CommentaryPeter Whewell解説ピーター・ヒューエル
The burden of patients with borderline personality disorder on mental health services is now recognised to be considerable (e.g. ,Oxfordshire Mental Healthcare NHS Trust, 1998), so that the importance of developing a potentially effective brief therapy for this difficult-to-treat population can hardly be overstated. 精神保健サービスで境界性人格障害の患者を治療することは相当な負担であると考えられている（例えば、オックスフォードシャー州メンタルヘルスケアNHSトラスト、1998）。従って、この治療困難な患者群のための潜在的に効果的な短期治療を開発することは、この上もなく重要である。 A recent cohort study of 27 patients with the disorder treated with cognitive analytic therapy (CAT) showed improvement at 18 months for 14 patients (Ryle & Golynkina, 2000). 認知分析療法（CAT）で治療された境界性人格障害を持つ27名の患者の最近のコホート研究では患者14人が18ヶ月で改善を示した（ライル＆Golynkina、2000）。 Five-year followups are not yet available nor, crucially, has there yet been a randomised control trial of CAT (Margison, 2000). 五年間のフォローアップは、まだ入手可能ではなく、また、致命的なことに、まだCATの無作為化対照試験はない（Margison、2000）。 Ideally, a comprehensive service for patients with borderline personality disorder should include facilities for brief hospitalisation (to manage suicidal crises), for partial hospitalisation (for short-term containment of dangerous or very disturbed behaviour), for brief therapies of up to 6 months’ duration (to stabilise impulsive behaviours and increase psychological mindedness) and for longerterm therapies (of 2 to 5 years, to allow personality change and growth) (Gunderson et al, 1997). 理想的には、境界性人格障害の患者さんのための包括的なサービスは、（自殺の危機を管理するために）短期間の入院施設を含める必要があり、また、（危険なまたは非常に乱れた行動の短期的な封じ込めのための）部分的な入院の必要があり、さらに、（衝動的な行動を安定させ、心理的な考え方を高めるために）最大6ヶ月間の短期治療が必要であり、（2年から5年の、人格変化と成長を可能にする）長期治療が必要である（ガンダーソンら、1997）。 CAT provides an option for brief therapy, while most longterm therapies are psychodynamically based. 多くの長期療法は精神力動に基づくものであるが、CATは、短期療法のひとつである。 Coming from a psychodynamic background, the creator of CAT, Anthony Ryle, has used psychodynamic concepts to underpin it , so that most analytically trained therapists will feel familiar with CAT theory. CATの生みの親、アンソニー・ライルは、精神力動的背景から出発しているので、CATを裏打ちするために精神力動的な概念を使用している。したがって精神分析的な訓練を受けたセラピストは、CATの理論に親しみを感じるだろう。 For instance, the important CAT concept of role reciprocity is a clear exposition of projective identification (Klein, 1946) and role responsiveness (Sandler, 1976). 例えば、CATの重要な概念である「役割相互性」は「投影性同一視（クライン、1946）」と「役割応答性（サンドラー、1976）」から明確に説明される。 However, the omission of the idea of defence against intrapsychic conflict (including both repression and splitting), the minimisation of destructive attacks by the self on knowledge and linking and the lack of place afforded the unconscious would place CAT outside the usual arena of psychodynamic theory. しかしながら、（抑圧とスプリッティングの両方を含む）精神内部の葛藤に対する防衛の概念を省略したり、破壊的攻撃の最小化 by the self on knowledge and linking 、「無意識」という概念に与えられる場所の欠如、などにより、精神力動理論の通常の競技場の外にCATを置く結果になっている。 Along a continuum of psychological views about the importance of drives v. cumulative trauma, Ryle would perhaps sit at the extreme traumagenic end of the spectrum. 欲動を重視するか、累積トラウマを重視するかの観点から言えば、ライルはおそらくスペクトラムのなかで極端なトラウマ原因派だろう。 However, his attacks on the drive end of the spectrum (Ryle, 1993, 1995a), as represented by Kleinian theory and its drive-related formulation of aggression, echo views expressed by Sutherland (1983). しかし、スペクトラムの欲動側に対する彼の反論（ライル、1993、1995a）は、サザーランド（1983）によって表明された見解の繰り返しである。スペクトラムの欲動側にはクライン理論と攻撃性を欲動に関係付ける理解がある。 Taking into account the mental set and the practical procedures of CAT, most analytically trained therapists would not see it as belonging to the spectrum of analytical therapies (Ryle, 1995b), and perhaps there are a number of reasons for this. the mental setとCATの実際の手続きを考慮すると、最も分析的に訓練を受けたセラピストも、CATを分析治療のスペクトラム（ライル、1995b）に属するものとは見なさないだろう。おそらくこれには多くの理由がある。 First, although both CAT and analytical psychotherapy would aim to increase insight, CAT is also aiming at specific symptom change. 第一に、CATと分析的心理療法の両方が洞察を増すことを目的としているが、CATはまた、特定の症状の変化を目指している。 Concentration on symptom change would, in the view of many analytical patients, take the therapist out of a state of analytical neutrality. 症状の変化への集中は、多くの分析患者の観点からいえば、セラピストは分析的中立の状態を保てなくなる。 This would in turn reduce the ability of the therapist to make an accurate transference interpretation, which would be thought to be the main mutative agent in analytical therapy. このことが今度は、セラピストが正確な転移の解釈をする能力を減じてしまうことになる。分析的治療では主に転移解釈により変化が生じると考えられる。 The mutative agent in CAT seems to be an increase in self-reflection; this is a cognitive function, which contrasts with the transference interpretation as an experience. CATの推移的エージェントは、自己内省の増加に見えるが、これは経験として転移解釈とは対照的な認知機能である。 Transference interpretations may occur at crucial times in CAT, but they are not a primary feature of the therapy. 転移の解釈は、CATにおいて重要な時期に発生する可能性があるが、治療の主な特徴ではない。 It should be noted that analytical neutrality does not equate with a bland, opaque or unresponsive therapist ; analytical therapists strive for a neutrality that is equidistant from points of conflict (Kernberg, 1984) in the patient. 分析的中立性は、当たり障りのない不透明なまたは無応答なセラピストと同じではないことに留意すべきである。分析的治療者は患者の葛藤のいくつかのポイント（カーンバーグ、1984）から等距離にあろうとする中立性を求めて努力する。 Second, analytical therapists operate optimally using two perspectives, described by Bion (1974) as binocular vision, whereby one eye views the patient and his or her material through theory, the other operating “without memory or desire”. 第二に、分析セラピストはビオン（1974）によって両眼視と記述された二つの視点を使用して、最適に操作する。片方の眼は、理論を通して患者と彼または彼女の研究材料を見ており、もう片方の眼で、”記憶や欲望のない”操作をする。
Too strong a concentration on theory may interfere with the evenly hovering reverie needed for the state of being without memory and desire , which has been described as follows: 理論に強く集中しすぎると、メモリや欲望なしの状態にとって必要な、均等に漂う夢想を妨害するかもしれない。それは次のように説明されている：
“Whilst the analyst (actively) tries to remember what the patient told him in the previous session (memory) 「分析者は（活発に）前回の面接で患者が言ったことを思い出そうとしたり（メモリ）、
or to think of what the patient will do at the end of sessions or of next weekend,面接や次の週末の終わりに患者が何をするのか考えたり、
or of his wish for the patient to improve and be “cured” (desire), 患者が改善して、『治る』ことを願っている（欲望）、一方で、
he lessens the possibility of observing and perceiving new facts which are evolving in the session at the moment.” (Grinberg et al, 1975, pp. 78) たった今、面接で進展している新しい事実を観察したり知覚する可能性を狭めている。」(Grinbergら, 1975, pp. 78) It is clear that in CAT the therapist is very busy forging a therapeutic relationship with the patient, a busyness that reduces the space for reflection. 明らかに、CATではセラピストは患者との治療関係をでっち上げるのに忙しすぎる。忙しさが（それがビジネスに通じるのだが）内省の場所を減少させる。 The need of the CAT therapist to spot certain prescribed role relationships may blind the therapist to what is unique about the patient in the room. CATのセラピストは、一定の規定された役割関係を見つけることが必要であるあまり、いいまここにいる患者のユニークさに盲目になるかもしれない。 In a state of viewing without memory or desire, the therapist is thrown back on his or her own internal world, which will include identification with his or her personal therapist and supervisors. メモリや欲望なしで見る状態では、セラピストは彼または彼女自身の内部の世界に投げ返される。その内部世界には彼または彼女の個人的なセラピストとスーパーバイザーとの同一視が含まれる。 For a therapist without a depth analytical training, such a situation may be quite frightening and may lead to counterprojective identification on to the patient. 深層分析トレーニングなしのセラピストの場合は、そのような状況は非常に恐ろしい可能性があるし、患者への逆投影同一化につながる可能性がある。 対象との「連結」（Link） 逆投影同一化counterprojective identification 逆転移という言葉は色々に使われるのでこの方が良いとの意見あり *************************************Depth psychologyについての挿入
Depth psychology is a broad term that refers to any psychological approach examining the depth (the hidden or deeper parts) of human experience. It is a applied in psychoanalysis.
It provides a set of techniques for exploring underlying motives and a method of treating various mental disorders. It seeks the deep layer(s) underlying behavioural and cognitive processes – the unconscious.
The initial work and development of the theories and therapies by Carl Jung, Sigmund Freud, Alfred Adler and Otto Rank that became to be known as depth psychology have resulted in three perspectives in modern times:
- Psychoanalytic: Freud’s object relations
- Adlerian: Adler’s Individual psychology
- Jungian: Jung’s Analytical psychology and James Hillman’s “Archetypal psychology”
Those schools most strongly influenced by the work of Carl Jung, a 20th century Swiss psychiatrist who in hisAnalytical psychology emphasise questions of psyche, human development and personality development (orindividuation).
Jung was strongly influenced by esotericism and draws on myths, archetypes and the idea of the collective unconscious.
The following is a summary of the primary elements of Depth psychology:
- Depth psychology states that psyche is a process that is partly conscious and partly unconscious. The unconscious in turn contains repressed experiences and other personal-level issues in its “upper” layers and “transpersonal” (eg. collective, non-I, archetypal) forces in its depths.
- The psyche spontaneously generates mythico-religious symbolism and is therefore spiritual as well as instinctive in nature. An implication of this is that the choice of whether to be a spiritual person or not does not exist – the only question is exactly where we put our spirituality: Do we live it consciously or unknowingly invest it in nonspiritual aspirations (perfectionism, addictions, greed, fame) that eventually possess us by virtue of their ignored but frightfully potent numinous power?
- All minds, all lives, are ultimately embedded in some sort of myth-making. Mythology is not a series of old explanations for natural events; it is rather the richness and wisdom of humanity played out in a wondrous symbolical storytelling. No story, no myth, and no humanness either.
- Because we have a psychical share in all that surrounds us, we are sane and whole only to the degree that we care for our environment and tend responsibly to the world in which we live.
************************************* 挿入終り The ‘scaffolding’ of the therapy and activity of the therapist in CAT may allow CAT therapists to function adequately in this model without depth training. Third, there may be, among analytical therapists, scepticism about what is internalised as a result of a brief therapy that has no guarantee of progress into a longer therapy. A core feature of borderline disorder is patients’ intolerance of being alone (Gunderson, 1996), and coming into any therapy they seek a containing relationship. A brief therapy (even if this is explained at the beginning) may be a teasing, frustrating experience for a patient, with the therapist taking on the role of Fairbairn’s exciting, rejecting bad object (Fairbairn, 1952) and the patient feeling (in a mental state that may be split off from an ongoing alliance-seeking state) retraumatised. Successful interpretations of a negative transference of an exciting, rejecting persecutory figure can be made only if the patient actually feels held, psychologically, by the therapist over time. Thus, in the case vignettes cited by Denman (2001, this issue), when Jenny, with a background of being abandoned as a child, explores feelings of disappointment at not being held in a longterm frame by her therapist, is the disappointing therapist internalised? When Paul, at assessment, sets a date to die, is this a retaliatory response to the therapist informing him that the therapy had a date to end? Could his changing states (of rebellion and defiance; then misery and dependence in relation to an uncaring other; then being furious and contemptuous of help offered) be understandable concomitants of the here-and-now recognition of relational disappointment? The transference link is apparently not made by the therapist, so is what is internalised at this point an ctual uncaring , unthinking therapist? Fourth, an analytical therapist might be afraid both of the use of suggestion and of closure in making a written formulation early on in a therapy. Patients with borderline personality disorder may identify with the content of a formulation (Fonaghy, 1995) without identifying with the ability to think about it. This may lead to a concrete closure around the formulation, preventing rather than promoting further psychic growth. Some of these reservations may be resolved with more precise outcome studies, but it may also be that those most at home as CAT therapists will be those coming straight into the therapy, rather than those with a psychodynamic background.
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