報酬系④ So called SP revised (11)

しかしこんな理解でいいのであろうか?心理学の本を読むと、結局私がこだわっている問題は、incentive salience model (誘因特徴モデル、略してISM)ということに関係しているらしい。(salience とは「際立っている」という意味だが、日本語にうまい訳がないらしく、定訳もないらしい。少し無理すると、誘因特徴というのが出てくるが。)ということで少しお勉強する。ISMが言っていることは、要するに欲するwanting と好きであるliking は異なる問題であるということだ。例えばこうだ。きれいな絵を見る。うれしい。これはliking. それとは別に、例えば喉が渇いているときにペットボトルの水を見る。それ自身はうれしくないが、欲しい。こちらは、wanting. 後者にはドーパミンが関係しているらしい。
この liking wanting の乖離は、例えば依存症などでも顕著であるという。例えばアルコール中毒の人にとって、酒はおいしいだろうか?飲んでいて美味しい liking というのとは違うらしい。しかし欲しい wanting となるのである。その人にとってはおそらくビールの広告を見るのはつらいことなのだ。それはとても liking にはなれない。なぜならばそれを手に取ることができないからだ。
 この「好き」と「欲しい」の違い、考えてみると実に面白い。例えばコマーシャルでタレントがおいしそうにビールを飲むシーンが映し出させる。ビール好きにとっては不快な内容ではないか?なぜならそれがビールを飲みたいという願望を生むにもかかわらず、根目の前にそれはないからだ。もちろんスポンサーとしては、それが多大なwanting を視聴者に生み、彼らがコンビニに走ることを目的とするのだろう。しかしなぜ大多数の視聴者が「不快なコマーシャルはやめろ!」と訴えないのだろうか?それはコマーシャルのタレントに同一化して「いいな!」と思わせるからだろう。その意味ではliking の状態を生んでいるのだ。ということはこういうことだろうか?ビールはいざとなったら手に入れることができる。だから不特定の未来に向かって先取りの快楽を味わうということだろうか?うーん、またわからなくなってきたぞ。それにしても面白いぞ、ISM。私のこだわりは特別のことではなかったのだ。というよりそれに対する理論はもう提出され始めてきているのだ。ドーパミン経路との関連で。

Implications for psychotherapeutic approach
So far, I described a hypothetical process in which different types of SPs are formed, with a help of some diagrams in order to make my points. Now I will discuss briefly what these understandings could inform us in handling SPs in our clinical settings. Unlike other non-SP parts of personality, SPs are difficult to handle as they often resist being called into the therapeutic situations. Therapists also tend to be loath to deal with them, as they are often destructive, aggressive and revengeful. However, if some SPs continue to haunt in the patient’s life and would not “go back to sleep” or become dormant, they often need to be dealt with in therapeutic situations, so long as enough security measures are provided, not only for the patient as well as the therapist. If a SP is expected to get easily out of control or become agitated to a degree that the therapist cannot subdue or control, even an attempt to handle SPs directly in a therapeutic setting is deemed to be inappropriate or untherapeutic. (Inpatient setting might be a different story if enough manpower is available and medical resource can be used if necessary, such as restraining devices or seclusion room, but I would like to limit my discussion to outpatient treatment setting without any helpful staffing, except for supportive and protective family members chaperoning the patient.)
The conditions and the rationales for handling SPs in psychotherapeutic setting should be as follows: The therapist should have established some degree of therapeutic alliance with an identified SP that he intends to handle, such an SP should be cooperative enough to keep therapeutic structure and intends to make use of the treatment for the benefit of the whole personalities of the patient. The host personality should be certain enough that the SP is not excessively disruptive and aggressive, so that the therapist should never be in any physical danger.
It is to be stressed that the handling of SP is actually called for for the benefit of the patient’s life. No heroic attempt on the part of the therapist to “arose” or “coax into disappear” with any SPs which are already dormant and never showed up recently to manifest themselves or disrupt the patient’s life and his/her relationship. The principle of “do not wake a sleeping baby” should be applied here. We need to be cautious that the therapeutic handling of an SP could cause any iatrogenic disturbance to the patient, such as unexpected worsening of the patient’s functional level, triggering of frequent appearance of any SPs.
The conditions in which the handling of SP can be appropriate and therapeutic should be summarized as follows.
A SP has been haunting frequently enough in the patient’s life for an extended period and the continuation of that pattern for the near future is expected.
That SP is cooperative enough to the therapist, and the host or the SP itself can assure that any physically aggressive or disruptive behavior can be avoided (or the therapeutic process should be suspended if any of such behaviors should occur).   

In clinical situations, the handling of SP is warranted and deemed appropriate if some SPs are sending frequent messages via auditory hallucination, disruptive verbal threats or remarks, any handwriting in the patient’s diary with aggressive messages that the host cannot remember making. If that appearance of SP is considered to be caused by any contact with past aggressors or recent retraumatization of any kind, the approach to these new episodes should be prioritized instead of delving into handling SPs.