I wish to present my work with a patient who discovered she had developmental prosopagnosia(facial blindness) after several years of psychoanalysis. Though as much as 2% of the population may have this, there is little if anything in the psychoanalytic literature about this condition, or it’s effects on development or treatment. I wish to highlight that many patients are unaware they have this condition or their therapist, including myself, don’t consider it.
我想呈报一个我的个案,案主在与我进行了数年精神分析工作之后察觉到自己患有发展性面部失认症[1](脸盲)。尽管有近2%的人口患有这类疾病,但精神分析文献中却很少提到这一点,也很少提到它对发育或者治疗的影响。我想强调的是,很多病人没有觉察到他们有这种情况,甚至他们的治疗师也没有察觉,这其中也包括我。
Freud创造,取自希腊语a-(“没有”)和gnosis(“知识”)。失认的意思是提取知识或再认的失败。(译者注。Michael S. Gazzaniga (2015),《认知神经科学——关于心智的生物学》第三版,北京:中国轻工业出版社,p.179.)
[1] 失认症(agnosia)这个术语正是由SigmundFacial blindness or developmental prosopagnosia (DP), was considered extremely rare in my training and as recently as the 2003 review by Kress and Daum (1). Since then there has been a surge in research findings that have greatly expanded our understanding. It is now estimated that 1.5 to 2% of the population is affected. An example is a 2008 study with Hong Kong medical students by Kennerknecht and Wong(2), showing a 1.9% distribution, demonstrating the universality of this condition.
在我的受训背景中,脸盲或称面部失认症是很少被提及的,这一点正如Kress和Daum在2003年的综述中提到的那样。自那以后便涌现了大量与此相关的研究,这极大地拓展了我们对此的理解。目前的估计是约1.5-2%的人口受此影响。例如香港医学院学生Kennerknecht和Wong 所做的研究显示有1.9%的流行率,这说明这一疾病有一定的普遍性。
Numerous publications in the popular press have appeared. Several prominent people have reported to suffer from it, Oliver Sachs (3), Brad Pitt, and the artist Chuck Close, to name a few. Jane Goodall, the famous chimpanzee researcher, describes her own experience as follows: I used to think it was due to some mental laziness, and I tried desperately to memorize the faces of people I met so that, if I saw them the next day, I would recognize them. I had no trouble with those who had obvious physical characteristics—unusual bone structure, beaky nose, extreme beauty or the opposite. But with other faces I failed, miserably. Sometimes I knew that people were upset when I did not immediately recognize them—certainly I was. And because I was embarrassed, I kept it to myself. (Goodall and Berman1999).
相关的书籍报道大量出现。一些杰出人士也报告说他们遭遇此类疾病,例如奥利弗·萨克斯,布拉德·皮特和艺术家查克·克洛斯。Jane Goodall, 一位著名的黑猩猩研究者,就描述过她的亲身经历:我曾经以为这是心智惰性导致的,我试图拼命地记住我曾经遇到过的人的脸,这样我下次再见到他们时就可以认出他们。对于那些有明显生理特征的人——比如有不同寻常的骨结构,鹰钩鼻,特别漂亮或非常丑的人我是可以记住的。但可悲的是,对于其他脸我就完全不记得了。有时候我知道那些我没能马上认出的人是不高兴的——对此我也不高兴。我因此而感到尴尬,因此只能把这件事当做一个我自己的秘密。
The author Heather Sellers has written a well-received book “You Don’t Look Like Anyone I Know: A True Story of Family, Face Blindness, and Forgiveness” describing her own experiences. The observed effects on children’s behavior is described and well expressed in the title of Dalrymple and Duchaine’s paper (4)“A room full of strangers every day”.
儿童行为的影响进行了详尽描述。
作家Heather Sellers写过一本很受欢迎的书《你看起来不像任何一个我认得的人:一个关于家庭,脸盲和原谅的真实的故事》,书中描述了她的亲身经验。Dalrymple和Duchaine合著的的《一个每天都充满陌生人的房间》一文,就将此病对于Facial recognition is a complex phenomena, that apparently involves several cortical areas. Some recent work suggests the defect in DP involves reduced connections between the occipital and visual areas. It appears to run in families and involve multiple genes. I defer to those better qualified in understanding this complex and now extensively studied area of cognitive research. See a current review by Bates and Tree(5).
面部识别是一个复杂的现象,它涉及到好多个大脑皮层区。近期的一些工作表明发展性面部失认症与枕叶和视觉区的联系减弱有关。它似乎与家族遗传有关并且涉及到很多基因。在此,我听从那些在这个热门的认知研究领域里,更有资格理解和研究这一现象的人的意见。可参见Bates 和Tree近期的综述。
I want to present a patient, who discovered she had DP in the course of a long standing analysis, surprising us both, and forcing some new understanding of our work together.
我想呈报一个病人。她在经历了长期的分析之后发现自己实际上患有发展性面部失认症, 这一点令我们双方都很吃惊,并促使我们对于我们共同的工作有了新的理解。
The pt. L is African American single professional woman in her late 50’s. She has been in some form of ongoing therapy most of her adult life. I remember my first impression of her as she came for her initial session. She was referred to me by another analyst, who was relocating out of state. She was a tall, awkward woman with masculine gestures yet still attractive, with a shy smile like a little girl trapped inside, her manish gestures and bearing. Her presenting symptoms were depression, difficulty in relationships, sexual preference, and episodes of transient dissociation described as “spacing out”.
女性。在她成年之后的大部分时间里,都在接受某些形式的持续治疗。我还记得初始访谈之际她留给我的第一印象。她是一个搬去其他州的分析师转介给我的。她个子高挑,带着些许男性姿态,尽管显得有些笨拙但仍不失风韵。她笑起来很羞涩,好像有一个小姑娘被困在那个身体里。她当时的症状是抑郁,难以建立关系,性取向和间歇性解离。
病人L,是一个非裔美国人,50多岁的职业Her psychiatric history included several hospitalizations in her early 20’s for suicide attempts and alcohol abuse. After being required to sign a contract not to commit suicide by her inpatient psychologist, she responded by burning down 2 buildings and being kicked out of the hospital. She did continue as an outpatient with a bearded social worker she was comfortable with. A gifted student and athlete, she finally finished her degree and moved to my city where she obtained a PhD. Her previous analyst, a woman, felt she had stabilized somewhat with multiple sessions weekly because she had object constancy problems. L initially was concerned about my capacity as a male to be helpful, but we did quickly connect. She has an excellent sense of humor and loves to banter about sports. I thought I could see glimpses of a positive brother transference emerging. I noticed a concreteness about her thinking in patches, a tendency to forget contents of sessions, and external events, that looked like dissociation. I made a conscious choice to be as interactive as possible, giving considerable here and now feed back as to my experience of her and what I was thinking. My thought was to deepen the engagement, counter the negative paternal projections, and present myself as much as possible as a real object in the hope of facilitating better object constancy.
精神病史显示在她20来岁时多次因试图自杀和酗酒入院治疗。当她的住院心理治疗师要求其签署不自杀协议时,她纵火烧了两栋房子来作为回应,因此被赶出医院。她继续以门诊病人的身份与一个大胡子社工开展工作,她对这个社工很满意。她是一个很有天分的学生还擅长运动,她最后拿到了学位并移居到我所在的城市,并在这里获得了博士学位。她的前任分析师是一名女性,这名分析师认为她有客体恒常性的问题,觉得一周数次的咨询设置能使她有所稳定。起初L担心我是个男性而不能对她有所帮助,不过我们很快就连接上了。她很有幽默感还爱拿体育开涮。我想我能瞥到一些对于兄长的正性移情。我注意到她思维上的一些固化,容易遗忘治疗所谈的内容和一些外部事件,这看起来很像解离。我在意识层面决定让自己尽量活跃地与之互动, 并就我此时此地对她的感受和我所想到的内容向她反馈。我的想法是去加深彼此的连接,以对抗负性的父亲投射,并让自己显得尽可能是一个真实的客体,进而促进其更好的客体恒常感。
她的She described a most unusual childhood. Her parents, both college graduates, were dairy farmers in a rural area. L. was the 4th child with 2 elder brothers and a sister 2 ½ years older. The family dynamics centered around L’s sister, who was developmentally delayed. L experienced almost constant intrusion and absence of boundaries with her sister. She was mostly ignored, and not allowed to complain. The father was deeply attached to the sister with nothing positive towards him experienced by L. In all my years of seeing L, she could never retrieve a single positive feeling towards her dad. She always remembers herself as seeing the world only as an observer of others not a participant. She learned by observing and imitating others. She felt closer to the calves than her family in many ways, naming them and touching them daily(notice the parallel with Jane Goodall and her chimpanzees). She attended a one-room school-house till grade 7 having no playmates in her isolated rural neighborhood. Her memories of father are of a cold stern man with his gloved hand artificially inseminating restrained bleating cows, or callously shipping off her beloved calves for sale. The mother and sister stayed in the house, while L worked outside doing chores with her Dad and brothers, modeling herself after them. The mother was a needy and helpless person. L. took pleasure in caring for her mother but expected little in return. She convinced herself that she would eventually grow into a boy like her brothers and was devastated with the onset of menses. This also coincided with L’s changing schools, becoming lost in a group of strangers all of whom knew each other. A gifted athlete and student she organized herself around these activities. She developed some difficulty with absenteeism and drugs as a junior in High School leading to her first seeing a bearded counselor with marked improvement in her behavior. She described him as the first person to ever listen to her, She developed the idea that he could always see her, which was both gratifying and scary. Going away to university led to her first psychiatric admission when the chaos seemed just too much. I was to be another in the line of bearded therapist for her.
记忆中她之于这个世界总是一个观察者而不是一个参与者。她从观察和模仿他人中学习。她觉得,她对小牛犊都比对家人在许多方面亲近得多,每天给它们起名字,并且抚摸它们(请注意,这恰好与Jane Goodall和她的黑猩猩之间的关系一样)。她在一个只有一间教室的乡村小学念书,直到7年级之前她在与世隔绝的乡下都没有玩伴。她记忆中的父亲是一个冷漠 严厉的男人,总带着手套在给咩咩叫的奶牛人工授精,或者冷酷地把她心爱的小牛运走卖掉。母亲和姐姐通常就待在屋里,L则学着父兄的样子跟着一起干活。母亲是一个高需求又无助的人。L乐于照顾母亲但很少期待回报。她说服自己终有一天她会长成像她哥哥那样的男孩子,但是例假的到来摧毁了这一幻想。这一点与L的转学也很一致, 她在一个别人都互相认识的陌生群体里感到迷失。起初她在活动中把自己塑造成一个有天赋的运动健将和好学生的形象。到了高中一年级她逃学和吸毒,为此她开始去见那个长胡子的咨询师,之后她的行为有了显著改善。在她的描述中,这是第一个倾听她的人,她以为他能一直见她,这既让她满意又让她害怕。上大学后她第一次被精神科收治,因为当时的麻烦实在太大了。我成为了下一个与她工作的大胡子治疗师。
她向我讲述了一个非常不同寻常的童年。她的父母都念过大学,是乡下的牧场主。L在家排行第四,上面有两个哥哥和一个大她2岁半的姐姐。L的姐姐有发育迟缓问题,整个家庭的动力以她为中心展开。L的生活总是不断地被姐姐闯入而且和姐姐之间缺乏边界。她总是被忽视,并且不得对此有任何抱怨。父亲和姐姐的联系紧密,L感受不到任何与父亲有关的积极体验。在她的I decided to see L 4x’s weekly sitting up. I felt this would help with her clear problems with object constancy and attachment. I also decided to be more interactive with her, building on a bearded therapist, big-brother transference that seemed pre-formed. The biggest difficulty developed in the second year when she developed a violent negative transference rising at times to almost delusional quality, whenever she saw me with another pt. This paralleled the developing positive transference, as she started expressing rage directed towards me or any other patient who might be waiting to see me, or if I was literally one minute late. In this state, she would be delusional and paranoid. I was setting her up, deliberately making her think she was important only to take pleasure in her humiliation. She called these her “rants,” which initially lasted days and were associated with severe suicidal ideation.
依恋方面的问题会有帮助。我同时也决定多与她互动,以促进似乎是预先就已经形成的对大胡子治疗师和大哥哥的移情。我们之间最大的困难始于第二年,她从那时起发展出一种暴力的负性移情,而且几乎带有妄想的性质,只要她一看到我和其他病人在一起就会这样。与此平行的是她也发展了正性移情,比如他开始向我或其他可能等着见我的病人直接表达愤怒,或者当我迟到哪怕一分钟时也会抱怨。在这种情况下,她可能是处在妄想中或者是偏执的。我试着启发她,谨慎地让她认识到,她只能在体验到被羞辱时才能感到自己是重要的。这样的状况一开始会持续好几天,并且伴随着严重的自杀观念。她把这些表现叫做她的“咆哮”。
我决定每周见L四次。我感觉这对她的客体恒常性和There was no looseness of thought process during these times, rather more like rigid delusional ideas. These could usually be dealt with by empathically talking her down in the following sessions, wondering with her about her amnesia for her good feelings towards me, how could I remember her last session and her history if I had truly forgotten her. She would insist that she knew I no longer had memory of her when I looked at the next patient. In these moments, I often felt a chilling sense of not being seen, becoming a thing in her mind while she raged at me. I tried a number of parameters. I shifted her to the last pt. of the day and scheduling a 5 minute buffer before her instead of my usual back to back schedule. Inevitably, a pt. might be in the restroom or talking on a cell phone outside the office and set off a rage, however they became less frequent, and over a long time less intense. The pt. experienced these as ego-dystonic and felt increasing frustration at the uncontrollable nature of them. I got a good bit of interpretive traction by connecting the intruders to the experience of her mentally disabled sister. The sister was 2 ½ years older, with the family focused exclusively on her needs. L described constantly being intruded upon by her sister. L’s clothes, mail, were all things the sister felt free to take with no limits being set. L’s considerable athletic and academic talents were never acknowledged. In contrast, she was always admonished to not make her sister feel badly by comparison, whenever she had success. The father was very involved with the sister who was very attached to him. Several parameters and the repeated interpretations as other patients’ intrusion into her space turned them into her sister were eventually helpful, but only after the explosion had begun to subside. Indeed many of my colleagues would see this as becoming intensive psychotherapy rather than analysis. My focus was on what was helpful and worked.
这些时候她并没有思维松散的表现,而是更像刻板的妄想观念。我面对这类情况通常的处理会是,在接下来的咨询中共情地与她交谈,和她一起探究她对我的好感觉的健忘,如果我真地忘了她,何以能够记得住她的上节治疗和她的过往呢。而她会坚持认为我在见下一个病人时就不再会记得她了。在这些时刻,我经常感到一阵不被看见的寒意,当她对我发火时,我在她头脑中成为了一个物品。 我尝试了很多办法。我把她放在当天工作的最后一个时段里,在上一个小节结束之后安排了一个5分钟的间隔。而我通常的做法是一个接一个的看病人。然而不可避免的是,总会有病人待在候诊室里,或者在办公室外面打电话,每当这个时候,都会激起她的愤怒。然而,这些愤怒爆发的频率在慢慢减少,很长一段时间以后,愤怒的强度也逐渐变低了。病人将这些体验为自我不和谐的,并且越来越为它们不可控的本质而感到沮丧。通过把入侵者和她对精神残疾的姐姐的体验联系起来,我得到了一个不错的解释。她姐姐比她大两岁半,全家人都只关注着姐姐的需要。L总是觉得被姐姐侵入。她姐姐总是会随意拿走她的衣服和信件,并且并不会被父母禁止那样做。L那相当令人瞩目的在田径和学业上的天赋从未被家人认可过。相反,她在获得成功时,却总是被告诫不要用自己的成就来使姐姐相形见绌。父亲对姐姐关爱有加,姐姐对父亲也十分依恋。我运用多种治疗手段,并且反复不断地把那些闯入到她的空间里的其他病人解释为她姐姐的替代者,这样的努力最终使她爆发出的愤怒逐渐减弱。确实,我的许多同事会把这个过程看做高密度的心理治疗,而不是精神分析。而我关注的重点是什么有益,什么起效。
Over time, she was increasingly successful at work and beginning to form a social network for the first time as she began playing an instrument in a local orchestra. She became a full professor, a licensed instrument rated pilot, and scuba instructor. Then while driving with a new friend M, they passed an attractive man in another car. L was astonished that her friend could describe his face in such detail when she had none. We had previously explored how differently our minds worked, in that I filed stories with faces and she did not. This time, she searched the internet, and discovered a trove of information about facial blindness. This information led her to take the Cambridge facial recognition test online scoring in the 40’s consistent with prosopagnosia. Suddenly our psychodynamic formulations had to be sharply altered to include this new information. I struggled to catch up with the new findings myself. In one session, I brought in a mirror from the waiting room. She was unable to see the mirror image as herself. “It’s like someone looking at me through a mirror,” she said. She experienced great discomfort in moving her arms and seeing them in the wrong place. This was amplified when I stood behind her so we were both visible. “I can’t see you and me at the same time. It’s too uncomfortable, if I concentrate hard, I can see us both but it’s too tiring to keep up very long. It’s like straining to focus on a difficult abstraction in math.
随着时间的推移,她在工作中越来越成功,而且由于她开始在一个当地的管弦乐队参与演奏,她第一次有了一个社交网络。她成为了一个正教授,获得了“靠仪表导航的飞行员”的执照,还是一个水肺潜水教练。在和一个新朋友M一起开车的途中,他们超过了旁边一辆车,那辆车上有一个很有魅力的男性。当她的朋友可以描述出那个男性脸上的许多细节时,她深感震惊。因为她自己对那些细节一点印象都没有。我们在此之前就已经知道,我俩头脑运行的方式是很不一样的。我用人脸来存档故事,而她却不这么做。这一次,她上网搜到了大量关于脸盲症的信息。这些信息让她参加了在线的剑桥脸部认知测试,只到了40分,这表示她有持续性的失认症。突然间,我们的心理动力性概念化必须被调整,因为我们需要把发展性面部失认症包含在内。我努力让自己跟上这个新的发现。在一个小节里,我从候诊室里拿来了一面镜子。她无法将镜子里的映像看做她自己。“这看上去就像有个人隔着镜子在看我一样。”她说。当她移动自己的胳膊,看到它们出现在一个错误的地方时,体会到极大的不适。当我站在她身后让她能同时看到我们俩时,这种感觉被放大了。她说:“我没办法让自己同时看着自己和你。这让人太不舒服了。如果我非常努力地集中注意力,我可以同时看到我们俩。但是那太累了,我没办法坚持很久。这就像专注于某个数学中很难的抽象概念时带来的紧张感。”