精神科デイケアの治療構造を揺さぶる患者の一考察—現代を生きる“みにくいアヒルの子”

Notes on psychiatric day care patients who disturb the therapeutic structure : The "ugly duckling" revisited

要旨：デイケアへ通う患者の中には，規則を破るなどして治療構造を揺さぶる患者がいる．このような行動を示したある患者は，自分の姿を童話の「みにくいアヒルの子」に喩えている．この童話の主人公を患者に重ね合わせるようにして，治療という枠組や治療者との関係を破壊して居場所を転々とすることの意味を探ってみた．そこには疎外感に圧倒されている患者の姿があり，多くの問題を引き起こすこのような患者の行動を，躁的防衛の観点から考察してみた．以上のことから，治療構造という枠組の中で患者と作業を行うために，治療関係を維持するという「作業」について，筆者の経験した症例を通して報告する．

　The summary of this paper is a discussion of the significance of patients who seek to undermine the therapeutic structure. The discussion is from the standpoint of the "ugly duckling" (Andersen HC), this tale which provides a vivid description of the patient who drops out of the therapeutic structure. At the present time, there are two different and contradictory attitudes to psychiatric day care among young patients. One is enthusiasm, the other is drop out. The emphasis is more on getting a job than on the "here and now." Their conduct seems to result from a sense of alienation and compulsive denial of their injured narcissism. A case study of a psychiatric day care patient is briefly presented. Some discussion is made of the therapist's sympathetic attitude and effectively keeping the patient within the therapeutic structure. By breaking the rules of day care (i. e., the therapeutic structure), it would seem they are providing us with clues as to the therapeutic approach and to an understanding of their psychopathology.