Paranoid Attitude 偏执态度 What was most characteristic of Bob's dealing with his repeated failures to achieve his narcissistic ambitions was his inability and unwillingness to accept responsibility for his own failure. His disappointments were always seen as due to circumstances, or due to the ill will and conspiratorial efforts of others against him. It became clear in this light that the paranoid attitude also served intense narcissistic needs. It served as a defense against the inner impairment of self-esteem and the devalued perception of himself. The projective aspect of this defense were clear, but Bob was consistently unable to perceive and understand not only the ways in which his projection operated, but also the ways in which he had provoked the hostile and antagonistic responses from his fellow residents—or for that matter from his most admired teachers. Even in discussing his relationships with his parents—during the course of his treatment—he was unable to grasp the ways in which he elicited and prolonged the hostility and dominating attacks of his father. The need to cling to his narcissistic expectations and to repress his destructive wishes was so intense that he was literally blinded to this aspect of his behavior. He persisted in wishing that his parents would treat him differently, saying that things would be better for him if only they would stop what they were doing, blaming them for trying to keep him a child, for not letting him sleep, etc. 鲍勃在处理自己屡次失败而未能实现自恋的野心时，最典型的特点是他无力也不愿意为自己的失败承担责任。他的失望总是被认为是环境造成的，或者是他人的恶意和对他的阴谋。由此可见，偏执态度也满足了强烈的自恋需求。它是对自尊的内在损害和自我贬低的价值的一种防御。这种防御的投射方面是显而易见的，但鲍勃始终无法察觉和理解他的投射是如何运作的，也无法察觉和理解他是如何激起他的住院医生同伴们的敌意和对抗反应的——或者说，他最钦佩的老师们是如何反应的。即使在治疗过程中，在讨论他与父母的关系时，他也无法理解他是如何引起并延长了父亲的敌意和主要攻击。他需要紧紧抓住他自恋的期望，压抑他破坏性的愿望，这种需求是如此强烈，以至于他真的对自己行为的这一方面盲目了。他坚持希望他的父母能对他另眼相看，说只要他们停止现在的所作所为，事情对他就会好一些。他还责怪父母试图让他继续做个孩子，不让他睡觉等等。 As the course of Bob's treatment progressed, the manic defenses and the paranoid attitude became less and less available to him. The result was the intense and prolonged phase of neurasthenic depression. It was this depression that he had struggled against, and had tried in so many ways to hide from, throughout the course of his life. It was not merely a reversion of his murderous aggression against himself; although the intensity of his wish reached suicidal proportions and the depression did serve defense interests, it was in part dealing with his murderous rage against both parents. But it also formed at a deeper level an integral part of his inner self-representation and self-perception. It was the inner introject of weakness and destructiveness that he was at last permitting to come to consciousness. 随着鲍勃治疗过程的进展，他的狂躁防御和偏执态度变得越来越少。结果是神经衰弱性抑郁的加强和延长。在他的一生中，他一直在与这种抑郁作斗争，并试图用各种方式来逃避。这不仅是他对自己谋杀性攻击的反转；尽管他的愿望达到了自杀的程度，抑郁也确实为防御服务，但这在一定程度上是为了应对他对父母的谋杀狂怒。但它也在更深层次上形成了他内在自体表征和自体感知的一个组成部分。他终于允许自己意识到软弱和破坏性的内部内摄物。 Thus the paralysis of will and intention that overcame him as he confronted the final step of committing himself to a career was multiply determined. From one side it was induced by the loosening of his defensive structure as a result of the therapeutic process. From another side, however, the commitment to the career of his father's choosing represented the final compliance—a submission of himself that was loaded with intense ambivalence. His wish to please his father and gain his approval was countered and balanced by his intense resentment and murderous rage toward him. Accepting a career in oral surgery, once and for all, carried with it the implications of both the final gesture to gain his father's acceptance and approval, as well as a final surrender of the last vestige of his own autonomy. 因此，当他面临投身一项事业的最后一步时，意志和意图的麻痹征服了他，这是多重决定的。从另一方面来看，这是由于治疗过程中他的防御结构松动引起的。然而，从另一个角度来看，对父亲选择的事业的投入代表了最终的顺从——他自己的顺从充满了强烈的矛盾心理。他想要取悦他的父亲，获得他的认可，但他对父亲的强烈怨恨和要命愤怒却使他的愿望遭到了反击和平衡。一劳永逸地接受了口腔外科的职业，这意味着他做出了获得父亲接受和认可的最后姿态，也意味着他最终放弃了自己最后一丝自主权。 What is underlined in this case in a unique way is that the pattern of Bob's illness and life experience form a meaningful whole. The entire complex of events and influences including his early life experiences, the course of his life and experience, the inner organization of needs and defenses, the patterning of family structure and influences, as well as the events surrounding his acute decompensation—and even the content of his delusional system—form an integral and understandable whole. The key and central defects in Bob's personality as they emerged in the course of his history and in the working out of his therapy focused around the issues of self-esteem and autonomy. The capacity for trust was also severely impaired. These issues became the central points of concentration in his treatment. We have seen the paradoxical ways in which these issues displayed themselves in the treatment relationship. Perhaps the most difficult issue was that of autonomy. The issues of trust and autonomy were intermingled in questions of health and sickness in ambiguous and confusing ways. 在这个案例中以一种独特的方式强调的是，鲍勃的疾病模式和生活经历形成了一个有意义的整体。整个复杂的事件和影响包括他的早期生活经历，他的生活和经历的过程，需求和防御的内部组织，家庭结构和影响的模式，以及围绕着他的急性失代偿的事件——甚至他的妄想系统的内容——形成了一个完整的和可理解的整体。在鲍勃的成长过程中和治疗过程中出现的人格中最关键和最核心的缺陷，集中在自尊和自主的问题上。信任能力也严重受损。这些问题成为他治疗的重点。我们已经看到了这些问题在治疗关系中表现出来的矛盾方式。也许最困难的问题是自主权问题。信任和自主问题以含糊不清，令人困惑的方式与健康和疾病问题交织在一起。 The course of therapeutic improvement had to lie in the direction of surrendering the intense sense of narcissistic expectation and omnipotence and in building the basic underpinnings of functional personality—trust and autonomy. Whether Bob will ever be able to accomplish this remains an open—and as yet unanswered—question. 治疗改善的过程必须朝着放弃强烈的自恋期望和全能感，并建立起功能性人格的基本基础——信任和自主——的方向发展。鲍勃是否能够完成这一点仍然是一个开放——并且是尚未回答的——问题。