Chapter 29 Chapter Seventeen Psychotherapist-1

Let's indulge a little and let's have a little fantasy. W. Wundt flashed out of nowhere, invisible to anyone but us.He had come back this time to see what had become of a scientific movement he himself had started a century earlier. He was dressed in a black lecture suit, with a serious and solemn expression. The shadow of the professor stared at some of his academic descendants in confusion.They were at a scientific conference on cognitive theory discussing the molecular basis of memory in undersea molluscs, while others were talking about computer programs that simulate parallel distributed processing.However, in some other respects, he allowed himself to show a little gratified smile quietly, because he learned that 50 years ago, there were only 4,000 psychologists in the United States, but today, there are an estimated 149,000 (70,000 psychologists). 79,000 are at the master's level) psychologists, an increase of nearly 40 times.

However, when Dr. Wundt floated to the American Psychological Association, the smile on his face disappeared immediately, revealing dissatisfaction.Here he learns that most of the new PhDs in psychology over the past two decades are not researchers but industrial, educational and—by far A category of clinical and counseling psychologists.Wundt had vehemently opposed educational psychology and similar practical uses of the science, but this—talking to people and listening to them about their personal problems—was the worst of all. A heinous downgrade to psychology.He was also amazed to hear that most Americans today think of a psychologist as one who works with patients with mental health problems.My goodness!

Of all the impacts of psychology on Americans over the past half century, none has been more pervasive than the changes it has brought about in the way Americans think about and deal with emotional and spiritual problems.Many misfortunes, failures, incapacities, dissatisfaction, and wrong words and deeds, which their parents once attributed to weakness, evil, or fate, are now caused by mental illness in the eyes of most Americans. Managed by mental health workers. In this light, some 50 million Americans visit psychotherapists each year, representing 120 million visits.Inpatients in psychiatric institutions and psychiatric wards of general hospitals have received millions of psychological consultations.Added up, one in three people has something to do with psychotherapy—that's about 80 million people.

About one third of the treatments were carried out by psychologists, another third by psychiatrists and the remainder by clinical social workers, clinical mental health consultants and parish staff.All of these professionals, in spite of their diverse backgrounds and obligations, are using psychologically appropriate treatments that are quite different from the physical, social, and religious approaches to treating mental illness. (Psychiatrists, however, treat patients with drugs, with or without psychotherapy.) Psychology was not originally a practical science, and its training centers did not produce "health workers" but researchers and theorists.The discipline grew rapidly after World War II, and like many other disciplines, the number of PhDs awarded each year increased tenfold between 1945 and 1970.But then the tide of undergraduate growth ebbed, new degree holders struggled to find teaching jobs, and doctorate production plummeted in all disciplines—except psychology, which continued to grow.

By the 1970s, however, psychology had grown not as a pure science but as several forms of applied science, of which health science was the largest.The output of research psychologists increased until the mid-1970s and then declined rapidly, while the output of health workers (clinical, counseling, and school psychologists) continued to increase. Although the absolute number of research psychologists has grown since 1970, it has steadily shrunk in proportion to the discipline and now accounts for only one-seventh of all doctoral and masters-level psychologists.Clinical and counseling psychologists now make up about half, and they mostly administer psychotherapy (the rest do testing and assessment work only).

Despite the growth in the number of clinical psychologists, about two-thirds of psychotherapy requirements are filled by others, as we have already mentioned: 1 of the 30,000 psychiatrists in the country 21,000 people, most of whom spend most of their time in private clinics; 81,000 clinical social workers, most of whom work in psychotherapy in institutional or hospital settings, but some of them also do Or private therapy only; 2,000 state-certified clinical mental health counselors; 2,000 parish workers; and an unknown number of others who also call themselves psychotherapists—a term not banned by law in most states Regulations - Some of these people have a fair amount of training, some don't at all.

Psychotherapy in all these disciplines now deals with a wider range of patients than ever before. (The word "patient" is used by psychiatrists and psychologists; many other therapists refer to these people as "clients" to avoid the medical connotations of the word "patient". The following are synonyms.) Previously, psychotherapy was used primarily for those who had no problems with contact with reality, but who had neurological problems, who suffered from anxiety, fear, obsession and compulsions, hysteria, delusions, physical illnesses of psychological origin. Torment—in general, all these people are neurotic. (DSM-Ill, American Psychiatric Association's diagnostic criteria 1980 edition and DSM-Ill-R, 1987 edition, both of which omitted the "neurosis" as a diagnostic category, and the mental disorders previously classified under this name are now referred to as However, terms such as "neurosis" and "neurosis" are still popular among ordinary medical practitioners and ordinary people, so they are used from time to time in this book.) Today, many people seeking psychotherapeutic help for marital conflicts, problems between parents and children, work-related troubles, loneliness, shyness, inability to succeed and anything that could be listed under the heading "Troubles of Existence" - according to the 1991 Some news accounts of the problems of urban life in New York even included unexplained difficulties in softball guarding, throwing straight balls, and batting.

In addition, some severe mental patients were previously treated with long-term warm water immersion, insulin or electric convulsion shock, and even lobotomy. Psychotherapy was rarely used, because such patients were generally not found in psychotherapy.But now, with some sedatives, they've all been brought back to reality and able to reap the benefits of psychotherapy.In the 1950s, more than half a million people were locked up in mental institutions across the country. Since the introduction of chlorpromazine and other psychoactive drugs in the mid-1950s, this number has dropped by two-thirds, to only 16. More than ten thousand people.Most of the patients who were locked up before now live in the living area, and their mental illness is controlled by drugs and psychological treatment in the mental health center in the living area.

Psychotherapy has thus had a great influence and is widely accepted—the number of people who have had it has nearly tripled in the past 30 years—but it has long been criticized , some people think that psychology is a pseudoscience, others think that psychotherapy is just a deceptive therapy. Some attack psychotherapy on the grounds that clinical psychologists and some other psychotherapists themselves admit that some of the things they do are more intuitive and less rational, and more An art rather than a science.Many academic and research psychologists have also long held the view that psychotherapy does not deserve to be called part of the science they practice. In 1956, David Bacon, a psychologist, wrote in The American Psychologist, a publication of the American Psychological Association:

There is a widespread feeling among many psychologists that clinical psychology (i.e., psychotherapy) is scientifically untenable.Clinical psychology is often seen as an art, or, if the critics are harsher, as an attempt to acquire knowledge by occult means and to conjure healing by magical means. A few years later, the psychologists Marvin Kahn and Sebastian Santos Delfino wrote in the same journal that clinical psychology "is in a state of anxiety, ambivalence, insecurity, and self-doubt. Clinical psychology says it's a science and then says it's an art." In 1972, and then again in 1986, I. Fullertoli devoted an entire book to explaining that psychotherapy, like witch doctors and alchemists, seeks to achieve curative effects on patients through comparable non-scientific methods , and Fuller Tori himself was a psychiatrist.

Another attack was perpetrated in 1961 by Thomas Schatz, a longtime nuisance among fellow psychiatrists and psychotherapists.He said that mental illness is a "myth" spun by clinicians. These people are followers of the social order, and they characterize some socially unacceptable, deviant or unique behaviors as mental illness. Still others attack that psychotherapists falsely claim that some therapy can treat a wide variety of mental illnesses, when in fact, these commentators emphasize, it is effective for only a limited number of conditions. In 1983, Bernie Silbergeld, a psychologist and psychotherapist in Oakland, stated in his "America's Withdrawal" that psychotherapy is effective for only a few problems, but for most In people it has little or no effect and is less effective than drugs and not as effective as simply talking to a friend. In recent years there has been another supportive commentary that some of the situations that psychotherapists say they can deal with actually have biological roots that cannot be cured by psychotherapy. For example, clinical (severe) depression, which in many cases is thought to have a biological origin.Especially in the case of the elderly, it is often an age-related problem of imbalance of certain nerve transmitters.Antidepressants such as tricyclic antidepressants, monoamine oxidase inhibitors, etc. can chemically restore this balance and eliminate depressive symptoms. Dürer's symptoms—uncontrollable facial paralysis, grunting, coughing, often involuntary repetition of foul language—are seen by some psychotherapists as a result of deep psychological disturbances and interpreted as hostile and Anal meaning, but for this, psychotherapists are helpless.But it is dopamine (DOPAMINE) inhibitor that can work, which shows that the disease is caused by too much dopamine in the body. Compulsive gambling and the pursuit of other forms of sensory stimulation have always been considered by psychotherapists to be some of the diseases that are more suitable for psychotherapy. However, recent studies based on urine samples and bone marrow biopsies have shown that compulsive gamblers And people who pursue sensory stimulation have long-term deficiency of the neurotransmitter norepinephrine (norepinephrine).Presumably, this deficiency leads to a decrease in alertness and feelings of boredom that patients hope to dispel through danger—in this case, the brain produces extra norepinephrine, although this makes many feel Extremely uncomfortable, but it will make such people feel comfortable. Obsessive-obsessive-compulsive disorder refers to some senseless behaviors triggered by obsessive thoughts, such as washing hands a dozen times a day. Recently, through PET scans (Positron Emission Tomography) technology, people found that It is associated with a highly abnormal excess of glucose metabolism in the basal ganglia, a region between the brain's sulci and lobar systems.Clomipramine, which was originally formulated as an antidepressant, clears up the symptoms very quickly over the course of a few weeks, apparently affects certain neurotransmissions along the axons of the brain material supplements. Psychotherapy has long been questioned, and many have affirmed that it is not science, at best a form of magic, or, more seriously, a form of deception. In this case, how can we explain its rapid What about grown and widely accepted facts?Some have suggested that it can be explained from a social point of view: we live in a time of separation and alienation from each other, we seek sources of comfort and a sense of stability, and so turn to those who provide them for money.In a secular age, psychoanalytic therapy replaced religious belief, it was a secular sanctuary, and so on. However, if we met a few of these practitioners, eavesdropped on their clinical practices, and looked at the accumulated evidence of efficacy, we might arrive at a more positivistic view of the success of psychoanalytic therapy and psychotherapists. Spiritual and less ideological interpretation. One of the few generalizations that can be made about psychotherapy today is that there is little that can be done about it.So far, there are half a dozen or more methods in use, with hundreds of variations.At one extreme, the patient lies on a couch and babbles, while the psychoanalyst babbles from time to time.At the other extreme, an alcoholic with wires strapped to his body receives an electric shock whenever he sees a picture of someone pouring wine into an iced glass in a bar. However, an accurate generalization about modern psychotherapy is that half or more of all psychotherapists use some form of dynamic therapy (also called "analytically oriented psychotherapy"), at least part of the time. of.These are based on dynamic psychology, which believes that psychological problems are the result of the interaction of internal conflicts in the mind, unconscious motivations and external demands, and factors of character structure. Although this concept belongs to psychology, its roots, as we have seen, are not in psychology itself, but in the accidental discovery of a neurologist, Freud, that he used "conversation "Therapy" had more success with hysteria than he had with physiotherapy or hypnosis.Psychology was slow to adopt his findings and theories.In the early part of this century, when the doctrine of psychoanalysis was gaining ground among European physicians and psychologists, American clinical psychologists were still primarily performing psychological tests and measurements.Some universities opened psychology clinics before World War I, but these were limited to testing and training children with learning difficulties.Psychotherapy is simply an exotic, foreign method of treatment, mainly within Europe. The American medical profession was also slow to adopt psychoanalytic methods at the turn of the century. American psychiatrists dealt primarily with hospitalized mental patients and relied almost exclusively on physical methods: bondage, warm water immersion, exercises, and physical work.However, World War I brought a large number of war-wounded veterans, and a large number of psychiatrists came into being. They knew that psychoanalytic therapy was said to have a very good effect on severe mental illness, so they had a special interest in it. interest. Some went to Europe for training, and when several psychoanalytical schools opened in American cities, some psychiatrists and others began analytical training.Some of the better mental institutions, such as the Pennsylvania Hospital Research Institute in Philadelphia, invited psychoanalysts from Europe to train their staff.Eventually, organized psychiatry made psychoanalysis one of their specialties, and, through its psychoanalytic society, restricted training to physicians, although only a few psychiatrists were trained to actually use it. There are fewer and fewer people.Psychologists and others who were not doctors but wished to be trained only went to Europe.Later, a number of institutes were established in the United States with the purpose of training "general analysts" (non-medical analysts). In the 1920s, psychoanalysis became one of the favorite topics of the avant-garde, and the concept of psychodynamics was embraced by the psychological authorities.As we have seen, they had a great influence on the inventor of the thematic apperception test, Henry Morey, and his research group at Harvard.By the 1930s, when some European psychoanalysts had come here to escape the Nazis and training schools had multiplied, psychoanalysis had achieved the status of an academic movement. However, like earlier movements in Europe, it underwent constant fission.In the 1930s, some psychoanalysts in the United States made some changes to Freud's theory and added a lot of content, and they distanced themselves from the mainstream psychoanalytic body.Most notable are some "neo-Freudian scholars" who have compiled their own systems and set up institutions to teach their own theories.Although they do not reject Freudian dynamics, they give equal or even greater importance to social and cultural factors in the explanation of character development and mental illness.One of them is the suave, philosophical Erik Eriksson, whose theory of development we have already discussed.The radically independent feminist leader Karen Horney was another, as was the poetic social reformer Erich Fromm, a refugee to the United States from the Nazis. Another notable neo-Freudian scholar is psychiatrist Harry Stark Sullivan.He was the only child in his family and the only Catholic child in his upper New York farm area.Perhaps because of his loneliness, he became interested in the developing child's relationship with a caring adult and how this affected character and behavior.The dynamical approach he developed, known as "Interpersonal Therapy," is based in part on Freud's theory, but instead of relying on free association, it calls for face-to-face discussions between therapist and patient, with the former as a reality The person, rather than a shadow figure, to whom the patient only projects transmitted images. So, in the thirties, the course of therapy, by Freudians and neo-Freudians, usually three or four sessions a week—Freud liked six—for at least a few years, In this way, the patients who receive treatment are limited to a few people who have both money and time.However, World War II produced far more traumatized veterans than World War I—44,000 inpatients in Veteran-run hospitals alone in 1946—and created a paradoxical There is an urgent need for a greater number of psychotherapists and simple methods of treatment.As a result, there has been a dramatic increase in the number of psychiatrists and clinical psychologists, who are increasingly using psychodynamic concepts and methods. At the same time, the statement about the human mind in psychoanalysis also spread, through the efforts of some writers such as André Breton, Thomas Mann and Arthur Kessler, as well as surrealist painters, it became A fashionable topic among intellectuals.Going through a psychoanalysis is almost a gateway to the avant-garde.The idea of ​​psychoanalysis has also spread to the mouths of millions of ordinary people.Dr. Benjamin Spock's "Handbook of Infant and Child Raising," an advocacy of a psychoanalytic anthropological perspective on child rearing, sold more than 24 million copies between the late 1940s and 1970s, and is the The most important single method of publicity, he spread Freudian psychology throughout American society.Unfortunately, psychoanalytic views are often distorted by enthusiastic individuals who use it as a shield to blame their parents for all their failures.Erik Eriksson lamented: "Even if we devise a cure for only a few, we are led to promote the moral disease of the majority." Considering how few psychoanalysts and people are analyzed, the influence of psychoanalytic doctrine is astonishing.When it was at its height in the 1950s, there were only 619 medical analysts and about 500 non-medical analysts in the country, and maybe 1,000 were trained as physician analysts in about 20 institutions, plus a dozen Institutions that train general analysts.Although there are no statistics on the number of people undergoing psychoanalysis, if most analysts work 8 hours a day and see each patient 4-5 times a week, the total number of patients treated at any one time is only about 10,000, which is all A very small fraction of patients with mental illness.There are relatively few psychoanalysts who specialize in children, and they are unlikely to deal with children other than wealthy parents. A case analysis report in "Children's Psychoanalytic Research" in 1949 talked about a 5-year-old boy who was afraid of going to school without his mother. Finally, he was cured by a psychoanalytic method and spent 3 years. time of year. (The analyst had never considered, and probably did not know of, simpler remedies for the child's phobia.) The cost and time required, as well as the interruption of regular doctor visits to normal life, doom this therapy to widespread adoption.However, there are other obstacles.Those in the know quickly see, and greatly exaggerate, the fact that this often appears to be a swindle in which the patient spends a great deal of time, money, and effort while the analyst does little or nothing. Say.Psychoanalysts trained in the traditional way still account for the majority of psychoanalysts, but compared with Freud at the time, they are getting farther and farther away from the general public, and it is becoming more and more difficult to approach them. (Freud once said: "I am not a Freudian.") Many people say little, they simply listen to their patients, and they often take some of the questions put to them, Debunking things like how he feels about a statement or symptom, such as: "Why is this important to you?" "Why do you think I see it that way?" The principle was (and still is) that the analyst's expression of thoughts and feelings would make him or her a real person rather than a vague figure and thus interfere with the patient's projection of an important childhood figure into this on a psychotherapist.For many psychoanalysts, this transference was, and still is, a fundamental arrangement in the therapeutic process.Yet even the most rigid analyst has to say something from time to time.Psychoanalytic training emphasizes that transformation of the condition is by free association of what is unconscious to conscious, and through three processes that require the analyst to speak (although not about his or her personal feelings): dream interpretation, translocation, affection and repulsion. However, despite the analyst's occasional remarks, the patients mostly sensed their silence and refrained from answering questions, which made them angry - but could not go away.One analyst wrote of treating a beautiful lady: "She yelled at me mercilessly, almost every hour, calling me a bastard, a quack, frigid, satyr, etc. Wait, but when it was over, she would give me another affectionate, longing look, and say softly, 'See you next time.'" In the International Journal of Psychoanalysis, another psychoanalyst also Reports of a female patient who scolded him on a bad day (slightly abridged): enough.I've been busy with it all year -- a messy year, a sad year, a wasted year.for what?Do nothing.Nothing the hell.These days I have to have the courage to leave you and never come back.Why do you want to come back?You didn't do anything for me, nothing.Year after year, you're just there to listen.How many more years do you need?Who do you really think you are?How can you do this? - You haven't changed anyone, you haven't healed anyone, scammed out of money and went to Bermuda for the weekend, don't have the guts to admit you're selling fakes.Trash collectors are more humane than you. Sometimes an analyst may even make a patient unable to express his or her thoughts lie in a recliner for an entire hour, or even several hours, without helping the patient to break through—but he does nothing, But the time fee will be charged.A humorous or sarcastic person can make this seem commonplace, even though it's actually very rare.Apart from a sense of duty to help the patient, most analysts find it very uncomfortable not to speak for hours. What kind of people were they, these terrible authorities?They lord it over their patients and at the same time stay on top and don't care.Some people, who, outside of clinical hours, take on a role they have come to recognize as their true selves: intelligent, thoughtful, piercing eyes, accustomed to contemplative silence, serious, wise, highly capable but vulnerable — In short, try to be as Freudian as possible.But in reality, they are no different from some physicists, violinists, or plumbers.There were (and still are) all kinds of psychoanalysts, from the cold to the fiery, from the harsh to the friendly, from the powerful to the weak.However, some veteran observers think they have a generalization.Many of them felt deeply different and lonely, said Arthur Burton, a non-medical analyst who edited the biographies of several analysts. They were bright Jewish teachers of Hebrew. (And so do some of the non-Jews), they have some so-called feminine qualities ("motherly", intuitive, sensitive, emotional) they tend to be agnostic, but also liberal. The writer and educator Martin Gross painted another portrait of them, with a vitriolic attack in Psychological Circles (1978).He sees psychoanalysts as cocky, money hustlers, arrogant, self-important, brainwashers who like to be patients, exaggerate their results, are either narcissistic self-worshippers or know-it-alls Quack doctors.There may also be reasons for his attacks, but some unbiased surveys and studies of psychoanalysts have given them a very positive picture.By the 1950s, some of them turned more to self-analysis, and they adopted some of the views of the neo-Freudians, emphasizing mutual contact with the patient's reality, and actually solving some problems, not only in the patient's unconscious and past events, but also address his or her conscious processes and current issues. Nevertheless, the many disadvantages of psychoanalysis, even in modified form, and its quest to develop simpler, less costly treatments, made its stature and popularity go away in the 1960s. downhill.There are more important reasons for its loss of status.Glenn Gerbard of the Menninger Fund writes: "After World War II, enthusiasm for psychoanalysis as a panacea for social problems led to bitter disappointment in the 1960s"—which is unfair indeed, because psychological Analysis has never appeared as a prescription for social problems, but as a solution to individual problems.Professional and popular magazines wrote at length about the "crisis of psychoanalysis," about its "decline," and about its lack of evidence that it was an effective solution.Dr. Judd Marmo summed it up when he wrote: "This calligraphy is left on the wall for us all to admire. Psychoanalysis is in grave danger." This was almost 25 years ago, and psychoanalysis has not disappeared.However, its status and usefulness have indeed diminished steadily.By the late 1980s, Helen Fisher, administrator of the American Psychoanalytic Association, lamentably admitted that "almost no one"—she was referring to medical professional psychoanalysts—"is now working full-time As for psychologists, the American Psychological Association recently reported that only 2.5 percent of its clinical members identify themselves primarily as psychoanalysts.Some psychotherapists, professional and non-professional, still use psychoanalysis with some patients - those who can afford the time and expense - for whom major personality changes, into the deep unconscious is the goal, but psychoanalysis is no longer the model and ideal method of therapy, nor is it the frontier of therapeutic knowledge and research. But its core concepts of human character and neurosis survive in a different form.Several new treatments gradually replaced psychoanalytic therapy with less cost, easier therapy, and simpler methods, the most important of which was based directly on psychoanalytic psychology and was called psychoanalytic therapy. , psychoanalysis-oriented therapy, or dynamic psychotherapy.It takes many forms, but in the most typical form, the healer only sees the patient two or three times a week.The patient sits facing the therapist, who has to be stared at like this all day long--you can recall, Freud couldn't stand this--he is a real person facing the patient, discussing, asking, Offer advice, share experiences and knowledge, and generally be more of a teacher than a listener and interpreter of unconscious material. But psychodynamic concepts became common and became central to the therapeutic process.The concept of transference, for example, can exist and be used in weekly face-to-face therapy sessions, but it differs in its approach from traditional analysis.Clinical mental health consultant Bernice Hunt described her relationship with a young woman some years ago as follows. (This case, although relatively recent, is typical of the changes that have taken place in dynamic psychotherapy in recent decades.): She was denied maternal love as a baby—in fact, she became a caregiver at the age of three, when her mother was paralyzed for life in a car accident.In the therapeutic relationship, I quickly became a good mother but she was slow to enter the role.I sympathized with her, I supported her, I comforted her, I "give her" permission to play and work at the same time, to let her lose her temper with others and me.She went through what Alexander (of the Chicago School of Psychoanalysis) called a "corrective affective experience," and relived her childhood more or less in a different form.As in normal development, when she begins to internalize our relationship, she can begin to be an adult, to be her own mother, like any healthy adult. By the 1970s and 1980s, a group of psychiatrists and psychologists began to develop "short-term dynamic therapy" based on psychoanalytic principles.These methods focus on a single problem that is currently troubling the patient. Instead of using free association, probing into the unconscious, demanding points of understanding, or thoroughly examining character, they rely primarily on the patient's empathy.Unlike the psychoanalyst, these therapists confront the patient positively, with evidence that he or she is relating to the therapist in an unrealistic way that is removed from other relationships.Therapists sometimes bring this relationship to light at the first meeting, as described below (slightly abridged) by this Boston psychiatrist, Peter Silverias: Patient: I like to do fake shows.I wear a mask.I give the impression that I am different from my real self.Before my girlfriend blew it off with me, she said she didn't like going out with a "fake thing".My previous girlfriend, Mary, said exactly the same thing, only with different words.My best friend Bob said the same thing.I know what they're all saying.Sometimes, even here, I have a great urge to put on a show and make you adore me. Therapist: So where does this urge come from? Patient: From a long time ago.I used to like to put on a show to please my mother.I remember once making up a whole set of stories about school.I told her, the teacher said, that I was the best student she ever had.My mother liked it, but, you know, doctor, it's not true.老师的确是表扬过我，但我把它夸大了。我把它编得走了样。 治疗师：这么说，你是在取悦你母亲，你是在取悦你的女友们，还有包勃，还有包括在这里—— 病人：您说“还有包括在这里”是什么意思？ 治疗师：一分钟之前你说，哪怕是在这里你也有这样一个倾向。 病人：我说过吗？ 治疗师：是的，你说过。另外，为什么这会使你惊讶呢？如果你喜欢跟任何人表演，你为什么不跟我也表演一番呢？ 病人：我的确有个想法，就是说这是有可能的，可这正是我不想去做的事情。我到这里来就是要理解我为什么这么干，这样的话，我就可以不再装下去了。我希望你能帮助我。 在传统的心理分析中，要达到这一点可能需要几个月的时间。加利福尼亚黑渥德的凯撒永久医学中心的临床心理学家莫什·塔尔蒙最近写了一本书，叫做《单次疗法》，在书中，他讨论了在第一次面诊中——经常也是惟一的一次，尤其是在门诊中——可以在病人身上达到多大效果，不是通过提供建议，而是通过动力心理学的相互交谈。 但是，总起来说，短期心理动力疗法需要12－25次每周的会面以达到其有限的效果，这样的疗法据报告对因压抑和丧亲而引起的毛病有效果。对于许多心理治疗师来说，动力治疗法，特别是期限更短，交互程度更高的一些疗法，是治疗大多数精神病和生存问题用得最多的一种。事实上，有令人信服的证据证明，在相对较少的几个小时的治疗中，会有很多好处发生。一个典型的研究显示，半数接受每周治疗的病人在第8次会面时，其严重症状即有很大的缓解，不过慢性和更深层的一些问题需要更长一些时间。 1981年，美国心理学会的一项临床心理学家调查发现，百分之三十的人认为他们自己主要是心理动力学派的；1986年，这个数字是百分之二十一。差不多是同样百分比的临床社会工作者和精神卫生顾问，加上更高百分比的精神病医生也可能会以同样的方法看待他们自己的取向。（另外，一些几乎在任何学科的行医者也在一部分时间里实施心理动力学方法。） 这样一来，所有心理治疗者中约有三分之一的人基本上是心理动力学派的。其它的人呢？自60年代开始，其它一些与心理动力学治疗方法大相径庭的治疗方法也吸引了相当多的一批信徒。这些方法当中，有一些在刚出现的时候好像是心理动力学治疗法的最终挑战者，可结果没有一种替代了它。所有的方法，新的也好，旧的也好，都在不断的应用之中。有些治疗者只用一种，或者主要地用一种方法；另外一些人把他们自己看作是随机应变的治疗者，根据需要使用好几种不同的方法。在最近几年里，对“心理治疗整合”——好几种主要的心理治疗理论的统一使用以及任何和所有主要方法的使用，这要根据问题的实质和病人的需要而定。 让我们来看一看这些较新的治疗方法并试着看一看，尽管这些方法之间有很大的不同，为什么它们都因为取得了差不多高的成功率而享有声誉？ 1951年，康奈尔大学的一位面容亲切、态度谦和、一头银发的心理学家霍华德·利德尔在做一项行外人士都会觉得有点虐待意味的研究。他用山羊、绵羊和一头取名泰尼的豪猪制造一系列的精神病——或者与人类精神病相类似的一些症状。在伊萨卡城外的一座农场上，利德尔或者他的好几名研究助手之一常常把山羊关在一只小圈里，接一根电线到羊腿上，然后，他用电灯往小圈里照一下，接着送一股电流到羊身上。 一开始，羊只是跳几跳而已，可电击十几次之后，它就明白了这个信号的意义，当电灯扫过时，他会在圈子里乱冲一阵，似乎是要避开电击——这毫无用处。这样做了约1000次之后，一当羊被领到羊圈时，它都会拼命扭动并冲撞，第一阵信号发送出来的时候，它会磨牙齿，出粗气，眼球乱转，浑身僵硬，双眼盯住地板。到这个阶段，哪怕把它带到草地上，它也出现了异常行动。它尽量与其它羊离得远远的。它已经形成了全过程的忧郁性精神病。 利德尔还想办法把这个过程逆转过来。一只创伤十分严重的羊常常会被电线绑在小圈里，它会看见电灯光可不会受到电击。由于羊不是一种特别聪明的动物，需要发送许多无刺激性的电灯光照来促使它忘掉这个信号的恐惧含义。最终，它会被彻底去除条件反射。 对照起来看，猪就聪明一些。泰尼慢慢很害怕它的实验室食槽了，因为它好几次拱开槽盖后都会遭一阵电击，因此，哪怕它看见往里面倒食物也不靠近它。为了让它驱散恐惧感，一名研究生就在猪圈外给它喂食。猪在这里感到安全，慢慢就开始相信他了。接着，他带它到实验室，把一只汁液丰实的苹果放进它的食槽里，一边摸它的背一边跟她轻轻说话。“泰尼，出什么事了？”他说。“为什么不吃苹果呢？去吧，去吃。”他指着苹果不断地与它谈话，并拍着猪背。泰尼哼哼几声，试探性地碰了几下食槽，吃到了苹果，没有遭电击。只这样试了几次之后，那位研究生一到身边泰尼就去打开食槽。后来，如果有人靠近它，它就去打开。最后，没有人在身边它也去打。它被治好了。 动物精神病的诱发是标准的巴浦洛夫心理学——巴浦洛夫本人也曾做过类似的实验，美国其它的实验者也曾做过类似的实验——可是，利德尔却走得更远一些，他要通过研究消除条件反射来治疗精神病。（“休息疗法”——在实验室外度过一段时间——没有什么效果，虽然动物会有所改善，但回到实验室后又会复发。）利德尔坚持不断地进行自己的实验，并发表了他的发现，可在二十多年的时间里，他都没有向任何临床治疗者暗示说，这种方法也许可以应用到人类。我在1952年询问他的时候，他不太愿意考虑这个问题，可他非正式地承认说，他希望这会证明是有用的。（很明显，他不知道，早在1924年，一位名叫玛丽·卡夫尔的心理学家，已经在使用传统的条件反射技术治疗一个3岁大的男孩，他害怕毛茸茸的东西。这位心理学家把一只兔子和一些他喜欢的食物一起由远及近地靠近孩子。） 事实比他预料的还要快。在南非约翰内斯堡，一位名叫约瑟夫·沃尔普的普通执业者1947年和1948年间在威特沃特斯兰德大学读书期间，曾读过巴甫洛夫的文章，并留下了深刻的印象。他自己进行过类似利德尔的实验，但用的是猫，他把猫关在一个实验室的笼子里，给它喂食的时候电击它，使它出现精神病。过一阵子后，它们哪怕是饿得半死也不在笼子里进食。然后，沃尔普想法把条件反射倒过来，让它们在一间看起来很不一样的房间里进食。它们在这间屋子里的焦虑程度要低些，因而很快就学会在这间屋子的笼子里进食。沃尔普然后在一间与实验室的房子差不多的笼子里进食，再在更像的屋子里，最后回到实验室本身去了。 他把这个方法叫做“反向抑制”，或者“脱敏”。他的理论是，如果一种抑制焦虑的愉快反应（如进食）在产生焦虑的刺激面前出现，则它会减弱这些刺激的强度。在这些猫的情况下，对食物的愉快反应与笼子而且最终与实验室里的笼子产生了联系，于是就克服了在这个地方产生的焦虑。 沃尔普开始寻找一种可比较的、能够用于病人的技巧。（进食在人类身上不会形成足够强烈的反应，而且在任何情况下也不可能在办公室里实际运用。）用脱敏的办法来重新培训人类，在他看来似乎是一种明显比动力心理疗法更为科学的精神病疗法。这位独断专行和冷漠的小个子男人对此事极感兴趣可能还有另外一些原因。许多年以后，一些对治疗者的性格研究发现，行为主义治疗者——那些其主要方法都是以行为主义的原则为基础的人一一倾向于是一些冷漠无情的人，喜欢客观处事而且保持距离感，而动力心理治疗者们大多是易于动情和喜欢主观及人际关系的人。沃尔普不喜欢也瞧不起心理动力疗法是绝对的，如他后来所说的：“弗洛伊德精神病概念当中没有科学的根据……精神病只是一种习惯——一种顽固的、不顺应潮流的行为，是由学习得来的。” 几年的实验和阅读之后，沃尔普发现了一个他认为会有效果的办法。从他以后，那就是他大部分医疗工作的基础。他在病人身上诱发一种近昏迷状态，通过联想性的培训使其愉快感受与引发恐惧的刺激联系起来，然后再克服恐惧。（这只适用于精神病型的恐惧；因真实和持续的危险，如生活在遭敌人轰炸的城市里等，而引起的恐惧，使用这个办法是无补于事的。） 进行这样的治疗时，沃尔普先花几个小时时间记录新病人的病历，再向他或她灌输他的理论，即，精神病只是一种或者多种由经验诱发的习惯，很容易被新的习惯所代替，根本不需要深挖一个人的潜意识或者童年时期的创伤。 然后，他会教病人进行深度肌肉放松，先让前额部的肌肉丛“松驰”，然后再松开脸肌，再然后一直到脚趾，直到完全放松，进入一种半昏迷状态为止。等病人能够熟练地放松自己时，他或她和沃尔普就会按照他们唤起焦虑的能力建立一个“层次关系”，或者是一个分等级的刺激单。沃尔普会让病人在放松的时候想象自己最软弱的情景。一旦它不再引起任何不快时，他们会解决下一个问题。病人会越来越多地被解除条件反射，直到最后和最厉害的刺激与放松的状态联系起来，并使其变得无害。 在一个典型病案的报告中，沃尔普讲到了约翰内斯堡的一位52岁的家庭妇女C·W·夫人，她因为极度害怕被遗弃、疾病和死亡以及因这些感觉引起的症状而造成的恐惧而来找他看病。他和她把她的每一种恐惧建立起了一种层次关系。身体症状分成9个项目，最轻的一个是左手的疼痛（旧伤引起的），最严重的是不规则的心跳引起的。到她的第18次脱敏时，他已经去除了她的全部症状，只剩下单子上3个最为严重的症状。这次，他专攻他最为严重的第三个恐惧，即左肩上的疼痛。首先，他让她深度放松，并让她集中精力想一些愉快的事情。再然后，他按下述方法进行： 如果碰巧有任何场景会干扰你，你要举起左手指明这一点。首先，我们要让你看看你在这些治疗中已经熟悉的一些东西——你左肩的疼痛。（在以前的诊疗中，她曾说过她想象到这一点的时候曾受到过干扰。）你将非常清晰地想象到此疼痛，而且你一点也不会受到干扰……不要再想这个疼痛了，再集中精力放松自己……请再想象你左肩上有疼痛……再停止想象并集中精力放松自己……（再进行第三轮。）如果你感觉到在第三轮场景时受疼痛干扰最少，请用左手举起来示意。（手没有举起来。）（病人后来报告说，第一次想象到疼痛的时候稍稍有点干扰她，可第三次想到的时候就一点也没有了。） 通过这种方法，沃尔普宣称，他不仅已经能够治疗恐惧症，而且还能治愈很多种精神病——通常只需要心理分析诊疗次数的二十分之一。他的许多病案比C·W夫人的病案更具戏剧性，从极度害怕驾车到非常怕拉尿（一位年轻人，曾经尿过床）。哪怕出现的一些症状听起来像是需要动力学治疗法的精神病，沃尔普还是找到一些以简单的恐惧症为基础的解释。一位27岁的妇女来找他治疗婚后生活中的性冷淡（沃尔普的话）和其它严重问题，特别是不能够维护自己。沃尔普没有像弗洛伊德式的心理分析师可能做的那样去追究深层的怕被控制的心理原因，他问过她一些问题之后得出结论说，她的焦虑是由看见或者触摸到阴茎的情形而引起的，因为她感到这种情景很难忍受。 接着，他和她建立了一个层次关系，在这层对她来说最不易引起害怕心理的关系里，她会想象看到公园里30英尺远的一座裸体男性雕塑。等她克服了想象这个情景的焦虑之后，他引导她一步一步地靠近这个雕塑，直到她可以想象她自己用手握住石头做的阴茎。他再转到一系列的情景之中，让她想象自己站在卧室的一侧，看见15英尺外她丈夫的阴茎。通过脱敏，她又被引导到更近的距离，直到她可以想象她自己轻轻地碰着阴茎，然后再做更长的时间。到约第20次诊疗的时候，她报告说，她已经可以欣赏到与丈夫的性快感了，而且有一半的时间可以达到高潮。 按照沃尔普的说法，这样系统的脱敏对其百分之七十的病人来说证明是最佳选择。对于其余的百分之三十，他想出了其它一些办法。在50年代早期，他开始在杂志上发表文章宣传自己的技巧了，1958年，他在《交互抑制疗法》一书中报告了一例全过程的治疗。 到这时，其他一些治疗师也如法炮制，并开始进行脱敏治疗和其它形式的行为治疗。最有影响的是另一位南非人阿诺德·拉扎勒斯，他曾到过美国，而且是第一位使用“行为疗法”这个术语的人。还有英国的H·J·艾森克。有一阵子，用行为疗法治疗精神病人显得新鲜而少见。临床医生中很少用这个方法的，因为它与当时占有主导地位的动力学传统正好相反，而且，不管怎么说，在美国无法得到这方面的培训。可是，1966年，当时在费城的登勃大学医学院的沃尔普主持了一个行为疗法研究及培训项目。同年，一个叫做行为疗法研宪院的非赢利性门诊和培训中心在加利福尼亚的骚塞利多市开业，由沃尔普和拉扎勒斯（当时是他在登勃大学的同事）写的一本新书《行为疗法技术》也出现了；再过了一年，沃尔普和行为疗法就被《纽约时报杂志》上的一篇文章介绍到这个国家的知识分子中去了。 打这以后，对行为疗法的研究以及有关行为疗法的出版物就呈几何级增长了。到70年代，它已经成为主导性的治疗办法，一直到今天依然如此，尽管它从来没有排除掉动力学疗法。一些心理治疗师只用这种方法，更多的一些人把它与其它一些认知疗法（这种方法我们马上就要谈到）；还有一些人，包括一些主要使用动力学疗法的人，不时也使用行为疗法来治疗一些特殊的恐惧症，如驾车恐惧、飞行恐惧、怕猫，或者怕人多的地方，这些病症通常不需要同时使用动力疗法就可以治愈。 脱敏技巧最知名的用途有可能就是治疗性功能紊乱，特别是性功能不全和女性的性高潮缺失。威廉·马斯特斯和弗吉尼亚·约翰逊两位都是性研究者，可两人都不是心理学家，他们研究出了一套办法来解决这些不是由于器官毛病，而是来源于心理焦虑的困难，这种办法是过去二十多年以来对这类患者基本的疗法。这个方法包括逐步的脱敏指导和实践——其步骤由一对伴侣在家里花几天或者几星期实行——开始的时候，两人彼此碰触身体，逐步发展到抚摸彼此的生殖器（禁止性交，以防出现操作焦虑），最终把阴茎插入阴道，但不进行性交动作，最终，当这个状况不再引起焦虑的时候，再进行全过程的性交。但是，医疗性功能障碍与简单的恐惧疗法不一样，它一般需要对两个伴侣之间的关系进行讨论和教育。 脱敏法一直是行为疗法中最常用的一种技巧，可是，在某些条件下，由沃尔普和其它人研究出来的其它办法却更为有效。这些疗法有： 厌恶培养：这个技巧的目的是要消除迫不得已的行为，如嗜酒，吸毒或者性欲怪癖。按照行为主义者的学说，当一种对刺激的反应与疼痛或者惩罚有关时，这个反应会被削弱或者被抑制。作为一种疗法，它需要在病人身上进行，或者想到要进行希望戒除的行为时，引起病人的不舒服。 在对一些住院嗜酒者进行厌恶培养的早期形式中，病人通常会喝一些带厌恶药剂的酒。喝完之后，病人会感到恶心并产生呕吐。这样做过几次后，病人有可能会在看到酒，或者想到看到酒时产生呕吐感。 以后，对于受激发的嗜酒者和很重烟瘾的人、进食过度的人、深受强迫性和迷恋型琐屑行为困扰的人和有性欲偏差的人的治疗，电击一般是使用较多的一种方法。举例如下：一位33岁的男子因为终生喜欢女人的内衣，并且在与女人性交时出现阳萎而前来治疗。他常常买女人的内衣，或者从晾衣绳上偷，然后自己穿上并手淫。治疗中，他会看着一条女内裤或者女内裤的照片，或者想象有一条女内裤，同时，治疗师会给他一个轻轻的、但很痛苦的电击。经过14周41次治疗后和492次电击后，病人说，女内裤再也不能引起他的性冲动了。除掉这道障碍后，他和他的治疗师就能够通过其它办法治疗他的性无能了。 有些治疗师使用厌恶疗法治疗男性同性恋，在他们看着裸体男性的照片时给他一个电击，但看着女性裸体照片时却不给电击。这种方法据报道说有一些疗效，可是，当同性恋在70年代被重新定义为一种性偏好而不是一种精神疾病之后，这种厌恶疗法就很少见了。 一种较轻的厌恶疗法叫做隐秘脱敏。病人经过培训后，当他们想要做任何他们想戒掉的行为时，通过想象一些恶心的事情来惩罚他们自己。比如，一位嗜酒者，当他走到一家酒巴准备买酒喝时，他立即会想象自己已经产生头晕，手上、衬衣和外衣上全是呕吐物，还吐到巴台和侍者身上，可是，当他转身走出酒巴时，却又感到好多了。然而，这种方法的有效性却很少有证据。 总起来说，公众和大多数心理治疗者都觉得厌恶疗法令人难以接受，且好像很有虐待意味和不人道。另外，其益处还没有得到长效的印证，而只是一些变换的行为方式代替了受禁止的那一种方法。由于这些原因，拉扎勒斯和其它一些人认为厌恶疗法是迫不得已的最后补救。 果断培训：这不是一种单独的技巧，而是数种技巧的合并使用，全部的目的都是要帮助病人克服社会性焦虑和禁忌，并在他们以前一直感到害羞和被动的情形下更为果断地行动。治疗先从教育开始：治疗师和病人讨论一些令病人感到害怕的情形，再分辨出合适的反应。病人接着会受到鼓励，把这些行为在有轻度挑战性的情形中表演出来，然后，等他感到有些把握以后，再一步一步推向更严重的挑战情形。 果断培训中最为重要的一个部分是“行为预习”。病人在一个挑战性的情形下扮演自己的角色，治疗师扮演造成威胁的人（老板、配偶、邻居）。病人有机会来练习他或她在现实生活中需要说的话和做的事，治疗师会发出反馈和给予指导，直到病人在这个角色里很有技巧，而且对新行为感到舒适为止，然后再以新的眼光来看待自己。 示范法：斯坦福大学的艾伯特·班杜拉研究出了一种方法，他的理论基础是，大多数人的行为是通过认同或者模仿对个人十分重要的一些人而得来的。这种疗法的中心是，病人要以特别的方式观察治疗者的行为，通过模仿学会，再据此修正他她自己的行为方式。如班杜拉指出的，通过这个方法，在“主持人俱乐部”观看和学习别人的好几百万人都克服了他们不敢在公共场所讲话的毛病。 最初用来改变儿童行为习惯的示范法，很快发现对克服一些成人的恐惧也有用。典型的治疗包括让病人观察示范者在一种相对不那么可怕的情形中接触令人害怕的东西，然后，再在一系列越来越可怕的情形下进行。比如，在治疗对蛇的害怕中，示范者先摸蛇，然后抓住它，最后让它在自己身上爬。治疗师鼓励病人经过同样的一系列活动过程，甚至引导病人的手，并因为他所做的努力而表扬他。慢慢地，治疗师减少演示、保护和引导的程度，直到病人独自在没有帮助的情形下面对他害怕的事物。 参与疗法：60年代和70年代，许多住院病人的行为通过使用奖励而得到修正，这种实验取得了很大的成功，之后，许多精神病人也泡制了类似建立在参与疗法基础之上的一些活动。护士和精神病工作者接受培训，把一些象征物（扑克牌、卡片或者假币）奖励给病人，以表彰他们自我清洁，保持房间卫生整齐，对别的病人行为正常和担起一些工作责任等。这些象征物可以换成一场电影，一份特别的食物，一个私人房间或者周末发一张免费票。这在很广泛的程度上取得了积极的成果，特别是在一些长期以来封闭不出或者缺乏情感的病人中。“象征经济”活动，他们这样说，对一些痴呆症患者、少年罪犯和受惊吓的学龄儿童也特别有效。