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大人のアスペルガー症候群(下)~セラピストとしての立場から

 今日は、1週間ぶりに、大学病院でお仕事です。
しかも今日はぴょろが職場についてきます。

 そういうわけで、あまり時間がなく、この記事も2回に分けて書くことにしました。

 その前に、とうとうVAIOのUSBが壊れてしまい、マウスもプリンターも使えなくなりました。うーん、どうしよう…。


 さて、アスペルガーについて書いた記事を読んで下さった方は、お気づきかもしれませんが、今回、全くリンクを張っていません。その理由は、アスペルガー症候群について紹介したいいサイトがあるのですが、英語で書かれているので、リンクをためらっているからです。でも、記事を全部書いた後に、サイトと本はまとめて紹介しようと考えています。

 子供のアスペルガーに関するサイトは日本語もあるのですが、大人となると、情報がかなり不足しています。本も、訳本がほとんどです。どうしてこんなに少ないのか、不思議に思います。

 前回触れたように、大人のアスペルガー症候群の診断は非常に難しいです。

 その理由の一つは、症状を元に診断するシステムにあると思っています。これは、心的外傷後ストレス障害(PTSD)にも全く同じ事が言えます。症状を中心に見てしまうと、他の精神疾患との広範囲な重なりがあるので、その他の疾患の診断が優先されてしまうからです。

 その他の疾患との識別のためには、認知、言語、対人関係、知能、その他の日常生活機能、そして身体的・精神的症状、と多面的な評価に基づいた診断基準が必要だと思います。

 アスペルガー症候群について話すとき、パートナーとしての立場と、セラピストとしての立場を明確に分けるのが難しいのですが、最初にセラピストの視点から見た、対応について触れておきたいと思います。

 いわゆるアスペルガーの典型例、というのは以外に少ない気がします。大人の場合の多くは「アスペルガー疑い」として判断されているのではないかと思います。他の自閉症スペクトラム障害と同様、アスペルガー障害も実に広範囲なものなので、大人の発達障害に詳しい医師やその他の専門職に出会わなければ、別の診断名がつけられアスペルガーへの対応を受ける機会が失われることになります。

 病院において、このような方が医師からカウンセリングを受けるように勧められるのは、社会不安障害(GAD)、強迫性障害(OCD)やパニック障害などの不安障害が存在する時で、対人関係や社会的活動の制限については、デイケアなどの集団療法を利用するように勧められます。

 私は、アスペルガーの典型例の大人(女性)との出会いがあったので、介入の難しさや課題についてその方との関わりから多くを学んできました。

 大人の発達障害全体に言えることですが、「何に困っているのか」がカウンセリングや治療的な介入の焦点になります。そして、認知なり行動なり、改善できる点を改善し、工夫をし、「困っていること」を減らしていくのが介入のゴールということに、理論上はなっています。

 アスペルガー症候群の場合、大半は、対人関係やソーシャルスキルを身につける援助と、感情のコントロールの仕方の改善の2つに、カウンセリングの時間が費やされます。

 また、不安障害がある場合には、不安・恐怖感への対処法や、不安を引き起こす状況に慣れるための訓練も行います。(方法としては通常と同じですが、時間がかかります)

 出来る限り視覚を利用すること、具体的で段階的な対応をすること、などは、子供の場合と基本的に同じです。しかし大人の場合は、それまでの間にすでに何らかのストレスや問題に対する、その人なりの対処法というのが身に付いてしまっているので、それを変えていくのは大変なことです。以前に触れたように、思考の柔軟性に難点があるため、今身に付いている方法以外に別の方法がある、と何度取り上げても、そうだと実際に理解し、日常に取り入れていくまでには、かなりの忍耐を必要とします。

 例えば、面接の間では、「そうですね、分かりました。やってみます」と約束できても、次の面接で尋ねてみると、全くやっていない、という返事がよく聞かれます。そこでかなりレベルを下げて、これだったらできるだろう、という非常に簡単な課題を出すのですが、自分の興味や考え方と合わないと、長続きしない傾向があります。

 自閉症スペクトラム障害全体にも言えることですが、アスペルガー症候群の場合、何かを変えようとするなら日常生活のなかで彼らを見守り、補う役割を負う家族などの第三者の存在が欠かせません。病院の、しかも60分枠というカウンセリングの時間の中では、家族への対応には限界があるのですが、それでも、家族へ障害の説明を行い対処法についての相談を受け、家族へのココロの援助が、本人への介入と同時進行でできる場合は、時間はかかっても、少しずつ日常生活に変化が出て、本人も安定するようです。1対1の面接だけで、うまくいっているという例はまだ経験したことがありません。

 感情のコントロールについては、爆発型と抑制型では対応が異なります。爆発型の場合、まず私は短時間でも毎日続けられる構造的な運動(早歩き、ジョギング、キャッチボールなど)をするようにアドバイスします。また、感情が爆発したときの対応について、本人と家族に別々にアドバイスをしています。大人の場合は、怒りが爆発する前に深呼吸をするとか10数えるという方法は取りにくいこともあり、タイムアウト(その場からちょっと離れる)のが最も効果的な印象があります。日常的に呼吸法などリラクセーションをやってもらい、運動と合わせてリラックスしているときの身体や気持ちを体験的に理解できるように援助しています。抑制型も、運動やリラクセーションという点では同じですが、自分の身体感覚や感情にどう気付いていくかという訓練を必要とします。

 パニック症状や、感情のコントロールに関しては、リスパダールという向精神薬もある程度の効果を示します。ただし、あくまでも少し落ち着くだけなので、結局行動や考え方を少し変えていく上で多少役に立つ程度です。もともと統合失調症の治療薬なのですが、なぜアスペルガーに効果があるのかはよく分かっていません。米国心理学会(APA)によると、それでも経験的に使われているそうです。

 対人関係スキルについては、やはり集団での訓練は必要だと思います。しかし、今の我が国のデイケアは統合失調症をはじめ精神障害者向けのプログラムなので、アスペルガー症候群やその他の自閉症スペクトラム障害の必要には必ずしも合っていないように思います。

 アスペルガー症候群の大人の方にとって、対人関係で一番大変なのは、相手の気持ちや周囲の状況をどう理解すればいいかということです。しかし子供のように、それを絵などで教えるのには抵抗を示されるので、大人向けにどう変えていくのか、これは今の私の課題になっています。自分が感じているように相手も感じている、と自動的に評価してしまうので、自分と他人の感情が異なることを、何から読みとればいいのか、という事を身につけてもらうのですが、これはなかなか骨折りな作業です。

 さて、そろそろ時間になったので、ここでやめておきます。

 
 

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Comments

なるほど。大変参考になりました。長々と書いていただいてありがとうございました。

Posted by: miyashu | 2004.08.05 at 09:56 PM

miyashuさん、

 ちょっと文章が長すぎたかもしれませんが、最後まで読んで下さってありがとうございます。

 もうちょっと短く編集したかったのですが、言いたいことがたくさんありすぎて…分割したほうがよかったかな?

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Posted by: picsiz | 2009.01.07 at 01:49 AM

とても参考になりました。
特に、自分の興味や考え方と合わないと、長続きしない傾向がある。という面は、正に的を得ているなと思いました。
何故なら私自身がきっと、そうであるからなのです。

アスペルガーは表側は隠していますけど、頑固な性格の人が多いと思うのです。私は、専門家でもないただのアスペルガーの主婦です。

私の持論なのですが、根底の問題は本人が解決するしかないと思っています。
周囲の人に欠点を理解してほしい、というのはいいのですが、
心の悩みを理解してほしいというのは、何か間違っていると思うのです。
人は、みんな孤独なのです。ひとりで死んでいくのです。
人の心をほしがることはそもそもいやしいことなのです。
アスペルガーは自分の独りよがりな性格の欠陥を人間関係において克服することが少し困難なのです。
それは、たぶん対セラピストさんにおいてもいえること
だと思います。

西洋哲学は孤独に誇り高く生きよと教えてくれます。
日本の古典文学は人間の愚かさ知って恥じよと教えてくれます。

そういうもので、自ら学んで気づくことがとても大切なのではないかと思っています。

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