International Journal of psychoanalysisInt J Psychoanal (2013) 94:1–5国际精神分析期刊（2013）
作者介绍：贝蒂 乔瑟夫（Betty Joseph，1917-2013)，克莱恩派精神分析师，早期在伯明翰大学接受社会工作训练，继而于伦敦学院攻读经济学。早期在一所儿童诊所从业，也就是在这里，1940年，她开始接受麦克 巴林特的分析。战后，她在伦敦完成了精神分析训练并于1949年成为了英国精神分析协会的一员。后来，她与梅兰妮克莱恩合作并于1951年到1954年之间接受了宝拉 赫曼（Paula Hermann）的深层分析。贝蒂 乔瑟夫延伸和发展了克莱恩的理论，尤其是投射和内摄认同。在克莱恩提出的"整体情境"（total situation）概念上，贝蒂发展出了她自己的独特技术。她将注意力集中在患者和分析师之间此时此地的分析情境并强调分析师的反移情。很多贝蒂的重要论文都收录在《精神病性平衡和精神病性改变》（暂译，Psychic Equilibrium and Psychic Change，1989年出版）
Here and now: My perspective1
作者：貝蒂 乔瑟夫 译者：王蕾
In this paper the author describes her particular perspective in doing analytic work. She stresses working in the here and now. For example, making interpretations that grow out of what the patient says or does in the sessions, keeping the patient’s history in mind, but not letting it lead interpretations. The analysis tries to understand why something is being said now, in this way, and what impact it may have or be designed to have in the analytic relationship. The term ‘here’ refers to what is going on between patient and analyst in the room while not leaving out the patient’s immediate reality in the outside world, his everyday life. The word ‘now’ implies awareness of time that is not just of the past and future but of the patient’s situation at the moment in analysis, which is constantly shifting. The author believes that by working primarily in the present the patient will feel more anchored, both patient and analyst can observe what is going on, for example how anxiety arises or decreases, how defences are mobilised or lessen. Both analyst and patient experience movement and change rather than relying on more theoretical explanations.
If I look back over my analytic career I realize that my work has increasingly focused on, or perhaps rather started from, what is going on in the room between patient and analyst. Today I want to think briefly why this is so. What is clear is that this focus allows the patient and analyst to feel more anchored.
By working in the here and now I mean this in a broad, global way but also in a minute way, and it is related to my understanding of psychic reality in the patient and the analyst. I like primarily to make interpretations that grow out of what the patient is saying or doing in the session, with his background and our previous work somewhere in the back of my mind and thus to eschew general explanations. The patient may tell me that her mother was so fragile that even when she was very young she felt that she had to be very protective towards her mother. It may seem from previous experience that this refers to myself, but I suspect this is not of real use to her, nor convincing to me, unless it is being manifested in some way in the session. But it would alert me to examine, for example, whether I was talking a bit carefully, was my tone a bit delicate, etc. and if so as a consequence she might have experienced me, whether consciously or not, as pussyfooting round her rather than interpreting straight. This can then give me a more global viewpoint – I may come to realize that over a series of sessions the patient and I have been talking to each other ‘carefully’ as if each was more comfortable of that way, so that the patient was feeling that interpretations were only ‘interpretations’ and not to be taken too seriously and I was colluding with this.
But the statement that the mother was so fragile may of course be stated for some quite other reason, for example, to express understanding she had gained from previous work, to control the analyst and prevent her from being straight and clear. The possibilities are legion and our attempt to understand what is going on in the here and now means trying to understand not only what is actually being said, but why it is being said now and said in this way, what impact it may be designed to have and what impact does it have.
When we are using the expression here and now, ‘here’ refers primarily to what is going on between the two participants in the room, but in addition it conveys the immediate, often concrete, reality of the individual’s experience, which may, for example, be focused on his body, the analyst’s room ⁄ - body. This aspect is particularly vivid in patients with strong psychotic anxieties. To give an example, a child patient at a certain point in his analysis, was almost unable to enter the playroom where the shadowy remains of another child’s scribbling remained indelibly crayoned on the wall. To him the shape of the scribbling became volcanoes, ‘here’, my room became an object of terror, and when he managed to come in he was extremely anxious and would stand flat against the opposite wall as far away as possible.
The notion of ‘here’ also implies that there is a world outside, and I like to keep this connection somewhere in the back of my mind so that links will occur, or will need to be made, between what is being understood in the consulting room and its implications in the patient’s everyday life. Some patients will resist this linking firmly and try, probably unconsciously, to hold the analyst’s mind fixing it into a kind of emotional pas de deux. This in itself will need understanding and interpreting.
The now, when we speak of here and now, implies a sense of time, not just past and future, but an awareness of the patient’s situation at the moment, one that is dynamic, never static, and that changes from moment to moment. The analyst is in a position to witness the movement and thus to gauge the forces operating in the patient, forces however that will find responses in the analyst, which should help in his understanding. Seen from this angle the analyst’s interest will lie in trying to understand the dynamics of change, without using the notions of progress or regression – rather observing that this is the way that this patient operates at this time – a kind of respect for his defences and his need for them.
I am very much concerned to try to follow the movement in the session, in the patient’s associations and in his response to interpretations, recognizing the brevity of ‘now’. As the analyst interprets the situation changes, the patient responds, or does not respond, anxiety increases and new defences are quickly mobilized, or there is a moment of relief, tension lessens and one can sense that the patient feels warmth towards the analyst. The nature of the response can help us to see something of the anxiety, for example, that lies behind it. The kind of movement going on in the session means constant change, change in the nature of defences or need for them, change in the perception of the object and change in the feelings towards the object. In this way we have a chance to see in a mini form the stuff that may lead to real stable psychic change. A further advantage of trying to follow in detail and in the present the movement of the patient and his material in the session is that it enables us to contact and begin to understand small quantities of anxiety or excitement as it arises and shifts rather than its accumulating or being evaded and the patient then being confronted with more massive anxiety or panic states later on.
I am stressing here the importance to me of trying to follow the moment to moment shifts in the session; there is of course always the risk of this leading to the patient feeling too closely followed or even harassed and trapped. Certainly the analyst needs to try to be aware of the possibility of this and be sensitive to the patient’s state of mind and his need for space to elaborate and stretch mentally.
Working in the here and now, I have indicated, of course involves an awareness not only what is going on immediately in the patient but is necessarily dependent on the analyst’s sensitivity, so far as is possible, to what is being evoked in himself. I gave an example of this where the analyst came to recognize that she was pussyfooting round the patient. To me this means that whatever our technical and theoretical knowledge our basic tool is our ability to try to recognize what we actually feel, experience or suspect is going on in ourselves – our psychic reality. In the absence of this capacity something quite fundamental will be lacking, I believe, in relation to our patients and our understanding of them.
Freud saw transference as being aspects of the patient’s early history being repeated, transferred in his relationship with the analyst. Melanie Klein took this further showing how aspects of the very early relationship of the child with his parents were internalized and built up his inner world of objects, and that aspects of these inner objects were projected into the relationship with the analyst forming the transference. I am suggesting that as we follow the moment to moment shifts in the session we can begin to get an idea of how his past was built up because we can see elements of it being reconstructed in the session. To give a very over-simplified kind of example – the analyst gives what seems to her a straightforward interpretation, the patient responds with anxiety and anger suggesting that he felt that the analyst was rebuking and mocking him, but his angry response evokes in the analyst a sense not only of being grossly misunderstood but of wanting to pressurize or bully the patient into understanding. If this type of situation seems in varying ways to be repeated as the analysis goes on and the analyst is aware of the pull towards this kind of enactment it can give us some idea of the kind of pressures the patient very possibly experienced in his past with, say, a father who actually did or was felt to bully or pressurize the child. And we see how the child probably responded with fear and anger or hostility. This would make the father more upset and hostile and the two would get caught up in a vicious cycle. A cycle that is repeated in the transference but there we may begin to be able to unwind it. (This I shall discuss further in a moment.) Thus fragments of history come alive under our eyes.
I like therefore to try to understand what is being lived out by the patient and the role that I am being asked to play. If what I have learnt about his past comes into my mind and seems relevant at that moment then I like to connect it in my interpretations. It means that the patient’s history so far as it is known, or assumed to be known, is at the back of my mind rather than leading my expectations. Premature linking with history can easily be a defensive move both for patient and analyst. But in the long term I do feel that an understanding of what has gone on in the past, its meaning to the patient and his involvement in it, is not only of great interest to me as his analyst. It is also important to the patient that he can feel that his analyst has a sense of continuity and has his history in his mind. I believe this gives the patient a sense that there can be some flexibility in the understanding and interpretation of his history, and a greater sense of integration of himself.
This I think has an important bearing, as I indicated earlier, on the whole issue of psychic change. To my mind real psychic change does not come about through the patient’s recognition of the way he repeats old patterns of behaviour and relating, important as this awareness may be. Psychic change I think must depend on the patient’s ability to feel how and why he experienced or was caught up in certain manoeuvres, anxieties, defences, and this will only come about as he not only repeats his past, but moment by moment reconstructs it in the transference. The process of reconstructing will have an impact on the analyst as he is drawn into the various roles he is required to enact – or rather, since he is the analyst, he needs to become aware of this, to verbalize what is going on rather than enact. I attempted to illustrate this with the example of the child with the bullying father. As the patient experiences an object, the analyst, who does not get drawn into bullying he may begin to feel less angry, more trusting, and thus the analyst will be experienced as more benign and internalized as a more benign object evoking less anxiety and rage in the patient. In this way the vicious cycle can begin to loosen. I believe that this is an import aspect of achieving psychic change – by minute but ascertainable changes that take place within the transference and hence in the patient’s internal world.
I want to return to the issue of analytic explanations. They, like the patient’s told history, have a place at the back of my mind. I do not like to try to explain to a patient in general, for example, why he is using a particular defence unless I can see what is happening in the transference, how, for example, he has gone silent or become withdrawn and what seems to have resulted from this, what has been achieved by it. My aim is to help both of us to observe and understand the movement rather than my giving my patient what is essentially a more theoretical explanation, however correct this may be. If we give our patients general explanations or show them simply the way they are repeating their past, I suspect we become, in their minds, someone who wants them to change, a needy or a superego figure, rather than an analyst who will really try to enter into their state of mind at that moment. I do not, as I said previously, think that our interpretations are only concerned about what is going on in the room; I like to start from there and be able then, or maybe much later, to understand and to help the patient to understand its relevance to what is going on in his outside life and to his general difficulties and hopes.
In this brief contribution I have been stressing the importance of movement; here I am adding the importance of the analyst’s mind being able to move from what is going on in the room to the outside world and the past, but understanding, I am suggesting, needs to start from what is going on here and now.