Immediate History 近期历史 At the time of his breakdown, Bob was nearing the completion of his residency in oral surgery. These had not been happy years for him. At the beginning of his program, he had been intent on proving that he was the best resident ever to go through it. He was intensely competitive, took every opportunity to show up his fellow residents, and was generally critical of the shortcomings of the program, of the caliber of the teachers, and particularly of the work of his immediate superiors. His attitude won him few friends, and he felt himself to be generally disliked and socially excluded by the other residents. At the same time he wanted desperately to be accepted and liked by them. The situation was difficult and unhappy for him. 在他崩溃的时候，鲍勃即将完成他在口腔外科的住院医师培训。这几年对他来说并不快乐。在课程开始时，他一直想证明自己是有史以来最好的住院医师。他有强烈的竞争意识，利用每一个机会来羞辱他的住院医师同事，并普遍批评项目的缺点，老师的素质，特别是他的直接上级的工作。他的态度为他赢得了很少的朋友，他觉得自己普遍被其他住院医师所不喜欢，被社交排除。同时他又极度希望被他们接受和喜欢。这种情况对他来说是困难的，也是不快乐的。 His ambition and almost grandiose competitiveness also got him into difficult relationships with members of the teaching staff. He would sometimes challenge teachers in a hostile and critical manner, which tended to foster defensiveness and some antagonism. Several times his hostilely competitive attitude was pointed out to him by well-disposed teachers, but Bob resisted their interest, feeling that they were trying to put him down or shut him up. The quality of this competitiveness was reflected particularly in his relations with one of the senior staff surgeons who was generally regarded as the most distinguished of the teaching staff. Bob entered this relationship in an argumentative and challenging manner. On rounds, for example, he would challenge and criticize what the older man had said, and on several occasions gave the impression of treating the older man with casualness or disrespect. The senior man responded by putting Bob in his place. There was several public arguments and continuing conflict. The relationship deteriorated to the point that the older man refused to ever speak with Bob and finally refused to allow Bob to enter the operating room with him. 他的雄心壮志和近乎狂妄的竞争性也使他与教职员工的关系陷入困境。他有时会以敌意和批评的方式挑战教师，这往往会助长防卫和一些对立情绪。有好几次，好心的老师向他指出他的敌意竞争态度，但鲍勃拒绝了他们的关心，觉得他们是想让他失望或闭嘴。这种竞争性的品质特别反映在他与一位被普遍认为是教学人员中最杰出的高级外科医生的关系上。鲍勃以一种争论和挑战的方式进入这种关系。例如，在巡视时，他会对这位年长者的言论提出质疑和批评，有几次给人的感觉是对这位年长者的态度很随意或不尊重。老人的反应是贬低鲍勃。双方多次公开争吵，冲突不断。双方关系恶化，以至于老者拒绝与鲍勃说话，最后拒绝让鲍勃与他一起进入手术室。 Bob felt very badly about the way this relationship had developed. He wanted badly to have this distinguished teacher and surgeon recognize him and acknowledge him as knowing more than any other resident on the service. Bob himself felt that he in fact knew more than the other residents and was a more skillful surgeon than they were. He even felt that in many respects he knew as much or more than the senior men. He felt that he could learn a great deal from this particular man and wanted desperately to be acknowledged by him. He complained bitterly about his inability to communicate with this older man. He felt that he could not let him know how he really felt, and that so much of what did transpire between them was due to misunderstanding. He felt hurt, rejected and undercut by the older man's response. As we shall see, the qualities of this difficult relationship mirrored many aspects of Bob's relationship with his own father. 鲍勃对这种关系的发展方式感到非常糟糕。他很想让这位杰出的老师和外科医生认可他，承认他比其他住院医生懂得更多。鲍勃自己也觉得，事实上，他比其他住院医师知道的更多，也是一个比他们更有技巧的外科医生。他甚至觉得在很多方面他跟那些资深医生知道得一样多，甚至更多。他觉得自己可以从这个特殊的男人身上学到很多东西，并迫切希望得到他的认可。他痛苦地抱怨自己无法与这位老人沟通。他觉得自己无法让他知道自己的真实感受，他们之间发生的很多事情都是由于误解。他觉得自己被伤害了，被拒绝了，被这位老人的反应削弱了。正如我们将看到的那样，这种困难关系的特质反映了鲍勃与自己父亲关系的许多方面。 Bob had his difficulties other than personal in the residency program. From the beginning, he had admitted that becoming chief resident was his ambition. He set his sights on that goal, and regarded that position as his due, since he saw himself in highly narcissistic terms, as far superior to the other residents in knowledge and skill. A few months prior to his breakdown, the new chief resident was announced—and it was not Bob. He was bitterly disappointed, intensely critical and devaluing of the man who got the job, seeing him as inferior in skill and lacking in any real surgical capacity. Bob was particularly critical of the new chief's conservatism. He felt that the new man's surgical judgment was poor because he would never take any chances and always took the safest course. In his disappointment, Bob began to think that he was deprived of this coveted position by his superiors simply because they did not like him and wanted to get back at him. They were afraid to acknowledge that he did in fact know more than they did, and they had to keep him down because otherwise his real worth—as superior to themselves—would then have to be acknowledged. He saw the entire staff, including his fellow residents, as involved in a conspiracy to keep him in an inferior position and to prevent any acknowledgment of his ability. 鲍勃在住院医师项目中除了个人的困难外，还有其他的困难。从一开始，他就承认，成为主任住院医师是他的抱负。他把目光投向了这个目标，并认为这个职位是他应得的，因为他以高度自恋的眼光看待自己，认为自己在知识和技能上远胜于其他住院医师。在他崩溃的前几个月，新的主任住院医师被宣布——并不是鲍勃。他感到非常失望，对得到这份工作的人进行了强烈的批评和贬低，认为他技术低劣，缺乏真正的手术能力。鲍勃对新任主任的保守主义尤为批评。他觉这位新人的手术判断力很差，因为他从来不会冒任何风险，总是采取最安全的方法。在失望之余，鲍勃开始认为，他被上级剥夺了这个梦寐以求的职位，只是因为他们不喜欢他，想报复他。他们不敢承认他事实上确实比他们知道得更多，他们必须让他低调，因为否则他的真正价值——比他们自己更优秀——就必须被承认。他认为整个工作人员，包括他的同伴，都参与了一个阴谋，让他处于低下的地位，并阻止对他能力的任何承认。 Along with this disappointment, Bob was subject to increasing criticism because of the management of his cases and because of what was felt to be poor judgment. This dissatisfaction with his work came to a head in one incident. Soon after the chief resident had been appointed, Bob was operating on a child with a known bleeding disorder. Since the bleeding was greater than expected, Bob ordered a transfusion. When the chief resident saw the order for blood, he came into the operating room to investigate the reason for a transfusion. Since the operation was an elective minor procedure he told Bob to interrupt the procedure rather than give a transfusion. Bob disregarded the order and completed the procedure. Bob's response to the chief's order was that he had no "balls" and that in Bob's judgment the risk in stopping the procedure and reoperating at some later date would have been greater. Clearly, however, Bob was motivated by the wish to show up the new chief resident and to demonstrate his own superior surgical ability. He wanted to show that he could carry off surgical procedures that the chief resident didn't have the guts to attempt. 伴随着这种失望，鲍勃因为对病例的管理和被认为判断力差而受到越来越多的批评。这种对他工作的不满，在一次事件中达到了顶点。在主任医师任命后不久，鲍勃就为一个已知有出血问题的孩子做手术。由于出血量比预想的要大，鲍勃就下令输血。当主任医师看到输血的命令时，他来到手术室调查输血的原因。由于手术是一个选择性的小手术，他让鲍勃中断手术而不要输血。鲍勃无视命令，完成了手术。鲍勃对主任命令的反应是他没有"睾丸"，而且根据鲍勃的判断，停止手术并在以后重新手术的风险会更大。然而，很明显，鲍勃的动机是贬低新主任医师，并展示自己高超的手术能力。他想证明他可以完成主任医师没有胆量尝试的手术。 The upshot of this episode was that doubts were cast on his professional judgment, and he was told that the teaching staff had such doubts. He was told that his knowledge and surgical skills seemed satisfactory, but in view of the questions about his maturity of judgment, he would have to remain in the program for an additional period of time in order to allow the staff to decide about this aspect of his overall performance. Bob's disappointment and anger can be easily imagined. This development only served to reinforce his resentment and his feelings of conspiracy against himself on the part of the staff. Within a few days after receiving this announcement, the acute decompensation occurred. Behind these struggles and defensive competitiveness, we can sense Bob's injured narcissism, but also the sense of fragility and the anxious pressure for approval and accomplishment that would somehow reassure him that he was whole, that his existence was meaningful and purposeful, that he was not weak, defective and inadequate. 这一事件的结果是，人们对他的专业判断力产生了怀疑，而且他被告知，教学人员也有这种怀疑。他被告知，他的知识和手术技能似乎令人满意，但鉴于对他判断力成熟度的质疑，他必须在这个项目中多留一段时间，以便让教职员工决定他在这方面的整体表现。鲍勃的失望和愤怒可想而知。这一事态的发展只会加深他的怨恨和对工作人员对自己的阴谋的感觉。在接到这个通知后的几天内，就发生了急性失代偿。在这些挣扎和防卫性竞争的背后，我们可以感受到鲍勃受伤的自恋，也可以感受到他的脆弱感，以及渴望得到认可和成就的焦虑压力，认可和成就将在某种程度上使他确信他是完整的，他的存在是有意义和有目的的，他并不是软弱的、有缺陷的和不胜任的。