奇番『动力取向精神医学第五版』第八章情感性疾患8

Psychodynamic clinicians tend to agree thattreaters who fall prey to the illusion that they can save their patients fromsuicide are actually decreasing their chances of doing so (Hendin 1982;Meissner 1986; Richman and Eyman 1990; Searles 1967/1979; Zee 1972). Onesalient psychological concern in the seriously suicidal patient is the desireto be taken care of by an unconditionally loving mother (Richman and Eyman1990; Smith and Eyman 1988). Some therapists err in attempting to gratify thisfantasy by meeting the patient’s every need. They may accept phone calls fromthe patient any time of the day or night and throughout their vacations. Theymay see the patient 7 days a week in their office. Some have even becomesexually involved with their patients in a desperate effort to gratify theunending demands associated with the depression (Twemlow and Gabbard 1989).This kind of behavior exacerbates what Hendin (1982) described as one of themost lethal features of suicidal patients—namely, their tendency to assignothers the responsibility for their staying alive. By attempting to gratifythese ever escalating demands, the therapist colludes with the patient’sfantasy that there really is an unconditionally loving mother out theresomewhere who is different from everyone else. Therapists cannot possiblysustain that illusion indefinitely; those who attempt to do so are setting upthe patient for a crushing disappointment that may increase the risk ofsuicide.

动力观点的临床工作者一般来说都会同意，如果治疗者落入想要拯救患者免于自杀的幻想里头，结果往往适得其反。

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严重自杀患者往往有个很重要的心理需求，便是希望有个无条件给予爱的母亲来照顾他，有些治疗者失之于企图满足对方的这种幻想，而满足患者的所有需求，最后变成不论早晚、一天二十四小时都得接听个案的电话，即使是在休假中亦然。他们可能一周七天每天都安排会谈，甚至不顾一切地为了满足对方无止境的、与忧郁症有关的需求，而与患者发生性关系。这一类的行为印证了海丁曾经指出的，自杀患者最致命的特点便是把挽救自己生命的责任转移到别人身上去。在企图满足个案节节高升的要求时，治疗者共谋构筑着患者的幻想，彷佛真有一个与众不同、愿意无条件付出的母亲在那里供人予取予求。然而，治疗者不可能无止境地维持这个幻象，企图这么做的治疗师，终将让患者陷入幻灭，更增加了自杀的危险性。

Clinicians who are drawn into the role ofsavior with suicidal patients often operate on the conscious or unconsciousassumption that they can provide the love and concern that others have not,thus magically transforming the patient’s wish to die into a desire to live.This fantasy is a trap, however, because, as Hendin (1982) noted, “Thepatient’s hidden agenda is an attempt to prove that nothing the therapist cando will be enough. The therapist’s wish to see himself as the suicidalpatient’s savior may blind the therapist to the fact that the patient has casthim in the role of executioner” (pp. 171–172). Therapists are more useful tosuicidal patients when they diligently try to understand and analyze the originof the suicidal wishes instead of placing themselves in bondage to the patient.

有些治疗者掉进了拯救者的角色里，他们在有意识或无意识中认为自己可以提供别人给不起的爱与关怀，进而像变魔术一样地把个案的死亡企盼转变为生存的欲求。这类的幻想是个极大的陷阱，海丁曾经说过：“个案经常隐藏着这样的动机，希望能够证明治疗者无论做什么都不够，如果治疗者把自己当成是救世主，反而会蒙蔽了自己，看不到个案已经把执行死刑的任务丢给自己。”当治疗者努力地理解与分析个案自杀欲求的原因，而不是把自己紧紧地和对方绑在一起时，对个案的帮助反而更大。

Therapists should be on the lookout foridealizing transferences, which often form rapidly when patients are lookingfor a rescuer. Predicting and interpreting transference disappointments earlyin the process may be helpful. Some therapists openly acknowledge that theycannot stop the patient from committing suicide and offer instead theopportunity to understand why the patient thinks that suicide is the onlyoption (Henseler 1991). Often this ad- mission has a calming effect and mayproduce greater collaboration in the psychotherapeutic task.

治疗者必须要留意理想化的移情。当个案期盼拯救者的出现时，这类的移情关系特别容易出现。事先预料到它的出现，早点诠释移情中的失望，可能会对治疗有所帮助。有些治疗师会坦然承认自己没有办法阻止个案自杀，但是愿意提供机会来了解为何患者认为自杀是唯一的选择，通常这种坦承有稳定局面的效果，能够促进彼此合作。

It is useful to distinguish betweentreatment and management of the suicidal patient. The latter includes measuressuch as continuous observation, physical restraints, and removal of sharpobjects from the environment. Although these interventions are useful inpreventing the patient from acting on suicidal urges, management techniques donot necessarily decrease a patient’s future vulnerability to resorting tosuicidal behavior. Treatment of suicidal patients—consisting of medication anda psychotherapeutic approach to understanding the internal factors and externalstressors that make the patient suicidal—is needed to alter the fundamentalwish to die.

明确地区分治疗(treatrnent)与处置(rnanagernent)是很重要的，后者包括持续观察、身体约束、移除危险物品等措施，这些举措尽管可以避免患者有机会将自杀意念付诸行动，却往往无法避免个案继续藉由伤害自己来解决问题，反过来说，所谓的治疗——包括药物治疗，以及以了解个案自杀的内在与外在因素为主的心理治疗，才是能够处理自杀欲求的有效方式。

The countertransference elicited by thesuicidal patient presents a formidable obstacle to treatment. Some clinicianssimply avoid any responsibility for seriously depressed patients who are atrisk for killing themselves. Those who do attempt to treat such patients oftenbelieve that their raison d’être is negated by the patient’s wish to die. Apatient’s suicide is also the ultimate narcissistic injury for the treater.Clinicians’ anxiety about the suicide of the patient may stem more from thefear that others will blame them for the death than from concern for theindividual patient’s welfare (Hendin 1982; Hendin et al. 2004). It iscommonplace for therapists to set one standard for others and another forthemselves. The therapist who assures other clinicians that he or she is notresponsible for a patient’s suicide may feel an exaggerated sense ofresponsibility for keeping his or her own patients alive, often with theassumption that other therapists will be critical if a patient dies.

自杀行为所引起的反移情会对治疗产生严重的阻碍。有些治疗者把责任完全推得一干二净，一点也不想要照顾有自杀危险的忧郁症病人，而那些愿意照顾的人，却又常常觉得自己存在的价值被对方的自杀意念给一笔勾消。事实上对治疗者来说，个案的自杀是一种终极的自恋创伤，与其说他担心的是个案的人身安危，倒不如说是害怕自己成为众矢之的。治疗者也常常对别人讲一套，对自己说的又是另一套，也许在别的治疗师面前说自己不须为个案的自杀负责，私底下却十分自责，这种表里不一往往和假定别人会因此而批评自己有关。

Therapists who treat seriously suicidalpatients will eventually begin to feel tormented by the repeated negation oftheir efforts. Countertransference hate is likely to develop at such times, andtreaters will often harbor an unconscious wish for the patient to die so that thetorment will end. Maltsberger and Buie (1974) noted that feelings of malice andaversion are among the most common countertransference reactions connected withthe treatment of severely suicidal patients. The inability to tolerate theirown sadistic wishes toward such patients may lead treaters to act outcountertransference feelings. The authors caution that although malice may bemore unacceptable and uncomfortable, aversion is potentially more lethalbecause it can lead clinicians to neglect their patients and provide anopportunity for a suicide attempt. On an inpatient unit, this form ofcountertransference may be manifested by simply “forgetting” to check on thepatient as dictated by the suicidal observation order.

面对严重自杀个案的治疗师，常常会觉得自己被病人的一再否定给折磨得相当不堪，恨意的反移情往往于焉而生。治疗者可能会产生一种无意识的期待，希望个案不如早点死掉算了，这么一来这场折磨才得以终止。马士伯格和布依发现敌意(malice)与厌恶感(aversion)是最常见的反移情反应，如果治疗者没有办法忍受自己对个案施虐的欲望，这些反移情反应便可能见诸行动。上述两位作者指出，尽管对治疗者来说敌意可能更难以接受，厌恶感却是比较危险的，它可能会使治疗者忽略个案，让个案有机会自杀成功。在住院情境中，“忘记”遵照医嘱上所要求的时间间隔去探视病人，可能就是反移情的表现。

Countertransference hatred must be acceptedas part of the experience of treating suicidal patients. It often arises indirect response to the patient’s aggression. Suicide threats may be held overthe therapist’s head like the mythical sword of Damocles, tormenting andcontrolling the therapist night and day. Similarly, the family members ofpatients may be plagued with the concerns that if they make one false move orone unempathic comment, they will be responsible for a suicide. Ifcountertransference hate is split off and disavowed by the therapist, it may beprojected onto the patient, who then must deal with the therapist’s murderouswishes in addition to the preexisting suicidal impulses. Clinicians may alsodeal with their feelings of aggression by reaction formation, which may lead torescue fantasies and exaggerated efforts to prevent suicide. Searles(1967/1979) warned therapists of the perils of this defensive style:

反移情的恨意必须要被接纳为治疗自杀患者经验的一部分，这样的反应往往是因病人的攻击性而生。对临床工作者来说，自杀的威胁就好比是悬在头顶上的一把利剑般，令人提心吊胆，不知道什么时候会掉下来。同样地，个案的家属可能也会有类似的遭遇，深怕一不小心犯了什么错、说错了什么话，就得负起害个案真地去自杀的责任。如果这种反移情的恨意被治疗者扬弃与否认，然后投射回到个案身上，此时个案除了原先已经存在的自杀意念之外，又多了来自于治疗者的谋杀欲望。此外治疗者也必须好好地处理另一种反应——反向作用，在此种防卫机制下，治疗者反而会产生拯救的幻想，无所不用其极地预防自杀的发生，瑟席尔斯对此曾经提出若干忠告：

And the suicidal patient, who finds us sounable to be aware of the murderous feelings he fosters in us through hisguilt- and anxiety-producing threats of suicide, feels increasinglyconstricted, perhaps indeed to the point of suicide, by the therapist who, inreaction formation against his intensifying, unconscious wishes to kill thepatient, hovers increasingly “protectively” about the latter, for whom he feelsan omnipotence-based physicianly concern. Hence, it is, paradoxically, the veryphysician most anxiously concerned to keep the patient alive who tends mostvigorously, at an unconscious level, to drive him to what has come to seem theonly autonomous act left to himnamely, suicide. (p. 74)

自杀病人会利用自杀作为威胁的手段，引发治疗者的内疚与焦虑，如果治疗者没有办法意识到自己内心应运而生的谋杀欲望，反而透过反向作用把自己变成一个万能的治疗者，不断地增加限制性的防范措施，病人可能因此会感受到极大的拘束；很吊诡地，表面上看起来最殷勤地保护病人免于自杀的医师，反而可能在无意识里把病人逼到最后一个可以展现自由意志的角落，那便是结束自己的生命。

Psychotherapists who treat suicidalpatients must help them come to terms with their dominant ideology (Arieti1977) and their rigidly held life fantasies (Richman and Eyman 1990; Smith andEyman 1988). When there is a disparity between reality and the patient’sconstricted view of what life should be like, the therapist can help thepatient mourn the loss of the life fantasy. This technique may paradoxicallyrequire the therapist to acknowledge the patient’s hopelessness so that thelost dreams can be mourned and replaced by new ones that are more realistic.For example, one 23-year-old man became suicidal when he realized that he wouldnever be accepted to Harvard, a dream he had cherished since early childhood.The therapist acknowledged that admission to Harvard was highly unlikely andthen helped the patient accept the loss of that dream. At the same time, hehelped the patient consider alternative pathways to an education that wouldbuild the patient’s self-esteem. Thus the therapist helped the patient see howmuch misery is caused by unrealistically high expectations (Richman and Eyman1990).

治疗师必须要帮助个案去面对支配他自己的“意识型态”以及他紧抓不放的幻想,当现实与个案狭窄的目光有所抵触时，治疗者可以帮助他们走过面对幻想失落的哀悼过程。要做到这样，治疗者反而要能够承认、接受对方的无望感，如此一来，这些失落的梦想才能够顺利地被哀悼，才有可能被更贴近现实的梦想所取代。举个例子来说，有个二十三岁的男孩子从小就想要念哈佛大学，当他发现美梦破碎的时候，便开始想要自杀，治疗者先了解到要得到哈佛的入学许可实在是遥不可及，接下来才能帮助个案哀悼这项失落，同时也帮忙他考虑其他的替代方案，让他可以恢复原有的自尊心。透过这些步骤，个案也了解到不切实际的过高期待会带来多么大的伤害。

To treat suicidal patients effectively,clinicians must distinguish the patient’s responsibility from the treater’sresponsibility. Physicians in general and psychiatrists in  particular are  characterologically  prone to  an  exaggerated sense of responsibility (Gabbard1985). In this regard it is useful to give a portion of the responsibility forstaying safe to the patient. A contract that the patient signs indicating he orshe will not commit suicide has no legal standing and is rarely of any clinicalvalue. An alternative is a safety plan jointly constructed by therapist andpatient (Stanley et al. 2009). This plan provides the patient with a specificset of coping strategies and sources of support when suicidal thoughts emerge.The plan’s perspective is based on the recognition that suicidal urges ebb andflow rather than remain constant. The safety plan also operates on theassumption that patients are not simply at the mercy of their suicidalfeelings—they can develop a plan of coping with the feelings that avoids aregular trip to the emergency room.

为了有效地治疗有自杀倾向的病人，临床医生必须分清病人的责任和治疗者的责任。总的来说，医生，尤其是精神病学家，都有夸大责任感的特征(Gabbard 1985)。在这方面，让病人承担一部分保持安全的责任是有益的。病人签署的表明他或她不会自杀的合同没有法律依据，也很少有任何临床价值。另一种选择是由治疗师和患者共同制定的安全计划(Stanley et al. 2009)。该计划为患者提供了一套特定的应对策略，并在出现自杀念头时提供支持。该计划的观点是基于这样一种认识，即自杀冲动是潮起潮落的，而不是一成不变的。安全计划的实施还基于这样一个假设:病人不只是受自杀感觉的支配——他们可以制定一个计划来应对这种感觉，从而避免经常去急诊室。

Within this model, the patient mustrecognize warning signs that suicidality has returned and then automaticallyimplement a series of steps that have been collaboratively developed with thetherapist. These may include socializing with specific family members orfriends; removing any item in the home that might be used for a suicideattempt; involving oneself in activities, such as exercise or cleaning up one’soffice or house, that will distract one’s thinking; or playing games or doingInternet searches that one finds gratifying.

在这个模型中，患者必须识别出自杀倾向复发的警告信号，然后自动执行一系列与治疗师合作开发的步骤。这些可能包括与特定的家庭成员或朋友进行社交活动;移除家中任何可能被用作自杀企图的物品;参加一些活动，比如锻炼，打扫办公室或房子，这会分散一个人的注意力;或者玩游戏或做互联网搜索,找到一些满足。

Therapists, on the other hand, must balanceconcern for the patient with calmness and must not be overly anxious. Amatter-of-factness is essential. There needs to be a tolerance developed forsuicidality because the patient will be less anxious if the therapist is calm.Finally, the therapist must do his or her part in the collaborative plan.

另一方面，治疗师必须平衡对病人的关心和冷静，不能过度焦虑。实事求是是至关重要的。需要对自杀行为形成一种耐受性，因为如果治疗师保持冷静，病人就不会那么焦虑。最后，治疗师必须在合作计划中扮演他或她自己的角色。

We tend to blame ourselves for adverseoutcomes beyond our control. Ultimately, we must reconcile ourselves to thefact that there are terminal psychiatric illnesses. Patients must bear theresponsibility for deciding whether they will commit suicide or workcollaboratively with their therapist to understand the wish to die.Fortunately, the vast majority of patients contemplate suicide with someambivalence. The part of the suicidal individual that questions the suicidalsolution may lead these patients to choose life over death.

我们很容易放大自己的责任,常常会为了一些无法掌控的不幸后果而自责。然而我们终究还是得和事实妥协，精神疾病就像其他身体的病痛一样，也有疾病的末期，病人有责任作决定到底是要一死了之，还是要好好和治疗者合作，了解自己为什么想要死。还好大部分个案在考虑自杀时都带有程度不一的犹豫，这个怀疑自杀是否真能解决问题的内在之声，也许就是促使他们选择继续活下来的关键。