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病人-中心解释和分析师-中心解释

王静华2016-5-03 17:48
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Patient-Centered and Analyst-Centered Interpretations:

Some Implications of Containment and Countertransference

John Steiner, M.B.Ch.B., F.R.C. Psych.

病人-中心和分析师-中心的解释:涵容性和反移情中的提示

翻译者:王静华,2016

翻译者按:

【……

分析师:还有吗?

来访者:我并没有不尊重你

分析师:恩,我是问“还有吗?”

来访者:我听成是“你有吗?”我怎么会听成是这个呢?

……

弗洛伊德说肉体伴随现象有着最完整的精神序列,意识的断裂处就是潜意识的浮现。

奥格登(心之母体,1986)指出心之母体是一个涵容性的空间、包容性的空间,心理和身体体验得以在其中发生,从温尼科特的角度来看,婴儿的心理内容唯有在这个母体中才能得到理解。随着母亲的分离或撤走,婴儿产生一个潜能空间,位于幻想和现实之间的中介性体验领域。分析空间就是一种潜能空间,是主体间状态,由治疗师和病人共同组成,在分析空间中可以把玩、思考和理解意义。

温尼科特说投射性认同是直接的交流,直接交流是指通过直接在另一个人身上引出某种感受状态,而不是通过语言符号来进行交流。语言作为思考性主体的有力的工具,区分象征符号和象征所指,用词来完成对分离的哀悼。

如何给出使用语言、给出解释是一个精致的事情。

德国心身科医生Heinz Weiss2014年发表在《The International Journal of Psychoanalysis》的一篇论文《投射认同的五阶段模型》中提到通过使用分析师-中心的解释传达包容性的感觉。具体可参考我对此论文的翻译:http://www.psychspace.com/home/space-15850-do-blog-id-4874.html

斯坦纳在这篇论文(1994. Psychoanalytic Inquiry, 14:406-422)中,通过精神病性病人和边缘性病人的治疗片段,来说明无论是病人-中心还是分析师-中心的解释都会遇到问题,都可能会被病人体验为有毒的、侵入的,想要通过粪便排泄出去或者是被病人体验为分析师不能忍受病人难以承受而投射出来的感受,引起病人的退缩。

因此,分析师需要具有“自由悬浮回应式能力”对自己的反移情保持觉察,这可以通过第三方视角或者病人的反应来达到。对精神病性和边缘病人的治疗,分析师接受病人的投射并在内在保留、形成理解,以此创造一个涵容性的空间并作为容器客体持续存在对这些病人是必要的、也是基础性目标,但持久的心理改变依赖于病人获得领悟和理解力。病人会通过全能幻想进入分析师内在并产生控制分析师的妄想,但在这种幻想的裂缝处,病人开始体会到与分析师的真实分离,因而触碰到悲伤,这也是病人真正对自己内在心灵过程,并能开始忍受与客体的真实分离,并开始内化分析师的容器能力,是能够忍受领悟和精神痛苦的开端,将投射出去的碎片重新整合回自我。】

 

The treatment of psychotic and borderline patients presents formidable technical problems for the psychoanalyst, and many of these arise from the uncomfortable countertransference feelings these patients evoke. They are usually aware of the disturbance around them to which they react but are unable to recognize their role in the creation of the situation and are unaware or unconcerned with their own internal problems. In analysis, the patient in this state of mind is not interested in discovering things about himself, and uses the analysis for a variety of purposes other than that of gaining insight into his problems.

精神分析在对精神病性和边缘性病人的治疗会遇到难以想象的艰巨的技术问题,主要是源于这些病人激起的令人不安的反移情。他们通常会对周遭感到非常困扰、心神不安,却不能认识到他们自己在促成这种局面所扮演的角色,也没有意识到或者不关心他们自己的内在问题。分析中,病人的心理状态使其没有兴趣探索了解自己,分析可被用于众多不同的目的,唯独不是对他自己的问题形成理解力。

Joseph (1983), who pointed out that many such patients are not interested in understanding, saw this as related to the fact that they are functioning at a paranoid-schizoid level. In these circumstances the patient's main concern is to obtain relief and security by establishing a mental equilibrium, and consequently he is unable to direct his interest toward understanding. The priority for the patient is to get rid of unwanted mental contents, which he projects into the analyst. In these states he is able to take very little back into his mind. He does not have the time or the space to think, and he is afraid to examine his own mental processes. Words are used, not primarily to convey information, but to have an effect on the analyst, and the analyst's words are likewise felt as actions indicating something about the analyst's state of mind rather than offering insight to the patient.

约瑟夫(1983)指出许多这样的病人对获得理解力并不感兴趣,并认为这是和他们处在偏执分裂功能水平有关。在这种情况下,病人主要关注建立精神平衡、获得安心与安全,因此就没有能力将他的兴趣指向获得理解力。对这些病人而言,首当其冲的是通过投射进分析师来摆脱有害的精神内容,这时他几乎没有能力撤回到他的心灵上。他没有时间和空间进行思考,并对核查他自己的精神过程感到害怕。话语不是用来传达信息,而是为了对分析师产生影响,并且同样地,分析师的话语被认为是表明分析师的心理状态,而不是提供对病人的洞察力。

 It is important to remember, however, that although he may not be interested in acquiring understanding, that is self-understanding, the patient does have a pressing need to be understood by the analyst. Sometimes this is consciously experienced as a wish to be understood and sometimes it is unconsciously communicated. A few patients appear to hate the whole idea of being understood and try to disavow it and get rid of all meaningful contact. Even this kind of patient, however, needs the analyst to register what is happening and to have his situation and predicament recognized.

重要的是记住,尽管病人可能对获得理解力、也就是自我理解没有兴趣,但是病人确实被分析师理解有着非常急迫的需求。有时,会在意识上体验为期望被理解,有时是通过无意识表达的。少许病人看起来似乎憎恨有被理解的想法并尽力否认、摆脱所有有意义的接触。可是,即使是这样的病人也需要分析师记下正在发生什么、辨识他的状态和困境。

 The transference is often loaded with anxiety, which the patient is unable to contend with, but which has to be contained in the analytic situation. Such containment depends on the analyst's capacity to recognize and cope with what the patient has projected and with his own countertransference reactions to it. Experience suggests that such containment is weakened if the analyst perseveres in interpreting or explaining to the patient what he is thinking, feeling, or doing. The patient experiences such interpretations as a lack of containment and feels that the analyst is pushing the projected elements back into him. The patient has projected these precisely because he could not cope with them, and his immediate need is for them to continue to reside in the analyst and to be understood in their projected state.

移情常常充满了焦虑,这是病人不能应对的,但是不得不在分析场景中被涵容。涵容性取决于分析师辨识和应对病人投射的能力以及分析师自身的反移情反应。如果分析师执意诠释或者解释病人的所思所感所做,涵容性就会被削弱。病人对解释的体验是缺乏涵容,会感到分析师正在把投射元素推回、进入他的内部。病人已经准确地投射了这些,因为他不能应对它们,他即可的需求是让这些持续地保留在分析师里,并在投射状态下获得对它们的理解。

 Some analysts, in these circumstances, tend to phrase their interpretations in a form that recognizes that the patient is more interested in what is going on in the analyst's mind than in his own. At these times the patient's most immediate concern is his experience of the analyst, and this can be addressed by saying something like, You experience me as …” or, You are afraid that I …” or, You were relieved when I or, You became anxious a moment ago when I …” I think of such interpretations as analyst centered and differentiate them from patient-centered interpretations, which are of the classical kind in which something the patient is doing, thinking, or wishing is interpreted often together with the motive and the anxiety associated with it. Of course, the distinction between the two types of transference interpretation is schematic, and in a deeper sense all interpretations are centered on the patient and reflect the analyst's attempt to understand the patient's experience.

在这些情况下,一些分析师趋向于以这种方式组织措辞:认为病人对分析师心灵体验更感兴趣,而不是他自己的。这些时刻,病人当下关心的是他对分析师的体验,可以用这种方式表达,“你体验到我”,或者,“你担心我,或者,“当我你感到如释重负。”,或者,“刚才当我你变得焦虑起来。”。我认为这样的解释是分析师-中心,与经典的病人-中心的解释不同,后者是解释病人的所做、所思、所期望以及动机和相关的焦虑。当然,这两种类型的移情解释的区别是概括性的,在更深的层次上,所有的解释都是以病人为中心、反应了分析师尽力去理解病人的体验。

 The problem is to recognize where the patient's anxieties and preoccupations are focused. In practice most interpretations take into account both what the patient feels and what the patient thinks the analyst feels, and include a reference to both patient and analyst. When we say, “You experience me as …” or “You are afraid that I …” a patient-centered element is present because we are talking about the patient's experience and fear.

问题在于要去识别病人的焦虑和成见会集中在哪里。在实践中,大多数解释需要同时考虑病人的感觉和病人对分析师感觉的看法,并且涉及到病人和分析师两者。当我们说,“你体验到我,或者,“你担心我”,病人-中心元素得以呈现,因为我们正在讨论的是病人的体验和恐惧。

 Moreover, it is clear that the distinction depends more on the analyst's attitude and state of mind than on his or her wording. If the analyst says, “You see me as …” and implies that the patient's view is one that is in error, or hurtful, or in some other way undesirable, then the emphasis is on what is going on in the patient and the interpretation is primarily patient-centered. To be analyst-centered, in the sense which I intend to use it, the analyst has to have an open mind, be willing to consider the patient's view, and try to understand what the patient means in a spirit of inquiry. Although these considerations complicate the distinction between the two types of interpretation and suggest gradations between them, I will consider them to be distinct for the sake of clarity. Both types of interpretation are necessary for the patient's total situation to be understood, and both types have dangers attached to them if they are used excessively and without due attention to the feedback the patient gives in reaction to them.

再者,很清楚的是,这个区别更多的是取决于分析师的态度和心理状态,而不是他或她的话语。如果分析师说,“你把我看成”,暗示病人的观点是错误的、有害的或者不受欢迎的,那么重点就是病人内在正在发生的是什么,那这个解释就是是病人-中心的。对于分析师-中心的解释,我认为需要在这样的意图上使用:分析师必须有开放的思想,愿意考虑到病人的观点,以探寻的精神尽力理解病人的意图。虽然这些考虑使得这两种类型解释之间的区别变得更加复杂并提示它们之间的连续渐进,但为了清晰起见、我将认为它们是截然不同的。对于理解病人的整体状况,这两种类型的解释都是必要的,如果它们被过度使用并且忽视病人对这些解释的反应和反馈,这两种解释都将是危险的。

 Sometimes the patient-centered element is elaborated further, and we may say something like, “You are trying to get me to feel … such and such,” or, Your attack on me just now gave rise to such and such a result.” The interpretation then involves a link between what the patient does, thinks, or wishes, and the state of the analyst. Sometimes these links take the form of a because clause that is added to an analyst-centered interpretation. We may say, “You are afraid that I am upset because of the fact that you did such and such.” Such links are the essence of deep analytic work but are particularly difficult for the patient who is operating at a paranoid-schizoid level. They imply that he is not only capable of taking an interest in his own actions but able to accept responsibility for them as well. Especially in the early stages of an analysis and particularly with schizoid, borderline, and psychotic patients, it is necessary to recognize the problems that ensure from both types of interpretation and from the links that arise between them.

有时病人-中心元素会说的更详细,我们可能说,“你正在尽力让我感到这样那样,”,或者,“刚才,你攻击了我造成这样那样的结果。”。这种解释就在病人的所做所思所期待和分析师状态之间建立联系。有时,这些联系会有在分析师-中心解释中使用的 因为”的结构形式。我们也许会说,“你怕我失望,因为事实上你的确这样那样做了。”。这样的联系是深度分析工作的核心,但是对于正在偏执-分裂水平上运作的病人而言是尤为困难的。这些解释暗示他不仅有能力对他自己的行为感兴趣并且能够对自己的行为承担责任。尤其在分析早期阶段,在与分裂性、边缘性和精神病病人工作时,有必要承认安全地给出这两种解释并建立联系是有困难的。

Clinical Material

临床材料

 I believe that the distinction between these two types of transference interpretation can help the analyst to examine the technical problems he has been struggling with and may allow him to shift from one type of interpretation to the other when it appears to be appropriate. To examine these issues I will first briefly look at some material from a psychotic patient whose case I have discussed in a previous article (Steiner, 1991).

我相信这两种类型的移情解释的区分将有助于分析师检验他一直与之斗争的技术性问题,分析师可以在合适的情况下从一种解释切换到另一种解释。为了说明这些议题,我将首先简短地回顾一个精神病性病人的材料,我在之前发表的文章中讨论过这个个案(斯坦纳,1991

 This patient had recently recovered from a major breakdown, and although just able to return to work was still very paranoid and concrete in his thinking. He began a session by voicing bitter complaints against his employers, who had been unfair to him, and then against his analyst, who did nothing to rectify this unfairness. He next described a breast infection that his mother had when he was a baby, and moved on to speak with triumph about his ability to hurt the analyst. He then announced his intention to change his job; since this would necessitate a move to another city, it meant the end of his analysis.

病人刚刚从一次重大事故中恢复过来,虽然仅仅是能够返回工作岗位,他的想法仍然是非常偏执而固执的。会谈开始,他发出一种痛苦的声音抱怨他的雇主对其不公,接着病人抱怨分析师对改变他的不公无所作为。接着,他描述了在他还是一个婴儿时母亲的乳腺发炎,然后转向为以胜利者的口吻表达他能伤害分析师。他接着宣布他想换工作,既然有必要换到另一个城市,这也就意味着分析的结束。

 The analyst felt sad at the idea of losing his patient and interpreted that the patient wanted to get rid of his own sadness and wanted him, the analyst, to feel the pain of separation and loss. The patient said, “Yes, I can do to you what you do to me. You are in my hands. There is an equalization.” A moment later he started to complain that he was being poisoned and he began to discuss government policies of nuclear deterrence. He argued these were stupid because they involved total annihilation, but the policies of nuclear disarmament were no better because you could not neutralize existing armaments. He then complained of gastric troubles and diarrhea and said he had been going to the toilet after each session recently. He explained that he had to shit out every word the analyst gave him in order not to be contaminated by infected milk.

想到要失去这个病人,分析师感觉到悲伤,并解释病人想要摆脱他自己的悲伤,想让分析师体验到分离和丧失的痛苦。病人说:“是的,我能对你做、你对我所做的。你在我的掌心里。势均力敌。”,过了一会儿,他开始抱怨他被毒害了,他开始讨论核威慑的管制政策。他争论到核武器根本就是愚蠢的,因为会导致人类灭绝,核威慑政策并没有让情况变得更好,因为不可能使现有的核武器销毁。他接着抱怨胃部不适和腹泻,最近每次会谈后他都不得不去卫生间。他解释他必须吐出分析师给出的每一个单词,为了不让自己被感染的牛奶污染。

 In his response to the analyst's interpretation the patient at first appeared to agree that he wants the analyst to feel the pain of separation and loss in order to effect an “equalization,” but a moment later he complained of being poisoned. I believe that he found this interpretation correct but threatening because it exposed him to experiences such as grief, anxiety, and guilt, which were associated with the loss of his analyst. He felt that the analyst had forced him to take these feelings back into himself and he experienced them concretely as poison and tried to evacuate them in his feces. The patient indicated the catastrophic nature of his anxiety by talking about nuclear disaster. His insistence that no defense was possible against a nuclear attack may have had its roots in his conviction that his defenses could not protect him against his analyst's words. He needed the analyst to recognize that he could maintain a relationship with him only if the analyst agreed to hold the experiences associated with loss in his own mind and to refrain from trying to return these prematurely to the patient. After a transient contact with the experience of loss, the psychotic process reasserted itself in the patient's assertion that he would shit out every word the analyst said.

对分析师的解释,病人最初的回应是承认他想让分析师感受到分离和丧失的痛苦、为了达到“势均力敌”的效应,但过了一会儿,他就抱怨被毒害。我相信他发现解释是正确的但也是危险的,因为伴随着失去分析师,这个解释使得他体验到悲痛、焦虑、罪恶感。他感到分析师正在强迫他把这些感受拿回去,他对这些感受体验为毒物并尽力通过排泄物排泄出去。病人通过谈论核灾难来表明焦虑带给他的毁灭感。他坚称没有什么防御能抵抗核袭击,也许他从根本上深信他的防御不能抵抗住分析师的话语。他需要分析师意识到他是可以和分析师维持一种关系,当且仅当分析师愿意将丧失体验保留在他自己的心灵里,避免过早地将它们返回给病人。和丧失感短暂的接触后,病人的声明再次呈现精神病性:他将把分析师说的每一句话通过粪便排泄出去。

 This is a situation where the interpretation may be unbearable even when it is correct. The psychotic process has made experience so concrete that insight is poison and has to be evacuated in feces. When the analyst suggested that the patient wanted to get rid of his sadness and wanted the analyst to feel the pain of separation and loss, he was making a link between the patient's wishes and the analyst's state of mind. The patient felt the analyst disapproved of these wishes and was himself pushing the distressed feelings back onto the patient.

这种情况下,即使解释是正确的,也可能是难以忍受的。精神病性过程使得体验如此具体真实,洞察是有毒的而不得不通过粪便排泄出去。当分析师解释病人想摆脱悲伤的感受并意图让分析师体验到分离和丧失的痛苦,就是在病人的愿望和分析师的心理状态之间建立联系。病人感到分析师不喜欢这些愿望并推着这些痛苦感受回给病人。

 A different situation is seen when the patient is not psychotic and has a greater capacity to tolerate understanding and insight. This was the case in the material I will next discuss, taken from the analysis of a 40-year-old academic woman some two years after her analysis began. As a child she habitually withdrew to a phantasy world in which she joined figures from books or television to escape from the distress and anxiety going on in the family around her. The history contained many reports of extremely disturbed, wild, and even violent behavior, and she often found herself in situations where she seemed to invite exploitation, mistreatment, and even danger. This was particularly true in her adolescence and was now being repeated by her 14-year-old son, who created enormous problems for her.

当病人不是精神病性并更能忍受理解和领悟,情况就不同了。接下来要讨论的材料是对一位40岁的女性的分析,她是一名大学教授,已接受2年的分析。当她还是一个孩子的时候就习惯性地退缩到幻想世界里,在幻想世界里她和来自书里或者电视里的人物一起逃离让她感到悲伤和焦虑的家庭。她的个人历史中包括很多极度紊乱的、疯狂的乃至暴力的行为,她经常发现自己处于似乎是她自己引来的剥削、虐待乃至危险的情境中。这在她的青春期尤为突出,而且现在正在她14岁的儿子身上重演,他给她制造了大量的问题。

 After missing a Monday session she began on Tuesday by saying, I wondered if you would get the message. I spoke to a girl who said that she would put it in your drawer. I know what happens to messages like that. On Sunday I had wondered about ringing you at home.

错过周一的会谈后,在周二的面谈一开始说到:“我想知道你是否收到那则留言。我告诉一个女职员,她说她会把这条留言放在你的抽屉里。我了解如果这样的话,这条留言会有什么结果。周日在家给你打电话让让我觉得很奇怪。“

 On the train I imagined meeting someone I know who would ask, How are you? I would reply, Fine, Only my department is collapsing, my son has run off and I don't know where he is, my husband is fed up and helpless, and otherwise I am fine.’”

“在火车上,我想象会遇到某个我认识的人,对方会问我,“嗨,你好吗?”,我会回答:“很好,只是我的部门垮了,儿子跑掉了并且我不知道他到底在哪儿,我丈夫受够了并且觉得很无助,除此以外,我很好。”

 She continued by explaining that she had missed Monday because of an important meeting with the University Bursar to discuss finance that she decided she had to attend. She knew about this on the weekend and had wondered if she would phone to see if I could offer a different time. Instead she phoned my secretary early on Monday morning, and, suspecting that the message would not reach me, had phoned again during her session time to explain that she was not coming. In fact it turned out that just before going into the meeting, she was told it would be better if she did not attend, and she said that they implied that she would be a liability. She added that there was something theatrical about the way her colleagues were behaving and that, as a result, the negotiation with the Bursar was not straightforward.

她继续解释到,她周一没来面谈是因为和Bursa大学的一个重要会议,她决定她必须参加。她在周末获知此事并且不知道她是否可以打电话给我换个时间。不过,她周一一早就打电话给我的秘书,并猜测留言可能并没有送到我手上,于是在会议期间再次打电话解释她不能来面谈。事实上,那正好就是在她进入会议前,她被告知她最好不要参加会议,她对此的解释是他们暗示她是个累赘。她补充到她同事的行为有些做作,而且,结果是,与Bursa大学的谈判并不坦率。

 It is clear that we already have a complex communication and enactment between patient and analyst. There is a patient who wants to get a message through to her analyst and various obstacles come in the way. There is a woman who tells a friend that everything is fine but makes sure that she knows there are disasters all around. Finally, there is a professor who tries to attend an important meeting but is told she is not wanted because she is a liability.

很明显,在病人和分析师之间有一个非常复杂的沟通和运作。病人想要让她的留言给到她的分析师,传达过程中却有各种不同的障碍。一位女性告诉她的朋友一切都好但却确信她周围到处都是灾难。最后,一个教授试图参加一个重要的会议但是却被告知她并不期望参加因为她是个累赘。

 These stories all have powerful transference implications, which I believe center on the patient's need to get through to the analyst that there is something very seriously wrong that needs attention. This need to get a message through is central to the interactions in the session, but it is complicated by other motives. For example, it was possible to recognize a perverse side of her, which hated being understood and which hindered or sabotaged communication, making everything far from straightforward. The imagined comment to the friend on the train was not simply a message indicating how she felt, but was likely to make the person hearing it very uneasy, guilty, and confused.

这些故事都有着强有力的移情性卷入,我相信核心就是病人需要让分析师理解有一些非常严重的事情需要注意。需要让留言被理解对于会谈的互动是非常重要的,但是却被其他一些动机复杂化了。例如,没有办法认识到她的乖戾的一面,她憎恨被理解,阻碍或妨碍沟通、远非直截了当。在火车上想象对朋友说的话,不单单是表明她感觉怎样,而很有可能使他人听起来非常不舒服、内疚和困惑的。

 In this situation I believe it is possible to concentrate our attention on either the patient's or the analyst's state of mind, mental mechanisms, and behavior. Ultimately the aim of an analysis is to help the patient gain an understanding of herself, and even with this material, interpretations could have been used to explore the way she reacted and behaved. However, in this instance, I believe the patient was primarily concerned with the way her objects behaved. She felt that I did not make it easy for her to make contact with me on the weekend, and she had to overcome a feeling that she was a liability and unwanted if she intruded. Consciously she felt that she did her best and tried to get through to my secretary, but she knew what happened to messages which are supposed to be left. When she imagined saying everything was fine she was partly being ironic, and partly trying to make me uncomfortable. Moreover, she left open the possibility that she was being theatrical, so that it was not clear what her inner reality was. I thought there were elements of despair and helplessness in the way she felt obliged to say she was fine and to go on coping somehow. The statement, although clearly a negation of feeling fine, left it open to me to choose to ignore the irony and against all the evidence to hear her to mean that she was actually fine. She herself was sometimes convinced that this was the case and that it was other people who were making an unnecessary fuss. These thoughts led me to feel that despite the fact that she was not always able to carry out a straightforward negotiation she needed me to recognize her desperation and she feared that I would prefer to agree that everything was fine even though I knew very well that the contrary was true.

在这种情形下,我相信将注意力集中在病人或者是分析师的心理状态、心理机制和行为上是有可能的。最终,分析师的目标是帮助病人获得对其自身的理解,使用这些材料,解释可以用于探索病人反应和行为的方式。可是,在这个例子中,我相信病人首先关注的是她的客体们的行为方式。她感到我没有让她在周末能很容易地联系到我,如果贸然侵入,她就不得不克服那种她感到是个累赘和令人讨厌的感觉。意识上,她觉得她尽其所能并给我的秘书打了电话,但是她知道留言以那种方式传达会有什么结果。当她想象着说一切都好时,她部分是讽刺性的,部分是竭力让我不舒服。再者,她保持了一种她是矫揉造作的可能性,以至于并不清楚她内在真实是怎样的。我认为当她不得不说她很好并不知如何去应对时,有着某些绝望与无助。尽管很清楚感觉并不好,这个陈述把选择权交给我去选择忽略这种讽刺性并反对所有的证据听从她觉得自己实际很好。她自己有时很确信这就是事实并且其他人有些大惊小怪。这些想法导致我感到尽管事实是她不能进行一次坦率的谈判,但她需要我识别出她的绝望,她害怕我宁愿选择同意一切都好,即使我知道正好完全相反。

 If I made patient-centered interpretations, I thought she would experience this as an attempt to make her responsible for her failure to get through to me, and that it would indicate my reluctance to accept responsibility for my contribution to the obstacles that stood in her way. In fact it was probably true that her passivity and inability to fight for her needs helped to achieve the projection into me of guilt, pain, and responsibility. If so she would, in principle, benefit from an understanding of these mechanisms, which no doubt contributed to her difficulties, but I feared that she was in no state to be interested in understanding issues such as this. What she wanted was that I recognised that something was terribly wrong with her, and that I accepted the feelings this aroused in me and refrain from projecting them back into her. She was afraid that I was not going to be able to cope with these feelings because they would disturb my mental equilibrium.

如果我进行病人-中心的解释,我认为她会将之体验为试图让她承担失误的责任,我不愿意对她给我电话遇到的阻碍承担起自己的责任。事实上,她在争取自己需要时的被动和无能,促使她投射给我内疚、痛苦和责任。原则上,她将会从理解这些心理机制中获益,毫无疑问,这些机制增加了她的困难,但是我担心她现在的状态并没有兴趣了解这些。她所想要的就是我承认她正在被糟糕地对待,并且我接受了我内在唤起的这些感受,克制住把这些感受投射回病人。她害怕我不能够应对这些感受,因为它们会妨碍我的精神平衡。

 I interpreted that she feared I was not able to create a setting where messages would get through to me, and I drew her attention to the atmosphere of the current session, where she seemed relatively composed. I thought that she hoped that I would see that beneath this composure things were very far from fine. However, I found myself adding that she also hinted that something theatrical was going on, and I wondered if this was expressed in the way she tried to make contact. I thought that this left her unsure if I could see through the theatricality to what she really felt.

我解释到,她担心我不能建立一个能让她联系到我的设置,我引导她注意目前会谈的气氛,这个气氛似乎她部分地参与组成。我认为她希望我能看到在这份沉静之下,事情远不够好。可是,我发现我自己补充到说她也暗示有些做作的事情在发生,并且我想知道这是否表达了这是她联系的方式。我认为这让她不确定我是否能识破做作、知道她的真实感受。

 After I had spoken I realized that this additional comment had a somewhat critical tone to it, which I suspected arose from my difficulty in containing feelings, including those of anxiety about her and possibly my annoyance that she made me feel responsible, guilty, and helpless. I also knew from past experience that a critical comment could lead to the enactment of a sadomasochistic relationship in which she would feel the victim of an unfair attack.

在我说完以后,我发现这个补充的评论带来了某些批评的论调,我怀疑这是源于我涵容这些感觉的困难,包括对她的那些焦虑和我恼怒她让我感到负有责任、内疚和无助。从过去的经验,我也了解到这个关键性的评论会导致再现一个施虐受虐的关系,在这个关系中她感到自己是不公平的攻击下的牺牲品。

 She was silent for a while and then spoke about her fraught relationship with her son. She described the way he wound everyone up, and how he had screamed that he could not bear to live with her and had stormed out. At first he said it was for good, but later he phoned and said he would be back for school on Monday. In fact he failed to turn up, and she had to ring the school and explain because they were also at the end of their tether with him and threatened expulsion. She told them she knew it was terrible, but what could she do?

她安静了一会儿,然后说起她和儿子之间充满忧虑的关系。她说儿子是如何让每一个人都感到紧张,他是如何尖声喊叫着他不能容忍和她生活在一起、并狂冲而出。起先,他说永远也不回家,但是不久他就打电话并说他周一会回到学校。事实上,他并没有出现,他就不得不给学校打电话解释,因为他们也受够了并威胁着开除他。她告诉他们她知道这很可怕,但是她还能做什么呢?

 I considered this to be a comment on the interaction that had just taken place and a reaction to the interpretation I had made. At one level I thought she felt I had been critical, and like her son she had the impulse to withdraw in anger. It was difficult to know how to respond, but I thought it was probably better to refrain from emphasizing this side of the relationship. I did not think she would be able to take responsibility for her contribution to the difficulties in communication between us, and that interpreting them would probably feed a view of herself as an abused victim. I thought she disowned these feelings in the session and identified with me as a parent who could not cope.

我设想这就是对刚才发生的互动的评论和对解释的反应。在某个程度上,我认为她感到我是批评的,像她的儿子一样,她有一种生气地想退缩的冲动。很难知道该如何回应,但我认为可能最好是避免强调这个。我认为她不能对她在我们之间造成的困难沟通承担起责任,对此进行解释很可能强化她认为自己是一个受虐的牺牲者的看法。我认为她在会谈中否认这些感觉并认同我是无法应付这些感受的父母。

 It was thoughts like these that made me interpret that she needed me to accept the sense of helplessness when my patient disappears which may be something like her feeling when her son disappears. She needed me to cope with the anxiety associated with her not coming to her session and not being able to get in touch with me. She felt I blamed her for this just as she now feared I was too critical and defensive to understand her anger and disappointment with me and to recognize that she also wanted to make contact and did try to reach me and get through to me.

诸如此类的想法促使我解释到,她需要我接受这种当我的病人消失时的无助感,这就类似于当她的儿子消失的时候她所感觉到的。她需要我能应对她不能来参加会谈、不能联系到我的焦虑。她感到我却为此责备她,仅仅是因为她现在害怕我太过挑剔和防御以至于不能理解她对我的愤怒和失望,不能理解她也想联系我并且尽力去做。

 After a silence she continued with more material about her son and the dangerous company of older criminal youths he was associating with. She described how she had tried to trace him by phoning his friends and their parents, and that when he had discovered this he was furious, abusing her and accusing her of spying on him and controlling him. She had also tried to get her ex-husband, his adoptive father, to go and bring him home but he said he was busy and had no car. He thought the boy should be allowed to find his own way back in his own time.

沉默了一会儿后,她继续提供更多的有关儿子的材料,说到儿子和一些比他大一些、有犯罪记录的年轻人混在一起。她描述她是如何通过给他的朋友和朋友的父母打电话追踪他,当他发现后他怒不可歇,辱骂她并指责她监视他、控制他。她也给她的前任丈夫、儿子的养父打电话,让他把儿子带回来,但是他说他很忙并且没有车。他认为男孩子本应被允许以他自己的时间、找寻他自己回家的路。

 This made a direct connection with my own experience of her behavior in the session. I thought that she was identified with her role as a helpless mother but that the angry disturbed patient who was furious with me, who could not bear to be with me, and who had such difficulties in getting through to me was not directly available. This was a familiar problem and left me uncertain whether I should try to pursue her or wait for her to return.

这与我体验到的她在会谈中的行为建立了直接的联系。我认为她认同自己是一个无助的母亲,但是愤怒不安的病人对我怒不可歇,不能忍受我,联系我是如此地困难,没有直接联系我的方式。这是一个熟悉的问题,让我开始不确定我是应该追踪她呢还是等她回来。

 I interpreted that she saw me as helpless when she withdrew and that I left it to her to find her way back to the session. This made her fear that I did not take the danger she was in seriously. However, she also made it clear that when she felt disturbed, violent, and out of control, she would be angry and feel intruded on and controlled if I tried to reach her with interpretations.

我解释到当她退缩的时候,她认为我是无助的、留下她自己找寻回到会谈的路。这使得她很恐惧我不能承担她生病的危险。可以,她也清楚当她不安、狂躁、失控,如果我通过解释接触她,她会感到生气、被侵入和被控制。

 The remainder of the session continued in a similar vein. She described how her colleagues had to put on an act with the Bursar to persuade him that the department was in a terrible state, but that with applicants and colleagues from other universities the problem was exactly the opposite—they had to be convinced that the department was viable. There were references to the real possibility of being closed down and to the necessity of making staff redundant to avoid this. I had a strong impression of her insecurity and, because of numerous recent hints that she may not be able to continue her analysis, of my own possible redundancy.

会谈的其余时间以类似的脉络继续。她描述她的同事是装腔作势地说服财务部门主管相信部门的状况很糟糕,但是从其他学校来的申请人和同事却对这个问题持相反看法——他们不得不深信这个部门是可行的。这涉及到真实的被关闭的可能性并且可能会裁员以避免被关闭的必要性。我能感觉到强烈的不安全感,因为最近很多暗示表明她可能不能继续她的分析了,被我裁掉。

 This session was fairly typical in terms of the anxiety she generated and also showed both the problems she had in staying in touch with it and the problems she generated in me. If I tried to make contact with a very disturbed patient who found it difficult to come to the session, she felt that I pursued her, and she made it clear that she would not tolerate that. If, on the other hand, I was too passive, if I seemed to throw up my hands as she did and claim, that there was nothing more I could do, she was afraid that I would give up and see the analysis as bankrupt and hopeless. If I made patient-centered interpretations, she felt intruded upon and experienced it as my failure to cope with the anxiety, which led to me blaming her and pushing the anxiety back onto her. I thought she tolerated analyst-centered interpretations better, but she sometimes saw them as a confession that I was not coping and as an admission that I was afraid to tackle her difficulties and face the consequences.

这节会谈中她产生的焦虑相当典型,也显示出她很难和这种感受保持联系以及她在我内在引发了这种感受这两方面的问题。如果我尽力和一个非常不安、很难来参加会谈的病人接触,她感到我追踪她,很明显她不能忍受这个。另一方面,如果我太被动,如果我和她所做和所宣称那样放手,似乎也没有需要我做的,她担心我会放弃、眼睁睁地看着分析完结、无助。如果我做病人-中心的解释,她觉得她被侵入并体验为我不能应对焦虑,这让我谴责她并把焦虑还给了她。我认为她更能容忍了分析师-中心的解释,但是她有时视其为表明我无法应对并承认我担心不能应对她的困难、面对结果。

Discussion

讨论

Technical problems such as those I encountered in this material can be thought of as expressions of the patient's resistance on one hand, and of the analyst's countertransference difficulties on the other. Our understanding of both of these has been enhanced as we have learned more about the mechanism of projective identification (Klein, 1946; Rosenfeld, 1971), and about containment (Bion, 1959, 1962, 1963) and countertransference (Heimann, 1950, 1960; Money-Kyrle, 1956; Racker, 1957; Sandler, 1976), which are closely related to it. Both Sandler (1976) and Joseph (1981) have recognized the way patients nudge and prod the analyst in order to create a particular situation in the transference. Sandler describes how an internal relationship between the self and an object becomes actualized in the relationship with the analyst, who is led to enact an infantile role-relationship. As a counterpart to Freud's free-floating attention, he points out, the analyst has to have a free-floating responsiveness and that the analyst's reactions, as well as thoughts and feelings, contribute to the countertransference. Joseph shows how through suchenactments the analyst is drawn into playing a role in the patient's phantasy and as a result is used as part of the patient's defensive system. The patient may of course interpret such actualizations and infantile role-relationships in a delusional way and come to believe that they were achieved not by natural means, but by omnipotent phantasy.

在这份材料我遇到的那些技术问题,一方面可以被认为是病人的阻抗,另一方面,可以认为是分析师的反移情困境。我们已经提高了对这两方面的认识,通过对投射性认同(克莱因, 1946; 罗森菲尔德 1971)、对容器(比昂, 1959, 1962, 1963)、反移情(海曼, 1950, 1960; 莫里-凯尔, 1956; 拉克尔, 1957; 桑德拉, 1976),这些与之相关机制越来越多的了解。桑德拉(1976)和约瑟夫(1981)都认识到病人推动和刺激分析师是为了创造一个特定的移情情境。桑德拉描述了内部自体和内部客体关系是如何在与分析师的关系中“被实现”的,这导致“婴儿式的角色关系”的活化。他指出,与弗洛伊德的“自由悬浮式注意”类似的是分析师必须具有“自由悬浮式回应能力”,而且分析师的反应以及想法、感受都构成了反移情。约瑟夫显示通过这样的“活化”,分析师成为病人幻想世界中的某个角色,成为病人防御系统中的一部分。病人当然以妄想的方式解释这样的实现和婴儿式的角色关系,并最后意识到这不是以自然的方式达到的,而是通过无所不能的幻想达到的。

 We have come to use countertransference to refer to the totality of the analyst's reactions in the relationship with the patient. The recognition of the importance of projective identification in creating these reactions led naturally to the idea that countertransference is an important source of information about the state of mind of the patient. The analyst can try to observe his own reactions to the patient and to the totality of the situation in the session and to use them to understand what the patient is projecting.

我们使用“反移情”来指涉分析师在与病人的关系中激起的所有反应。承认投射性认同对制造这些反应的重要性就自然地会想到反移情是关于病人心理状态的重要信息来源。分析师可以尽力观察他自己对病人和整体会谈的反应,并利用这些反应来理解病人正在投射的是什么。

 But countertransference also has its problems when we come to try to use it in practice, perhaps most of all because the analyst's introspection is complicated by his own defensive needs so that many important countertransference reactions remain unconscious. Self-deception and unconscious collusion with the patient to evade reality makes countertransference unreliable without additional corroboration. Here a third point of view can help the analyst to recognize his blind spots and fortify his judgments (Britton, 1989; Segal, 1991). He may use colleagues and supervisors between sessions and to some degree internalize them. Most of all an analyst can use the help the patient gives, sometimes through a direct criticism of his work, but more often through reactions to interpretations he has given.

但是当我们想要在临床中使用反移情也会遇到问题,主要是因为分析师的内省会因为他自己的防御需要而变得复杂了,以至于许多非常重要的反移情停留在无意识状态。自欺欺人和与病人逃避现实的无意识共谋使得反移情变得不可靠,除非有额外的证据。第三方视角能帮助分析师认识这个盲点并确定他的判断(布里顿, 1989; 西格尔, 1991)。他可以通过同事和督导们并在一定程度上内化他们。大多数情况下,分析师可以通过病人获得帮助,有时是通过病人对分析师工作的直接的批评,但更常用的是病人对分析师解释的反应。

 Because of the propensity to be nudged into enactments with the patient, it is often impossible to understand exactly what has been happening at the moment when it is taking place. Sandler (1976) suggests that the analyst may catch a countertransference reaction, within himself, particularly if it is in the direction of being inappropriate, but he recognizes that such self-awareness may only occur after the responses have been carried over into action. In either case it is clear that immediate countertransference reactions have to be reviewed a few minutes later when the patient's reaction is available, and this may have to be repeated as further understanding develops later in the session or in subsequent sessions. Using all the means available, including selfobservation, the observation of his actions, the can arrive at some kind of understanding of his patient and of his interaction with him. If the analyst can stand the pressure, he can use this understanding to formulate an interpretation that allows the patient to feel understood and contained. When this is convincing the patient feels that the analyst can contain those elements the patient has projected into him, and as a result the projected elements become more bearable. The patient feels relief and is able to use the analyst's capacity to think, feel, and experience to help him cope.

因为通常是被推着与病人活化出来,当发生的时候分析师经常不能准确理解那个时刻正在发生什么。桑德拉(1976)建议分析师可在其内在捕捉到反移情反应,尤其是如果它在一个不恰当的方向上时,但是他承认可能在付诸行动才有这种自我觉察。无论哪种情况,很明显的是必须在获得病人反应后几分钟内审视即刻的反移情反应,接下来的会谈或者以后的会谈中会再次发生、以推进进一步的理解。使用各种可行的方法,包括自我观察,行为观察,分析师可以在一定程度上获得对病人以及与病人互动方式的理解。如果分析师可以承受压力,他可能利用这个理解形成一个解释,让病人感到被理解和包容。当这让病人确实感觉到分析师可以包容那些病人投射进分析师的元素,那么接着这些元素就变得更能忍受了。病人因此感到放松并能利用分析师的能力去思考、感觉并体验到这帮助他去应对这些。

 If the analyst is unable to contain the projections and closes himself off or counterprojects, the patient feels attacked and misunderstood and is likely to become increasingly disturbed and to intensify the splitting and the projective mechanisms he has been using. On the other hand, successful containment leads to integration and the experience of being understood may then provide a context where further development can take place.

如果分析师不能包容这些投射并关闭自己或者反投射,病人会被感到被攻击和误解并且很有可能持续增加困扰并强化他一直使用的分裂和投射机制。另一方面,成功的涵容会引起整合和被理解的体验,提供可促进进一步发展的环境。

 Such further development is necessary for lasting psychic change to occur, and, in my view, it does not automatically follow containment but depends on the acquisition of insight and understanding by the patient. Successful containment, which is associated with being understood rather than with acquiring understanding, is a necessary but not a sufficient condition for these developments. Containment requires that the projected elements have been able to enter the analyst's mind, where they can be registered and given meaning that is convincing. It does not require that the patient himself is available or interested in achieving understanding. If the patient is to develop further he must make a fundamental shift and develop an interest in understanding, no matter how small or fleeting. This kind of shift, which reflects the beginning of a capacity to tolerate insight and mental pain, is associated with a move from the paranoid-schizoid to the depressive position. I will try to illustrate how such a development depends on the experience of separateness and loss.

这种进一步的发展对持久的心灵改变是必要的,而且在我看来,它并不是在涵容以后自动发生的,而是依赖于病人获得领悟和理解力。成功的涵容,是与被理解有关,而与获得理解力无关,对发展而言是必要条件的、而不是充分条件。涵容要求投射元素能够进入到分析师心灵并在那里驻留、赋予令人信服的意义。并不要求病人自己可以获得理解力或对此感兴趣。如果病人想要进一步发展,他必须有根本性的转变,并对获得理解力感兴趣,或多或少、或长或短。这种转变,反应了能够容忍洞察和精神痛苦的开端,并意味着从偏执分裂位向抑郁位的移动。我将尽力称述这样的发展是如何依赖于对分离和丧失的体验。

 A few months following the sessions already described, the patient was told that I was taking an extra week's break in mid-term. She usually dealt with such disruptions in routine by missing a few sessions, partly in revenge, but mostly, I thought, to serve as a means of projecting the experience of being left onto me. This time she began a session by describing how she had walked to work as usual with her husband and passed a neighbor's house, where she saw that a light was on in an attic room. She knew that this room had been recently converted to house the family's new baby, and she imagined one of the parents attending to the baby as they passed. This made her wonder if it really was too late for her to have a baby with her present husband, and she shuddered as she thought of all the gynecological problems that would have to be overcome and that had led to so many complications and to endless painful investigations in her first pregnancy. They turned a corner and she passed the street where her colleague and chief rival lived. She had a very difficult relationship with this woman, whom she admired but also felt controlled by, and she described how, normally, when she passed she would look right into the house and would often see her colleague moving around choosing what she was going to wear that day. On this occasion, however, she could not see into the house clearly because tears were in her eyes.

在会谈后的几个月,病人被告知我在期中的时候会中断一周。她通常对此类中断反应是通过错过几次会谈,部分是出于报复,但大部分时候,我认为是以这种方式将体验投射给我。这次,她描述她是如何像往常一样和丈夫一起走去工作,经过邻居的房子,她看见阁楼上有一束光。她知道这个房间里是这家新出生的小婴儿,她想象着当他们经过房子的时候、婴儿的父母正在照料婴儿。这让她想起和丈夫再有一个孩子是否太迟了,她不由地发抖,因为在她第一次妊娠时她不得不克服的妇科问题、以及因此导致的许多复杂的、无休止的令人痛苦的检查。他们转了个弯,她经过她的同事同时也是主要竞争者所住的街道。她和这位女性的关系非常困难,她钦佩这位女性又觉得被她控制,她描述当她经过时能正好看到房屋里的情形,通常会看到她的同事走来走去地选择今天将要穿什么。可是这次,她不能清楚地看到房屋里,因为她的眼眶充满了泪水。

 I interpreted that while she reacted to my week off in various ways she seemed today to associate this with the idea that I had other things to attend to like a baby—and that this put her in touch with her grief and made her feel more separate and tearful. Her mood was quiet and thoughtful, and I was able to go on to interpret that she had previously dealt with separations by entering my mind just as she used to enter her colleague's house, her family, and her department.

我解释了她过去对我请假的不同反应,今天看起来让她联想到我有其他事需要照顾——例如一个婴儿——这让她接触到她的悲伤、使她体会到更多的分离感和伤心。她的情绪沉静、若有所思,我能进一步解释她以前处理分离是通过进入到我的心理,就如她过去“进入”她同事的房屋、她的家庭和她的部门。

 Periods of contact like this were not frequent and were not sustained, but they did give rise to moments when she seemed genuinely interested in the way her mind worked and was consequently able to accept patient-centered interpretations. On this occasion the shift was associated with the patient's sadness when she feared that she no longer had the mental and physical capacity to have a baby of her own. She felt more separate from me and her tears enabled her to accept a momentary contact with a psychic reality. This small and transient shift to the depressive position allowed her to become interested in her own mind and her own mental processes.

像这样的接触时刻是不常有的也不是持续存在的,但是这些时刻确实促使她对她的心灵运作方式有了兴趣,因此能够接受病人-中心解释。在这种情况下,转变是和病人的悲伤紧密联系,当她恐惧她不再具有精神和身体能力去拥有一个她自己的孩子。她感到与我更加的分离,她的眼泪促使她能够接受与心理现实的短暂接触。这个细微的短暂的向抑郁位的转变,允许她对自己心理过程和她自己的精神过程有了兴趣。

 Further Discussion

进一步讨论

 In psychotic and borderline patients, as well as others functioning at a paranoid-schizoid level, containment brings relief but does not necessarily depends on the continuing presence of the containing object since, at this level of organization, true separateness from the object cannot be tolerated, and, as a result, the capacity to contain cannot yet be internalized. The threatened loss of the object leads to panic and to the deployment of omnipotent phantasy to create the illusion that the object is possessed and controlled. The patient internalizes an object containing the projected elements and does not truly face the experience of separateness. Sometimes such omnipotent phantasies are delusional and survive all evidence to the contrary, but in most cases contrary evidence is more subtly evaded and experiences such as the regular timing of sessions fuel the patient's illusion that the analyst is not free to act independently and unexpectedly.

精神病性和边缘性病人,以及功能水平是偏执分裂的病人,虽然涵容减轻了痛苦却不是必要的,而是取决于容器客体的持续存在,在这个结构水平上与客体的真实分离不能忍受,结果,也导致不能内化容器的能力。去客体的威胁导致了恐慌,使用全能幻想来创造客体是被拥有、被控制的幻想。病人内化的客体是容纳了投射性元素而且不能面对真实的分离体验。有时,这样的全能幻想是妄想性的,即使所有的证据都是相反的,但是大多数情况下,反证以更微妙的方式被规避了,例如会谈的规律性助长了病人的幻想:分析师不是自由独立和不可预期的。

 This was illustrated by the way my patient ordinarily dealt with separations by projective identification, which she experienced as entering my mind and body, where she was able to control me but where she also saw herself as inside me and hence as my responsibility. In the first section of the clinical material I tried to show how difficult she was to contain when this happened. Her wild, dangerous, and aggressive behavior was subtly hidden behind her composure but was apparent when I had such trouble finding and reaching her. My worries about her were paralleled in the terrible worries she had about her son. When I was able to contain her anxiety about my ability to cope with such responsibility she seemed relieved. But this relief needed my presence to act as a container and could survive beyond the end of the session only through a denial of separateness. Such denial was associated with a possessive hold of her objects, which remained under her omnipotent control.

用我的病人通过投射性认同来应对分离的例子说明,这时她体验她进入我的心灵和身体,在那里她能够控制我,但她也在那里看作她在我里面因而视为是我的责任。第一个临床材料中,我尽力显示她在涵容所发生的是会有怎样的困难。她的疯狂、危险和侵略性的行为微妙地隐藏在她的沉着后面,但明显的是,这时我很难发现并触及她。我对她的担心就如同她对她儿子也有的担心。当我能够容纳她对我承担这种责任的能力所持有的焦虑,她看起来放松多了。但是这个放松需要我充当容器的在场,只有通过否认分离才能活到会谈结束。这种否认与强烈的占有掌控她的客体有关,仍处于她的全能控制下

 Inevitably, occasions arise when the analyst temporarily steps outside the patient's omnipotent control and a degree of separateness is achieved. This seemed to take place in the session I reported soon after I announced an unexpected break in the analysis, and was connected with a recognition that it was her neighbor and not herself who had the baby she so much wanted. My freedom to act was associated with a lessening of omnipotent control and led to an experience of loss that enabled her to feel more separate and in the process to express some of her sadness and grief, which I think made up part of the work of mourning her lost objects and lost opportunities. I (Steiner, 1990, 1993) have argued elsewhere that it is through the work of mourning that the patient is able to regain those parts of herself that she previously got rid of through projective identification, and that with further work these projected fragments can be reintegrated into the ego.

不可避免的是,当分析师短暂地超出病人的全能控制,就在一定程度上触及到分离。看起来发生在我所报告的会谈中,紧跟在我告知分析过程中这个意外的中断后,并与是她的邻居而不是她拥有一个她想要的婴儿相联系。我行动的自由与全能控制感的削弱相联系,体验到丧失使她有更多的分离感,进而表达了她的悲伤和悲痛,我想这就构成了哀悼她丧失的客体和丧失的机会的工作。我(斯坦纳,1990,1993)在其他地方讨论过,通过哀悼,病人能够再次保留她那些以往通过投射性认同摆脱的部分,下一步工作就是将这些投射碎片可以再次整合到她的自我中。

 It is at these times that the patient can take a true interest in her own mind and begin to differentiate what belongs to the analyst and what belongs to her. Such moves toward the depressive position are clearly more frequent in less disturbed patients and at later stages of an analysis, but they may occur at any time even if only for brief and isolated moments. They require a prior capacity on the part of the analyst to contain and integrate the projected elements, but I believe that they also demand that the analyst have the courage to take risks and, when appropriate, give a patient-centered interpretation even if this may lead to a persecuted patient.

就是在这些时候,病人才对她自己的内在心灵有真正的兴趣,开始区分什么是属于分析师的、什么是属于她自己的。较少焦虑不安的病人在分析后期,向抑郁位移动更明显而且更频繁,但是它们可能在任何时候发生,即使是一些很短的、孤立的时刻。它们需要分析师首先具有容纳、整合投射元素的能力,但是我相信它们也需要分析师有承担风险的勇气,在合适的时候给出病人-中心的解释,即使这可能导致一个有迫害感的病人。

 Shifting Between the Two Types of Interpretation

在两种解释方式之间转换

 In the clinical material I presented I tried to be sensitive to the need to shift between the two types of interpretation, and I encountered problems with both. When I focused on the patient's behavior and, for example, interpreted her theatricality or her withdrawal into silence, she felt intruded upon and blamed for the failure to make contact with me. It was when patient-centered interpretations implied that she was responsible for what happened between us that she became most persecuted and tended to withdraw. It was particularly over the question of responsibility that she felt I sometimes adopted a righteous tone, which made her feel that I was refusing to examine my own contribution to the problem and unwilling to accept responsibility myself. In the countertransference this issue created serious problems for me since, when the patient projected feelings with such intensity, I often felt that I was being made responsible for the patient's problems as well as my own.

在我给出的临床材料中,我尽力对在两种解释方法之间进行转换的必要性保持敏感。而且这两种方式我都有遇到问题。例如,当我集中在病人的行为并解释她的不自然或者她退缩至沉默,她感到被侵入并且被责备没有和我保持联结。使用病人-中心解释方式暗示了她对我们之间所发生的负有责任,这让她变得更加被困扰而倾向退缩。就是在问题的责任性上,她感到有时我使用一种理直气壮的语气,这让她感到我正拒绝核查我自己是怎样促成这个问题的并且不愿接受我自己的责任。这种反移情制造了严重的问题,当病人投射如此强烈的感受时,我经常感到我正在不但为自己也要为病人的问题承担责任

 In such situations I believe it may be better to be sparing with the patient-centered elements in the interpretation, to concentrate on the patient's view of the analyst, and to avoid making premature links between the two. Of course this is not a formula that can be used to solve technical problems, and, as we have seen, analyst-centered interpretations have their own difficulties. They too can fail to offer sometimes because the patient feels the analyst is interpreting to cover up the situation rather than to confront it. Too many analyst-centered interpretations make the patient feel that the analyst is preoccupied with himself and unable to observe and respond to the patient and his problems. Moreover, sometimes this view of the analyst is justified. The patient is always listening for information about the analyst's state of mind, and whatever form of interpretation the analyst uses, verbal and nonverbal clues give the patient information about him. The patient can use these to see if what the analyst says matches how he expresses himself and this is important in the patient's view of the analyst's character and trustworthiness.

在这种情况下,我相信谨慎地给出病人-中心的解释会更好,集中于病人对分析师的视角,并避免在两者之间过早地做出连接。当然,这不是解决技术问题的准则,而且,正如我们已经看到的,分析师-中心的解释也会有困难。有时分析师-中心的解释是很失败的,因为病人感到分析师正在掩盖问题而不是去面对问题。太多分析师-中心的解释会让病人感到分析师过度关注于他自己而不能关注、回应病人和病人的问题。而且,有时这种观点被认为是合乎情理的。病人总是会倾听有关分析师心理状态的信息,分析师所使用的任何形式的解释,口头的和非语言信息都呈现给病人关于分析师的信息。病人使用这些来观察分析师是否与他如何表达他自己的方式是一致的,病人对分析师的性格和可信度是非常重要的。

 Sometimes, interpreting the patient's view of the analyst helps the patient recognize that he has projected an archaic internal figure onto the analyst and is expecting the analyst to behave, say, as his mother would have behaved. The interpretation may clarify this and enable the patient to see the analyst subsequently in a different light. Sometimes, however, the interpretation simply confirms the patient's fears. To be effective it must neither be a confession, which simply makes the patient anxious, nor a denial, which the patient sees as defensive and false.

有时,解释病人对分析师的看法可以帮助病人认识到他将一个古老内在影像投射给分析师,期望分析师所做所说可以和他母亲做过的一样。这样的解释可能会澄清并帮助病人之后从不同的角度看待分析师。可是有时,这样的解释仅仅是强化了病人的恐惧。做到有效,就必须既不能是坦白性的,这只会让病人焦虑,也不能是否认性的,病人会认为这是防御且虚假的。

 The technical challenge is to find an appropriate balance of patient-centered and analyst-centered interpretations. Interpretations may temporarily have to emphasize containment, but ultimately must be concerned with helping the patient gain insight. An analyst who is perceived as reluctant to pursue this fundamental aim is not experienced as providing containment. Indeed, these two aspects of interpretation can be thought of as feminine and masculine symbols of the analyst's work. Both are required, and insight, which is so often disturbing, is only acceptable to the patient who is held in a containing setting. If the analyst remains sensitive to the patient's reaction to his interpretation and listens to the next piece of material partly as a comment on what has preceded it, then it is possible to shift from one type an interpretation to the other sensitively, flexibly. As development proceeds, the distinction becomes less important, and many interpretations of an intermediate kind become possible, often showing the links between the activity of the patient and the resultant view of the analyst. Such links are impossible to make when the patient is functioning at a more primitive level where containment and being understood take priority over understanding.

技术挑战就是找到在病人-中心和分析师-中心的两种解释方式之间的一种恰当的平衡。解释暂时性地不得不强调包容,但最终必须是关注帮助病人获得领悟。分析师被认为是不愿意关注这个基础性目标、不愿意提供包容。确实,这两个解释可以被认为是分析师工作的女性和男性象征。二者都需要,这常常是令人不安的,而且病人的领悟只有在包容性的设置中才能达到。如果分析师对病人对他的解释的反应保持敏锐,将随后提供的材料部分地视为对其解释的评论,那么就有可能敏锐地、灵活地从一种解释方式转换到另一种解释方式。随着治疗的进展,两者之间的区别变得越来越不重要了,会更多出现中间类型的解释,这常常表明病人的行为和分析师的观点之间建立起了联结。功能水平更加原始的病人,这样的联结是不可能的,因为容器和被理解的目标远胜于获得洞察力。

——这篇论文是殷一婷老师在《心之母体》课程上提供。



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