Current Illness 当前疾病 It must be said that the beginnings of the treatment experience with Miss C. were not particularly optimistic. She was transferred to our hospital from a local general hospital where she had been treated for a near-fatal ingestion and for multiple lacerations. The acute episode had been building for several weeks. She had been feeling increasingly depressed in the weeks preceding this, and had taken some LSD. The trip was rather euphoric, but as soon as she came off it she ingested a large enough amount of medication to require emergency care at a hospital. During the following days there were several more ingestions. Finally, she ingested an excess amount of bar-biturates and was found by a boyfriend sitting on the toilet in her apartment, naked, drowsy, and trying to lacerate her abdomen with a razor blade. 必须指出的是，C小姐治疗经历的开始并不特别乐观。她从当地一家综合医院转院到我们医院，在那里，她因一次几乎致命的摄食[指嗑药]和多处划伤而接受治疗。急性发作已经持续了几个星期。在此之前的几个星期里，她感到越来越沮丧，服用了一些迷幻药。这次旅行[指吃了迷幻药后的感受]相当愉快，但她一结束就摄入了足够多的药物，需要在医院接受紧急治疗。在接下来的几天里，又吃了几口。最后，她摄入了过量的巴比妥酸盐，被她的一个男友发现，当时她赤身裸体，昏昏欲睡，正试图用剃须刀片割伤腹部。 The series of events that required hospitalization had been building up gradually. The patient was an attractive young woman in her mid-twenties. Her life during the preceding few months had presented a peculiar study in contrasts. She was living in a dirty and run-down apartment with several other "hip" friends who were a few years younger than herself and who were a very sick and marginally adjusted group. There were two males, both homosexual, and two other girls, one of whom was schizophrenic. Clare was the only one in the group who was making money. The rest of the group was much involved in the drug scene, with a good deal of pot-smoking, LSD, and some dabbling in narcotics. Clare resented the fact that these people depended on her to support them and keep the apartment livable. She felt that she was being taken advantage of, but felt unable to acknowledge or effectively deal with her anger. She later described her friends as "creeps, schizophrenics, and weirdos." In typical style she gradually and more intensely began to turn her destructive impulses against herself. The self-laceration was her preferred channel for expressing this self-destructive bent. When she was first seen, there were multiple lacerations over her lower abdomen, groin, thighs, and feet. 需要住院治疗的一系列事件逐渐增多。病人是一位二十多岁的漂亮年轻女子。在过去的几个月里，她的生活呈现出一种奇特的对比研究。她和几个比她小几岁的“时髦”朋友住在一间又脏又破的公寓里，他们是一群病得很重、勉强适应了环境的人。有两个男人，都是同性恋，还有两个女孩，其中一个患有精神分裂症。克莱尔是这群人中唯一一个赚钱的人。小组的其他成员则与毒品有很大的关系，他们大量吸食大麻、迷幻药，有些还涉猎麻醉品。克莱尔对这些人依赖她来养活他们、维持公寓的宜居感到不满。她觉得自己被利用了，但无法承认或有效地处理自己的愤怒。她后来形容她的朋友们是“卑鄙小人、精神分裂症患者和怪人”。在典型的风格，她逐渐和更强烈地开始把她的破坏性冲动转向自己。自残是她表达这种自我毁灭倾向的首选渠道。当她第一次被发现时，她的下腹、腹股沟、大腿和脚上有多处划伤。 The striking contrast in her life pattern was presented by her functioning as a nurse. She was an R.N., and was working at the time in a very responsible and demanding position in the intensive care unit of a large general hospital. Her work there was outstandingly efficient and effective. She would set out each morning dressed in her crisp white uniform—adopting the role of the intelligent, capable, efficient, and hardworking nurse. When she returned to the apartment in the evening, the white uniform would come off, and in its place she would don dirty and sloppy dungarees. She would then immerse herself in the life-style and level of functioning that obtained in the rest of the group living with her. She felt as though this latter form of behavior represented her real self, and that the efficient nurse was a facade that she could put on to impress people and to deceive them into thinking she was something that she really was not. 她作为护士的工作使她的生活方式形成了鲜明的对比。她当时是个注册护士，在一家大型综合医院的重症监护室一个非常非常负责任、要求很高的岗位上工作。她在那里的工作非常有效率。每天早上，她都会穿上洁白的制服——扮演一个聪明、能干、高效、勤奋的护士。晚上回到公寓时，她会脱掉白色制服，换上又脏又邋遢的工装裤。然后，她会让自己沉浸在和她一起生活的其他人所获得的生活方式和功能水平中。她觉得后一种行为方式似乎代表了她真实的自我，而高效的护士只是一种假象，她可以装出一副给人留下深刻印象的样子，并欺骗人们，让他们以为她是某种她实际上不是的人。 While her work in the ICU was of high caliber, it took its toll on her. The ICU was a place where death was never far away. A high percentage of the patients she cared for died. If they did not die, they would get better and then be transferred out of the ICU back to the medical or surgical floors. One way or another people were always leaving. This situation was particularly stressful for Clare, for reasons that we shall see. She tried to keep her relationships in the ICU impersonal and professional. She kept herself distant from colleagues who worked with her. She tried to isolate herselfemotionally from the patients. She became increasingly depressed. Also, shebegan to have disturbing and frightening dreams. She dreamt of people dying and of dead bodies lying beside her in the bed. She would awaken frightened and terribly anxious. 虽然她在重症监护室的工作是高水平的，但她付出了代价。重症监护室是一个死亡从未远离的地方。她照顾的病人中有很大一部分都死了。如果他们没有死亡，他们会好起来，然后被转移出ICU回到医疗或外科楼层。人们总是这样或那样地离开。这种情况对克莱尔来说特别有压力，原因我们以后会看到。她试图让自己在ICU里的人际关系保持客观和专业。她与与她一起工作的同事保持距离。她试图使自己在感情上与病人隔绝。她变得越来越沮丧。同时，她开始做令人不安和恐惧的梦。她梦见人们死去，尸体躺在她身边的床上。她会惊恐不安地醒来。 It should be noted at the beginning that the paranoid element in this case does not form a striking or predominant aspect of her pathology. It was an aspect of her illness that would erupt from time to time in situations of great stress and anxiety. It remained for the most part an element in the central core of her illness. It was a long time in the course of the development of a therapeutic relationship before she was able to tell me about her ideas of reference, her paranoid fears, persecutory anxieties—fears that people wanted to kill her or hurt her. The content of these paranoid fears sometimes seemed to reach delusional intensity, but most of the time she kept them under control and under wraps. However, they formed a central element in her pathology which she was constantly dealing with and which often motivated her behavior. It accounted in a primary way for her style of relating to other people and for her difficulties in establishing meaningful relationships. Her entire demeanor was permeated by a distrustfulness, an abiding suspiciousness, and an expectation of hurt or destruction. Ideas of reference and suspiciousness—as it turned out—were a constant feature of her experience.I came to know of these inner thoughts and feelings only through the course of several years of therapeutic contact. It was a hidden aspect of her experience that she kept concealed from even her closest friends and contacts. She had written about them to her former therapist: 应该在一开始就注意到，在这个病例中偏执的因素并不构成她的病理的一个显著或主要方面。这是她疾病的一个方面，在巨大的压力和焦虑的情况下会时不时地爆发。这在很大程度上仍然是她疾病的核心因素。在一段治疗关系的发展过程中，她花了很长时间才能够告诉我她的援引观念，她偏执的恐惧，迫害性焦虑——害怕人们想要杀了她或伤害她。这些偏执恐惧的内容有时似乎达到了妄想的程度，但大多数时候，她都把它们控制在自己的控制之下。然而，它们在她的病理中形成了一个核心因素，她一直在应对，并经常激发她的行为。这在很大程度上解释了她与他人交往的方式，以及她在建立有意义的人际关系方面的困难。她的整个举止都充满了不信任，一种挥之不去的怀疑，以及对伤害或毁灭的期待。事实证明，援引和怀疑的观念是她经历的一个永恒的特征。只有经过几年的治疗接触，我才了解到这些内心的想法和感受。这是她经历的一个隐藏的方面，她甚至对她最亲密的朋友和熟人都隐瞒了。她曾给她以前的心理医生写过关于这些的信: Now I see that those feelings are returning after a year of successfully squashing them, and after many years of trying to squash them. They brought on that siege of cutting when.... And I see them, since then, in tentative fantasies which I quickly push back into the cellar and slam the trapdoor over. They are biding quite quietly, waiting till someone arrives and my mental back is turned so that they may leap out of the black cellar and fasten tight on the person. Then I'll be forced to deal with them. 现在我看到，在成功地压制了一年之后，在多年试图压制它们之后，这些感觉又回来了。他们在…从那以后，我在幻想中看到了他们，我迅速把他们推回地窖，砰的一声关上活板门。他们静悄悄地等待着，等着有人来，等着我回过神来，好让他们跳出黑洞洞的地窖，紧紧地抓住那个人。那我就不得不和它们打交道了。 From our present perspective, Clare's words describe what we can recognize as expressions of the malignant introjects which constituted her inner world. 从我们现在的角度来看，克莱尔的话描述了构成她内心世界的那些恶毒的内摄物。