精神分裂病患者の自己のあり方に着目した治療的対応

Therapeutic Self-strengthening: An approach to the disordered self of schizophrenic patients

【抄録】　本稿の目的は，精神分裂病患者の自己のあり方に着目した一つの治療的対応を提示することである。この対応では，精神分裂病の病的状態において患者の自律やまとまりが損なわれているという理解の下で，患者の自己評価を保護し自己概念を強化する介入によって，その状態からの回復が援助される。このようなアプローチが奏効したと考えられる例として，被害妄想を抱き周囲の援助を受け入れなかった症例および対人的葛藤に巻き込まれて決断不能の状態に陥る症例を提示した。さらにこの精神分裂病に由来する障害された自己の状態に対して，従来の自己愛や自己評価についての議論を参照しながら，この自律や自己のまとまりの回復を進める心理的介入の有効性について検討を加えた。

　Adequate self-esteem and solid self-concept facilitate functionings of the self, such as self-other differentiation and opportune attitude-determination. Nevertheless, many patients with schizophrenia suffer from impairment of these functions, which augments a difficulty in coping with the pathological experiences. In this article, two case vignettes were presented to illustrate an approach of self-strengthening in which enhancing self-esteem and delineating self-concept based on positive therapeutic relationships can produce a clinical improvement.

　In the first case presentation, pervasive suspiciousness was an obstruction in implementing psychiatric treatment. Approval of her struggle against persecutory figures by a therapist successfully opened her mind to treatment. Clinical features of the second patient were prominent indecisiveness and extreme ambivalence toward treatment and her family, which often resulted in an explosion of reckless and impulsive behavior. An intervention to raise her self-esteem succeeded in considerably ameliorating those pathologies. After reviewing several theories on developmental and adaptational aspects of narcissism and self-concept, the importance of the clinical intervention was discussed. The conclusion is that clinical attention should be made in preserving realistic self-esteem and self-concept of patients with schizophrenia to antagonize adversities of the psychotic condition.