The 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.
今天我想与大家探讨一个问题,即心理治疗师与患者进行工作时做了些什么?他有哪些特定的活动,他的内部工作模型又是什么?我的演讲将集中在几个非常基础的要点上,关乎心理治疗师如何工作,以及他在作为心理治疗师而工作时的所作所为本质如何。这种特别的工作方式基本上与我们常说的心理治疗态度有关,而这种态度又与心理治疗的精神分析概念紧密相连。因此,我会主要聚焦于这样的治疗师:他使用精神动力学疗法,运用精神分析的潜意识概念,并根据移情和反移情的概念以及治疗关系中出现的各种冲突形式来处理心理治疗性关系。
Today 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?”
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?”
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:
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:
“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).
“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)。
As we can conclude from his statement there are three essential aspects of psychoanalytic work which may be described as following:
1) The process of listening
2) The process of conceptualization
3) The process of intervening
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:
1) 倾听的过程
2) 概念化的过程
3) 干预的过程
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.
换言之,我们可以说精神分析的胜任力包含了遵循上面这三个紧密相连的框架进行工作的能力。这三个框架可被称作参与者-观察者框架,概念化框架,最后是同样重要的干预性框架。这三点可被视作我们进行精神分析导向的心理治疗工作的基本要素。
If 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.
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。
1) The process of listening
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.
1) 倾听的过程
当我们在心理治疗的设置下以治疗师的身份去倾听患者时,必须事先给出一个框架。可以这么说,没有框架,何谈内容。它需要有一个框架,才能允许会谈双方之间能发生一些有意义的事情。我们作为心理治疗师所提供的这个框架包括内部成分和外部成分。
The 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.
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。
The 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.
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。
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