慢性運動性抽動症心理治療個案報告：結合遊戲治療與心理諮詢

Case Report of Chronic Motor Tic Disorder Psychotherapy: Combine Play Therapy and Consultation

研究目的：本文闡述心理師對一名男性12歲的慢性運動性抽動症患者進行心理治療的過程，案主伴隨有人際／社交、拒學、選擇性緘默與強迫行為等困擾。研究方法：心理師（第一作者）以多模介入的心理治療方式協助，包括兩個管道：直接以遊戲治療協助案主﹔間接以諮詢協助案主母親與認輔教師，分別在家實施習慣倒反訓練與在學校的輔導活動。心理師每週安排一小時的晤談，包括母親諮詢20分鐘與案主遊戲治療40分鐘；另外每個月以電話方式接受認輔教師求詢。研究結果：歷經八個月共26次晤談，案主求助時的主訴症狀都獲得明顯的改善﹔三個月之後追蹤，仍維持治療效果。研究結論：本文從案主病史、診斷澄清、病理分析、治療目標與過程等角度進行分析討論。

Purpose: This thesis describes the psychotherapy process. The client is a 12 year-old boy with a chronic motor tic disorder associated with symptoms of social refusal, school phobia, selective mutism, and compulsive behavior. He was referred to the first author by his guidance teacher. He lives with his mother and an elder brother.
Method: Under the supervision of the second author, the psychologist (first author) conducted a psychological assessment using DSM-IV as a conceptual framework and though reviewed related references regarding client’s diagnoses and etiology. It is hypothesized that inherited vulnerability, parents marital conflict, and peer sneering at him, huge frustration and pressure were the precipitators to the development of tic syndromes.
After a comprehensive understanding of the client’s problems, the following psychotherapeutic needs should be taken care: on the emotional aspect, client’s anxious, frightened, and angry mood, as well as the sense of defeat need to be dealt with, and replaced with satisfying, comfortable feelings. On the behavioral aspect, his tense muscles which gave rise to the tic symptoms required training through competing muscle contraction and behavioral response that opposes the tic movement. This training is combined with relaxation training, and classical and instrumental conditioning. And, through the experiences of positive and negative reinforcements as well as reciprocal inhibition, he could build up capabilities of academic and interpersonal adaptation in the campus.
In order to meet above-mentioned demands as quickly as possible, it was better to combine accessible resources in the client’s life situation, and adopt a multimodal approach. Namely, the psychologist treated the client directly with play therapy which could break through restrictions of the language, and obtain interpersonal corrected experiences. In addition, indirectly helped his mother and his teacher through consultation to administer revised form of habit reversal training at home and school guidance activities separately. The goal of this treatment plan was constructing a balanced environment between challenge and protection, through which the client could benefit for his self-concept, re-constructing a self-confident and self-efficient internal self-evaluation system. (Note: The client’s medicine reaction was poor in the past, so was no longer considered for the moment.) Results: The treatment session was one hour per week, including 20 minutes of consultation with the mother and 40 minutes of play therapy with the client; in addition, a telephone consultation for the client’s guidance teacher was provided once a month. After 26 sessions treatment in 8 months, the majority of the presenting symptoms decreased significantly. Three months after the completion of therapy, therapeutic effects still persist. Conclusions: The client’s history of this disorder, the differential diagnoses, etiology, treatment goals and progress were discussed.