Precipitants 诱因 The circumstances of Ellen's decompensation and admission to the hospital were of importance, particularly in that they give us the flavor of her illness and begin to point us in the direction of seeing some of the pathogenic influences in her history. Since her previous discharge from the hospital, Ellen had been living at home with her mother and was seeing her therapist on a weekly basis. During this period, she managed rather well. She was able to function relatively well and had completed a nursing refresher course at one of the local hospitals. She did quite well in this course and was able to get a nursing position at a large city hospital. However, about three weeks prior to her admission, her mother suffered a heart attack. The mother had had several such attacks in preceding years, and a fresh attack was a source of considerable threat to Ellen, as we shall see. 埃伦的失代偿和住院的情况是很重要的，尤其是因为它们使我们了解了她的病情，并开始向我们指出她的历史中一些致病的影响。自从上次出院后，埃伦一直和母亲住在家里，每周都去看心理医生。在这段时间里，她做得相当好。她的功能相对较好，并在当地一家医院完成了护理进修课程。她在这门课上成绩很好，能够在一家大城市的医院谋得一个护理职位。然而，在她入院前大约三周，她的母亲突发心脏病。母亲在过去几年里也受过几次这样的袭击，我们以后会看到，一次新的袭击对爱伦构成了相当大的威胁。 About the same time, her therapist brought up the subject of terminating their relationship. The circumstances had to do with his service-connected obligations which required that he reduce his patient load. Ellen was one of the patients to be reduced. This was a great disappointment to her, and stirred a considerable amount of anger and resentment. She felt that the doctor was just dumping her and that she was being pushed around from one doctor to another without any consideration of her wishes or preferences. She resented being shoved around—as she put it—and treated like any other patient. And indeed, there was some truth in this. She was being treated through the facilities of a state hospital, in which patient care is subject to the shifting complexities of resident turnover and the shifting of personnel from service to service. She in fact, had little to say about who her doctor was to be or how long she could remain in treatment with any one of them. Breaking off treatment with her present doctor, with whom she had been in therapy for nearly a year and a half, was a severe blow to her. She was obviously affected by the loss of the relationship. 大约在同一时间，她的治疗师提出了结束他们关系的话题。这种情况与他与服务有关的义务有关，这些义务要求他减少病人数量。埃伦是其中一个要裁掉的病人。这使她大失所望，激起了相当多的愤怒和怨恨。她觉得医生只是在抛弃她，她被从一个医生推到另一个医生，而没有考虑她的愿望或偏好。正如她所说，她痛恨被人随意摆布，并像对待其他病人一样对待。事实上，这是有一定道理的。她是通过一所州立医院的设施接受治疗的，在这家医院里，病人的护理受到住院人员流动和人员从一个服务机构转到另一个服务机构的复杂性的影响。事实上，对于她的医生是谁，或者她能和他们中的任何一个一起治疗多久，她几乎没有话语权。中断与她现在的医生的治疗对她是一个沉重的打击，她跟这个医生已经治疗了将近一年半了。她显然受到这段关系破裂的影响。 In addition, Ellen had started to work about a week before her decompensation. She was apparently in the incipient stage of decompensation when she started the job and she had difficulty from the very beginning. She felt increasingly tense and anxious, became easily enraged, and her angry outbursts became more frequent. Her paranoid ideas became more prominent and intense and she became preoccupied with highly paranoid ideas about blacks and sexuality. She found it increasingly difficult to perform her duties at the hospital and became increasingly delusional. She finally reached the point where she was attending a black patient who was on intravenous fluids. She thought that this patient had wanted to assault her sexually, had pulled the needle out of his arm and had tried to stab her with it. She fled in terror from the hospital. She tried then to stay at home, but became increasingly disruptive and difficult to control. 此外，埃伦在失代偿前大约一个星期就开始治疗了。当她开始这项治疗时，她显然正处于失代偿的初期阶段，从一开始就有困难。她感到越来越紧张和焦虑，很容易被激怒，她的愤怒爆发变得更加频繁。她偏执的想法变得更加突出和强烈，她开始沉浸在对黑人和性的高度偏执想法中。她发现自己越来越难以在医院履行职责，并变得越来越妄想。最后，她来到了一位正在接受静脉输液治疗的黑人病人身边。她认为这个病人想要性侵犯她，并把针从手臂上拔出，并试图用针刺伤她。她惊恐地从医院逃走了。她当时试图呆在家里，但变得越来越爱捣乱，很难控制。 The string of precipitants was revealing. The first was the mother's life-threatening heart attack. Ellen's relationship with her mother was difficult and highly ambivalent—as her history will suggest. She was strongly dependent on her mother, but her dependence was mixed with intense hostility. Their relationship was conflictual and strongly argumentative. Ellen resented her mother and hated her. Her murderous wishes were a constant feature of her relationship. The mother's attack put Ellen under severe stress and threat from at least two sides. She was confronted by tremendous guilt and remorse in relation to her murderous wishes against her mother in the face of mother's imminent death. She was also confronted by the impending loss of the object on which she was so intensely, if ambivalently, dependent. It should be noted that the mother exploited this aspect of Ellen's pathology. She played the role of the helpless cardiac cripple who was being tormented and brought to the brink of death by her daughter's anger and argumentativeness. Any of us, who had the opportunity to observe some of the interaction between mother and daughter, were impressed by the intense hatred of Ellen's mother for her—a hatred that was masked under a facade of self-sacrifice and self-martyrdom for the sake of her poor child. 一连串的沉淀显现出来。第一个是母亲危及生命的心脏病发作。埃伦和她母亲的关系是艰难的，充满了矛盾——正如她的历史所表明的那样。她非常依赖母亲，但她的依赖中夹杂着强烈的敌意。他们的关系充满了冲突和激烈的争论。埃伦憎恨她的母亲，憎恨她。她的谋杀愿望是她这段关系的一贯特点。母亲的攻击使埃伦承受着来自至少两方面的巨大压力和威胁。她面临着巨大的内疚和悔恨，因为她在母亲即将死亡之际，对母亲怀有谋杀愿望。她还面临着客体迫在眉睫的失去，她是如此强烈地，矛盾地，依赖着这个客体[客体指她的母亲]。应该指出的是，母亲利用了埃伦的这方面的病理。她扮演的角色是一个无助的心脏残障者，由于女儿的愤怒和争论，她被折磨到了死亡的边缘。我们中任何一个有机会观察母亲和女儿之间互动的人，都对埃伦母亲对她的强烈仇恨留下了深刻的印象——这种仇恨被为了她可怜的孩子而自我牺牲的表象所掩盖。 The conjunction of the termination of her treatment with these events was a severe blow for Ellen. It served to reinforce her feelings of worthlessness, of being unwanted and rejected, of being treated as second-rate and as not counting for much. Her relationship with the therapist had been tempestuous, ambivalent, and difficult—as we might expect of any relationship in which Ellen was involved. Much of it was due to her need to test whether the therapist was really concerned for her welfare, whether he cared at all about her, whether she counted for him—and her doubts and fears were confirmed by the decision to terminate. The circumstances were indeed unfortunate, if unavoidable. The one prop that had enabled her to function in a healthier manner was torn out from under her. Her disappointment was intense, and her feelings of inner worthlessness and shame and her corresponding need for her paranoid defenses, were intensified. The stress of returning to nursing and the implicit challenge to her self-esteem only served as the appropriate setting in which her paranoid decompensation could play itself out. How did this relatively attractive young woman come to this state of incapacitating rage? 她的治疗终止与这些事件同时发生，对爱伦是一个沉重的打击。这加深了她的感觉，觉得自己毫无价值，觉得自己不受欢迎、被拒绝，觉得自己被当作二流人物，觉得自己无足轻重。她和治疗师的关系一直是狂暴的、矛盾的、困难的——正如我们可以预料到的任何涉及到埃伦的关系。这在很大程度上是因为她需要测试治疗师是否真的关心她的幸福，他是否真的关心她，她是否对他来说算什么——她的怀疑和恐惧被终止的决定证实了[被治疗师决定终止关系的决定证实了]。如果无法避免，情况确实是不幸的。唯一能使她以更健康的方式运转的支柱被从她的身下拔了出来。她的失望是强烈的，她内心的无价值感和羞耻感，以及相应的对偏执防御的需要，都在加剧。重返护士岗位的压力和对她自尊的含蓄挑战，只是她偏执的失代偿能力得以发挥作用的适当条件。这个相对有吸引力的年轻女子是如何变得如此愤怒的?