張凱理：暗夜行路 歸鄉猶遙
The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, by S. Nassir Ghaemi, Paul R. McHugh (Foreword), The Johns Hopkins University Press, 2007
暗夜行路 歸鄉猶遙
The possibility or impossibility
Of objective study of subjectivity
三周前工坊編輯謝君來訊，轉達登義兄囑為序。未及熟慮倉促應允後，開始忐忑不安，因為我祇能以個人偏頗所見為之。
偏頗之關鍵在，客觀地探究主體性經驗的可能性抑或不可能性 (The possibility or impossibility of objective study of subjectivity)，我認為是不可能的。
Ruth Behar為一猶裔古巴籍人類學家，曾著書The Vulnerable Observer: Anthropology that Breaks Your Heart (1996)，上述不可能的意思即為The Vulnerable Observer: Psychiatry that Breaks Your Heart。
因為，精神醫學面對的，正是人的現象和經驗的苦境，它必讓你心碎。
這個面對，我嘗言，是現象學的路，詮釋學的精神，存有的關懷，和實證經驗的累積和歸納。
這樣講的緣由是，我的入徑是心理治療。
但，這早已是人跡罕至的路。
美國精神醫學的鐘擺，1940-70曾以精神分析為主流，1980迄今，則以生物精神醫學為顯學，包括神經科學、精神藥理學、腦影像學、遺傳學。如果十年前，精神科醫師猶有Of Two Minds: The Growing Disorder in American Psychiatry (Luhrmann, 2000)的兩難，現在應祇剩下Of One Mind的篤信罷。這個信，當然是信科學，信RCT，信EBM。
Organic Mental Disorders和Major Psychoses之病理機轉在中樞神經，但其它的精神病理現象呢？尤其是界於Psychosis和Neurosis之間的”that area” (註一)，尤其是與成長過程、與人的生命經驗有關的精神病理現象，豈可將之用biological reductionism解釋掉 (explain away)？
這個不該輕易解釋掉的地方，正是心理治療的關注。(註二)
David Brendel在2006著書，Healing Psychiatry: Bridging the Science/Humanism Divide。
Nassir Ghaemi此書立義在the legacy of Karl Jaspers，正是要說明這個Healing如何發生。
“The history of psychiatry over the past century has been a yin and yang between the two (Kraepelin and Freud). First Kraepelin’s views were popular (from the late 1890s until the 1930s), then Freud’s views were supreme (from the 1930s until the 1970s), and then Kraepelin made a rebound in the 1970s with many considering current psychiatry to be ‘neo-Kraepelinian’.
It is my view that the person who deserves to be the most important figure in psychiatry, however, is Karl Jaspers. Today what psychiatry needs to learn from Jaspers is that there is something available after Freud and Kraepelin, i.e., there is something beyond the conflict between natural science-like biological psychiatry and the pseudo-”understanding” psychology of classical psychoanalysis. “ (On Reading the General Psychopathology: The Importance of Karl Jaspers’ Methodological Pluralism for Contemporary Psychiatry, by Nassir Ghaemi, in ‘Karl Jaspers’ Philosophy: Expositions & Intrepretations’, ed by Kurt Salamun & Gregory J. Walters, Humanity Books, 2008)
註一
That Area …
• The Phenomena of borderline and narcissism
• The paranoid-schizoid position (Melanie Klein)
• Borderline Personality Organization (BPO) (Otto Kernberg)
• Basic Fault (Michael Balint)
• The insecure attachment (John Bowlby)
• Poor differentiation of the self (Murray Bowen)
• Enmeshed / Disengaged vs. Clear Boundaries (Salvador Minuchin)
• Self Disorders (Heinz Kohut)
• The conditions for one to be one cannot be taken for granted.
註二
(1) 詮釋學是人文精神重建的基礎 。
(2) 互為主體性理論，本質上為詮釋學的實踐。
(3) 疏離(alienation)之定義為，失去脈絡(context)的存在狀態。
(4) 工具理性的極度發展，與疏離有關，遂隱含極度非理性的反撲。
(5) 臨床所見最瑰麗悚人之精神病理現象，率皆在此範疇。
(6) 精神分析誕生於此。
(7) 但精神分析本身屬上述症狀的一部份，並不打算、或無法帶來救贖。
(8) Now，互為主體性理論，欲與狼共舞 。
(9) 如何與狼共舞？
(10) 漂亮的共舞，須兼顧一和二的細緻之處(the intricacies of one and two)。
(11) 還有，互為主體性理論，因其源自詮釋學，遂無法迴避知識論上的質疑。
(12) 我們遂回到如下諸versus：
human studies vs. natural sciences
verstehen (understanding) vs. erklaren (explanation)
idiographic vs. nomothetic
qualitative vs. quantitative
two-person psychology vs. one-person psychology
iterative hermeneutic circle vs. linear logic reasoning
(To understand any given part, you look to the whole; to understand the whole, you look to the parts. This has been criticized from a logical perspective, because of its inherent circularity. In analytic terms, however, it describes the processes of interpretation very effectively and speaks to a dynamic, non-linear, style of thinking.) (Interpretative Phenomenological Analysis: Theory, Method and Research, by Jonathan Smith, Paul Flowers, Michael Larkin, Sage, 2010, p. 28) 所以這裡，知識論的質疑的關鍵在詮釋學的循環。
(13) 有趣的當代心理治療理論，率皆在上述versus中掙扎。
(14) 詮釋學為，看待人世之基本態度，屬歷史感甚深，人文誠意甚篤的、溫煦的哲學。
(15) 回到現象，回到經驗，回到沉默的見證，回到傳神的記錄。
(16) 在亙久的凝視中，希望我們對生命，更有趣的理解得以發生。
