中德班晚间演讲20170925 心理治疗的态度——心理治疗师是如何工作的?
作者: Klaus Kocher / 1290次阅读 时间: 2017年9月06日
来源: 郑诚 译 标签: Kocher 郑诚 中德班晚间演讲


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On Psychotherapeutic Attitude – How Does a Psychotherapist Work?
Klaus Kocher心理学空间sK:sb;D\KYm+F'?
September 5th 2017 2017年9月5日
German Chinese Training Course on Psychodynamic Psychotherapy中德精神动力学心理治疗培训课程
Shanghai Mental Health Center 上海市精神卫生中心

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-t@[EzB5H0The topic I would like to discuss with you today deals with the question what a psychotherapist does when he is working with a patient. What is his specific activity and what are his inner working models? In my lecture I would like to concentrate on some very basic points concerning the question how a psychotherapist works, and what are the essential aspects of what he does when he is doing his work as a psychotherapist. This specific way of working is basically linked with what we use to call the psychotherapeutic attitude which again is intimately linked with a psychoanalytic concept of psychotherapy. Therefore I shall focus mainly on a psychotherapist who is working with psychodynamic methods using psychoanalytical concepts of the unconscious and dealing with the psychotherapeutic relationship as it is unfolding according to the concepts of transference and counter-transference and all included forms of conflicts as they occur within the therapeutic relationship.

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B%}5_ ?[9f+mA0Today we seem to encounter an immense variety of different psychodynamic schools which seem to contradict each other in many points leading at first glance to uncertainty and even confusion. Facing this variety of differences it might be helpful to ask if there is still some kind of common ground from which all these different branches of the psychoanalytic tree stem from. Facing this development, David Tuckett, a British psychoanalyst who is very much interested in the research of psychoanalytic methodology was raising quite a simple the question in his paper published in 2005 just by asking: “Does anything go?”心理学空间1I|$y9Jul%Z


如今我们似乎能遇到多种形式的精神动力学派别,它们看起来彼此间有许多方面是相互矛盾的,乍一看会令人不太确定甚至迷惑不解。面对这些丰富多样的差异,最好能探究其中是否有某种共同的基础,即所有这些精神分析分支学派的根源。面对这种发展,一位热衷于研究精神分析方法论的英国精神分析师David Tuckett在他2005年发表的文章中将这个问题凝缩成很简单的一句话:“去掉了什么?”

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His aim was to look beyond all obvious differences and to formulate some kind of general assessment of what could be a common ground of psychoanalytical oriented psychotherapeutic activity. As a main result of his research he stated:心理学空间h;hu vBq

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他旨在超越所有显而易见的差异,制定某种综合性评估,找到可能成为精神分析导向之心理治疗性活动的共同基础。他的主要研究成果显示:心理学空间B zT}7A&T ?

-|a8F$GUc8W"r0“I assume that working as a psychoanalytically oriented psychotherapist requires a set of specific capacities: 1. to sense relevant clinical material (for example affects and unconscious meaning of the patient), 2. the ability to conceptualize what has been perceived from the patient and 3. to give an interpretation to the patient according to what has been sensed by the therapist and to have an understanding of the effect in the patient of what has been said” (Tuckett 2005).心理学空间s0Qd X0x-~N V

+z;@ T;Jl.[0Y-y0“我假定身为精神分析导向的心理治疗师需具备一套特别的能力:1. 能觉察到相关的临床资料(例如患者的情感和潜意识的含义),2. 能将患者感知到的内容概念化,以及3. 根据治疗师的觉察对患者作出解释,并了解所说的话对患者产生的效果”(Tuckett 2005)。


+vu\`2mP4f0As we can conclude from his statement there are three essential aspects of psychoanalytic work which may be described as following:心理学空间0@8Bx~$V#F(O3xi

dYas E!?|*G\01) The process of listening心理学空间-m_3w`9@qKo|2[t

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2) The process of conceptualization

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3) The process of intervening心理学空间7q$\5iyl N!h

7iu!Kv1J db"k']0我们从他的陈述中可以总结出,精神分析工作有三个基本方面,如下所示:


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In other words we may say that psychoanalytical competence contains the capacity to work within these three frames which are intimately connected with each other. These three frames can be described as a participant-observing frame, a conceptualizing frame and last but not least a frame of intervention. These three components can be considered as essential for our work as psychoanalytically oriented psychotherapists.心理学空间7GZ;i D7?Orhy

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5B7n3d T | o\5W/]0If I want to give you an idea today what psychotherapeutic attitude is about and how it can be understood in the therapeutic process I might well use Tuckett’s formulation of what are the essential components of psychotherapeutic work. According to my thinking there is a deep and mutual connection between working as a psychotherapist and applying psychoanalytic attitude. In a way we are dealing with the two sides of the same coin, because without applying some form of psychotherapeutic attitude there is no psychotherapeutic process and vice versa. According to that it is well possible to describe psychoanalytic work along the criteria mentioned by Tuckett. So by commenting these essential aspects of therapeutic work it seems adequate to introduce at the same time the concept of psychoanalytic attitude.

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今天若要问心理治疗性态度究竟为何物,它又如何在治疗过程中加以运用,我可能会用到Tuckett对心理治疗性工作之基本元素的构想。依我看来,以心理治疗师的身份进行工作与应用精神分析式态度之间有着深刻且交互的关联。某种程度上说我们处理的是一件事的正反两面,因为若是不去运用心理治疗性态度的某些形式,也就不存在心理治疗性过程,反之亦然。据此,借助Tuckett提出的标准,我们可以很好地描述精神分析工作。因此,对治疗工作的这些基本方面进行评论,似乎也有助于介绍精神分析式态度的概念。心理学空间Boq1h!W M t3x

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1) The process of listening

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When we listen to a patient in a psychotherapeutic setting acting in the role of a therapist an essential precondition to do this is that we provide a frame. In a way we might say that without a frame there is no content. It needs a frame that something meaningful is allowed to happen between the two persons meeting there. This frame that we provide as psychotherapists consists of external and internal components.

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hF e+z)ZF ]7U0The external components are for example the room which we provide for the patient where he can come to speak to us. This room may represent in a way our personal style because we have furnished it to give it a certain atmosphere. Another component is the time we are providing for the patient. The time should not be arbitrary but clearly announced to the patient before so that he is able to adapt to the time frame. Other components might for example be the context in which we meet our patient – whether the meeting takes place in our private practice or within a hospital where we are working. All this shapes and modulates the content of the frame. Also the financial context plays a role, depending on the question whether the patient is paying the treatment personally or if it is paid by another person from whom the patient is depending – or maybe if the treatment is provided by the health insurance system.

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:D]1pj i0外部成分包括,比方说,我们为患者提供的房间,他可以在这儿与我们交谈。这个房间可能带有我们个人的风格,因为我们在装修时赋予了它特定的氛围。另一个成分是我们提供给患者的时间。定时间一定不能随意,应当提前和患者讲清楚,这样他才能适应时间框架。其他成分可能还包括我们面见患者时的情境——即会谈是在私人诊所进行,还是在工作的医院内进行。所有这些都在对框架的内容进行塑造和调整。经济条件当然也扮演了重要的角色,它取决于患者是自费治疗还是由监护人出资——或者治疗也可能由健康保险体系支付。

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YDc/mF8co&?0The internal components of the frame can be already considered as the result of psychoanalytic conceptualization. Here we are dealing with a variety of psychoanalytically influenced concepts. A very important one is the concept of neutrality which means that we are listening to our patient in a non-judging way. This non-judging attitude is important to allow the patient within he unfolding process to open himself increasingly realizing that it is possible to use his therapist for deeper understanding of himself and his own problems in the presence of the other. Another very basic concept which is important for the concept of psychotherapy is abstinence. This means that in our professional role as psychotherapists we do not by any means use or abuse the patient for our own personnel satisfaction in a sexual or narcissistic way. From a psychoanalytical viewpoint the concept of negative-capability is also important. This refers to the capacity of the therapist to tolerate his not understanding his patient immediately but allowing instead to give time dealing with this not understanding instead of shaping his way of perceiving the patient in a strict and rigid theoretic scheme. Further components are the omnipresent phenomena of transference and counter-transference which unconsciously influence every meeting of human beings – but within the specific setting of the psychotherapeutic encounter they may be used for a deeper understanding of the unfolding relationship between the two persons meeting.心理学空间j&b:M"\:N0K

'I9jQp5N:jF|0框架的内部成分先前已被视作精神分析概念化的结果。此处我们讨论的是各种受精神分析影响而提出的概念。其中一个非常重要的概念是中立性,即我们需要以不带批判色彩的态度来倾听我们的患者。这种不作批判的态度的重要性在于,它允许患者在发展过程中逐渐敞开心扉,认识到他可以借助治疗师的力量、在他人在场的情况下加深对自己和对自身问题的了解。另一个概念也是心理治疗中非常重要的一个概念,节制。它意味着我们作为专业的心理治疗师,决不能为满足自身需求而以性的方式或自恋的方式利用或虐待患者。从精神分析的角度来看,负性感受力也是非常重要的。它指的是治疗师能够容忍自己无法立刻理解患者,并且给自己一点时间来处理这种不理解,而不是迫使自己一丝不苟地遵从僵化的理论体系去感知患者。还有一些成分是无处不在的移情和反移情,它们从潜意识角度影响到人们的每一次相遇——但有了心理治疗性会面的特殊设置之后,它们或许可以用来对两人会面时不断展开的关系进行更深层次的理解。心理学空间 OC|(C4}9wRQXc

2a^/kD b0So listening to a patient seems to be a combination of all the aspects I just have mentioned briefly. If we try to do this we are able to enrich our impressions with unconscious thoughts and affects thus approaching Freud’s dictum of free flowing attention. This way of listening refers to the psychoanalytic situation where the patient is able to follow his own free associations, and the analyst listens to him with free flowing attention. The aim is to catch unconscious meaning to promote deeper understanding of the patient and the conflicts which have brought him into treatment. We can see that this specific method of listening already contains the essential elements of psychoanalytic attitude and is in itself an integral part of our work as psychotherapists. So the listening process contains the listening to what the patient is communicating verbally and even without words and at the same time the therapist is also listening to his own inner world and the feelings which occur inside of himself.

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所以对患者的倾听似乎结合了上文简述的所有方面。若我们试着这么做,便可以用潜意识的想法和情感丰富我们的观感,然后趋近于弗洛伊德所说的自由悬浮式注意。该倾听方式指的是这样一种精神分析式情境,即患者能够跟随自身的自由联想,分析师则以自由悬浮式的注意来倾听他。其目标是抓住潜意识的含义,以促进对患者及导致他前来治疗的冲突进行更深层的理解。我们可以看到,这种特定的倾听方式已然包含了精神分析式态度的基本要素,而且就它本身而言也是我们心理治疗师工作中必不可少的一部分。因此,倾听的过程包含了对患者语言甚至非语言交流的倾听,同时治疗师也需要倾听自己内部世界的声音和自身的感受。心理学空间0F7T!t pVY7J


2) The process of conceptualization心理学空间s3FP9rL)~0oMa

C*s)O\O6{q?0To be good enough as a psychotherapist it is not sufficient just to be able to provide a frame of participant observation as mentioned in the first part of my lecture. You also have to be capable to cope with the task of conceptualization. At this point we have to deal with theory, and of course there is a vast variety of different psychotherapeutic and psychoanalytic concepts. Conceptualization in the proper sense means that we have to try to understand the clinical material as presented by the patient in the light of theoretical understanding in order to use it for his benefit. Understanding clinical material involves theory as an abstract level to link personal history with theoretical concepts which are helpful for our understanding. Psychoanalytic theory covers for example the theory of neurosis, the theory of psychological and sexual development and provides a frame for understanding. Of course again the multitude of varieties may appear confusing for a beginner in this field, but it helps a lot to look at different concepts, and in the end many clinicians develop their own specific mixture of different concepts.

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For example object relations theory may help us to get an impression how to classify information received from the patient in categories of self and object representations, leading to an understanding of unconscious communication between patient and therapist including the concept of projective identification which plays an enormous role in dealing with interpersonal conflicts. Also the concept of holding and containment are helpful for this understanding as well as the use of the results of attachment research and the concept of mentalization.



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%U9qc+\:v,`*_ R0This third part of my lecture covers all kinds of clinical interventions a competent psychotherapist can make use of in order to promote and maintain a therapeutic process fostering progress and understanding of the patient in order to support his personal development. I would think that working therapeutically on one hand involves some kind of technical ability but on the other hand without doubt it also is a question of personal style – some people would call it: the art of practicing the craft of psychotherapy. As a matter of fact the topic of intervention very much depends on the individual skills and the personal style of the therapist. But yet there are some common aspects of how to address to a patient and last but not least getting into contact by intervening again will involve and make evidence of our therapeutic attitude.

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3) 干预的过程



.fz&R wuy9B0For example it takes some frustration tolerance to be able not to answer immediately questions asked by the patient but to allow time for deeper understanding what the underlying topic may be about. We make use of our non- judging attitude trying to get to the issues the patient is really dealing with, avoiding to be caught in our own prejudices. We try to ask open questions to foster an attitude of self-examination of the patient himself and we implicitly invite him by doing so to identify himself with this attitude. Interpretations in the proper sense aim to illuminate unconscious topics and often give way to various forms of resistance because usually getting in contact with unconscious matters will provoke fears and anxieties. An experienced therapist will have an idea of these phenomena and will try to find a good combination of a cautious and at the same time persistent way of sticking to the topic. A central matter of intervening is to address feelings which are difficult to bear – and again it is a question of therapeutic attitude to deal with this delicate matter in a good, respectful and acceptable way. Working with the feelings of the patient and at the same time with our own emotions – which is to say dealing with transference and counter-transference – can be extremely helpful in working through these difficult topics.心理学空间8J t0t[Q1uD

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例如,我们需要有些耐挫力,才能忍住不去立即回答患者的疑问,而是花一些时间对潜在的话题进行更深入地理解。我们利用自己不作批判的态度设法抓住患者实际面对的问题,避免受自身的成见所累。我们尽量提出开放式问题,以培养患者产生自省的态度,这样我们也含蓄地邀请患者以这种态度认同自己。解释的本意旨在阐明潜意识的主题,也常常让步于各种形式的阻抗,因为事情一旦与潜意识相连,通常容易激起恐惧和焦虑。经验丰富的治疗师会对这些现象心中有数,也会试着找到一种兼具谨慎和执着的方式来守住这个主题。干预的核心问题是处理难以忍受的感觉——这仍然是治疗态度的问题,即需要用一种良好的、尊重的且易于接受的方式来处理这种微妙的问题。在对患者感受进行工作的同时还能兼顾我们自身的情绪——也可以说是处理移情和反移情——对于修通这些困难的主题大有裨益。心理学空间1h*W$w{ j^ uu

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As we can see dealing with our therapeutic attitude is something rather complex. It was my intention to make this topic evident by using David Tuckett’s quest to understand the basic conditions for being a competent psychotherapist. Using his method of naming three essentials which are the common ground in psychodynamic psychotherapy helps in my opinion to make this complicated topic a little more vividly and understandable. But the question remains complex because psychotherapeutic attitude cannot be reduced to a technical level but is an integral part of the psychotherapist’s personality.

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如我们所见,处理自身的治疗态度可以说相当复杂。我希望能借助David Tuckett的探索去理解成为一个称职的心理治疗师所需要的基本条件,并将这个主题发扬光大。在我看来,用他的方法来命名三个要素(也是精神动力学心理治疗的共同基础)有助于使这个复杂的主题更为生动和容易理解。但这个问题仍然很复杂,因为心理治疗性态度无法被简化成一种技术水平,而是心理治疗师人格中必不可少的一部分。心理学空间 })F:{#uZ Lm

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WJ?\]$r$z0Tuckett, David (2005): Does anything go? International Journal of Psychoanalysis, p. 31-49.心理学空间Up(Z.kc-~ m~

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