Threat to Autonomy 对自主权的威胁 One of the striking clinical aspects of paranoid conditions relates to the issue of autonomy. The paranoid patient lives in a state of continually threatened autonomy. He is constantly preoccupied with issues of control and domination. He may feel in an acute delusional condition that his thoughts are being controlled. Events and relationships are cast in the mold of an impending need to submit. Simple requests or directives from others become a demand for submission to the will of the other. Paranoid cooperation or obedience becomes a groveling prostration of self, in which the patient feels his weakness and impotence and hates it. Such patients cannot give in to another person or accede to the will of another without such compliance taking on the proportions of a total or near-total surrender of any sense of personal autonomy or independence. 偏执状态的一个显著临床特征与自主性有关。偏执患者生活在一种自主权不断受到威胁的状态中。他总是全神贯注于控制和支配的问题。在严重的妄想状态下他可能会感到他的思想被控制了。事件和关系被浇铸在这样一个模子里——屈服的需要，迫在眉睫。来自他人的简简单单的请求或指示变成了服从他人意愿的要求。合作或顺从变成了自己匍匐在地，卑躬屈膝，在这种情况下，患者感到自己的软弱无能，并憎恨这种状态。让偏执者向另一个人让步或同意另一个人的意愿，相当于让他完全或几乎完全放弃任何个人自主或独立的感觉。 The issue of autonomy in paranoid states has rarely been commented on, but it seems to play a central role in all of the paranoid patients I have known. Attention has been drawn to this aspect of paranoid functioning by (1965). He feels that the paranoid's most characteristic concerns are related to the issue of autonomy. He comments: 偏执狂状态下的自主权的问题很少被讨论到，但它似乎在我所认识的所有偏执患者中扮演着核心角色。Shapiro(1965)已经将注意力吸引到偏执功能的这一方面。他认为偏执者最典型的担忧与自主权问题有关。他的评论 Where, for the normal person, autonomy brings a sense of competency, pride, and self-respect, the paranoid person, instead, is either arrogant and pseudo-competent or furtive and ashamed or, perhaps most often, both(p.81). 对普通人来说，自主权来的是一种能力感、自豪感和自尊，而偏执的人则相反，他们要么傲慢自大、自命不凡，要么鬼鬼祟祟、羞愧难当，或许最常见的情况是两者兼而有之(p.81) [我感觉可以用克莱因“偏执-分裂心位”关于好乳房、坏乳房的语言来解释：好乳房保全了婴儿的全能感，而坏乳房则重重地挫伤了婴儿的全能感。如果前者会导致自命不凡，后者必然导致羞愧难当等感受。] The paranoid is continually taken up in the struggle over personal autonomy, continually confronted wiht the threat of external control and subjection. 偏执者不断地卷入个人自主权的斗争中，不断地面临着外部控制和臣服的威胁。 A mature and stable sense of autonomy can allow room for a relaxation of inner controls so as to permit a certain degree of spontaneity or even of regression for adaptive or creative purposes-regression in the service of the ego. It can also allow itself to be open to the suggestion or influence of others, or can even submit itself to their will. It is capable of recognizing and respecting the autonomy of others and allowing them their measure of self-determination and independence. It can do these things without a sense ofshame or humiliation, without any loss of self-esteem or self-respect. The autonomous person can give in without giving up, without surrendering himself to another's control and prostrating himself in humiliating abjection. 成熟和稳定的自治意识可以给放松内在控制留出空间，从而允许一定程度的自发性，甚至是为了适应或创造性目的的回归——为自我服务的回归。它也可以允许自己接受他人的建议或影响，甚至可以服从他人的意愿。它能够承认和尊重他人的自主权，并允许他们采取自决和独立的措施。它可以做这些事情而不感到羞耻或羞辱，没有任何自尊或自尊的丧失。自主的人可以屈服，但这不意味着放弃，屈服于他人的控制并让自己拜倒在屈辱的卑微中。 The paranoid can do none of these things. His sense of autonomy is rigid and fragile and unstable. He cannot tolerate giving in to external control or authority. He is acutely sensitive to any such influence, whether external or internal. The subjective world of the paranoid is marked by constant tension over the threat of giving in to external domination or to internal pressures-since both threaten the sense of autonomy. The relationship between this aspect of paranoid functioning and the issues of power and control is central to the understanding of the paranoid style. It also serves to clarify the relation between the paranoid style and the authoritarian attitude. Both are preoccupied with basic issues of autonomy. 偏执者这些他都做不到。他的自主性是刚性的、脆弱的、不稳定的。他不能容忍屈服于外部控制或权威。他对任何这样的影响都非常敏感，无论是外部的还是内部的。偏执者的主观世界，其特征是对屈服于外部控制或内部压力的威胁的持续紧张，因为这两种威胁都威胁到自主性。偏执功能的这一方面与权力和控制问题之间的关系是理解偏执风格的核心。这也有助于厘清偏执型风格与威权主义态度之间的关系。两者都专注于自治的基本问题。 The threat to autonomy can assume a variety of forms. The patient may see any request or demand as implying submission to another's will, such that to comply represents surrender of all rights of personal decision and independent judgment. The patient may feel that any authority-based directives which are not concerned with his immediate welfare and interest are an attack upon his individuality and an implicit disregard for him personally. This is equivalently a threat to his sense of self, which is placed in jeopardy by such distancing and group-based decisions of impersonal administration. Other patients may keep themselves in a state of constant vigilance, scanning the environment assiduously to detect any statement, any happening, any event, which raises the possibility of an infringement of their personal rights and autonomy as an individual. 对自治的威胁可以采取多种形式。病人可能认为任何请求或要求都意味着服从他人的意愿，因此服从就意味着放弃了个人决定和独立判断的所有权利。病人可能会觉得，任何与他眼前的福利和利益无关的以权威为基础的指示都是对他个性的攻击，是对他个人的一种隐含的蔑视。这同样是对他的自我意识的威胁，他的自我意识由于这种非个人管理的疏远和基于群体的决策而处于危险之中。另外一些病人则可能时刻保持警惕，孜孜不倦地观察周围环境，以发现任何可能侵犯其个人权利和自主权的陈述、事情和事件。 It has been my clinical experience that such patients invariably are precipitated into their paranoid thinking and guardedness by the least suggestion that someone or some institution or process has power to control,manipulate,direct,influence,or in other ways determine the course of their activity or lives. Often patients are driven to extreme alternatives of submission and self-effacement and react to the least slight or imposition on their sense of autonomy by violent rebellion and outraged counterattack. This is often difficult for persons around them to understand, since it is not always apparent that the real issue for the patient is a threat to his autonomy. It often seems that he has become intensely enraged over an apparently trivial issue. 根据我的临床经验，这类患者总是会突然陷入偏执的思维和警惕之中，只要一点点提示：有人或某个机构或流程有权力控制、操纵、指导、影响或以其他方式决定他们的活动或生活的进程。通常，病人会被驱使到与顺从，自我消隐截然不同的另一种选择，并对对他们自主权最小的轻视或强迫，回以暴力的反叛和愤怒的反击。这对他们周围的人来说往往很难理解，病人的真正的问题是对自主权的威胁，这点并不是总是很明显。他似乎常常因为一件明显微不足道的小事而怒不可遏。 The threat to autonomy to which these patients are so sensitive derives from both the inner and the outer worlds. It is of course immediately apparent that social interaction takes place in an elaborate social network, in which a wide spectrum of external influences and expectations are generated, and to which every individual in the society is expected to conform. Social structures are permeated by the functions of authority which organize and direct the activity of individuals. Such social influence is seen by the paranoid as intrusion, controlling infringement, and an invasion of self which restrict his free self-direction and deprives him of the right to self- determination, which has become essential to the preservation of his sense of self. The sources of infringement often are integrated in the paranoid delusion on the basis of their common involvement in undermining the patient's sense of autonomy. The projective distortion plays a role in bring ing suspect objects into line with the threat to autonomy. In one female patient, decompensation required hospitalization and subsequently any per son, group, or institution even remotely or possibly related to the process of hospitalization was linked in a system of projective distortions. This includ ed the doctor(or any doctor who might be involved in committal), her parents who permitted it, the hospital(or any hospital that might commitpatients), the police who brought her there, the government which allowed such proceedings, etc. The issue was that they all constituted a threat to her autonomy, since the same agents that once conspired to put her in a hospital against her will could undoubtedly do so again. The role and function of each of these respective social and personal agents were distorted by massive projections of malignant intent in her regard. 对自主权的威胁，病人对这个很敏感的，既来自于内心，也来自于外部世界。当然，很明显，社会互动发生在一个复杂的社会网络中，在这个网络中产生了广泛的外部影响和期望，社会中的每个人都被期望遵守这些影响和期望。社会结构渗透着组织和指导个人活动的权威职能。偏执者认为这种社会影响是一种入侵、控制和侵犯，它限制了他自由的自我导向，剥夺了他自我决定的权利，而自我决定对保持自我意识至关重要。侵权的来源往往是在妄想妄想的基础上，他们共同参与破坏病人的自主权的基础上整合。投射扭曲在使可疑对象与自治威胁保持一致方面起着重要作用。在一名女性患者中，失代偿需要住院治疗，随后，每一个儿子、群体或机构，甚至与住院过程有一点关系或可能有关系的，都与投射扭曲系统相联系。这包括医生(或任何可能参与交付的医生)、允许交付的父母、医院(或任何可能交付病人的医院)、把她带到那里的警察、允许进行此类程序的政府等等。问题是，他们都对她的自主权构成了威胁，因为那些曾经合谋让她违背自己意愿住进医院的特工，无疑会再次这样做。在她看来，这些各自的社会和个人代理人的作用和功能都被大量恶意的投射所扭曲。 The threat to autonomy is not merely external but derives from the patient's own inner world. It is perhaps not unreasonable to expect that the external threat to personal autonomy is intensified to the extent that the inner capacity for autonomy is compromised. The sense of autonomy rests on a complex of factors, but an important aspect of it has to do with the inner structure of the self. The sense of autonomy rests on the individual's real capacity for ego autonomy. The integration of an autonomous ego depends on a capacity for object-relatedness and on a capacity for meaningful identifications which contribute to inner structure formation in the ego. Introjects can contribute to structure formation in the ego, but only indirectly by reason of consequent identificatory processes(Meissner,1971b). As long as introjects remain in a quasi-autonomous state and operate in terms ofdrive-dependent processes, they compromise the inner autonomy of the ego. The paranoid introjects consequently put the patient under constant threat, in that his autonomy is perceived as precarious and susceptible. In relation to this threat to autonomy, his sense of personal integrity and self-esteem are endangered. The genesis of such introjects is an important part of the understanding of paranoia. 对自主权的威胁不仅来自外部，还来自患者自己的内心世界。期望外部对个人自治的威胁加剧到损害内在自治能力的程度，也许并非没有道理。自主感建立在一系列复杂的因素之上，但其中一个重要方面与自我的内在结构有关。自主感取决于个体自我自主的真正能力。自主自我的整合依赖于客体关系的能力和有意义的认同的能力，这有助于自我内部结构的形成。注入可以促进自我结构的形成，但只能通过随后的识别过程间接地起作用(Meissner,1971b)。只要注入物保持准自治状态，并以依赖驱动的过程运作，它们就会损害自我的内在自治。偏执狂的注射因此使病人处于不断的威胁之下，因为他的自主性被认为是不稳定和易受影响的。与这种对自主权的威胁有关，他的个人正直和自尊受到了威胁。这种注入的起源是理解偏执狂的一个重要部分。