智。
　　
活下來，成了創傷的起點。
　　
【在事件之後……】

幾天後，阿良走過公園時，忽然側身撲向路旁的草叢，但飛過他眼前的並不是人孔蓋，而是一片飛盤。那片飛盤彷彿解開了某種封印，阿良就此被喚醒，於是他不敢再開車，即便搭公車也要戴耳塞，因為他受不了輪胎壓過人孔蓋的聲音，那聲音會讓窗外出現逐漸擴大的黑點，而他只能閉上眼。糟糕的是，黑點不僅會穿過他的眼皮，還會穿透他的夢境。他時常被驚醒，卻無法跟太太重述事發經過，他腦中只有不斷閃回的片段，包括鐵片撞擊玻璃的聲音、蛋餅的味道、碎玻璃灑在臉上的刺痛感，還有兒子在車窗外說再見的臉。
　　
於是，他選擇避開蛋餅店，避開熟悉的巷口，避開送孩子上課的機會，也避開下班後的聚會。因為，巷口爆米香的巨響、柏油路面的震動和玻璃杯互相撞擊的聲音，都會瞬間把他拖回當天的駕駛座，在動彈不得的情況下，再度跟死神打照面。他憂鬱，也覺得自己超沒用，但只要能躲回房間，吞下藥丸，防堵人孔蓋穿過夢的邊界就好，他不需要跟這段記憶爭輸贏。
　　
以上這些症狀，正是典型的創傷後壓力症（post-traumatic stress disorder，PTSD）。
　　
【創傷後壓力症】

創傷事件的威力在於，即便不傷及肉體，如影隨形的恐懼也會隔山打牛，讓大腦產生「誤判」。於是就可以看到，那天當飛盤飛近阿良眼前時，他的杏仁核再度閃出紅光，但由於先前的人孔蓋威脅過於強烈，導致辨識系統變得異常敏感，杏仁核一下化身高敏感族。為了避免二度傷害，它寧可放出誤判的假警報，也不要和外界威脅博奕，於是下視丘收到的是逃跑計劃，而不是接住飛盤。
　　
因此，在不需要逃跑的情形下，阿良的身體又被迫動員了一輪，逐漸失控的杏仁核，一旦經過幽微的暗示便會敲響警鐘，不斷釋放壓力荷爾蒙，它們就像一組疲於奔命的消防隊員，一次又一次趕赴現場卻持續撲空。就心理學而言，這過程便是所謂的「制約現象」，人孔蓋原本是無害的刺激物，然而經過創傷事件之後，它便與「威脅」二字連結在一起，因此一旦接觸與人孔蓋相似的刺激，身體便會自然出現抗壓反應，也就是所謂的「看到黑影就開槍」。
　　
這場荷爾蒙演習讓阿良身心俱疲，他每次都要花費比前一次更久的時間來安撫身體，嚴重影響睡眠品質與工作效率。壓力荷爾蒙不僅會內耗能量，也會間接傷害杏仁核，讓有關創傷的記憶無法連成一線，只剩衝擊強烈的素材，包括畫面、聲音與氣味在腦中不斷迴放。為了不讓杏仁核接收到這些訊息，阿良試圖關掉周圍的訊號來源，最直接的方式就是遠離案發現場與人群，回到自己的房間。
　　
但他不知道，只要創傷記憶還在，所有的逃避都是徒勞，無論是從天而降的人孔蓋、凌晨三點的強震、父親酒後的一巴掌、教堂的爆炸現場或一輛衝進人群的休旅車。不可抗力的天災也好，精心預謀的犯罪也罷，一直到最後才會了解，創傷最可怕的，不是從身上奪走了什麼，而是強加了一段不堪回首的記憶。
　　
【創傷記憶之後的治療】

該如何處理這段創傷記憶呢？根據福艾（Edna B. Foa）與布鲁因（Chris R. Brewin）等人的研究顯示，其中一個作法，就是「重寫一段新的記憶」，讓它與舊有的創傷記憶一起競爭。
　　
因此，認知重建、暴露治療或正念療法（mindfulness），都是臨床心理師會採取的方案。認知重建，是指讓案主「重述事發過程」，但不是為了折磨對方，而是像「仔細檢查傷口，避免對傷勢的胡亂臆測」，畢竟人常用想像力來加深恐懼。逐步回憶，讓創傷記憶重新連成一線，反而能幫助案主檢視故事的漏洞及對事件的扭曲想法。此外，也會進行放鬆練習，無論是腹式呼吸或覺察身體反應，都能使自律神經逐漸恢復平靜。這些作法強調的是「先前的經驗確實很可怕，但我現在很安全」，將過往與當下做出區隔，而這也通常是創造新記憶的絕佳素材。當然，這不會是一段舒適的旅程，但只要願意相信自己的身體，記憶會留在過去，療程會成為一場壯遊。
　　
創傷記憶可能是一場事故的終點，卻也可能是一段犯行的起點，根據弗賴貝格（Selma Fraiberg）及馬隆（Johanna C. Malone）等人的研究顯示，曾經歷兒童虐待而導致創傷後壓力症的母親，容易引發孩子的無助與恐懼感。謝克特（Daniel S. Schechter）等人的研究也發現，曾受家暴或有創傷後壓力症候群病史的母親所養育的孩子在說故事時，可能會比一般孩子更容易聚焦在災難或危險的情節上，態度也較具敵意。
　　
而身受家暴創傷的孩童，日後或將以暴行還諸他人或下一代，這可能是他們用來「對抗創傷記憶」的方式。遺憾的是，他們創造的並不是提醒自己早已脫離險境的記憶，而是以另一段施虐記憶，來與記憶中的施虐者抗衡，藉以證明自己不會再被對方壓制，於是暴力傳承暴力，惡意滋長惡意。
　　
然而，有朝一日我們會明白，記憶是一種選擇的過程。選擇增加施暴的記憶和過往的創傷較勁，記憶就會變成一種提醒。選擇相信大腦的彈性，努力把自己留在當下，記憶就會變成一種證明。雖然傷疤一直都在，但就像派特森（Per Petterson）在《外出偷馬》（Ut og stjaele hester）所說的：
　　
痛不痛的事，我們真的可以自己決定。
　　
　　
後記：
本文同步刊登於科學月刊11月號，感謝 科學月刊 Science Monthly 邀稿，以及 教育電台聲動全世界- 國立教育廣播電臺 - 《科學 so easy》邀訪。科月與教育電台推廣科普訊息不遺餘力，十分榮幸能與之合作，感謝主持人燕子姐的生動引導，以及科月編輯家銘學弟的滴血認親，這是一次愉快的錄音經驗。

此次專訪除內文探討外，亦延伸討論PTSD的治療實例，以及戰逃反應的傳輸路徑。專訪預計於11/28（四）上午11:05-12:00播出，頻道FM101.7，或直接進入官網點選「收聽頻道」，歡迎對科學有興趣的讀者一同收聽。

　　　　
延伸閱讀
　　
王秀美、曾儀芬(2012)。一位家暴受虐兒的家庭特質。嘉南學報，38，608-628

Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103(4), 670-686.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20(2), 155-176

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry,14, 387-422

LeDoux , J. E (1996) The Emotional Brain (Simon and Schuster, New York)

Malone, J. C., Levendosky, A. A., Dayton, C. J., & Bogat, G. A. (2010). Understanding the “ghosts in the nursery” of pregnant women experiencing domestic violence: Prenatal meternal representations and histories of childhood maltreatment. Infant Mental Health Journal, 31(4), 432-454

Schechter, D. S., Zygmunt, A., Coates, S. W.,Davies, M., Trabka, K. A., Mccaw, J.,Kolodji, A., & Robinson, J. (2007). Caregiver traumatization adversely impacts young children’s mental representations on the MacArthur Story Stem Battery. Attachment & Human Development, September, 9(3), 187-205.

【腦中小劇場　第53場　歷經腥風血雨後的記憶傷痕】
　　　　
「今早八點，本市北區一處工地突然發生氣爆，初步懷疑是下水道沼氣引發事故。據目擊民眾表示，氣爆當時人孔蓋瞬間噴飛，火勢隨即竄出，造成四名工人臉部四肢不等面積的灼傷，傷患三人意識清醒，另一人意識模糊，現場一片狼藉，由於爆炸威力強大，導致附近商家與診所均受波及，幸無其他民眾傷亡...」
　　
【事件發生之時】

這是三個多月前的新聞，我移開手機頁面，慢慢將視線轉向眼前的男子。阿良是這次意外的受害者，但他不是那些身負重傷的工人，也不是行經現場的路人或診所裡的患者，新聞沒給他版面，事發當時他甚至不在現場，而是在兩條街以外的地方。當時的他剛送完孩子上學，在路邊嗑光最愛的古早味蛋餅，突然間遠處傳來爆炸聲，他不知該望向何方，於是坐上車，關掉臨停號誌，繫上安全帶，然後──
　　
一塊人孔蓋筆直地插進擋風玻璃。
　　
如果能用數字呈現，他很確定自己跟死亡的距離大概是20公分，20公分比兒子的塑膠尺還長，感覺上卻比兩公分還短。等他回過神，才發現自己迎接死亡的動作有兩個，一個是把頭轉向車門，一個是用手護住副駕駛座。他的臉緊貼左側車窗，如果照平常的駕駛位置，他的天靈蓋應該跟擋風玻璃的下場一樣。他不知道他這姿勢維持了多久，只聽到有人用手機拍照的聲音，鏡頭裡的他被快門定格，現實中的他則被那20公分的距離定格。
　　
當時他的右臉還卡了些玻璃屑，下車後，他抖掉身上的碎玻璃，打給警方及保險公司，然後和老婆報平安，到目前為止，他覺得自己的每個動作都是被搖控完成的。他聽不見任何聲音，只感受到路面的震動，突然間他開始狂吐，然後抱頭痛哭，他一直以為是自己怕死，後來才發現，他是慶幸副駕駛座的兒子已經去上學。
　　
阿良說，人孔蓋飛進來那一刻，超像《不可能的任務》（Mission: Impossible）的最後一幕，一陣爆炸阿湯哥跳上車廂，直昇機墜落在軌道上，螺旋槳尖端慢慢停在他的面前。只是電影會暗幕，觀眾會離場，阿湯哥不會有任何創傷，整件事有明確的結束時間，但自己的記憶卻彷彿沒有終點。
　　
這就是電影與現實的距離，雖然同樣都是20公分。
　　
【回到事發現場】

如果可以，將時間倒轉回到事發當天，想像阿良的腦袋有個透明頭罩，然後再把時間調慢十倍，於是就會清楚地看到：
　　
在人孔蓋由遠而近，準備撞擊擋風玻璃前，阿良看見一顆不斷擴大的黑點，黑點透過視網膜傳向視覺神經，接著傳到視丘（thalamus）。視丘負責整合各類感官訊息，可以把它想成像一個不太會抱怨的行政秘書，它將不同單位的信息彙整完畢後，分別轉給杏仁核（amygdala）與大腦皮質（cerebral cortex），此時傳輸路徑一分為二。杏仁核路徑又稱「情緒路徑」，作用是感受情緒後做出即時反應；大腦皮質路徑則稱「認知路徑」，作用是對外界刺激進行細緻的分析與判斷，再傳給杏仁核，做出合宜的應對。
　　
杏仁核位於邊緣系統，是掌管情緒的重要單位，負責辨識與解釋。於是，當杏仁核辨識出人孔蓋是一個「威脅」之後，它會閃出紅光，立刻下達指令給下視丘（hypothalamus）。下視丘是人體的「軍備庫房」，儲存各種彈藥武器來保護人體，於是，當杏仁核的紅燈一閃，紅色電流通過下視丘，便會釋放壓力荷爾蒙，包括腎上腺素與皮質醇（cortisol），同時啟動交感神經作用。於是，心跳便會開始加速，像個救命的泵浦，把血液往重要器官傳送，接著用力吸進氧氣、肌肉瞬間緊繃、腸胃持續翻滾，而這場動員，全是為了抵抗外界的威脅。可以應戰，也可以棄逃，不管衝或縮（fight-or-flight response），身體都會幫你做好策應。
　　
這條路徑，通常會在一秒內完成傳輸。
　　
經過杏仁核辨識，確認威脅過強，阿良選擇棄逃，但他來不及解開安全帶，於是血液往上半身集中，以洪荒之力將頭撇向另一側，成功為自己續命。可惜的是，人一旦腦充血或面對突如其來的危機，通常會讓「情緒路徑」接管大腦，一切由杏仁核說了算，「認知路徑」只能退居二線。也因此，才會時常看到有人在電視螢幕前哭著說我太衝動、現在很後悔之類的話。於是，大腦皮質雖然幫阿良處理後續流程，卻無法幫他在日後面臨威脅之際恢復理智。
　　
活下來，成了創傷的起點。
　　
【在事件之後……】

幾天後，阿良走過公園時，忽然側身撲向路旁的草叢，但飛過他眼前的並不是人孔蓋，而是一片飛盤。那片飛盤彷彿解開了某種封印，阿良就此被喚醒，於是他不敢再開車，即便搭公車也要戴耳塞，因為他受不了輪胎壓過人孔蓋的聲音，那聲音會讓窗外出現逐漸擴大的黑點，而他只能閉上眼。糟糕的是，黑點不僅會穿過他的眼皮，還會穿透他的夢境。他時常被驚醒，卻無法跟太太重述事發經過，他腦中只有不斷閃回的片段，包括鐵片撞擊玻璃的聲音、蛋餅的味道、碎玻璃灑在臉上的刺痛感，還有兒子在車窗外說再見的臉。
　　
於是，他選擇避開蛋餅店，避開熟悉的巷口，避開送孩子上課的機會，也避開下班後的聚會。因為，巷口爆米香的巨響、柏油路面的震動和玻璃杯互相撞擊的聲音，都會瞬間把他拖回當天的駕駛座，在動彈不得的情況下，再度跟死神打照面。他憂鬱，也覺得自己超沒用，但只要能躲回房間，吞下藥丸，防堵人孔蓋穿過夢的邊界就好，他不需要跟這段記憶爭輸贏。
　　
以上這些症狀，正是典型的創傷後壓力症（post-traumatic stress disorder，PTSD）。
　　
【創傷後壓力症】

創傷事件的威力在於，即便不傷及肉體，如影隨形的恐懼也會隔山打牛，讓大腦產生「誤判」。於是就可以看到，那天當飛盤飛近阿良眼前時，他的杏仁核再度閃出紅光，但由於先前的人孔蓋威脅過於強烈，導致辨識系統變得異常敏感，杏仁核一下化身高敏感族。為了避免二度傷害，它寧可放出誤判的假警報，也不要和外界威脅博奕，於是下視丘收到的是逃跑計劃，而不是接住飛盤。
　　
因此，在不需要逃跑的情形下，阿良的身體又被迫動員了一輪，逐漸失控的杏仁核，一旦經過幽微的暗示便會敲響警鐘，不斷釋放壓力荷爾蒙，它們就像一組疲於奔命的消防隊員，一次又一次趕赴現場卻持續撲空。就心理學而言，這過程便是所謂的「制約現象」，人孔蓋原本是無害的刺激物，然而經過創傷事件之後，它便與「威脅」二字連結在一起，因此一旦接觸與人孔蓋相似的刺激，身體便會自然出現抗壓反應，也就是所謂的「看到黑影就開槍」。
　　
這場荷爾蒙演習讓阿良身心俱疲，他每次都要花費比前一次更久的時間來安撫身體，嚴重影響睡眠品質與工作效率。壓力荷爾蒙不僅會內耗能量，也會間接傷害杏仁核，讓有關創傷的記憶無法連成一線，只剩衝擊強烈的素材，包括畫面、聲音與氣味在腦中不斷迴放。為了不讓杏仁核接收到這些訊息，阿良試圖關掉周圍的訊號來源，最直接的方式就是遠離案發現場與人群，回到自己的房間。
　　
但他不知道，只要創傷記憶還在，所有的逃避都是徒勞，無論是從天而降的人孔蓋、凌晨三點的強震、父親酒後的一巴掌、教堂的爆炸現場或一輛衝進人群的休旅車。不可抗力的天災也好，精心預謀的犯罪也罷，一直到最後才會了解，創傷最可怕的，不是從身上奪走了什麼，而是強加了一段不堪回首的記憶。
　　
【創傷記憶之後的治療】

該如何處理這段創傷記憶呢？根據福艾（Edna B. Foa）與布鲁因（Chris R. Brewin）等人的研究顯示，其中一個作法，就是「重寫一段新的記憶」，讓它與舊有的創傷記憶一起競爭。
　　
因此，認知重建、暴露治療或正念療法（mindfulness），都是臨床心理師會採取的方案。認知重建，是指讓案主「重述事發過程」，但不是為了折磨對方，而是像「仔細檢查傷口，避免對傷勢的胡亂臆測」，畢竟人常用想像力來加深恐懼。逐步回憶，讓創傷記憶重新連成一線，反而能幫助案主檢視故事的漏洞及對事件的扭曲想法。此外，也會進行放鬆練習，無論是腹式呼吸或覺察身體反應，都能使自律神經逐漸恢復平靜。這些作法強調的是「先前的經驗確實很可怕，但我現在很安全」，將過往與當下做出區隔，而這也通常是創造新記憶的絕佳素材。當然，這不會是一段舒適的旅程，但只要願意相信自己的身體，記憶會留在過去，療程會成為一場壯遊。
　　
創傷記憶可能是一場事故的終點，卻也可能是一段犯行的起點，根據弗賴貝格（Selma Fraiberg）及馬隆（Johanna C. Malone）等人的研究顯示，曾經歷兒童虐待而導致創傷後壓力症的母親，容易引發孩子的無助與恐懼感。謝克特（Daniel S. Schechter）等人的研究也發現，曾受家暴或有創傷後壓力症候群病史的母親所養育的孩子在說故事時，可能會比一般孩子更容易聚焦在災難或危險的情節上，態度也較具敵意。
　　
而身受家暴創傷的孩童，日後或將以暴行還諸他人或下一代，這可能是他們用來「對抗創傷記憶」的方式。遺憾的是，他們創造的並不是提醒自己早已脫離險境的記憶，而是以另一段施虐記憶，來與記憶中的施虐者抗衡，藉以證明自己不會再被對方壓制，於是暴力傳承暴力，惡意滋長惡意。
　　
然而，有朝一日我們會明白，記憶是一種選擇的過程。選擇增加施暴的記憶和過往的創傷較勁，記憶就會變成一種提醒。選擇相信大腦的彈性，努力把自己留在當下，記憶就會變成一種證明。雖然傷疤一直都在，但就像派特森（Per Petterson）在《外出偷馬》（Ut og stjaele hester）所說的：
　　
痛不痛的事，我們真的可以自己決定。
　　
　　
後記：
本文同步刊登於科學月刊11月號，感謝 科學月刊 Science Monthly 邀稿，以及 教育電台聲動全世界- 國立教育廣播電臺 - 《科學 so easy》邀訪。科月與教育電台推廣科普訊息不遺餘力，十分榮幸能與之合作，感謝主持人燕子姐的生動引導，以及科月編輯家銘學弟的滴血認親，這是一次愉快的錄音經驗。

此次專訪除內文探討外，亦延伸討論PTSD的治療實例，以及戰逃反應的傳輸路徑。專訪預計於11/28（四）上午11:05-12:00播出，頻道FM101.7，或直接進入官網點選「收聽頻道」，歡迎對科學有興趣的讀者一同收聽。

　　　　
延伸閱讀
　　
王秀美、曾儀芬(2012)。一位家暴受虐兒的家庭特質。嘉南學報，38，608-628

Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103(4), 670-686.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20(2), 155-176

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry,14, 387-422

LeDoux , J. E (1996) The Emotional Brain (Simon and Schuster, New York)

Malone, J. C., Levendosky, A. A., Dayton, C. J., & Bogat, G. A. (2010). Understanding the “ghosts in the nursery” of pregnant women experiencing domestic violence: Prenatal meternal representations and histories of childhood maltreatment. Infant Mental Health Journal, 31(4), 432-454

Schechter, D. S., Zygmunt, A., Coates, S. W.,Davies, M., Trabka, K. A., Mccaw, J.,Kolodji, A., & Robinson, J. (2007). Caregiver traumatization adversely impacts young children’s mental representations on the MacArthur Story Stem Battery. Attachment & Human Development, September, 9(3), 187-205.