Early Treatment 早期治疗 Clare was hospitalized at this point for the first time. She remained an inpatient for about four months, and during this time entered on a very meaningful and intensive course on psychotherapy. In retrospect,I would tend to regard the excellent progress she made therapeutically in later years as in part due to some of the solid work that was done during this first experience in treatment. At this time, however, Clare presented a very ominous picture. Some felt that she was a case of anorexia nervosa—probably associated with a schizophrenic process. Others felt that her pathology was deep and long-standing. She was repeatedly labeled in her hospital records from this period as suffering from an acute or possibly chronic undifferentiated schizophrenic reaction. Projective test data from this period seemed consistent with this overall impression. Her Rorschach contained many gory anatomical responses which were inappropriate and persevered from card to card. The focus was on pelvic and sexual anatomy. This picture was consistent with psychosis and severe conflict over sexuality. Moreover there was little to suggest any resources for strength or flexibility. Her capacity to tolerate emotional involvement was minimal. The theme of suicide following emotional loss was a prominent aspect of her TAT stories. The overall impression was that of an undifferentiated schizo-affective psychosis in a chronically fragile personality structure. 克莱尔此时第一次住院。她在医院里住了大约四个月，在这段时间里，她参加了一个非常有意义的密集的心理治疗课程。回想起来，我倾向于认为，她在治疗方面取得的卓越进步，在一定程度上要归功于第一次接受治疗期间所做的一些扎实工作。然而，在这个时候，克莱尔呈现了一幅不祥的景象。有些人认为她是神经性厌食症——可能与精神分裂症有关。其他人则认为她的病状根深蒂固。在这段时间的医院记录中，她多次被贴上急性或慢性未分化精神分裂症的标签。这一时期的投射测试数据似乎与这一总体印象相符。她的罗夏墨迹[给你一幅墨迹图，让你想象图上画的是啥，可以反映测试者的内心]包含了许多血淋漓的解剖学反应，这些反应是不恰当的，而且是张张卡片如此。重点是骨盆和性解剖学[指罗夏墨迹测试联想到的解剖结构都与盆骨和生殖器有关]。这幅图与精神病和性上严重的冲突是一致的。此外，测试显示几乎没有任何资源可以提供力量或灵活性。她容忍情感介入的能力微乎其微。情感丧失后自杀的主题是她的“以牙还牙”故事的一个突出方面。总的印象是，在长期脆弱的人格结构中，存在着一种未分化的分裂情感型精神病。 The treatment was difficult and arduous. Clare was extremely suspicious, guarded, cautious, and unwilling to enter into any close or emotionally involved relationship. Despite her caution, defensiveness, and resistance, Clare developed an intense and a generally positive transference for her doctor. She struggled against her feelings toward him. She would not admit to any positive feelings and could not tolerate any hostile or angry feelings. She refused to cry—even though she often felt like it—because that would be admitting that she was weak and helpless and that she needed his help. The work of the treatment was progressing nonetheless. She was able to finish her nursing training and performed academically on a high plane. She became much less depressed and during this entire period of two years there were no further episodes of cutting or other self-destructive pieces of acting out. 治疗是困难和艰巨的。克莱尔非常多疑，警惕，谨慎，不愿意进入任何亲密或情感上的关系。尽管她很谨慎、有戒心，也很抗拒，克莱尔还是对她的医生产生了一种强烈而积极的移情。她竭力克制自己对他的感情。她不承认任何积极的情绪，也不能容忍任何敌对或愤怒的情绪。尽管她经常想哭，但她拒绝哭，因为哭就等于承认自己软弱无助，需要他的帮助。尽管如此，治疗工作仍在进展。她能够完成她的护理培训，并在学业上表现出色。她变得不那么抑郁了，在这整整两年的时间里，她再也没有剪掉或其他自我毁灭的行为片段。 The crisis, however, came with the induction into the armed services of her doctor. This was a relatively precipitous event and somewhat unexpected on his part. For Clare it loomed as a sudden and major catastrophe. She had struggled for nearly two years with the issue of trust. At a point where she felt finally that she could begin to trust her doctor, she was losing him. At that point she began to realize how much the relationship meant toher and how much she depended on it. She felt desperate. Her sensitivity to loss and the feelings of rejection were intensified. She began to feel that he really did care for her—and even as she realized that, she had to lose him. She felt desperate and helpless, and unable to tolerate the rage that she felt at being abandoned. In their final meeting she cried for the first time. 然而，她的医生被调入军队，危机随之而来。这是一个相对紧急的事件，对他来说有点出乎意料。对克莱尔来说，这似乎是一场突如其来的大灾难。她在信任问题上挣扎了近两年。当她终于开始相信她的医生时，她失去了他。就在那时，她开始意识到这段关系对她有多么重要，她对它有多么依赖。她感到绝望。她对失去和被拒绝的感觉更加敏感。她开始觉得他真的很关心她——即使她意识到，她必须失去他。她感到绝望和无助，无法忍受被遗弃时的愤怒。在他们最后一次见面时，她第一次哭了。 In the face of this loss she decompensated, became severely self-destructive, cut herself again, and ingested a lethal dose of drugs. She was again hospitalized but had sufficiently recompensated within a few weeks to be discharged. Attempts were made to get her into therapy with another doctor, but the effort proved abortive. 面对这样的损失，她失去了自我，变得严重的自我毁灭，再次割伤自己，并服用了致命剂量的药物。她再次住院，但在几周内得到了足够的补偿，出院了。人们曾试图让她接受另一名医生的治疗，但最终以失败告终。 The subsequent months were rocky ones. She was seen periodically at the emergency ward, usually for lacerations. On each occasion she would become acutely depressed and cut herself. This was usually in the context of a disappointment or of her rage at someone on whom she had become dependent and who had let her down. These episodes were marked by a severe tension and anxiety along with her depression, and experiences of depersonalization which were quite frightening to her. The cutting served as a release mechanism for the pent-up rage, and also served to reassure her of the fact that she was real and alive. It was a self-destructive mechanism forcontrolling and dealing with the rage that she felt within her and could not express in any other way. Her functioning throughout this period was adequate—she was able to work steadily—but her interpersonal relationships were sparse and very poor. Her reality testing remained intact and the general diagnostic impression of her doctors at this stage was that of a borderline personality. The paranoid elements in these repeated episodes went undetected, and the elements of thought disorder and autistic behavior that had been seen previously were no longer part of the clinical picture. Attempts were made all along this course to get her back into treatment, butthey were resisted. She continued to live in this way, living an unstable and precarious existence until her final hospitalization. 接下来的几个月充满坎坷。她定期被送往急症室，通常是由于划伤。每次她都会极度沮丧，割伤自己。这通常是在她对某个人感到失望或愤怒的情况下发生的，因为她已经依赖这个人，而这个人让她失望了。这些事件的特点是严重的紧张和焦虑，伴随着她的抑郁症，和人格解体的体验，这对她来说非常可怕。这种切割是一种释放被压抑的愤怒的机制，也让她确信自己是真实存在的。这是一种自我毁灭的机制，用来控制和处理她内心无法用其他任何方式表达的愤怒。在这段时间里，她的工作能力是足够的——她能够稳定地工作——但是她的人际关系很差。她的现实检验能力保持完好，她的医生在这个阶段对她的总体诊断印象是边缘型人格。这些反复发作的偏执因素没有被发现，之前被发现的思维紊乱和自闭症行为的因素也不再是临床表现的一部分。在整个治疗过程中，人们一直试图让她重新接受治疗，但都遭到了抵制。她继续以这种方式生活，过着不稳定和不确定的生活，直到她最后一次住院。 The story thus far gives us a bizarre and tragic picture of a young woman of extraordinary gifts and intellectual abilities who was caught up in a process that had led to increasing isolation, withdrawal, and a pattern of self-destructive behavior that could only end in suicide unless it were somehow reversed. It is important to note that when she came to my attention at the point of her last hospitalization—despite the bizarre and quite disturbed quality of her behavior—there had been a definite shift in the structure of her pathology. By the time of my first contacts with her, one could not justify any diagnostic label that would indicate anything more pernicious than that of borderline personality. She was able to maintain areas of adequate ego-functioning in her life on a fairly steady basis. Her reality testing was intact. There was no indication of thought disorder, and the delusional elements of her paranoia were well controlled and concealed. The picture she presented, therefore, was an encouraging one, since it implied that she was capable of benefiting from treatment if the treatment process could meet and respond to the growth potential that was in her. 迄今为止的故事给了我们一个奇异并悲惨的年轻女人的印象，她具有卓越的天赋和智力，她被卷入到这样一个过程，在这个过程中，她变得越来越隔离、退缩，并且卷入了一种自我毁灭的行为模式,只能以自杀结束,除非它在某种程度上扭转。值得注意的是，在她最后一次住院时，我注意到了她——尽管她的行为古怪且相当令人不安——她的病理结构确实发生了变化。当我第一次与她接触时，没有人能证明任何比边缘型人格更有害的诊断标签。她能够在相当稳定的基础上维持生活中充分的自我运作。她的现实检验能力是完好的。没有迹象表明她的思维紊乱，她偏执的妄想成分被很好地控制和掩盖了。因此，她所呈现的情况是令人鼓舞的，因为这意味着如果治疗过程能够满足并对她体内的成长潜力作出反应，她就能够从治疗中获益。 Before we begin to look at her therapeutic development, we need to look back in time at the original course of development. In order to begin to grasp some of the elements that contributed to her more current plight, we need to consider her early life experience and how it was patterned and influenced by the family environment in which she grew up. What was the family background out of which this tragically disturbed yet fascinating young woman emerged? 在我们开始研究她的治疗发展之前，我们需要回顾一下她最初的发展过程。为了开始掌握导致她现在的困境的一些因素，我们需要考虑她早期的生活经历，以及它是如何被她成长的家庭环境所塑造和影响的。这个不幸而又迷人的年轻女子的家庭背景是什么呢?