精神分析治疗的过程

null the initial interview OF PSA the initial interview OF PSA武汉中德心理医院 李孟潮nullBefore the first encounter, processes of transference, countertransference, and resistance have been set in motion. nullFirst, transference,Countertransference, and resistance begin before the first encounter between patient and analyst. Second, the patient's hopes also start to affect his dream thinking before the initial interview.nullinitial interview as the first opportunity for the psychoanalytic method to be adapted to the individual patient. The first encounters carry a heavy burden of responsibility. The information which must be gained in just a few meetings will be incomplete and unreliable. 初始访谈主要任务——评估初始访谈主要任务——评估1一般信息：姓名、地址、住所、电话、紧急情况下可联系的另一个人的名字、年龄、性别、文化、民族、语言、婚姻、职业 2外观：身高、体重、衣着、修饰、举止 3主诉 null4现病史：症状初次发生的时间，同时伴随的事件、发生的频率、发生症状时的想法、感受、行为是什么、何种情况下最容易发生（缓解），有什么事件促进问题发生、对工作和生活有什么影响、以前如何解决、结果如何、本次如何来就诊5既往史——精神病史和心理治疗史5既往史——精神病史和心理治疗史治疗类型、治疗疗程、治疗者、治疗场所、当时结果、为何结束治疗。 住院经历、时间、地点、药物（剂型、剂量）、药物服用情况 6既往史——既往医疗史6既往史——既往医疗史出生情况——顺产、难产？是否有宫内窘迫、窒息？ 童年发育情况、哺乳期、分床时间 重大疾病史、手术史、过敏史 7健康史7健康史目前与健康有关的疾病、所接受的治疗 上一次体检结果 家族中重大健康问题 目前睡眠、饮食状况 典型日常饮食 锻炼情况 8成长史8成长史现在生活状况、居住条件、职业和经济状况 与他人关系 爱好 信仰 早期回忆早期回忆最早记忆 0-6岁重大记忆 6-13岁 13-21岁 21-30岁 30岁以后 9家族、婚姻、性9家族、婚姻、性家庭人口、年龄、职业 父母：母亲奖励和惩罚的方式、父亲。是否受到虐待；与母（父）亲相处是典型活动、父母关系 兄弟姐妹：排行、那一个和咨询者最相似、哪一个最不相似？那个最受宠，哪个最不受宠，哪个相处最融洽，哪个最不融洽。 null两系三代内精神病史 恋爱史、婚姻史，现在与伴侣的关系 孩子，年龄、关系 其他经常交往者 null第一次性经历 现在性生活 手淫 性交情况 对性的态度 女性：月经史 与家庭成员性接触、性虐待 其他评估其他评估心理测验 器械检查 各种疗法的不同侧重方面 精神科问诊 亚文化因素 总结评估（诊断、治疗关系（同盟、移情-反移情）、防御、阻抗、治疗假设） 治疗（设置、方法、预后、疗程） trial interpretationstrial interpretationsThe patient reacts to trial interpretations, since for obvious reasons this may provide useful pointers to his capacity for insight and awareness of conflicts. nullEven more important is the experience that patients' reactions to trial interpretations and to other special tools of psychoanalytic technique depend on a multitude of determinants, for example timing. Brief history1 :FreudBrief history1 :FreudFreud's diagnostic explorations served to exclude somatic illness or psychosis. Freud did not take a detailed history until the first phase of treatment; his preliminary interview was brief, as can be seen in the case of the Rat Man (1909d, p. 158). Bh:2试验分析——初始访谈的前身Bh:2试验分析——初始访谈的前身The breaking off of large number of analyses after only a short time can be explained. In most of these cases, the patients' accessibility to analysis was doubtful from the outset but they nevertheless underwent a "trial analysis," at the end of which the analyst had to recommend termination. (Fenichel 1930, p. 14) nullIt is plain why the trial analysis was dropped; the rejection at the end can be very painful for the patient if he is simply branded "unsuitable for psychoanalysis" and not given any suggestions as to alternative treatment. nullOf course, dropping the trial analysis did not solve the problem, but just shifted it to the initial interview. 发展发展In the course of the 1950s, numerous different psychodynamically oriented interview strategies were developed by psychoanalysts working within dynamic psychiatry. 70‘s70‘sKernberg's "structural interview" (1977, 1981) is a good example of the second generation of psychoanalytically oriented psychiatric initial interviews following in the tradition of the dynamic interview. nullHe attempts to relate the history of the patient's personal illness and his general psychic functioning directly to his interaction with the diagnostician. Kernberg's technical guidelines recommend a circular process. On the one hand, returning continually to the patient's problems and symptoms defines the psychopathological status; on the other, attention is focussed on the interaction between patient and therapist in the psychoanalytic sense, and interpretations, including interpretations of transference, are given in the here-and-now. nullThe main goal is clarification of the integration of ego identity or identity diffusion, the quality of the defense mechanisms, and the presence or absence of the capacity for reality testing. nullThis permits the differentiation of personality structure into neuroses, borderline personalities, functional (endogenous) psychoses, and organically determined psychoses. The interviewer mobilizes clarification, confrontation, and interpretation in the effort to gather material which will yield important prognostic and therapeutic information. nullHe is particularly concerned to appraise the patient's motivation, his capacity for introspection, his ability to work together with the therapist, his potential for acting out, and the danger of psychotic decompensation. Occasionally, unconscious connections are offered as interpretations to a neurotic patient, or a borderline patient is told about splits in his self-representations. From the patient's reactions, conclusions can be drawn which help the therapist decide on further diagnostic and therapeutic measures. 目标目标The first aim is to establish rapport between two strangers,(建立关系） The second aim is appraisal of the patient‘s psychological status. （评估状态） （强化动机）The third aim is reinforcement of the patient's wish to continue with therapy whenever this is indicated, and to plan with him the next step in this direction. (Gill et al . 1954, pp. 87-88) The Tavistock model, Development of the Doctor-Patient Relationship The Tavistock model, Development of the Doctor-Patient Relationship 1. How does the patient treat the doctor? Are there any changes in this respect? Does this point to habits of behavior or to his relationship to the illness? null2. How does the doctor treat the patient? Are there any changes in the course of the interview? a) Was the doctor interested in the patient's problems? b) Did he have the feeling he could do something for him? c) Did he notice any human qualities on the part of the patient which he liked in spite of all the patient's faults? Important Moments in the Interview Important Moments in the Interview The focus of attention here is the development of events within the interview, i.e., the results of transference and countertransference. 1. Surprising statements or expressions of emotion by the patient, parapraxes etc., obvious exclusion of specific periods of his life or particular people in his environment, and so on. 2. What interpretations were offered in the course of the interview, and what were the patient's reactions? Findings and Assessment Findings and Assessment 1. How is the disturbance expressed in the patient's life (listing of the symptoms revealed in the interview, including those the analyst vaguely suspects at this juncture)? null2. Presumed significance of the disturbance, expressed in psychodynamic terms. null3 Choice of therapy: a) Suitability for a short therapy (focal psychotherapy); reasons b) Potential arguments against c) Suitability for psychoanalysis; reason d) Refusal of any form of psychotherapy; reasons e) Other possibly suitable forms of treatment null4. Next goals: What does the doctor consider the essential symptom, the one he wants to tackle first? How might the treatment of this symptom affect other symptoms? Thoughts on the frequency and duration of treatment. Balint 的建议Balint 的建议目标：use "the patient's potentiality for developing and maintaining human relationships" (Balint and Balint 1961, p. 183) Balint的建议：成功访谈的必要条件Balint的建议：成功访谈的必要条件 1proper and adequate introduction to the encounter null2creation and maintenance of an appropriate atmosphere, in which the patient can open up enough for the therapist to be able to understand him. This is a test of the interviewer's capacity for active empathy, and thus of his ability to adjust himself to every new patient. null3Statements about a patient should always include information on the situational parameters created by the interviewer which have acted as "stimuli" - on the patient 4 (recommendation 4) 4 (recommendation 4) It is very important that the psychoanalyst have some idea of the future direction of the relationship before he begins to mold it in the interview. The concrete interview plan depends on whether the analyst can anticipate that the interview relationship will develop into a therapeutic relationship, (recommendation 5).(recommendation 5). it is vital that novice analysts, in particular, set themselves a definite framework for the configuration of the initial interview, but avoid having an unlimited number of sessions depending on their own personal degree of insecurity(recommendation 6). elastic interview technique.(recommendation 6). elastic interview technique.The analyst must react differently to different patients and not allow himself to be restricted by stereotypes such as the traditional understanding of countertransference nullWe can speak of a capacity for countertransference when the analyst recognizes countertransference and can use it to good diagnostic effect (see Dantlgraber 1982). 其他变化其他变化1适应征：少——多。 2治疗目标：人格整合"the best possible psychological conditions for the functions of the ego" (Freud 1937c, p.250). ——自我适应 3促使访谈的目的由判断预后变为适应病人人格列出个体化的治疗方案。 适应性访谈适应性访谈 We have to consider how the most favorable conditions for the patient's development can be created and which psychoanalyst is the best for this task. At the end of the first meeting, if not before, the analyst must face the questions: What happens now? Which external conditions have to be satisfied if treatment is to take place? How can a therapy be harmonized with the patient's personal and professional life? 家庭家庭I must give a most earnest warning against any attempt to gain the confidence or support of parents or relatives by giving them psycho-analytic books to read, whether of an introductory or an advanced kind. This well-meant step usually has the effect of bringing on prematurely the natural opposition of the relatives to the treatment -- an opposition which is bound to appear sooner or later -- so that the treatment is never even begun. (Freud1912e, p. 120) nullAs we know, Freud later expected his analysands to have read his works, but did not wish to give their relatives access to the same information. 1917freud1917freudPsycho-analytic treatment may be compared with a surgical operation and may similarly claim to be carried out under arrangements that will be the most favourable for its success. You know the precautionary measures adopted by a surgeon: a suitable room, good lighting assistants, exclusion of the patient's relatives, and so on. Ask yourselves now how many of these operations would turn out successfully if they had to take place in the presence of all members of the patient's family, who would stick their noses into the field of the operation and exclaim aloud at every incision. In psycho-analytic treatments the intervention of relatives is a positive danger and a danger one does not know how to meet. (1916/17, p.459) Aber Two factsAber Two factsThe relatives' interest in the analyst and the treatment arises from their realization that not only the patient's life will be changed, but theirs too. The relatives then feel all the more excluded, and their mistrust grows. They tend to react by either idealizing or totally rejecting the analyst. nullit is essential that the analyst give the patient's relatives the feeling that he is aware of the burden on them and recognizes that the psychoanalytic process has repercussions on them too. Kohl (1962) wrote that all the partners also suffered some form or another of mental illness and endangered the success of the therapy. 决定见家属的三种情况决定见家属的三种情况 (I) during the initial interview; (2) in an emergency (accident, suicide risk, committal to hospital); (3) in the course of the treatment. nullThe patient's partner can enter the treatment situation at the wish of the patient or the analyst, but also at his or her own request. nullIf the patient's conflicts are not included in his transference, they manifest themselves outside the transference in all his activities and relationships. This compulsion toward repetition outside the therapeutic situation takes the place of the impulse to remember, and is acted out mainly within the family. The analyst must then try to ascertain whether the patient who behaves in this way is avoiding working through his conflicts in the doctor-patient relationship by using his relatives as substitutes, or whether his acting out is so egosyntonic that he cannot include his suffering in the transference relationship; whichever is the case, therapeutic influence is obstructed. I nullProvision of adequate information to the partner guarantees confidentiality of the patient's relationship to the analyst, but also reinforces his loyality to his partner. If patients talk too much about the analysis, their relatives may become anxious and be tempted to intervene. On the other hand, relatives who are told little about the therapy feel excluded, and any pre-existing skepticism concerning the analyst is reinforced. This acting out must be interpreted if a change in the patient's behavior is to be induced. nullThe patient's anxiety that he will change but that his partner will not is often so strong that no progress can be made. In this case, the analyst must accede to the patient's wish and arrange to have an explanatory talk with the partner. Such a talk can be very effective in a situation where the patient is placed under strain by the partner's feeling of being excluded. nullHere too, it is important to distinguish whether a relative is brought in at the wish of the patient or is driven by his own anxieties to seek contact with the analyst. If a patient withdraws into the analysis and tells his family little about it, this behavior may strengthen their justifiable sense of exclusion, and they tend to counterreact. nullon the one hand we have to preserve the patient's regression, but on the other, too great a retreat into an infantile dyad may indicate an exaggerated regressive tendency. The analyst must carefully elucidate the patient's degree of readiness to exclude external reality, and must sometimes head off exaggerated regressive tendencies by means of technical intervention (for example by confronting the patient with reality). If this fails and a relative intervenes from outside in the therapeutic process, a joint discussion may release the tension. null, it is also possible for the patient's progress in the course of the treatment to awaken the partner's own previously suppressed wishes for therapeutic help, and such wishes must be taken very seriously. nullOccasionally, the analyst has to consider enlarging the therapy to include the partner. In such a case the interpersonal relationship will relegate the individual intrapsychic conflicts to the background. A large proportion of such therapies are indeed direct continuations of individual therapies (Bolk-Weischedel 1978). null It may also seem appropriate to offer the partner separate treatment or even to refer him or her to another analyst. The latter is preferable if the couple is considering a separation. null, we believe we can discern a trend toward inclusion of members of the patient's family in the therapy plan. This certainly results in part from the broadening of the spectrum of indications for psychoanalysis. A higher proportion of those seeking treatment are people with developmental problems or narcissistic personalities, borderline cases, or psychotics. Among these, some also have alcohol and drug problems, and many have marital difficulties, with all the consequences. nullThe inclusion of relatives is necessary not only in treatment of children psychotics, and patients with inadequate ego structures, but also with some compulsive neurotics. A friend or partner, for instance, can serve as "auxiliary ego" (see Freud 1909d, p.175). nullmore patient- than method-oriented; they now pay more attention to family and environment. null谢谢