www.psychspace.com心理学空间网移情与反移情的毒害及精神分析伦理的作用
乔治 布朗司通，医学博士
乔治 布朗司通，医学博士
翻译：邓雪康
1937年，弗洛伊德在他的晚年写了一篇关于反移情的文章，刊登在《Analysis Terminable and Interminable》上，这是他为数不多的几篇关于反移情的文章之一。在这篇文章里，他批评了分析师们尽管接受过培训和分析，仍然逃避分析对他们产生的批评性和修正性影响的行为。这些人处于他称之为“分析的危险”之中，他把这种反移情情境比作“X射线对那些没有防护措施的人产生的危害”。由此他提到了一句名言：“权力产生腐败，绝对的权力将产生绝对的腐败。”他这样说当然是基于他所知道的卡尔古斯塔夫荣格、桑德拉费伦齐以及其他人，甚至很可能包括他自己的经历。他提出的唯一的补救办法是分析师定期接受更多的分析，分析是“一项永远不会完成的任务”，尽管他承认这不一定能解决问题。他完全忽略了伦理维度以及这种恶劣行为的后果。
这很令人不安。精神分析被视为治疗患者的一种医术，神经精神医学的一个分支，还有些别的什么，一直延续至今。自希波克拉底时代即公元前5世纪以来，医学就被公认需要强制性的伦理准则来严格界定并约束从业者的行为，目的是让公众对医生有足够的信任，这样医生才能治病救人。希波克拉底宣言直到今天都一直是医学行业的指导原则。大多数司法体系都承认，至少在一定程度上，行业行为不应该适用于一般法律，而应该适用于更高的权威，即行业本身。我不知道希波克拉底宣言在东方有多么广为人知，但我知道中国医学界在公元7世纪出现了类似的法典，它出自唐代伟大的医药学家孙思邈。弗洛伊德及很多早期的精神分析师都是医生出身，遵守类似的宣言，弗洛伊德曾经无数次提到过在精神分析治疗中作为一个医生的伦理责任。
但是，尽管在其成员中出现过无数次臭名昭著的不道德行为，不管是弗洛伊德还是国际精神分析协会（IPA），在精神分析伦理方面的姿态都是完全无视这些行为，直到再也不能无视为止。对此我们有一个技术术语：否认，它和不信不是一个概念。否认是一种初级的很弱的防御机制，它的使用常常会使潜在的问题更恶化。否认似乎是他们对其成员的不当行为的一种典型的初始反应。后续的应对经常是，如果事件掩盖不了也抵赖不掉，他们就“除掉害群之马”，小团体一致对外，从来不想可能会有些深层次的问题需要审视，而这些问题正潜在地威胁着整个团体。所有这些都突出了一个问题，为什么行业伦理准则非常必要，为什么精神分析师和他们所处的行业都会因意识到这一问题而受益。
希波克拉底宣言要求一个医生在做好其它事的同时，令人尊敬地工作和生活，永远服务于患者的利益，哪怕需要战胜自己的欲望也要保护生命，并保持最大限度的审慎。精神分析伦理也服从同样的原则，但是更加严格，因为它专注于移情/反移情之间的动力，以及因患者和分析师之间的权力差异可能会造成的后果，而这一点其它医学领域都不涉及。
如果你翻阅国际精神分析协会（IPA）或者其团体的伦理准则——后者必须与前者一致——你很可能会发现那上面的大部分内容都不稀奇。你甚至会觉得有些规定简直太显而易见了，你都很纳闷为什么连那些都要写进去。“为什么”，你可能会问，“有些人需要被告知他们不应该跟患者发生性关系？这是任何精神分析师都应该知道的呀。”好吧，很可能是这样，但是我相信你知道这样的事时不时地就是会发生。如果没有伦理准则，有些分析师或许会说“哦，我不知道呀”或者“这是个特例”，甚至“我不同意这个观点”，然后事情就不了了之了。所以才需要有一个能让所有人看到的清晰的规定，必要时还要有一个负责执行的伦理委员会。
但是伦理准则的意义绝不仅仅是精神分析师的一套行为规范或者是一套法律准则，团体可以依此来惩罚违反者——尽管确实会起到这样的作用。如果伦理委员会和团体永远都不需要这样做当然就最好。更重要的一点是：精神分析准则和精神分析技术几乎是密不可分的。糟糕的技术往往是不合伦理的，不合伦理的行为也总是因技术上的拙劣和理论上的无知造成的。
对伦理准则最好的应用是早早地防患于未然，分析师一旦意识到了苗头就赶紧打住。我们来想象一个圆形的安全表，比如汽车的测速表，有个指针从绿区开始移动，然后是黄区，再后面是红区。就像所有的优秀职业赛车手都知道的那样，你不会总是甚至不会经常待在绿区。很多时候都需要把发动机推到黄区，但是优秀的赛车手同样知道，如果把发动机推得再狠些，进到红区，越过了“红线”，就是在冒险，很可能会有灾难性的后果，比如说发动机爆炸，然后就再也没办法完成比赛了。红区是有毒的，绝对不能碰。所以就算再想超过前面的赛车，一个优秀的赛车手也绝不会踏进红区，而是会等待时机，寻找其它解决办法，因为他知道，完成比赛才是最重要的。很多新手不明白这一点，或者无法约束自己，他们的职业生涯会很短，因为没人会用他们。用俗语说，他们就是传说中的“有勇无谋”。
我今天的主题是移情与反移情的毒害，这一说法是受了弗洛伊德X射线的启发。450年前，毒理学之父帕拉塞尔斯有句名言：“万物皆有毒，无一例外；唯剂量使之不致成为毒药。”这是事实，但是有些东西很显然毒性更强，也更危险。砒霜就比水更容易致人死地，而弗洛伊德所说的X射线也是高危的，但同时又非常有用。至于解决办法，像放射线学者们所知道的那样，就是使用它，但是要小心。当然，弗洛伊德所指的是在精神分析中激发出来的强烈情感所具有的潜在危害。这些情感可能是患者的也可能是医生的，但双方以及精神分析治疗本身都是潜在的受益者和潜在的受害者。
处于或接近精神分析工作核心的是对移情的分析。我理解的移情包括一个人对另一个人——在精神分析中就是患者对分析师——感受到的所有的想法和情感，包括意识的和潜意识的。我们用以察觉移情的最主要的工具是我们的反移情，也就是分析师对患者的移情。我们的日常生活中移情无处不在——人类天生最有这样的能力——唯一的差别是精神分析中的移情不仅仅被体验到、被付诸行动，还会像其它东西一样被分析。一个人的感情将影响另一个人的感情，分析师的工作中最重要的部分就是与患者合作，努力去理解在患者身上影响着他的是什么。
但是分析师不仅仅是一个被动的观察者。他的感情影响着患者，就像患者影响着他一样。正如亨利斯坦克苏立文(Henry Stack Sullivan)所描述的那样，分析师是一个参与着的观察者。因此，他必须让自己在与患者的即时互动中成为一个真正的参与者，否则，对于是什么感动了患者他就会错过至少是一部分的察觉。但是，与此同时，他还必须观察互动，监控在他自己身上发生着什么，努力看清在患者身上发生着什么，并且对这一部分进行分析。听起来有点像是走钢丝，有时候就是这样。分析师必须让他自己被感动，但绝对不能身陷其中。这是可以做到的，只是像用X射线工作一样，需要很小心。
情感有可能是非常强烈的，强烈的情感有可能是压倒一切的。压倒什么呢？压倒判断力、理性和良知。这种疯狂的情形不仅会发生在患者身上，也会不时地发生在每个人身上，以不同的方式，在不同的程度上。我们的患者与其它人的区别仅在于他们在这方面有更多的问题，多到他们及他们周围的人都无法舒服地接受。那么当某些可以压倒一切的事情发生时，比较有利的情形是一个人至少可以意识到“我做了什么什么不该做的事”。这样虽然不好，但它是自我不协调的、冲突的，所以有改正的可能性，至少可以修复。更糟的情形是一个人做了可怕的事却感觉很好。糟糕之处在于，它是自我协调的没有冲突的，根本就不承认有什么需要改正的。分析师不比其它同等智力和教育程度的成年人更健康，也有七情六欲，也操心柴米油盐，我们不能指望他感受不到任何常人会有的情感。我们可以做的以及应该做的，是希望他愿意并且能够通过从事精神分析工作来满足他的情感需要。
回到我举的赛车的例子，我们的伦理准则是写在红区的。在进行分析时，你常觉得自己是在绿区工作，进展十分顺利。但是你会发现——事实上你应该经常会发现——你进了黄区。这可能意味着你发现自己感觉到了一些关于患者的特别的东西，令人兴奋的东西，有好也有坏。你可能会觉得无聊透顶，黔驴技穷，或是热衷于做一些不合常理的事；也可能会在强烈的情感旋涡里挣扎。这些都没关系，事实上这甚至还是好事，因为这是你的反移情在告诉你或许有些重要的事情正在发生。一个负责任的分析师必须当机立断，对他的绝望、迷恋或是其他任何情感进行分析，而不是把它们付诸行动。
性、爱、金钱、权力和自尊都带着强烈的情感。这些东西把患者带到治疗中，并将在分析素材和移情中扮演重要角色。同样的这些东西对分析师也很重要，而且是反移情的一部分。随着这些素材以及随之而来的冲突的展开，部分表达出来了部分还没有，部分意识到了部分还没有，双方都会被感动——或许以不同的方式在不同的程度上，但总归都会被感动。这就是精神分析工作最能有效发生作用的地方，如果它确实能够发生作用。
分析可能会由于患者的内在原因根本无法发生作用，要么是移情太多或太少，要么是缺少接受分析的动机。这个话题很大也很重要，但我今天先不讲它，因为我的关注点是精神分析的伦理，而这完全是分析师的责任，跟患者无关。分析师对这类患者唯一的伦理责任是，一旦他已经认定这些患者不适合接受精神分析，就不要为他们提供精神分析工作，并且告诉他们为什么，然后建议他们其它合适的选择。
现在我们来谈谈分析师。分析师对患者最重要的伦理责任就是完成患者付钱给他并且通过协议规定他应该做的事：进行精神分析。说到这里你们应该能猜到我要讲什么了。当分析处在黄区，即充满了强烈情感、有可能有重大发现时，分析师的责任是确保不会滑入或掉进红区。反移情在红区就变得有害了。分析会出现妥协，会中毒，或者被其它东西替代。最好的情形是分析师没有在工作，最坏的情形是他已经在有意欺骗患者。
这样的事在很多情况下都有可能发生，而且每种情况的动力都不一样。格莱恩格巴德（Glen Gabbard）和伊娃莱斯特（Eva Lester）对此有过很多描述[Gabbard & Lester, Gabbard]。有些患者，常常是创伤事件的受害者和有自杀倾向的患者，总想迫使分析师表现得不像在做分析——不那么专业——而且他们很擅长达到目的。有些分析师会爱上被分析者，有时他们是彼此相爱，甚至还会结婚。有些分析师会充当患者生活中的其它角色，比如教练或者咨询师，而且还是收费的。还存在一些“掠夺性”的分析师，他们的终极目标是剥削被分析者，不管是在性关系、财务、社会关系还是其它方面。这些违反边界的行为常常微妙地发生，迈出一小步或者说出一个字，但是这一步是迈下一个光滑的斜坡，下去了就再也上不来。遗憾的是，那些高级的有影响的分析师似乎不仅没有跟这些事不相干，反而比他们的同事更容易犯这样的错，很显然他们是觉得一般的规矩不适用于他们，他们可以自行其事。所以我们看到，就像阿克顿爵士（Lord Acton）观察到的那样，即使是在分析师当中，权力也会导致腐败。东窗事发之后，我们会发现这些分析师违反伦理的行为极其明目张胆，但他们却极少表现出任何反省或悔恨。
宗教、种族、政治倾向等也会模糊反移情，而且很可能会使分析失败，即使双方都意识到了他们这对组合所面临的潜在困难并且在努力克服困难。组合要么基于双方的相似性——这会导致彼此默契地维持在一个隐蔽的“舒适地带”——要么基于差异性——这会导致同样隐蔽的友善的或不那么友善的“虚假宽容”。鉴于我们所有人都具有某种身份——犹太人、儒家弟子、共和党人或民主党人、男人或女人、白人、有色人种，等等——提防这些因素可能会起的作用对我们总是有好处的。
还有另外一种几乎是觉察不到的不当行为，因为任何一方都没注意到，它就像一氧化碳一样不知不觉之中造成危害。爱尔文赫什(Irwin Hirsch)在他那本巧妙地取名为《在反移情中打酱油》的书里对此做了很好的描述。这种分析几乎一直是待在绿区，事实上，这根本不是分析，而是分析陷入了某种僵局，原因是分析师出于私心只舒服地做些华而不实的表面文章，根本没有出于责任感真正为患者做有效的分析。同样的，发生这种情况也有很多原因——由于咨询关系太舒服、钱赚得太爽或是具有别的意义，导致分析师要么绕开可能会打破现状的重要问题，要么就是简单地回避结束，这二者都会使分析没完没了地进行下去。再有就是分析师出于自身原因很难保持专注，或者一天下来把自己搞得太忙了。这些问题我们可能一时注意不到，但是如果足够警醒，我们还是能够在造成太多伤害之前发现问题。只是，从最终的结果看，这还是对患者的背叛，不亚于一个士兵在站岗时睡着了。
我还没讲到保密性，这个话题太大，也太复杂，以至于有些团体成立了委员会专门处理这个问题。简单地说，分析师除了需要会诊或督导以外必须绝对保密，精神分析的保密性才能做到最好，这里说的会诊也适用于同样的保密原则。克里斯托弗波拉斯（Christopher Bollas）清晰有力地论述了这一点。我并不完全赞同他的立场，但他的基本观点很重要也很有道理。保密性正在由于法律和官僚因素而遭受侵蚀，很多司法机关都有关于报告危险或犯罪嫌疑行为的法律，很多分析师也赞同这样的司法观点，这就在咨询室里制造了一种对抗氛围，由此很可能导致滥用或毁掉精神分析。保险索赔则提出了另外一个难题。分析师和患者都同意至少有些信息需要跟保险公司共享，而机构在这个问题上通常被认为没什么伦理要求。所以，为了让治疗能够进行，分析师经常按照双方认为对患者有利的原则歪曲临床报告。虽然患者感觉到他得到了帮助，但与此同时他也发现他的分析师是可以被腐化的。这种事本来没必要发生而且也是可以避免的，但是精神分析团体及医学团体在保护患者的私密性方面做得严重不够。另一个常见的违反保密原则的行为发生在分析师之间漫不经心的聊天中，即使是在社交场合，他们也会谈到相互都认识的或者相互转介的患者。我突然想起了二战期间美军的一幅海报，上面写着“管不住嘴就hold不住命”，我们应该考虑把它贴在墙上。
最后，我简单谈谈机构的伦理问题。我之前有说过，很久以来，精神分析组织基本上一直在忽视违反边界的行为，直到1990年代马苏德可汗事件在伦敦彻底曝光[Sandler&Godley]，国际精神分析协会（IPA）才总算给它自己套上了伦理准则的约束。有一个机构问题值得特别讲讲。某同事违反伦理的行为其他成员一般都会知道，而且在被正式处理之前早就成为过道里的谈资。这经常会使支持或反对过失者的成员分成两派，从而进一步促成了团体里阵营的分化。这种小集团的破坏性相当强，包括不仅无法有效地讨论事件本身，也无法讨论任何事，不管是在学术会议上还是在督导中。它还影响到对新人的培训与分析。一方面新人会向坏榜样学习，另一方面他们会知道有些重要事件是不能公开处理的。这种代际传承一点都不奇怪：那些违反边界的分析师在他们自己的培训中往往是违反边界行为的受害者。
我们的精神分析伦理准则十分直白易懂，所以，简单明了的事实是：很清楚，以任何方式违反准则都是不对的。但是，就像奥斯卡王尔德(Oscar Wilde)所说的那样，“简单明了的事实从来都不简单也很少是明了的。”伦理准则本身不可能穷尽一切也不是不可更改的，会随着时间发生变化。随着我们对心理的了解越来越多，精神分析理论和技术都会向前发展。但是荣誉与责任将一直保持下去，移情与反移情——带着他们潜在的好处与坏处——也将仍是科学与艺术的核心。一名分析师可以选择遵守规定，也可以选择不遵守，但是他的选择以及对这一选择的后果所负有的责任，将全部由他承担。
作为结束，我想提四点建议，或许可以对移情与反移情的毒害作用提供一些有效的保护。第一，接受一个好的分析——在你执业一段时间之后或许还得加多一个。第二，要让新人向以希波克拉底宣言为蓝本的我们的伦理宣言正式宣誓，在培训开始之前及在培训合格之后都要宣誓，要让他们清楚自己的责任。第三，记住你永远不需要马上行动，你永远都有技术上伦理上的其它选择，你永远都不必独自应对困难，当你需要的时候你可以接受会诊，有很多有经验的同事愿意并且能够帮助你，而不会让你感到难为情。第四，最重要的，我们必须更经常更开放地把反移情提交到临床讨论中、教学中和督导中，这可能会使情绪加剧，把我们更多地推进黄区，但是，那里才是你取得进步的地方。
谢谢大家。
参考与阅读
略
The Toxicology of Transference and Countertransference
and the Role of Psychoanalytic Ethics
George Brownstone, M.D.
In 1937, close to the end of his life, Sigmund Freud wrote one of his few contributions about countertransference in Analysis Terminable and Interminable. In it, he criticized the behavior of analysts who, though trained and analyzed, “evade the critical and corrective influence of analysis” on themselves. They are subject to what he termed the “dangers of analysis”, and likened their countertransference situation to “the effect of the X-rays on those who use them without due precaution”. Related to this, he alluded to the dictum “power corrupts, and absolute power tends to corrupt absolutely”. He was speaking from experience, of course, what he knew of Carl Gustav Jung and Sandor Ferenczi and others, probably even including his knowledge of himself. The only remedy he proposed was that analysts periodically submit themselves to more analysis, though he acknowledged that this didn’t always work, adding that analysis “is a task which is never finished”. He entirely ignored the ethical dimensions and the consequences of such bad behavior.
This is unsettling. Psychoanalysis was conceived and practiced as a healing art, a sub-specialty of neuropsychiatry, to treat patients, and, whatever else it has become, that has remained. Since the time of Hippocrates, in the 5th Century B.C., it was recognized that the practice of medicine required an obligatory ethical code which strictly defined and limited the conduct of its practitioners, in order to allow the public to have sufficient trust in a doctor so that they could avail themselves of their services. The Hippocratic Oath has remained the guiding principle for medical professionals up the present day. Most legal systems recognize, at least to some extent, that professional behavior should not answer to common law, but to a higher authority, the profession’s own. I don’t know how well-known this oath is in the East, but I understand that Chinese medicine has incorporated something very similar since the 7th century AD, texts written by the great Tang physician Sun Simiao. Freud and many of the early psychoanalysts were physicians and subscribed to a similar oath, and Freud made numerous references to a doctor’s ethical duties during psychoanalytic treatment.
Nevertheless, despite numerous well-known instances of unethical behavior among its members, both Freud’s and the IPA’s stance on psychoanalytic ethics was to ignore the matter entirely until it was no longer possible to do so. We have a technical term for that, denial, which is not the same as disbelief. Rather, it is a primitive and pretty weak defense mechanism, and its use often tends to exacerbate the underlying problem. Denial seems to be the typical initial response of many groups to misbehavior among their members. A frequent later reaction, if the issue is unavoidable and undeniable, is to self-righteously “get rid of the rotten apple”, circle the wagons, and never question that there might be some underlying problem potentially affecting the whole group which would be worthy of examination. All this highlights the very reason why codes of professional ethics are necessary, and why psychoanalysts and our profession would profit from an awareness of them and their basis.
The Hippocratic Oath requires a physician, among other things, to practice his profession and lead his life honorably, to always serve for the benefit of the patient, even above his own desires, to protect life, and to observe utmost discretion. Psychoanalytic ethics follows the same principles, but is more stringent, since it centrally addresses the dynamics of the transference/countertransference interaction, and ramifications of the power differential between patient and analyst which might not be so relevant in other medical situations.
If you look over the IPA’s ethics code, or that of any local Society – whose code must reflect the IPA’s – you’ll probably find that much of what’s there is no surprise. You might even feel that at least some of these points are so obvious you wonder why they’re included at all. “Why,” you might say, “would anyone have to be told that they shouldn’t have sex with a patient? Surely, that must be obvious to any psychoanalyst.” Well, I assume it probably is, but I’m sure you know that it happens every now and then anyway. Lacking an ethics code, an analyst could say “Oh, I didn’t know”, or “This is a special case”, or even “I don’t share that view”, essentially dismissing the issue. So it’s necessary to have a clear rule for all to read, and an Ethics Committee which will take action, if required.
But our ethics code is far more meaningful than just a catalog of proper etiquette for psychoanalysts, or as a code of law, enabling societies to punish the guilty – although it will be applied that way, too, in the extreme. Ethics committees and societies would be delighted if they never had a case to investigate. The much more important point is this: psychoanalytic ethics and psychoanalytic technique are almost indivisible. Bad technique is frequently unethical, and unethical behavior is always technically bad and theoretically wanting.
The best use of our ethics code is long before anything actually happens, and as soon as something listed there comes to the analyst’s attention. Imagine one of those round safety gauges, like a car’s tachometer, with a pointer which travels first through a green area, then into orange, and finally into red. As any good professional driver knows, you don’t always, not even often, stay in the green zone. Many situations require pushing the engine into the orange zone. But a good driver knows that pushing the engine even harder, into the red zone, going over the “red line”, risks catastrophic damage, like the engine blowing up, and the race will never be finished. The red zone is toxic, and an absolute no-no. So even if he really wanted, really needed, to pass the car in front of him, a good racing driver will never overstep that red line, but instead bide his time until he found another way to solve his problem, knowing that above all, he must finish the race. Many would-be racing drivers don’t grasp this, or can’t limit themselves. Their careers are short, because no one will hire them. In the rude but clear American slang, they are known as having “all balls, no brains”.
My theme today is the toxicology of transference and countertransference, sparked by Freud’s X¬¬¬-ray analogy. An old dictum by the father of toxicology, Paracelsus, about 450 years ago, is that "all things are poison and nothing is without poison; only the dose makes a thing not a poison." That’s true, but some things are obviously more toxic, and thus more dangerous, than others. It takes more water to kill a person than arsenic, and the X-rays Freud referred to are highly toxic. They are also highly useful. So the solution, as radiologists know, is to use them, but carefully. What Freud was talking about, of course, was the potential toxicity of human feelings as they emerge forcefully in psychoanalysis. The feelings can be either the patient’s or the doctor’s, and both parties and the psychoanalytic treatment itself are the potential beneficiaries or the potential victims.
At or near the center of psychoanalytic work is the analysis of transference. I understand transference to include all the thoughts and feelings, conscious and unconscious, one person feels about another – in psychoanalysis, all the feelings the patient has about the analyst. The preeminent instrument we have for perceiving the transference is our countertransference, which is simply the analyst’s transference to the patient. Transference is ubiquitous in everyday life, too – humans are biologically well equipped to do this – and the only difference is that in psychoanalysis the transference is not simply experienced and acted upon, but analyzed, like everything else. One person’s feelings influence the other person’s feelings, and a fundamental part of the analyst’s work is to try, in collaboration with the patient, to understand what, in the patient, is influencing him.
But the analyst is not only a passive observer. His feelings affect the patient, just as the patient has affected him. The analyst is, as Henry Stack Sullivan described, a participant observer. He must, therefore, allow himself to be an authentic participant in the immediate interaction with the patient, otherwise he will miss perceiving at least some of what moves the patient. At the same time, however, he must also observe the interaction, and monitor what is going on in himself, trying to clarify what is going on in the patient, which can then be analyzed. This may sound a bit like a tight-rope act, and sometimes it is. The analyst must allow himself to be moved, but never so much that he is swept off his feet. It can be done, but, like work with X-rays, it requires caution.
Feelings can be powerful, and powerful feelings can be overpowering. Overpowering what? Overpowering judgment, reason, and conscience. Insanity like that doesn’t only happen to people who are, or ought to be, our patients, but to everybody now and then, in different ways, to differing degrees. What differentiates our patients is only that they have more problems with this, more than they and the people around them can comfortably live with. Now, when something overpowering like this has already happened, the better situation is when someone can at least realize “I did so-and-so against my better judgment”. That’s not good, but it’s ego-dystonic and conflicted, and allows the possibility of corrective, or at least reparative, measures. The worse case is when someone does something terrible, but feels it’s fine. This is bad because, since it’s ego-syntonic and unconflicted, there is no recognition that anything needs correction. The average analyst is no more or less neurotic than the average intelligent, educated adult, and is susceptible to all the feelings everybody else has, and all the vicissitudes of daily life. We can’t expect him to not experience any of the feelings humans can have. What we can, and should, expect is that he is willing and able to subordinate the gratification of his feelings in the service of conducting a proper psychoanalysis.
Going back to my driving analogy, our ethics code is written in the red zone. While conducting an analysis, you will often feel yourself working in green, moving along easily. But then you discover – actually, you should fairly often discover – that you’re in orange. That might mean finding yourself registering something special, perhaps something exciting, about your patient, something good, or bad. Or you might feel bored to death; or you’re at wit’s end, entertaining doing something unorthodox or drastic, or even improper; or you might be in the throes of some other substantial wave of emotion. All that’s fine. Better than fine, in fact, because that’s your countertransference telling you that something important is probably going on. And once you’ve noticed it, but before you act on it, you have a choice to make, and you have to decide what to do. Remember, you always have a choice, make no mistake about it. A responsible analyst must decide, unhesitatingly and without reservation, to analyze, rather than to act out, his desperation, or infatuation, or whatever.
Sex, love, money, power, and self-esteem are all emotionally highly charged. These are the matters which bring patients into treatment, and they will figure prominently in the analytic material and in the transference. These same things are important to the analyst, and are part of the countertransference. As the material unfolds, with all of its attendant conflict, partly verbalized and partly not, partly conscious and partly not, both parties will be moved – perhaps in different ways and to different degrees, but moved nonetheless. This is where the psychoanalytic work will most usefully take place, if it takes place at all.
Analysis might not take place because of factors within the patient. This could be because of too much transference or too little, or simply a lack of motivation to do the analytic work. This is a large and important topic, but I’ll leave it aside today because my focus is psychoanalytic ethics, which is entirely the analyst’s responsibility, not the patient’s. The analyst’s only ethical duty to such patients, once he has determined that they’re not suitable for psychoanalysis, is to not offer them psychoanalysis and tell them why, and to advise them about suitable alternatives.
So now we turn to the analyst. His foremost ethical responsibility to the patient is to do the job he was hired for and which he contracted to do: to conduct the psychoanalysis. I suppose you can all guess by now where I’m headed. When the analysis is in the orange zone, that emotionally charged zone where it could make its greatest discoveries, it is the analyst’s responsibility to see to it that it doesn’t slip, or slide, or fall into the red zone. In the red zone the countertransference has become toxic. The analysis has been compromised, poisoned, and is replaced by something else. In the best case, the analyst is no longer doing his job, and in the worst case he is knowingly cheating the patient.
There are many situations in which this may occur, and the dynamics vary from instance to instance; Glen Gabbard and Eva Lester have described many of them [Gabbard & Lester, Gabbard]. There are patients, often the victims of trauma, often suicidal, who seem to want to force the analyst to behave unanalytically – unprofessionally – and seem pretty good at making it happen. Then there are analysts who fall in love with analysands, which is sometimes mutual, and has even resulted in marriage. There are analysts who allow themselves to become involved in other roles with their patients, often paid, such as coaching or advising. Then, there exist what may be called “predatory” analysts, whose ultimate goal is to exploit analysands, whether sexually, financially, socially, or otherwise. Such boundary violations usually begin subtly, with just a small step or word, but often that step is onto a slippery slope from which there is no recovery. Unfortunately, it seems that senior and influential analysts, far from being above such things, are actually somewhat more likely to commit boundary violations than their colleagues, apparently feeling that the usual rules don’t apply to them and they can make their own. So we see that even among analysts, power corrupts, as Lord Acton observed. When they come to light, these analysts’ ethical breaches are usually obvious and dramatic, but it’s not unusual for them to show neither insight nor remorse.
Religion, race, politics, and so forth can also cloud the countertransference and potentially doom an analysis, even when both parties are aware of the potential problems facing that particular dyad, and earnestly strive to overcome them. This may come in the form of a similarity between the two parties – leading to a collusion to maintain a blind “comfort zone” – or a difference – leading to equally blind benign, or less benign, “pseudo-tolerance”. Since all of us are something – Jews, Confucians, Republicans or Democrats, men or women, white, colored, whatever – it behooves us to be on the alert for the possible effects of these factors.
There is another, almost invisible kind of misbehavior, because it’s often unnoticed by either party, and works its toxin insidiously, like carbon monoxide. It is well described by Irwin Hirsch in his aptly-titled book, Coasting in the Countertransference. Such analysis remains almost entirely in the green zone. In fact, this is not analysis, but a kind of analytic impasse produced by an analyst’s being guided more by his comfortable, outwardly benign self-interest than by his responsibility to do useful psychoanalytic work with his patient. Here, too, there are many reasons this can occur – too comfortable, or too financially or otherwise meaningful a relationship with a patient, causing the analyst to either shy away from important material which might upset the equilibrium, or simply to avoid termination, both of which can lead to an interminable analysis. Or the analyst may have difficulty paying attention because of his own concerns, or he may have too full a workday. Such things may be out of our awareness for a while, but if we are suitably alert we can catch these lapses before they’ve caused too much damage. But the net result, again, is a betrayal of the patient, not unlike a soldier falling asleep on guard duty.
I have not yet mentioned confidentiality, which is a huge topic, and so complex that some societies have even created committees to deal with nothing else. Put briefly and simply, psychoanalytic confidentiality is best when it’s absolute, the only exception being an analyst’s need for consultation or supervision, in which case the consultant is bound to the same rules. Christopher Bollas makes this point most strongly and lucidly. While I don’t subscribe entirely to his stance, his fundamental point is important and valid. Confidentiality is being eroded for legal and bureaucratic reasons. For instance, many jurisdictions have laws about the reporting of suspected dangerous or criminal activity, and many analysts share that legal view, creating a potentially adversarial climate in the consulting room which can pervert and effectively destroy psychoanalysis. Insurance claims present a different problem. Both analyst and patient agree that at least some information will be shared with the insurance agency, an institution generally felt to have no meaningful ethics in such matters. So, to make treatment possible, analysts often distort the clinical report to what both parties consider the patient’s advantage. But at the same time as the patient feels he has been assisted, he also discovers that his analyst can be corrupted. Much of this is unnecessary and avoidable, and psychoanalytic and medical societies have not done nearly enough to protect patients’ confidentiality. Another unfortunately widespread breach of confidentiality occurs among analysts who thoughtlessly chat with one another, even in social situations, about patients they both know, or one has referred to the other. I find myself fondly recalling a W.W.II U.S. Army poster with the slogan “Loose Lips Lose Lives”, which we might consider posting on our walls.
Finally, let me touch briefly on our institutional problems with ethics. As I mentioned earlier, for a long time organized psychoanalysis has mostly tried to ignore boundary violations, and it wasn’t until the case of Masud Khan literally exploded in London in the 1990’s [Sandler & Godley] that the IPA could finally bring itself to adopt a binding code of ethics. One aspect of the institutional problem deserves special mention. Ethics violations by a colleague are generally pretty well known by other members, and are often the topic of hallway gossip long before they’re formally addressed. This often has the effect of polarizing members for or against the wrongdoer, furthering the formation of warring camps within societies. The destructive force of such cliques is quite strong, and includes not only an inability to usefully discuss the matter itself, but to discuss anything at all, whether in scientific meetings or in supervision. It also detrimentally affects the training and analysis of candidates. On the one hand they learn from bad role models, and they also learn that there are some important matters which can’t be openly addressed. The transgenerational legacy is not surprising: analysts who commit boundary violations were often the victims of boundary violations during their own training.
Our code of psychoanalytic ethics is pretty straightforward and easy to understand. So the pure and simple truth is, it’s clear, and it’s bad to violate it in any way. But, as Oscar Wilde said, “The pure and simple truth is rarely pure and never simple.” Ethics codes themselves can never be exhaustive nor definitive, and they are subject to change over time. Psychoanalytic theory and technique will also evolve as we learn more and more about the mind. But honor and responsibility will remain, and transference and countertransference will probably remain at the center of our art and science, with all their potential for benefit or harm. An analyst can choose to abide by the rules, or he can choose not to, but the choice, and the responsibility for the consequences of that choice, are entirely his.
In closing, let me suggest four measures which might offer useful protection against the toxic effects of transference and countertransference. First, get a good analysis – maybe even a second one, after you’ve been practicing for a while. Second, have candidates formally swear to our ethics in an oath modeled on the Hippocratic Oath, both at the beginning of their training and again upon qualification, to clearly bind them to their responsibilities. Third, remember that you almost never have to act immediately, you always have a technical and ethical choice to make, and you never have to master a difficult situation alone. So get consultation when you think you might need it. There are experienced colleagues very willing and able to help you, and not cause you embarrassment. And fourth, and most important, we must all bring countertransference more often and more openly into our clinical discussions and our teaching and supervision. This will probably heat up the atmosphere a bit, and put us more often into the orange zone with each other, but that’s where progress is made.
Thank you.
References and Reading
Bollas, C., Sundelson, D. (1995). The New Informants: Betrayal of Confidentiality in Psychoanalysis and Psychotherapy. London: Karnac Books.
Brenner, C. (1985). Countertransference as Compromise Formation. Psychoanal Q., 54:155-163.
Freud, S. (1912). Recommendations to Physicians Practicing Psycho-Analysis. SE, XII:109-120.
Freud, S. (1915a). Observations on Transference-Love (Further Recommendations on the Technique of Psycho-Analysis III). SE, XII:157-171.
Freud, S. (1915b). The Unconscious. SE, XIV:159-215
Freud, S. (1937). Analysis Terminable and Interminable. SE, XXIII:209-254.
Gabbard, G.O., Lester, E. (1995). Boundaries and Boundary Violations in Psychoanalysis. New York: Basic Books.
Gabbard, G.O. (2003). Miscarriages of psychoanalytic treatment with suicidal patients. Int. J. Psycho-Anal., 84:249-261.
Hirsch, I. (2008). Coasting in the Countertransference. New York: The Analytic Press.
Sandler, A., Godley, W. (2004). Institutional responses to boundary violations: The case of Masud Khan. Int. J. Psycho-Anal., 85:27-42.
Sullivan, H.S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton.
Author:
George Brownstone, M.D.
Vienna Psychoanalytic Society (IPA)
Girardigasse 3/24
A-1060 Vienna, Austria
Tel.: +43 1 587 1818
Email: georg.brownstone@chello.at
www.psychspace.com心理学空间网
1937年，弗洛伊德在他的晚年写了一篇关于反移情的文章，刊登在《Analysis Terminable and Interminable》上，这是他为数不多的几篇关于反移情的文章之一。在这篇文章里，他批评了分析师们尽管接受过培训和分析，仍然逃避分析对他们产生的批评性和修正性影响的行为。这些人处于他称之为“分析的危险”之中，他把这种反移情情境比作“X射线对那些没有防护措施的人产生的危害”。由此他提到了一句名言：“权力产生腐败，绝对的权力将产生绝对的腐败。”他这样说当然是基于他所知道的卡尔古斯塔夫荣格、桑德拉费伦齐以及其他人，甚至很可能包括他自己的经历。他提出的唯一的补救办法是分析师定期接受更多的分析，分析是“一项永远不会完成的任务”，尽管他承认这不一定能解决问题。他完全忽略了伦理维度以及这种恶劣行为的后果。
这很令人不安。精神分析被视为治疗患者的一种医术，神经精神医学的一个分支，还有些别的什么，一直延续至今。自希波克拉底时代即公元前5世纪以来，医学就被公认需要强制性的伦理准则来严格界定并约束从业者的行为，目的是让公众对医生有足够的信任，这样医生才能治病救人。希波克拉底宣言直到今天都一直是医学行业的指导原则。大多数司法体系都承认，至少在一定程度上，行业行为不应该适用于一般法律，而应该适用于更高的权威，即行业本身。我不知道希波克拉底宣言在东方有多么广为人知，但我知道中国医学界在公元7世纪出现了类似的法典，它出自唐代伟大的医药学家孙思邈。弗洛伊德及很多早期的精神分析师都是医生出身，遵守类似的宣言，弗洛伊德曾经无数次提到过在精神分析治疗中作为一个医生的伦理责任。
但是，尽管在其成员中出现过无数次臭名昭著的不道德行为，不管是弗洛伊德还是国际精神分析协会（IPA），在精神分析伦理方面的姿态都是完全无视这些行为，直到再也不能无视为止。对此我们有一个技术术语：否认，它和不信不是一个概念。否认是一种初级的很弱的防御机制，它的使用常常会使潜在的问题更恶化。否认似乎是他们对其成员的不当行为的一种典型的初始反应。后续的应对经常是，如果事件掩盖不了也抵赖不掉，他们就“除掉害群之马”，小团体一致对外，从来不想可能会有些深层次的问题需要审视，而这些问题正潜在地威胁着整个团体。所有这些都突出了一个问题，为什么行业伦理准则非常必要，为什么精神分析师和他们所处的行业都会因意识到这一问题而受益。
希波克拉底宣言要求一个医生在做好其它事的同时，令人尊敬地工作和生活，永远服务于患者的利益，哪怕需要战胜自己的欲望也要保护生命，并保持最大限度的审慎。精神分析伦理也服从同样的原则，但是更加严格，因为它专注于移情/反移情之间的动力，以及因患者和分析师之间的权力差异可能会造成的后果，而这一点其它医学领域都不涉及。
如果你翻阅国际精神分析协会（IPA）或者其团体的伦理准则——后者必须与前者一致——你很可能会发现那上面的大部分内容都不稀奇。你甚至会觉得有些规定简直太显而易见了，你都很纳闷为什么连那些都要写进去。“为什么”，你可能会问，“有些人需要被告知他们不应该跟患者发生性关系？这是任何精神分析师都应该知道的呀。”好吧，很可能是这样，但是我相信你知道这样的事时不时地就是会发生。如果没有伦理准则，有些分析师或许会说“哦，我不知道呀”或者“这是个特例”，甚至“我不同意这个观点”，然后事情就不了了之了。所以才需要有一个能让所有人看到的清晰的规定，必要时还要有一个负责执行的伦理委员会。
但是伦理准则的意义绝不仅仅是精神分析师的一套行为规范或者是一套法律准则，团体可以依此来惩罚违反者——尽管确实会起到这样的作用。如果伦理委员会和团体永远都不需要这样做当然就最好。更重要的一点是：精神分析准则和精神分析技术几乎是密不可分的。糟糕的技术往往是不合伦理的，不合伦理的行为也总是因技术上的拙劣和理论上的无知造成的。
对伦理准则最好的应用是早早地防患于未然，分析师一旦意识到了苗头就赶紧打住。我们来想象一个圆形的安全表，比如汽车的测速表，有个指针从绿区开始移动，然后是黄区，再后面是红区。就像所有的优秀职业赛车手都知道的那样，你不会总是甚至不会经常待在绿区。很多时候都需要把发动机推到黄区，但是优秀的赛车手同样知道，如果把发动机推得再狠些，进到红区，越过了“红线”，就是在冒险，很可能会有灾难性的后果，比如说发动机爆炸，然后就再也没办法完成比赛了。红区是有毒的，绝对不能碰。所以就算再想超过前面的赛车，一个优秀的赛车手也绝不会踏进红区，而是会等待时机，寻找其它解决办法，因为他知道，完成比赛才是最重要的。很多新手不明白这一点，或者无法约束自己，他们的职业生涯会很短，因为没人会用他们。用俗语说，他们就是传说中的“有勇无谋”。
我今天的主题是移情与反移情的毒害，这一说法是受了弗洛伊德X射线的启发。450年前，毒理学之父帕拉塞尔斯有句名言：“万物皆有毒，无一例外；唯剂量使之不致成为毒药。”这是事实，但是有些东西很显然毒性更强，也更危险。砒霜就比水更容易致人死地，而弗洛伊德所说的X射线也是高危的，但同时又非常有用。至于解决办法，像放射线学者们所知道的那样，就是使用它，但是要小心。当然，弗洛伊德所指的是在精神分析中激发出来的强烈情感所具有的潜在危害。这些情感可能是患者的也可能是医生的，但双方以及精神分析治疗本身都是潜在的受益者和潜在的受害者。
处于或接近精神分析工作核心的是对移情的分析。我理解的移情包括一个人对另一个人——在精神分析中就是患者对分析师——感受到的所有的想法和情感，包括意识的和潜意识的。我们用以察觉移情的最主要的工具是我们的反移情，也就是分析师对患者的移情。我们的日常生活中移情无处不在——人类天生最有这样的能力——唯一的差别是精神分析中的移情不仅仅被体验到、被付诸行动，还会像其它东西一样被分析。一个人的感情将影响另一个人的感情，分析师的工作中最重要的部分就是与患者合作，努力去理解在患者身上影响着他的是什么。
但是分析师不仅仅是一个被动的观察者。他的感情影响着患者，就像患者影响着他一样。正如亨利斯坦克苏立文(Henry Stack Sullivan)所描述的那样，分析师是一个参与着的观察者。因此，他必须让自己在与患者的即时互动中成为一个真正的参与者，否则，对于是什么感动了患者他就会错过至少是一部分的察觉。但是，与此同时，他还必须观察互动，监控在他自己身上发生着什么，努力看清在患者身上发生着什么，并且对这一部分进行分析。听起来有点像是走钢丝，有时候就是这样。分析师必须让他自己被感动，但绝对不能身陷其中。这是可以做到的，只是像用X射线工作一样，需要很小心。
情感有可能是非常强烈的，强烈的情感有可能是压倒一切的。压倒什么呢？压倒判断力、理性和良知。这种疯狂的情形不仅会发生在患者身上，也会不时地发生在每个人身上，以不同的方式，在不同的程度上。我们的患者与其它人的区别仅在于他们在这方面有更多的问题，多到他们及他们周围的人都无法舒服地接受。那么当某些可以压倒一切的事情发生时，比较有利的情形是一个人至少可以意识到“我做了什么什么不该做的事”。这样虽然不好，但它是自我不协调的、冲突的，所以有改正的可能性，至少可以修复。更糟的情形是一个人做了可怕的事却感觉很好。糟糕之处在于，它是自我协调的没有冲突的，根本就不承认有什么需要改正的。分析师不比其它同等智力和教育程度的成年人更健康，也有七情六欲，也操心柴米油盐，我们不能指望他感受不到任何常人会有的情感。我们可以做的以及应该做的，是希望他愿意并且能够通过从事精神分析工作来满足他的情感需要。
回到我举的赛车的例子，我们的伦理准则是写在红区的。在进行分析时，你常觉得自己是在绿区工作，进展十分顺利。但是你会发现——事实上你应该经常会发现——你进了黄区。这可能意味着你发现自己感觉到了一些关于患者的特别的东西，令人兴奋的东西，有好也有坏。你可能会觉得无聊透顶，黔驴技穷，或是热衷于做一些不合常理的事；也可能会在强烈的情感旋涡里挣扎。这些都没关系，事实上这甚至还是好事，因为这是你的反移情在告诉你或许有些重要的事情正在发生。一个负责任的分析师必须当机立断，对他的绝望、迷恋或是其他任何情感进行分析，而不是把它们付诸行动。
性、爱、金钱、权力和自尊都带着强烈的情感。这些东西把患者带到治疗中，并将在分析素材和移情中扮演重要角色。同样的这些东西对分析师也很重要，而且是反移情的一部分。随着这些素材以及随之而来的冲突的展开，部分表达出来了部分还没有，部分意识到了部分还没有，双方都会被感动——或许以不同的方式在不同的程度上，但总归都会被感动。这就是精神分析工作最能有效发生作用的地方，如果它确实能够发生作用。
分析可能会由于患者的内在原因根本无法发生作用，要么是移情太多或太少，要么是缺少接受分析的动机。这个话题很大也很重要，但我今天先不讲它，因为我的关注点是精神分析的伦理，而这完全是分析师的责任，跟患者无关。分析师对这类患者唯一的伦理责任是，一旦他已经认定这些患者不适合接受精神分析，就不要为他们提供精神分析工作，并且告诉他们为什么，然后建议他们其它合适的选择。
现在我们来谈谈分析师。分析师对患者最重要的伦理责任就是完成患者付钱给他并且通过协议规定他应该做的事：进行精神分析。说到这里你们应该能猜到我要讲什么了。当分析处在黄区，即充满了强烈情感、有可能有重大发现时，分析师的责任是确保不会滑入或掉进红区。反移情在红区就变得有害了。分析会出现妥协，会中毒，或者被其它东西替代。最好的情形是分析师没有在工作，最坏的情形是他已经在有意欺骗患者。
这样的事在很多情况下都有可能发生，而且每种情况的动力都不一样。格莱恩格巴德（Glen Gabbard）和伊娃莱斯特（Eva Lester）对此有过很多描述[Gabbard & Lester, Gabbard]。有些患者，常常是创伤事件的受害者和有自杀倾向的患者，总想迫使分析师表现得不像在做分析——不那么专业——而且他们很擅长达到目的。有些分析师会爱上被分析者，有时他们是彼此相爱，甚至还会结婚。有些分析师会充当患者生活中的其它角色，比如教练或者咨询师，而且还是收费的。还存在一些“掠夺性”的分析师，他们的终极目标是剥削被分析者，不管是在性关系、财务、社会关系还是其它方面。这些违反边界的行为常常微妙地发生，迈出一小步或者说出一个字，但是这一步是迈下一个光滑的斜坡，下去了就再也上不来。遗憾的是，那些高级的有影响的分析师似乎不仅没有跟这些事不相干，反而比他们的同事更容易犯这样的错，很显然他们是觉得一般的规矩不适用于他们，他们可以自行其事。所以我们看到，就像阿克顿爵士（Lord Acton）观察到的那样，即使是在分析师当中，权力也会导致腐败。东窗事发之后，我们会发现这些分析师违反伦理的行为极其明目张胆，但他们却极少表现出任何反省或悔恨。
宗教、种族、政治倾向等也会模糊反移情，而且很可能会使分析失败，即使双方都意识到了他们这对组合所面临的潜在困难并且在努力克服困难。组合要么基于双方的相似性——这会导致彼此默契地维持在一个隐蔽的“舒适地带”——要么基于差异性——这会导致同样隐蔽的友善的或不那么友善的“虚假宽容”。鉴于我们所有人都具有某种身份——犹太人、儒家弟子、共和党人或民主党人、男人或女人、白人、有色人种，等等——提防这些因素可能会起的作用对我们总是有好处的。
还有另外一种几乎是觉察不到的不当行为，因为任何一方都没注意到，它就像一氧化碳一样不知不觉之中造成危害。爱尔文赫什(Irwin Hirsch)在他那本巧妙地取名为《在反移情中打酱油》的书里对此做了很好的描述。这种分析几乎一直是待在绿区，事实上，这根本不是分析，而是分析陷入了某种僵局，原因是分析师出于私心只舒服地做些华而不实的表面文章，根本没有出于责任感真正为患者做有效的分析。同样的，发生这种情况也有很多原因——由于咨询关系太舒服、钱赚得太爽或是具有别的意义，导致分析师要么绕开可能会打破现状的重要问题，要么就是简单地回避结束，这二者都会使分析没完没了地进行下去。再有就是分析师出于自身原因很难保持专注，或者一天下来把自己搞得太忙了。这些问题我们可能一时注意不到，但是如果足够警醒，我们还是能够在造成太多伤害之前发现问题。只是，从最终的结果看，这还是对患者的背叛，不亚于一个士兵在站岗时睡着了。
我还没讲到保密性，这个话题太大，也太复杂，以至于有些团体成立了委员会专门处理这个问题。简单地说，分析师除了需要会诊或督导以外必须绝对保密，精神分析的保密性才能做到最好，这里说的会诊也适用于同样的保密原则。克里斯托弗波拉斯（Christopher Bollas）清晰有力地论述了这一点。我并不完全赞同他的立场，但他的基本观点很重要也很有道理。保密性正在由于法律和官僚因素而遭受侵蚀，很多司法机关都有关于报告危险或犯罪嫌疑行为的法律，很多分析师也赞同这样的司法观点，这就在咨询室里制造了一种对抗氛围，由此很可能导致滥用或毁掉精神分析。保险索赔则提出了另外一个难题。分析师和患者都同意至少有些信息需要跟保险公司共享，而机构在这个问题上通常被认为没什么伦理要求。所以，为了让治疗能够进行，分析师经常按照双方认为对患者有利的原则歪曲临床报告。虽然患者感觉到他得到了帮助，但与此同时他也发现他的分析师是可以被腐化的。这种事本来没必要发生而且也是可以避免的，但是精神分析团体及医学团体在保护患者的私密性方面做得严重不够。另一个常见的违反保密原则的行为发生在分析师之间漫不经心的聊天中，即使是在社交场合，他们也会谈到相互都认识的或者相互转介的患者。我突然想起了二战期间美军的一幅海报，上面写着“管不住嘴就hold不住命”，我们应该考虑把它贴在墙上。
最后，我简单谈谈机构的伦理问题。我之前有说过，很久以来，精神分析组织基本上一直在忽视违反边界的行为，直到1990年代马苏德可汗事件在伦敦彻底曝光[Sandler&Godley]，国际精神分析协会（IPA）才总算给它自己套上了伦理准则的约束。有一个机构问题值得特别讲讲。某同事违反伦理的行为其他成员一般都会知道，而且在被正式处理之前早就成为过道里的谈资。这经常会使支持或反对过失者的成员分成两派，从而进一步促成了团体里阵营的分化。这种小集团的破坏性相当强，包括不仅无法有效地讨论事件本身，也无法讨论任何事，不管是在学术会议上还是在督导中。它还影响到对新人的培训与分析。一方面新人会向坏榜样学习，另一方面他们会知道有些重要事件是不能公开处理的。这种代际传承一点都不奇怪：那些违反边界的分析师在他们自己的培训中往往是违反边界行为的受害者。
我们的精神分析伦理准则十分直白易懂，所以，简单明了的事实是：很清楚，以任何方式违反准则都是不对的。但是，就像奥斯卡王尔德(Oscar Wilde)所说的那样，“简单明了的事实从来都不简单也很少是明了的。”伦理准则本身不可能穷尽一切也不是不可更改的，会随着时间发生变化。随着我们对心理的了解越来越多，精神分析理论和技术都会向前发展。但是荣誉与责任将一直保持下去，移情与反移情——带着他们潜在的好处与坏处——也将仍是科学与艺术的核心。一名分析师可以选择遵守规定，也可以选择不遵守，但是他的选择以及对这一选择的后果所负有的责任，将全部由他承担。
作为结束，我想提四点建议，或许可以对移情与反移情的毒害作用提供一些有效的保护。第一，接受一个好的分析——在你执业一段时间之后或许还得加多一个。第二，要让新人向以希波克拉底宣言为蓝本的我们的伦理宣言正式宣誓，在培训开始之前及在培训合格之后都要宣誓，要让他们清楚自己的责任。第三，记住你永远不需要马上行动，你永远都有技术上伦理上的其它选择，你永远都不必独自应对困难，当你需要的时候你可以接受会诊，有很多有经验的同事愿意并且能够帮助你，而不会让你感到难为情。第四，最重要的，我们必须更经常更开放地把反移情提交到临床讨论中、教学中和督导中，这可能会使情绪加剧，把我们更多地推进黄区，但是，那里才是你取得进步的地方。
谢谢大家。
参考与阅读
略
The Toxicology of Transference and Countertransference
and the Role of Psychoanalytic Ethics
George Brownstone, M.D.
In 1937, close to the end of his life, Sigmund Freud wrote one of his few contributions about countertransference in Analysis Terminable and Interminable. In it, he criticized the behavior of analysts who, though trained and analyzed, “evade the critical and corrective influence of analysis” on themselves. They are subject to what he termed the “dangers of analysis”, and likened their countertransference situation to “the effect of the X-rays on those who use them without due precaution”. Related to this, he alluded to the dictum “power corrupts, and absolute power tends to corrupt absolutely”. He was speaking from experience, of course, what he knew of Carl Gustav Jung and Sandor Ferenczi and others, probably even including his knowledge of himself. The only remedy he proposed was that analysts periodically submit themselves to more analysis, though he acknowledged that this didn’t always work, adding that analysis “is a task which is never finished”. He entirely ignored the ethical dimensions and the consequences of such bad behavior.
This is unsettling. Psychoanalysis was conceived and practiced as a healing art, a sub-specialty of neuropsychiatry, to treat patients, and, whatever else it has become, that has remained. Since the time of Hippocrates, in the 5th Century B.C., it was recognized that the practice of medicine required an obligatory ethical code which strictly defined and limited the conduct of its practitioners, in order to allow the public to have sufficient trust in a doctor so that they could avail themselves of their services. The Hippocratic Oath has remained the guiding principle for medical professionals up the present day. Most legal systems recognize, at least to some extent, that professional behavior should not answer to common law, but to a higher authority, the profession’s own. I don’t know how well-known this oath is in the East, but I understand that Chinese medicine has incorporated something very similar since the 7th century AD, texts written by the great Tang physician Sun Simiao. Freud and many of the early psychoanalysts were physicians and subscribed to a similar oath, and Freud made numerous references to a doctor’s ethical duties during psychoanalytic treatment.
Nevertheless, despite numerous well-known instances of unethical behavior among its members, both Freud’s and the IPA’s stance on psychoanalytic ethics was to ignore the matter entirely until it was no longer possible to do so. We have a technical term for that, denial, which is not the same as disbelief. Rather, it is a primitive and pretty weak defense mechanism, and its use often tends to exacerbate the underlying problem. Denial seems to be the typical initial response of many groups to misbehavior among their members. A frequent later reaction, if the issue is unavoidable and undeniable, is to self-righteously “get rid of the rotten apple”, circle the wagons, and never question that there might be some underlying problem potentially affecting the whole group which would be worthy of examination. All this highlights the very reason why codes of professional ethics are necessary, and why psychoanalysts and our profession would profit from an awareness of them and their basis.
The Hippocratic Oath requires a physician, among other things, to practice his profession and lead his life honorably, to always serve for the benefit of the patient, even above his own desires, to protect life, and to observe utmost discretion. Psychoanalytic ethics follows the same principles, but is more stringent, since it centrally addresses the dynamics of the transference/countertransference interaction, and ramifications of the power differential between patient and analyst which might not be so relevant in other medical situations.
If you look over the IPA’s ethics code, or that of any local Society – whose code must reflect the IPA’s – you’ll probably find that much of what’s there is no surprise. You might even feel that at least some of these points are so obvious you wonder why they’re included at all. “Why,” you might say, “would anyone have to be told that they shouldn’t have sex with a patient? Surely, that must be obvious to any psychoanalyst.” Well, I assume it probably is, but I’m sure you know that it happens every now and then anyway. Lacking an ethics code, an analyst could say “Oh, I didn’t know”, or “This is a special case”, or even “I don’t share that view”, essentially dismissing the issue. So it’s necessary to have a clear rule for all to read, and an Ethics Committee which will take action, if required.
But our ethics code is far more meaningful than just a catalog of proper etiquette for psychoanalysts, or as a code of law, enabling societies to punish the guilty – although it will be applied that way, too, in the extreme. Ethics committees and societies would be delighted if they never had a case to investigate. The much more important point is this: psychoanalytic ethics and psychoanalytic technique are almost indivisible. Bad technique is frequently unethical, and unethical behavior is always technically bad and theoretically wanting.
The best use of our ethics code is long before anything actually happens, and as soon as something listed there comes to the analyst’s attention. Imagine one of those round safety gauges, like a car’s tachometer, with a pointer which travels first through a green area, then into orange, and finally into red. As any good professional driver knows, you don’t always, not even often, stay in the green zone. Many situations require pushing the engine into the orange zone. But a good driver knows that pushing the engine even harder, into the red zone, going over the “red line”, risks catastrophic damage, like the engine blowing up, and the race will never be finished. The red zone is toxic, and an absolute no-no. So even if he really wanted, really needed, to pass the car in front of him, a good racing driver will never overstep that red line, but instead bide his time until he found another way to solve his problem, knowing that above all, he must finish the race. Many would-be racing drivers don’t grasp this, or can’t limit themselves. Their careers are short, because no one will hire them. In the rude but clear American slang, they are known as having “all balls, no brains”.
My theme today is the toxicology of transference and countertransference, sparked by Freud’s X¬¬¬-ray analogy. An old dictum by the father of toxicology, Paracelsus, about 450 years ago, is that "all things are poison and nothing is without poison; only the dose makes a thing not a poison." That’s true, but some things are obviously more toxic, and thus more dangerous, than others. It takes more water to kill a person than arsenic, and the X-rays Freud referred to are highly toxic. They are also highly useful. So the solution, as radiologists know, is to use them, but carefully. What Freud was talking about, of course, was the potential toxicity of human feelings as they emerge forcefully in psychoanalysis. The feelings can be either the patient’s or the doctor’s, and both parties and the psychoanalytic treatment itself are the potential beneficiaries or the potential victims.
At or near the center of psychoanalytic work is the analysis of transference. I understand transference to include all the thoughts and feelings, conscious and unconscious, one person feels about another – in psychoanalysis, all the feelings the patient has about the analyst. The preeminent instrument we have for perceiving the transference is our countertransference, which is simply the analyst’s transference to the patient. Transference is ubiquitous in everyday life, too – humans are biologically well equipped to do this – and the only difference is that in psychoanalysis the transference is not simply experienced and acted upon, but analyzed, like everything else. One person’s feelings influence the other person’s feelings, and a fundamental part of the analyst’s work is to try, in collaboration with the patient, to understand what, in the patient, is influencing him.
But the analyst is not only a passive observer. His feelings affect the patient, just as the patient has affected him. The analyst is, as Henry Stack Sullivan described, a participant observer. He must, therefore, allow himself to be an authentic participant in the immediate interaction with the patient, otherwise he will miss perceiving at least some of what moves the patient. At the same time, however, he must also observe the interaction, and monitor what is going on in himself, trying to clarify what is going on in the patient, which can then be analyzed. This may sound a bit like a tight-rope act, and sometimes it is. The analyst must allow himself to be moved, but never so much that he is swept off his feet. It can be done, but, like work with X-rays, it requires caution.
Feelings can be powerful, and powerful feelings can be overpowering. Overpowering what? Overpowering judgment, reason, and conscience. Insanity like that doesn’t only happen to people who are, or ought to be, our patients, but to everybody now and then, in different ways, to differing degrees. What differentiates our patients is only that they have more problems with this, more than they and the people around them can comfortably live with. Now, when something overpowering like this has already happened, the better situation is when someone can at least realize “I did so-and-so against my better judgment”. That’s not good, but it’s ego-dystonic and conflicted, and allows the possibility of corrective, or at least reparative, measures. The worse case is when someone does something terrible, but feels it’s fine. This is bad because, since it’s ego-syntonic and unconflicted, there is no recognition that anything needs correction. The average analyst is no more or less neurotic than the average intelligent, educated adult, and is susceptible to all the feelings everybody else has, and all the vicissitudes of daily life. We can’t expect him to not experience any of the feelings humans can have. What we can, and should, expect is that he is willing and able to subordinate the gratification of his feelings in the service of conducting a proper psychoanalysis.
Going back to my driving analogy, our ethics code is written in the red zone. While conducting an analysis, you will often feel yourself working in green, moving along easily. But then you discover – actually, you should fairly often discover – that you’re in orange. That might mean finding yourself registering something special, perhaps something exciting, about your patient, something good, or bad. Or you might feel bored to death; or you’re at wit’s end, entertaining doing something unorthodox or drastic, or even improper; or you might be in the throes of some other substantial wave of emotion. All that’s fine. Better than fine, in fact, because that’s your countertransference telling you that something important is probably going on. And once you’ve noticed it, but before you act on it, you have a choice to make, and you have to decide what to do. Remember, you always have a choice, make no mistake about it. A responsible analyst must decide, unhesitatingly and without reservation, to analyze, rather than to act out, his desperation, or infatuation, or whatever.
Sex, love, money, power, and self-esteem are all emotionally highly charged. These are the matters which bring patients into treatment, and they will figure prominently in the analytic material and in the transference. These same things are important to the analyst, and are part of the countertransference. As the material unfolds, with all of its attendant conflict, partly verbalized and partly not, partly conscious and partly not, both parties will be moved – perhaps in different ways and to different degrees, but moved nonetheless. This is where the psychoanalytic work will most usefully take place, if it takes place at all.
Analysis might not take place because of factors within the patient. This could be because of too much transference or too little, or simply a lack of motivation to do the analytic work. This is a large and important topic, but I’ll leave it aside today because my focus is psychoanalytic ethics, which is entirely the analyst’s responsibility, not the patient’s. The analyst’s only ethical duty to such patients, once he has determined that they’re not suitable for psychoanalysis, is to not offer them psychoanalysis and tell them why, and to advise them about suitable alternatives.
So now we turn to the analyst. His foremost ethical responsibility to the patient is to do the job he was hired for and which he contracted to do: to conduct the psychoanalysis. I suppose you can all guess by now where I’m headed. When the analysis is in the orange zone, that emotionally charged zone where it could make its greatest discoveries, it is the analyst’s responsibility to see to it that it doesn’t slip, or slide, or fall into the red zone. In the red zone the countertransference has become toxic. The analysis has been compromised, poisoned, and is replaced by something else. In the best case, the analyst is no longer doing his job, and in the worst case he is knowingly cheating the patient.
There are many situations in which this may occur, and the dynamics vary from instance to instance; Glen Gabbard and Eva Lester have described many of them [Gabbard & Lester, Gabbard]. There are patients, often the victims of trauma, often suicidal, who seem to want to force the analyst to behave unanalytically – unprofessionally – and seem pretty good at making it happen. Then there are analysts who fall in love with analysands, which is sometimes mutual, and has even resulted in marriage. There are analysts who allow themselves to become involved in other roles with their patients, often paid, such as coaching or advising. Then, there exist what may be called “predatory” analysts, whose ultimate goal is to exploit analysands, whether sexually, financially, socially, or otherwise. Such boundary violations usually begin subtly, with just a small step or word, but often that step is onto a slippery slope from which there is no recovery. Unfortunately, it seems that senior and influential analysts, far from being above such things, are actually somewhat more likely to commit boundary violations than their colleagues, apparently feeling that the usual rules don’t apply to them and they can make their own. So we see that even among analysts, power corrupts, as Lord Acton observed. When they come to light, these analysts’ ethical breaches are usually obvious and dramatic, but it’s not unusual for them to show neither insight nor remorse.
Religion, race, politics, and so forth can also cloud the countertransference and potentially doom an analysis, even when both parties are aware of the potential problems facing that particular dyad, and earnestly strive to overcome them. This may come in the form of a similarity between the two parties – leading to a collusion to maintain a blind “comfort zone” – or a difference – leading to equally blind benign, or less benign, “pseudo-tolerance”. Since all of us are something – Jews, Confucians, Republicans or Democrats, men or women, white, colored, whatever – it behooves us to be on the alert for the possible effects of these factors.
There is another, almost invisible kind of misbehavior, because it’s often unnoticed by either party, and works its toxin insidiously, like carbon monoxide. It is well described by Irwin Hirsch in his aptly-titled book, Coasting in the Countertransference. Such analysis remains almost entirely in the green zone. In fact, this is not analysis, but a kind of analytic impasse produced by an analyst’s being guided more by his comfortable, outwardly benign self-interest than by his responsibility to do useful psychoanalytic work with his patient. Here, too, there are many reasons this can occur – too comfortable, or too financially or otherwise meaningful a relationship with a patient, causing the analyst to either shy away from important material which might upset the equilibrium, or simply to avoid termination, both of which can lead to an interminable analysis. Or the analyst may have difficulty paying attention because of his own concerns, or he may have too full a workday. Such things may be out of our awareness for a while, but if we are suitably alert we can catch these lapses before they’ve caused too much damage. But the net result, again, is a betrayal of the patient, not unlike a soldier falling asleep on guard duty.
I have not yet mentioned confidentiality, which is a huge topic, and so complex that some societies have even created committees to deal with nothing else. Put briefly and simply, psychoanalytic confidentiality is best when it’s absolute, the only exception being an analyst’s need for consultation or supervision, in which case the consultant is bound to the same rules. Christopher Bollas makes this point most strongly and lucidly. While I don’t subscribe entirely to his stance, his fundamental point is important and valid. Confidentiality is being eroded for legal and bureaucratic reasons. For instance, many jurisdictions have laws about the reporting of suspected dangerous or criminal activity, and many analysts share that legal view, creating a potentially adversarial climate in the consulting room which can pervert and effectively destroy psychoanalysis. Insurance claims present a different problem. Both analyst and patient agree that at least some information will be shared with the insurance agency, an institution generally felt to have no meaningful ethics in such matters. So, to make treatment possible, analysts often distort the clinical report to what both parties consider the patient’s advantage. But at the same time as the patient feels he has been assisted, he also discovers that his analyst can be corrupted. Much of this is unnecessary and avoidable, and psychoanalytic and medical societies have not done nearly enough to protect patients’ confidentiality. Another unfortunately widespread breach of confidentiality occurs among analysts who thoughtlessly chat with one another, even in social situations, about patients they both know, or one has referred to the other. I find myself fondly recalling a W.W.II U.S. Army poster with the slogan “Loose Lips Lose Lives”, which we might consider posting on our walls.
Finally, let me touch briefly on our institutional problems with ethics. As I mentioned earlier, for a long time organized psychoanalysis has mostly tried to ignore boundary violations, and it wasn’t until the case of Masud Khan literally exploded in London in the 1990’s [Sandler & Godley] that the IPA could finally bring itself to adopt a binding code of ethics. One aspect of the institutional problem deserves special mention. Ethics violations by a colleague are generally pretty well known by other members, and are often the topic of hallway gossip long before they’re formally addressed. This often has the effect of polarizing members for or against the wrongdoer, furthering the formation of warring camps within societies. The destructive force of such cliques is quite strong, and includes not only an inability to usefully discuss the matter itself, but to discuss anything at all, whether in scientific meetings or in supervision. It also detrimentally affects the training and analysis of candidates. On the one hand they learn from bad role models, and they also learn that there are some important matters which can’t be openly addressed. The transgenerational legacy is not surprising: analysts who commit boundary violations were often the victims of boundary violations during their own training.
Our code of psychoanalytic ethics is pretty straightforward and easy to understand. So the pure and simple truth is, it’s clear, and it’s bad to violate it in any way. But, as Oscar Wilde said, “The pure and simple truth is rarely pure and never simple.” Ethics codes themselves can never be exhaustive nor definitive, and they are subject to change over time. Psychoanalytic theory and technique will also evolve as we learn more and more about the mind. But honor and responsibility will remain, and transference and countertransference will probably remain at the center of our art and science, with all their potential for benefit or harm. An analyst can choose to abide by the rules, or he can choose not to, but the choice, and the responsibility for the consequences of that choice, are entirely his.
In closing, let me suggest four measures which might offer useful protection against the toxic effects of transference and countertransference. First, get a good analysis – maybe even a second one, after you’ve been practicing for a while. Second, have candidates formally swear to our ethics in an oath modeled on the Hippocratic Oath, both at the beginning of their training and again upon qualification, to clearly bind them to their responsibilities. Third, remember that you almost never have to act immediately, you always have a technical and ethical choice to make, and you never have to master a difficult situation alone. So get consultation when you think you might need it. There are experienced colleagues very willing and able to help you, and not cause you embarrassment. And fourth, and most important, we must all bring countertransference more often and more openly into our clinical discussions and our teaching and supervision. This will probably heat up the atmosphere a bit, and put us more often into the orange zone with each other, but that’s where progress is made.
Thank you.
References and Reading
Bollas, C., Sundelson, D. (1995). The New Informants: Betrayal of Confidentiality in Psychoanalysis and Psychotherapy. London: Karnac Books.
Brenner, C. (1985). Countertransference as Compromise Formation. Psychoanal Q., 54:155-163.
Freud, S. (1912). Recommendations to Physicians Practicing Psycho-Analysis. SE, XII:109-120.
Freud, S. (1915a). Observations on Transference-Love (Further Recommendations on the Technique of Psycho-Analysis III). SE, XII:157-171.
Freud, S. (1915b). The Unconscious. SE, XIV:159-215
Freud, S. (1937). Analysis Terminable and Interminable. SE, XXIII:209-254.
Gabbard, G.O., Lester, E. (1995). Boundaries and Boundary Violations in Psychoanalysis. New York: Basic Books.
Gabbard, G.O. (2003). Miscarriages of psychoanalytic treatment with suicidal patients. Int. J. Psycho-Anal., 84:249-261.
Hirsch, I. (2008). Coasting in the Countertransference. New York: The Analytic Press.
Sandler, A., Godley, W. (2004). Institutional responses to boundary violations: The case of Masud Khan. Int. J. Psycho-Anal., 85:27-42.
Sullivan, H.S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton.
Author:
George Brownstone, M.D.
Vienna Psychoanalytic Society (IPA)
Girardigasse 3/24
A-1060 Vienna, Austria
Tel.: +43 1 587 1818
Email: georg.brownstone@chello.at
