10 Paranoid Personalities 10 偏执型人格 Most of us have a clear mental image of a paranoid person and recognize the type when it is portrayed fictionally. Peter Sellers’s brilliant performance in the classic movie Doctor Strangelove, for example, captures the suspiciousness, humorlessness, and grandiosity that strike familiar chords in any of us who have paranoid acquaintances, or who recognize the comic elaboration of the paranoid streak we can all find in ourselves. Identifying less flagrant paranoid presentations requires a more disciplined sensibility. The essence of paranoid personality organization is the habit of dealing with one’s felt negative qualities by disavowing and projecting them; the disowned attributes then feel like external threats. The projective process may or may not be accompanied by a consciously megalomaniac sense of self. 我们大多数人对偏执人格都有一个清晰的心理形象，当它被文艺作品刻画出来的时候，我们能认出这种类型。 比如Peter Sellers在经典电影《奇爱博士》中出色的表演，成功刻画了多疑、缺乏幽默感和自命不凡的一类人。如果我们有偏执的熟人，或者认出了我们每个人都可以在自己身上发现的偏执倾向的滑稽再现，我们就会觉得似曾相识。 然而识别不那么夸张的偏执表现则需要一种受过训练的敏感性。偏执型人格组织的本质是一种习惯，即通过否定和投射自己所感觉到的消极特质来处理消极特质;被否认的特性于是感觉起来像是外部威胁。投射性过程可能伴有有意识的自体夸大感，也可能没有。[Peter Sellers在该片中一人分饰三角：英国上尉、总统、奇爱博士。然而这三者都不是偏执。下令发起攻击的基地将军才是偏执] The diagnosis of paranoid personality structure implies to many people a serious disturbance in mental health, yet as with other dynamics that infuse personality, this type of organization exists on a continuum of severity from psychotic to normal (Freud, 1911; Meissner, 1978; D. Shapiro, 1965). As with the personality types in the preceding chapters, the defense that defines paranoia may derive from a time before the child had clarity about internal versus external events, where self and object were thus confused. Paranoia intrinsically involves experiencing what is inside as if it were outside the self. It may be that “healthier” paranoid people are rarer than “sicker” ones, but someone can have a paranoid character at any level of ego strength, identity integration, reality testing, and object relations. 对许多人来说，诊断出偏执型人格结构即意味心理健康存在严重的问题，其实这类人格也和其他人格类型一样，处于精神病态至健康常态的连续谱系中（Freud，1911；Meissner，1978；D.Shapiro，1965）。和前面几章所描述的人格类型相似，定义偏执者的防御机制可能在儿童能够区分内部事件与外部事件之前就已开始形成，这一时期幼儿对自体和客体是混淆的。偏执者的本质正是将内在的东西体验为自体之外的东西。“偏病态”的偏执者要比“偏健康”的偏执者更为多见，但一个具有偏执人格的人在自我强度、身份整合、现实检验和客体关系上处在任何级别都是有可能的。 The trait-based descriptions of paranoid personality disorder in DSM-IV are from a clinician’s perspective rather superficial, but the manual is accurate in noting that our knowledge of this personality type may be limited. A paranoid person has to be in fairly deep trouble before he or she seeks (or is brought for) psychological help. In contrast to depressive, hysterical, or masochistic people, for example, higher-functioning paranoid individuals tend to avoid psychotherapy unless they are in severe emotional pain or are causing significant upset to others. Because they are not disposed to trust strangers, paranoid people are also unlikely to volunteer to be research subjects. 从临床医生的角度来看，DSM-IV中对偏执型人格障碍基于特征的描述相当肤浅，但手册中准确地指出，我们对这种人格类型的了解可能有限。只有深陷困境，偏执者才会寻求(或被带来寻求)心理帮助。例如，与抑郁型、癔症型或自虐型人格相比，高功能偏执者倾向于避免心理治疗，除非他们处于严重的情感痛苦或对他人造成重大的不安。由于偏执者倾向于不信任陌生人，他们也不太可能自愿成为研究对象。 People with normal-level paranoid characters often seek out political roles, where their disposition to oppose themselves to forces they see as evil or threatening can find ready expression. Reporters and satirists have often portrayed Dick Cheney as paranoid, but even if they hate his politics, they have seldom questioned his capacity to cope efficaciously in the world. At the other end of the continuum, some serial murderers who killed their victims out of the conviction that the victims were trying to murder them exemplify the destructiveness of projection gone mad; that is, paranoia operating without the moderating effects of more mature ego processes and without a solid grounding in reality. Several recent notorious murders seem to have had a paranoid basis. 具有正常程度偏执性格的人通常会寻求政治角色，在政治角色中，他们倾向于反对他们认为邪恶或威胁的力量，这一点可以随时得到表达。记者和讽刺作家经常把Dick Cheney[小布什时期的美国副总统]描绘成偏执者，但即使他们讨厌他的政治，他们也很少质疑他有效应对世界的能力。在连续统的另一端，一些连环杀手杀害他们的受害者，因为他们坚信受害者是在试图谋杀他们，这是投射的破坏性进入疯狂的明证;也就是说，偏执者没有更成熟的自我过程的调节作用，也没有坚实的现实基础。最近发生的几起臭名昭著的谋杀案似乎都有偏执的嫌疑。 I want to emphasize again as I did in Chapter 5 that attributions of paranoia should not be made on the basis of an interviewer’s belief that a person seeking help is wrong about the danger he or she is in. Some people who look paranoid are actually being stalked or persecuted—by members of a cult they have left, for example, or by a rejected lover or a disaffected relative. (Some people who are diagnosably paranoid are also realistically imperiled; in fact, the off-putting qualities of many paranoid people make them natural magnets for mistreatment.) Some people who are not characterologically paranoid become temporarily so in paranoiagenic situations that are humiliating and entrapping. When interviewing for diagnostic purposes, one should not reject out of hand the possibility that the interviewee is legitimately frightened, or that those who are urging him or her to seek therapy have a personal stake in making the client look crazy. 我想再次强调，正如我在第5章中所强调的那样，访谈者不能因为认为来访者对其所处危险的判断是错误的，就将其归为偏执。有些看起来偏执的人实际上正被跟踪或迫害——例如，被他们离开的邪教团体的成员跟踪或迫害，或者被一个被拒的追求者或一个心怀不满的亲戚跟踪或迫害。(有些诊断为偏执的人实际上也处于危险之中;事实上，许多偏执者令人生厌的特质使他们天生就容易受到虐待。有些人不是性格上的偏执，而是在具有侮辱性和陷害性的情境中暂时变得如此[这种情境容易产生偏执]。当出于诊断目的进行访谈时，我们不应该立刻否认这样一种可能性，即受访者有理由感到害怕，或者那些敦促他寻求治疗的人与让来访者看起来疯狂有某种关系。 Contrastingly, some individuals who are in fact paranoid do not appear to be. Nonparanoid associates in their social group—and the interviewer for that matter—may share their beliefs about the dangers of certain people, forces, or institutions (terrorists, capitalists, religious authorities, pornographers, the media, the government, patriarchy, racists—whatever is seen as the obstacle to the triumph of good) and may therefore fail to discern that there is something internally generated and driven about their preoccupations (Cameron, 1959). If Congressman Allard Lowenstein had fathomed the paranoid character of Dennis Sweeney, one of his protégés in the student movements of the 1960s and the man who later assassinated him in the grip of a delusion, he might have known better than to behave in a way that was interpretable as sexually seductive, and he might still be alive (see D. Harris, 1982). But Lowenstein and Sweeney had similar beliefs about what social evils required confrontation, and where Lowenstein’s were not primarily projections, Sweeney’s were. 相反，有些人实际上是偏执，但看起来却不像。在这些人所属的社会团体中的非偏执的同事可能与他们共享相同的信念(关于哪些人，哪些力量，哪些机构是危险的，比如：恐怖分子、资本家、宗教权威、色情作品作者、媒体、政府、父权制、种族主义者，反正就是所有阻碍真善美获得胜利的东西)，从而没能看清楚有些东西是由他们的先占观念产生和驱动的(Cameron, 1959)。如果国会议员Allard Lowenstein早点发现Dennis Sweeney的偏执性格(后者是前者在1960年代学生运动中的门徒之一，在妄想发作时将前者杀害),他就不至于用被当作性诱惑的方式行事，可能现在还活着(参见D.Harris，1982)。Lowenstein和Sweeney对于有哪些需要对抗的社会邪恶势力有着相似的看法，只不过Lowenstein是基于客观事实，而Sweeney是内心先占观念的投射。 There are also people whose perceptions turn out to be prescient, who are nevertheless paranoid. Howard Hughes had a consuming terror of the consequences of atomic testing in Nevada at a time when few others were concerned with nuclear contamination of the environment. Years later, as the toll exacted by radiation became clearer, he looked a lot less crazy. But the eventual vindications of his point of view do not make his psychology less paranoid; the events of his later life speak for the extent to which his own projections were the source of his suffering (Maheu & Hack, 1992). My aim in bringing up all these possibilities is to stress the importance of making informed, reflective diagnostic judgments instead of automatic, a priori assumptions—especially with clients whose grim, suspicious qualities may make them hard to warm up to. 当然也有人的先占观念恰好与现实吻合，但仍属偏执本质。在多数人对核辐射污染问题尚未重视之时，Howard Hughes就已经提出了对内华达州原子弹试验后果的极度担忧。多年后，随着辐射造成的损失越来越清晰，他看上去不那么疯狂了。但最终证明他的观点是正确的，并没有让他的心理变得不那么偏执;他晚年的经历说明，他的真正痛苦来源于自己的投射(Maheu & Hack, 1992)。我之所以指出上述可能性，是强调应该综合各种信息做出深思熟虑的诊断，而不应仅凭来访者固执、多疑、冷淡就主观臆断。 DRIVE, AFFECT, AND TEMPERAMENT IN PARANOIA 偏执者的驱力、情感和气质 Because they see the sources of their suffering as outside themselves, paranoid people in the more disturbed range are likely to be more dangerous to others than to themselves. They are much less suicidal than equally disturbed depressives, although they have been known to kill themselves to preempt someone else’s expected destruction of them. The angry, threatening qualities of many paranoid people have prompted speculations that one contributant to a paranoid psychology is a high degree of innate aggression or irritability. It stands to reason that high levels of aggressive energy would be hard for a young child to manage and integrate into a positively valued sense of self, and that the negative responses of caregivers to an obstreperous, demanding infant or toddler would reinforce the child’s sense that outsiders are persecutory. There has not been much recent research relating paranoia to temperament; in 1978 Meissner marshalled empirical evidence connecting it with an “active” symptomatic style in infancy (irregularity, nonadaptability, intensity of reaction, and negative mood) and with a thin stimulus barrier and consequent hyperexcitability. 处在病态范围内的偏执者认为导致他们痛苦的根源在他们外部，所以他们对他人的危险性可能比对自己更大。他们的自杀倾向要比同等程度心理失常的抑郁症患者低得多，尽管他们会用自杀来防止别人对他们预期的毁灭发生。许多偏执者具有愤怒和威胁性的特质，这促使人们猜测，造成偏执心理的一个因素是高度的先天攻击性或易怒。顺理成章地,一个小孩很难管理高水平的攻击性能量，并将其集成到一个积极价值的自我感受中,养育者对这种难管束、要求多多的婴幼儿的负面反应,会强化孩子外部世界是迫害性的感觉。最近没有多少研究把偏执与性情联系起来;Meissner（1978）收集了大量的经验证据，将偏执与婴儿期的“活跃”症状类型(不服管教、不适应、反应过激和负面情绪)、薄薄的刺激屏障[刺激屏障是自我的一种功能，它使一个人能够调节内部和外部刺激的数量，以保持最佳的稳态和适应]以及随之而来的过度兴奋联系起来。 Affectively, paranoid people struggle not only with anger, resentment, vindictiveness, and other visibly hostile feelings, they also suffer overwhelmingly from fear. Silvan Tomkins (e.g., 1963) regarded the paranoid stance as a combination of fear and shame. The downward-left eye movements common in paranoid people (the “shifty” quality that even nonprofessionals notice) are physically a compromise between the horizontal-left direction specific to the affect of pure fear and the straight-down direction of uncontaminated shame (S. Tomkins, personal communication, 1972). Even the most grandiose paranoid person lives with the terror of harm from others and monitors each human interaction with extreme vigilance. 在情感上，偏执者不仅与愤怒、怨恨、报复性和其他明显的敌对情绪作斗争，他们还受到压倒性的恐惧折磨。Silvan Tomkins(例如，1963)认为偏执的思维方式是恐惧和羞耻的结合。偏执者普遍存在的眼睛向左下运动(这是即使是非专业人士也会注意到的“狡诈”特征)，可视作为眼睛水平向左（纯粹的恐惧感）和垂直向下（纯粹的羞耻感）两种眼动方向的折中（S.Tomkins，私人交流，1972）。即使是最浮夸的偏执者也会生活在他人伤害的恐惧中，并以极度的警惕监视着每一次互动。 Analysts have long referred to the kind of fear suffered by paranoid clients as “annihilation anxiety” (Hurvich, 2003); that is, the terror of falling apart, being destroyed, disappearing from the earth. Anyone who has experienced this level of dread knows how terrifying it is. The research of Jaak Panksepp (1998) into mammalian affect has identified this kind of anxiety as part of the FEAR system that evolved evolutionarily to cope with the possibility of predation. Panksepp differentiates it from attachment/separation anxiety that belongs neurobiologically to the PANIC system and is mediated by serotonin. Paranoid anxiety tends not to be quelled by serotonin reuptake inhibitors, but is instead responsive to benzodiazepines, alcohol, and other “downer” drugs, which may be why paranoid patients often struggle with addiction to those chemical agents. 长期以来，分析人士将偏执型来访者所遭受的那种恐惧称为“毁灭焦虑”(Hurvich, 2003);也就是说，崩溃的恐惧，被摧毁的恐惧，从地球上消失的恐惧。任何经历过这种级别的恐惧的人都知道它有多可怕。Jaak Panksepp(1998)对哺乳动物情感的研究发现，这种焦虑是恐惧系统的一部分，进化过程中，恐惧系统的进化是为了应对可能的捕食。Panksepp将其与依恋/分离焦虑区分开来，依恋/分离焦虑在神经生物学上属于恐慌系统，由血清素调节。偏执焦虑往往不会被血清素再摄取抑制剂[血清素又名5-羟色胺。血清素含量高，人就镇静。“再摄取”会导致血清素含量下降，抑制剂就是抑制“再摄取”过程的]所抑制，而是对苯二氮平类药物、酒精和其他“镇定剂”产生反应，这可能是偏执型患者常常对这些化学制剂上瘾的原因。 As for shame, that affect is as great a menace to paranoid people as to narcissistic ones, but paranoid people experience the danger differently. Narcissistic individuals, even arrogant ones, suffer conscious feelings of shame if they feel unmasked. Their energies go into efforts to impress others so that the devalued self will not be exposed. Paranoid people, contrastingly, may use denial and projection so powerfully that no sense of shame remains accessible within the self. The energies of the paranoid person are therefore spent on foiling the efforts of those who are seen as bent on shaming and humiliating them. People with narcissistic character structures are afraid of revealing their inadequacies; those with paranoid personalities are afraid of other people’s malevolence. This focus on the assumed motives of others rather than on what is happening internally can be, as anyone experienced with paranoid patients can testify, a formidable obstacle to therapy. 至于羞耻感，这种感情对于偏执者是极大的威胁，正如对于自恋者也是，但是偏执者对危险的体验是不同的。自恋者，哪怕傲慢的那些，如果他们觉得自己被揭穿了，就会清楚地感到羞愧。他们的精力都用来努力给别人留下深刻印象，这样贬值的自我就不会暴露。相反，偏执者可能会强有力地使用否认和投射，以至于没有羞耻感存在于自我之中。偏执者的精力因此总是花在挫败那些被视决心羞辱他们的人上。具有自恋型性格结构的人害怕暴露自己的不足;偏执型人格的人害怕别人的恶意。任何经历过偏执患者的人都可以证明，专注于他人的假设动机，而不是专注于自己内心发生的事情，这可能是治疗的一个巨大障碍。 Also like narcissistic people, paranoid individuals are vulnerable to envy. Unlike them, they handle it projectively. The degree of anger and intensity they have to manage may account for some of the difference. Resentment and jealousy, sometimes of delusional proportions, darken their lives. These attitudes may be directly projected (the conviction that “others are out to get me because of the things about me that they envy”); more often, they are ancillary to the denial and projection of other affects and impulses, as when a paranoid husband, oblivious to his own normal fantasies of infidelity, becomes convinced his wife is dangerously attracted to other men. Frequently involved in this kind of jealousy is an unconscious yearning for closeness with a person of the same sex. Because such longings may be unconsciously confused with erotic homosexuality (Karon, 1989), which can frighten heterosexual males, the wishes are abhorred and denied. These desires for care from a man then resurface as the conviction that it is, for example, one’s girlfriend rather than oneself who wants to be more intimate with a mutual male friend. 又和自恋者一样，偏执的人也容易受到嫉妒的感染。但与自恋者不同，偏执者以投射的方式处理嫉妒。他们必须控制的愤怒程度和(感情的)强度可能是造成这种差异的部分原因。怨恨和嫉妒，有时到了妄想的程度，使他们的生活暗无天日。这些态度可能是直接投射出来的(相信“别人是因为嫉妒我而故意找我事”) [这是第一种情形];更常见的情况是，它们[指嫉妒]是对其他情感和冲动的否认和投射的附属[这是第二种情形]，就像一个偏执的丈夫，丝毫意识不到自己对不忠的幻想，却变得确信他的妻子被其他男人危险地吸引。通常这种嫉妒与潜意识里对与一个同性别的人亲近的渴望有关。因为这种渴望可能被潜意识地与同性恋混淆(Karon, 1989)，而这会吓到一个异性恋男性[指偏执者]，这些愿望于是被憎恶和否认。这些从男人那里得到关爱的欲望会重新浮现，变成确信自己的女朋友而不是自己想要和一个共同的男性朋友更亲密。 Finally, paranoid people are profoundly burdened with guilt, a feeling that may be unacknowledged and projected in the same way that shame is. Some reasons for their deep sense of badness will be suggested below, along with ways of trying to relieve it therapeutically. Their unbearable burden of unconscious guilt is another feature of their psychology that makes paranoid clients so hard to help: They live in terror that when the therapist really gets to know them, he or she will be shocked by all their sins and depravities, and will reject or punish them for their crimes. They are chronically warding off this humiliation, transforming any sense of culpability in the self into dangers that threaten from outside. They unconsciously expect to be found out, and they transform this fear into constant, exhausting efforts to discern the “real” evil intent behind anyone else’s behavior toward them. 最后，偏执者背负着深深的罪恶感，这种感觉可能不会被意识到，但会被投射出来，正如羞耻一样[罪恶感会被投射]。下面将介绍一些导致他们产生严重不良感觉的原因，以及试图通过治疗来缓解这种感觉的方法。潜意识里的罪恶感造成的不可承受之负担是他们的另一个心理特征[“另一个”是指恐惧，不同于前边的罪恶感，恐惧并未被投射]，该特征使得偏执来访者很难得到救助：他们生活在一种恐惧中，这种恐惧就是一旦治疗师真的了解他们，治疗师就会为他们的罪恶与堕落所震惊，于是因为他们的罪恶拒绝或惩罚他们。他们习惯性地避开这种羞辱，把自己的罪恶感转化为来自外界具有威胁性的危险。他们潜意识里预计会被揭穿，并将这种恐惧转化为持续的、精疲力尽的努力，以辨别其他人对他们行为背后的真正邪恶意图。[罪恶感被投射出去，但还有所保留，保留着的罪恶感=>想象中罪恶被发现后的羞辱=>对羞辱的恐惧=>来自外界的威胁=>寻找潜在的威胁] DEFENSIVE AND ADAPTIVE PROCESSES IN PARANOIA 偏执者的防御和适应机制 Projection, and disavowal of what is projected, dominate the psychology of the paranoid person. Depending on the patient’s ego strength and degree of stress, the paranoid process may be at a psychotic, borderline, or neurotic level. Let me first review those differences. In a frankly psychotic person, upsetting parts of the self are projected and fully believed to be “out there,” no matter how crazy the projections may seem to others. The paranoid schizophrenic who believes that homosexual Bulgarian agents have poisoned his water is projecting his aggression, his wish for same-sex closeness, his ethnocentrism, and his fantasies of power. He does not find ways of making his beliefs fit with conventional notions of reality; he may be quite convinced that he is the only one in the world who sees the threat. 投射，以及对投射之物的否认，支配着偏执者的心理。根据患者的自我强度和压力程度，偏执的过程可能处于精神病性、边缘性或神经症性的水平。让我先回顾一下这些差异。在一个正儿八经的精神病性来访者身上，自体的烦乱部分被投射出来，并被完全相信是“在外部”，他并不管这些投射在别人看来有多疯狂。那个偏执的精神分裂症患者认为同性恋的保加利亚助理在他的水里下了毒，就是正在投射他的攻击性、他对同性亲密关系的渴望、他的种族优越感以及他对权力的幻想。他没有找到使自己的信念与传统的现实观念相适应的方法；他可能深信自己是世界上唯一一个看到这种威胁的人。 Because reality testing is not lost in people at a borderline level of personality organization, paranoid patients in the borderline range project in such a way that those on whom disowned attitudes are projected are subtly provoked to feel those attitudes. This is projective identification:The person tries to get rid of certain feelings, yet retains empathy with them and needs to reassure the self that they are justified. The borderline paranoid person works to make what is projected “fit” the target. Thus the woman who disowns her hatred and envy announces to her therapist in an antagonistic manner that she can tell that the therapist is jealous of her accomplishments; comments made in a sympathetic spirit are reinterpreted by the client as evidence of envy-driven wishes to undermine and control, and soon the therapist, worn down by being steadily misunderstood, is hating the patient and envying her freedom to vent her spleen (Searles, 1959). This remarkable process torments therapists, who do not choose our profession expecting to have to endure such powerful negative feelings toward those we hope to help; it accounts for the general intolerance among many mental health professionals toward both borderline and paranoid patients. 处在人格组织边缘水平上的人，其现实检验能力并未丧失，所以边缘性范围内的偏执患者会以这样一种方式进行投射——偏执者把被自己否认的态度投射到被投射者身上，然后被投射者会被偏执者巧妙地激惹以感觉到这些态度[即被投射者被偏执者激惹后产生了一种与偏执者一样的态度，即那些偏执者自己不想要的态度]。这就是投射性认同：一个人[即偏执者]试图驱除某些感觉(但仍保持对这些感觉的同理心)并让自己安心(即让自己相信那些感受是正当的)。[偏执者不想要那些感受，所以他将其投射出去。但他仍旧对这些感受具有同理心，所以才会将其认同回来。他这样做就是为了让自己安心(那些感受是正当的)]边缘性偏执者努力使被投射之物“符合”被投射者[其实是努力使被投射者“符合”被投射之物]。 因此，一个否认自己的仇恨和嫉妒的女人会以一种敌对的方式向她的治疗师宣布，她可以看出治疗师嫉妒她的成就；治疗师出于同情的精神所做的评论被来访者重新解释为能够证明治疗师因为嫉妒而想要诋毁和控制她，很快，治疗师就会被不断的误解弄得疲惫不堪，开始憎恨病人，并嫉妒患者可以随心所欲地发泄自己的坏脾气(Searles, 1959)。这一不寻常的过程折磨着治疗师，治疗师们选择这个职业，并不是希望承受对我们希望帮助的那些人产生的如此强烈的负面感受;这解释了为什么许多精神卫生专业人员都对边缘性偏执患者难以忍受。 In paranoid people at the neurotic level, internal issues are projected in a potentially ego-alien way. That is, the patient projects yet has some observing part of the self that eventually will be capable, in the context of a reliable relationship, of acknowledging the externalized contents of the mind as projection. People who, in an intake interview, describe themselves as paranoid are often in this category (though borderline and psychotic paranoid clients may sometimes talk this way also, in an effort to show that they know the jargon but without any real internal appreciation that their fears constitute projections). I knew one of my patients was getting better when he came in announcing that he was having fantasies that I was critical, even though he couldn’t find any evidence of my critical attitude. Sensitive to the possible grain of truth in a projection, I said something like, “Well, let me think about whether there is some way in which I may have been critical,” and he responded, “Can’t you sometimes just let it be my crazy paranoia?!” 神经症水平的偏执者会不知不觉地将内心的问题以自我不协调的方式投射出来。即来访者在投射时，自我会同时具有一定的观察力，在良好的咨访关系背景下，来访者的这种能力有助于他们认识到自己内心思维的外化，认识自己的投射。在初始访谈中就描述自己偏执状态的来访者，多数属于这一类型（虽然边缘水平和精神病水平的偏执者有时也会如此，但目的多为显示自己懂行，并非真正认识到自己的恐惧构成了投射）。有位来访者曾告诉我，那段时间他曾想象我是位声色俱厉的治疗师，但在现实中却找不到任何证据，而我由此得知他的病情正在逐渐好转。出于对投射中可能存在的真实成分的警觉，我说道：“既然这样，那我来回忆一下是否严厉地批评过你，”他反问道：“你就不能偶尔让我偏执一下吗？！” A talented and healthy but characterologically paranoid client of mine was subject to profound fears that I would sell him out in the service of my need to look good to others. If a professional in the community who knew both of us were to criticize him to me, he was sure that I would somehow convey agreement. (Meanwhile, when he felt hurt by me, he had no reluctance to complain about me in ways that made some of my colleagues quite critical of my treatment of him.) Even before he was able to understand this fear as the projection of his own—unnecessarily hated —needs for acceptance and admiration, plus the projection and acting out of his defensive criticism, he was willing to consider that he might be putting on me something that I did not deserve. 我有一位健康且颇有才华的来访者，性格比较偏执，一直担心我会以他的案例四处炫耀以标榜自己的才能。他猜想如果某位治疗师对我说他的坏话，我一定会欣然表示赞同。（其间，当他在治疗中感到受伤时，会毫不留情地指责我的过失，从而让我的一些同事对我对他的治疗持相当的批评态度）甚至在他意识到这种担心其实是对他自己需要接纳和赞扬的投射(他恨自己竟然有这种需求)，以及对他的预防性批评[防御性批评：觉得别人要批评我，我先把别人批评一遍]的投射和付诸行动之前，他就愿意考虑，他可能在给我强加一些我并不具有的东西。[来访者想得到别人的赞美，但他的超我觉得这种念头是不好的。于是他将这种念头投射到治疗师身上，认为是治疗师想得到别人的赞美。来访者受不了超我的指责，于是他把超我也投射了出去，投射到了治疗师身上，认为治疗师会在背地里指责他。然后为了对付这种潜在的指责，他对治疗师进行了预防性批评。预防性批评其实是先把超我对自我的批评投射到别人身上，认为别人要批评自己，然后自己再去预防性反击。] The need of the paranoid person to handle upsetting feelings projectively entails the use of an unusual degree of denial and its close relative, reaction formation. All of us project; indeed, the universal disposition toward projection is the basis for transference, the process that makes analytic therapy possible. But paranoid people do it in the context of such a great need to disavow upsetting attitudes that it feels like a whole different process from projective operations in which denial is not so integral. Freud (1911) accounted for paranoia, at least of the psychotic variety, by the successive unconscious operations of reaction formation (“I don’t love you; I hate you”) and projection (“I don’t hate you; you hate me”). Implicit in this formulation is the paranoid person’s terror of experiencing normal loving feelings, presumably because prior attachment relationships were toxic. Freud thought same-sex longing was particularly implicated in paranoia, but my own experience suggests that any kind of longing feels unbearably dangerous to a paranoid person. 偏执者普遍需要以投射来应对消极情绪，这必然导致他们频繁地使用否认及作用相似的反向形成。我们每个人都使用投射，事实上普遍的投射倾向正是移情的基础，移情的存在使得分析性治疗成为可能。但偏执者投射的目的是强烈地回避负性态度，这种态度使投射的过程是如此不同，使该过程充斥着全然否认的气息。弗洛伊德（1911）将偏执（至少是精神病水平的偏执）解释为潜意识中的反向形成（“我不爱你；我恨你”）和投射（“我不恨你；是你恨我”）的连续运作。这种表述暗含了偏执者对体验爱意的恐惧，这很可能与偏执者早年的不良依恋关系有关。弗洛伊德还认为偏执中也包含着强烈的同性渴望，而且据我所知，任何形式的渴望对于偏执者而言，都是难以承受的危险因素。 Freud’s paradigm shows only one of several possible routes by which a paranoid person may emerge at a psychological place very far from the original, more humanly comprehensible attitudes that initiated the paranoid process (Salzman, 1960). Karon (1989) summarizes the ways in which a delusional paranoid person can handle wishes for same-sex closeness: 弗洛伊德的范式只显示了偏执者可能出现在远离最初引发偏执过程的、人类可理解态度的心理场所的几种可能途径之一(Salzman, 1960)[就跟犯罪分子把尸体从第一现场转移到其他地方一样]。Karon (1989)总结了妄想型偏执者处理同性亲密渴望的方式: If one considers the different ways in which one could contradict the feeling “I love him,” one derives many typical delusions. “I do not love him, I love me (megalomania).” “I do not love him, I love her (erotomania).” “I do not love him, she loves him (delusional jealousy).” “I do not love him, he loves me (projecting the same-sex longing, producing a delusional homosexual threat).” “I do not love him, I hate him (reaction formation).” And, finally, most common, projecting the delusional hatred as “He hates me, hence, it is alright for me to hate him (and if I hate him, I do not love him).” (p. 176) 如果一个男人用不同的方式来否认“我爱另一个男人”的感觉，他就会产生许多典型的妄想。“我不爱他，我爱我自己(自大狂)。“我不爱他，我爱她(色情狂)。”“我不爱他，她爱他(妄想性嫉妒)。”“我不爱他，他爱我。”（对同性渴望的投射，将导致妄想性同性恐惧）“我不爱他，我恨他(反向形成)。”最后，也是最常见的一种，把这种妄想式的仇恨投射成“他恨我，因此，我有理由恨他(因为如果我恨他，我就不爱他)。””(176页) Again, a significant difficulty in working with paranoid people concerns how long and convoluted is the distance between their basic affects and their defensive handling of them. 由此可见，治疗偏执者的棘手问题是：判别他们的基本情感与防御后的情感表现之间相距几何、有多迂回。 RELATIONAL PATTERNS IN PARANOID PSYCHOLOGY 偏执心理中的关系模式 Clinical experience suggests that children who grow up paranoid have suffered severe insults to their sense of efficacy; they have repeatedly felt overpowered and humiliated (MacKinnon et al., 2006; Tomkins, 1963; Will, 1961). The father of Daniel Paul Schreber, from whose report of a paranoid psychosis Freud (1911) extracted a theory of paranoia, was reportedly a domineering patriarch who advocated, and insisted on his son’s adopting, arduous physical regimes intended to toughen up children (Niederland, 1959). Then Schreber suffered humiliation by authorities he had trusted and by the legal system of his era (Lothane, 1992). 临床经验表明，自我效能感受到严重损伤的儿童最后会成长为偏执者;他们反复体验到被压制和羞辱(MacKinnon et al., 2006; Tomkins, 1963; Will, 1961)。Daniel Paul Schreber(弗洛伊德从其关于自己偏执性精神病的报告中萃取出关于偏执的理论)的父亲据说是一位专横跋扈的家长，他主张用严酷的躯体训练来增强儿子的意志（Niederland，1959）。后来，Schreber被他信任的当局和他那个时代的法律体系羞辱(Lothane, 1992)。 Criticism, capricious punishment, adults who cannot be pleased, and utter mortification are common in the backgrounds of paranoid people. Those who rear children who become paranoid also frequently teach by example. A child may observe suspicious, condemnatory attitudes in parents, who emphasize—paradoxically, in view of their abusive qualities and the objectively kinder worlds of school and community—that family members are the only people one can trust. Paranoid people in the borderline and psychotic ranges may come from homes where criticism and ridicule dominated familial relationships, or where one child, the future sufferer of paranoia, was the scapegoat—the target of the family members’ hated and projected attributes, especially those in the general category of “weakness.” In my experience, those in the neurotic-to-healthy range tend to come from families in which warmth and stability were combined with teasing and sarcasm. 批评、反复无常的惩罚、难以取悦的成年人以及彻底的苦行，是偏执者很常见的成长背景。那些把孩子养育成偏执的家长也经常言传身教。孩子可能会注意到父母的怀疑和谴责态度，他们强调家庭成员是唯一可以信任的人(矛盾的是，他们的虐待品质，对比客观上相对友善的学校及社区)。处于边缘和精神病范围的偏执者可能来自批评和嘲笑主导家庭关系的家庭，或者孩子(未来的偏执者)成为替罪羊的家庭——这样的孩子是家庭成员憎恨和投射自身不好属性的目标。以我的经验来看，那些从神经症到健康的人往往来自于温暖、稳定与戏弄、讽刺交织在一起的家庭。 Another source of paranoid personality organization is unmanageable anxiety in a primary caregiver. A paranoid patient of mine came from a family in which the mother was so chronicallynervous that she took a thermos of water with her everywhere she went (for her dry mouth) and described her body as having “turned into a cement block” from accumulated tension. Whenever her daughter would come to her with a problem, the mother would either deny it, because she could not bear any additional worries, or catastrophize about it, because she could not contain her anxiety. The mother was also confused about the line between fantasy and behavior and hence conveyed to her child that thoughts equaled deeds. The daughter got the message that her private feelings, whether loving or hateful, had a dangerous power. 偏执型人格组织的另一个来源是主要养育者难以控制的焦虑。我的一位偏执型病人来自一个家庭，她的母亲长期以来都非常紧张，以至于无论她走到哪里(因为她口干)，她都随身带着一保温瓶水，她形容自己的身体由于紧张累积而“变成了水泥块”。每当她的女儿向她提出问题时，她的母亲要么否认(因为她无法承受任何额外的担心)，要么把灾难化思考(因为她无法控制自己的焦虑)。这位母亲也对幻想和行为之间的界限感到困惑，因此向她的孩子传达了这样的信息:思想等同于行动。女儿得到的信息是，她的私人感情，无论是爱还是恨，都有一种危险的力量。 For example, when once as an adult my patient told her mother that in reaction to her husband’s arbitrariness she had challenged him, her mother first contended she was misreading him: He was a devoted husband, and she must be imagining anything objectionable coming from him. When my patient persisted with an account of the argument, her mother urged her to be careful, as he might beat her up or abandon her if provoked (she herself had been battered and then divorced by her husband). And when my patient went on to vent anger at how he had acted, she was begged to think about something else so that her negative thoughts would not make things worse. An adolescent prototype for this interaction was her telling her mother of her father’s effort to molest her. The mother managed both to insist that it had not happened and to blame it on her daughter’s sexuality. 例如，有一次我的病人，作为一个成年人，告诉她的母亲，为了回应她丈夫的专横跋扈，她向他发起了挑战，她的母亲首先辩称她误解了丈夫:女婿是一个忠诚的丈夫，女儿一定是在想象他会说出什么令人不快的话。当我的病人持续说她争吵的原因时，她的母亲劝她要小心，因为他可能会打她，或者在被激怒时抛弃她(她自己也曾被丈夫殴打，然后被离婚)。当我的病人继续对他的行为发泄愤怒时，她被要求想点别的事情，这样她的消极想法就不会使事情变得更糟。这种互动的一个青春期原型是她告诉母亲，她的父亲曾试图骚扰她。这位母亲坚持认为这一切都没有发生，并将其归咎于女儿太性感。 This well-meaning but very disturbed mother, who had had no comfort as a youngster, was incapable of comforting. In her daughter’s formative years, her anxiety-soaked advice and dire predictions compounded the girl’s fears. My client thus grew up being able to console herself only by drastic transformations of her feelings. When I began working with her, she had already seen several therapists who had been defeated by her bottomless need and relentless hostility. All of them had seen her as paranoid in either the psychotic or low-level borderline range. Her capacity to report transactions like the preceding to me, and to comprehend how destructive similar ones had been all her life, came only after many years of therapy. 这位慈祥而又十分不安的母亲，年轻时没有得到过安慰，现在也无法安慰人。在女儿的成长过程中，她充满焦虑的建议和可怕的预言加重了女儿的恐惧。因此，我的来访者在成长过程中只能通过感情的剧烈转变来安慰自己。当我开始和她一起治疗时，她已经见过好几位治疗师，他们都被她无尽的需求和无情的敌意打败了。他们所有人都认为她的偏执要么处在精神病水平，要么处在较低的边缘水平[意思就是很接近精神病水平了]只有在多年治疗后，她才有能力向我报告类似的事情，并理解类似的事情在她的一生中造成了多大的破坏。 One can detect in the preceding example of distorted maternal responsiveness several different seeds of paranoia. First, both reality and the patient’s normal emotional reactions to it were disconfirmed, instilling fear and shame rather than a sense of being understood. Second, denial and projection were modeled. Third, primitive omnipotent fantasies were reinforced, laying the foundation for a diffuse and overwhelming guilt. Finally, the interaction created additional anger while resolving none of the original distress, thus magnifying the patient’s confusion about basic feelings and perceptions. In situations like this, in which a person has been implicitly insulted (in this case, seen as unappreciative, incapable of managing feelings, dangerous), he or she must at some level feel even more aggravated than originally. But such a reaction may be judged as either incomprehensible or evil because the insulting party was only trying to help. 在前面扭曲的母亲回应的例子中，我们可以发现一些不同的偏执的种子。首先，现实和病人对现实的正常情感反应都是被驳斥的，同时灌输的是恐惧和羞耻，而不是被理解的感觉。其次，否认和投射被模仿。第三，原始全能幻想得到了强化，为弥漫和压倒性的罪恶感打下了基础。最后，这种互动产生了额外的愤怒，而没有解决任何最初的痛苦，从而放大了病人对基本感觉和感知的困惑。在这种情况下，一个人受到了隐式的羞辱(在这种情况下，被视为不领情、无法控制感情、危险)，她一定在某种程度上感到比最初更加愤怒。但是这样的反应可能会被认为是不可理解的，或者是邪恶的，因为羞辱人的一方只是想帮忙。 Such mind-muddling transactions get replicated repeatedly in the adult relationships of paranoid people. Their internalized objects keep undermining both the paranoid person and those to whom he or she relates. If a child’s primary source of knowledge is a caregiver who is deeply confused and primitively defended, who—in desperate attempts to feel safe or important—uses words not to express honest feeling but to manipulate, the child’s subsequent human relations cannot be unaffected. The struggle of the paranoid person to understand what is “really” going on (D. Shapiro, 1965) is comprehensible in this light, as is the bewilderment, helplessness, and estrangement that beset people dealing with paranoid friends, acquaintances, and relatives. 这种让人头脑混乱的互动在偏执者长大成人后的关系中反复出现。他们的内部客体[内部客体就是内化的母亲]不断地损害偏执者以及与偏执者有关系的人。如果一个孩子的主要知识来源是养育者，而养育者自己就很糊涂，而且使用原始防御机制，并在为了获取安全感和重要感的绝望努力中，使用语言不是为了表达真情实感，而是为了操控，孩子后来的人际关系不可能不受影响。从这个角度看，偏执者想要了解“真正”发生了什么(D. Shapiro, 1965)的挣扎是可以理解的[偏执者就跟敌营里的特工一样，总觉得自己暴露了，总觉得别人有阴谋]，同样，困惑、无助和疏远，这些困扰着与偏执者(朋友、熟人和亲戚)打交道的人们的东西也是可以理解的了。 The mother’s anxiety was not the only influence on this woman’s psychology, of course. If she had had any significant caregiver capable of relating in a confirmatory way, her personality would probably not have developed in a paranoid direction. But her father, prior to abandoning his family when she was an older teenager, was frighteningly critical, explosive, and disrespectful of boundaries. The tendency of paranoid people to lash out rather than endure the anxiety of passively awaiting inevitable mistreatment (“I’ll hit you before you hit me”) is another well-known and unfortunate cost of this kind of parenting (Nydes, 1963). The presence of a frightening parent and the absence of people who can help the child process the resulting feelings (except by making them worse) is, according to many therapists who have successfully mitigated the condition, a common breeding ground for paranoia (MacKinnon et al., 2006). 当然，母亲的焦虑并不是影响这个女性来访者心理的唯一因素。如果她有任何一个重要的养育者能够以一种确定的方式与她交流，她的性格可能不会朝着偏执的方向发展。但是她的父亲，在她十几岁时抛弃家庭之前，是一个非常挑剔，暴躁，不尊重界限的人。这种教育的另一个众所周知的不幸代价，就是偏执者宁可先发制人，也不愿坐以待毙，忍受被动地等待不可避免的虐待带来的焦虑(“先下手为强”)，(Nydes, 1963)。根据许多成功缓解了这种情况的治疗师的说法，可怕的父母的存在，以及没有人能帮助孩子处理由此产生的感觉(除了使其变得更糟)，是产生偏执的温床(MacKinnon et al.， 2006)。 Because of their orientation toward issues of power and their tendency to act out, paranoid people have some qualities in common with psychopathic ones. But a critical difference lies in their capacity to love. Even though they may be terrified by their own dependent needs and wracked with suspicion about the motives and intentions of those they care about, paranoid individuals are capable of deep attachment and protracted loyalty. However persecutory or inappropriate their childhood caregivers were, paranoid clients apparently had enough availability and consistency in their early lives to be able to attach, albeit anxiously or ambivalently. Their capacity to love is what makes therapy possible in spite of all their hyperreactivity, antagonisms, and terrors. 因为偏执者在意权力问题，趋向于付诸行动，在这两点上他们与精神变态患者[精神变态人格即反社会人格]有一些相似。但关键的区别在于他们的爱的能力。尽管偏执型的人可能会被自己的依赖需求吓到，对自己关心之人的动机和意图产生怀疑，但他们能够对他人产生深深的依恋和持久的忠诚。无论他们的童年养育者是多么的虐待或不称职，偏执者显然在他们的早年生活中得到了足够的可得性[指能够得到养育者的照管]和一致性，从而能够依恋他人，尽管是焦虑和矛盾地依恋。尽管偏执者具有高度敏感、对抗和恐惧的特点，但这种爱的能力使得治疗成为可能。 THE PARANOID SELF 偏执型自体 The main polarity in the self-representations of paranoid people is an impotent, humiliated, and despised image of the self versus an omnipotent, vindicated, triumphant one. A tension between these two images suffuses their subjective world. Cruelly, neither position affords any solace: A terror of abuse and contempt goes with the weak side of the polarity, whereas the strong side brings with it the inevitable side effect of psychological power, a crushing guilt. 偏执者自体表征的对立是：无能、被羞辱、被轻视的形象 与 无所不能、反败为胜[指众人说他错了，最后却证明他是对的]、得意洋洋[指因获胜而得意洋洋]的形象的对立。两种形象之间的紧张对立，充斥着他们的主观世界。残酷的是，无论哪种形象都不能提供任何安慰：对受虐和蔑视的恐惧伴随着弱的一面，而强的一面则带来了心理力量不可避免的副作用——强烈的负罪感[心理力量是指这样一种能力，拥有这种能力的人可以掩盖他们的真实想法，不让你知道他们正在试图说服你或影响你。这种心理力量显然与无所不能的全能感有关]。 The weak side of this polarity is evident in the degree of fear with which paranoid people chronically live. They never feel fully safe and spend inordinate energy scanning the environment for dangers. The grandiose side is evident in their “ideas of reference”: Everything that happens has something to do with them personally. This is most obvious in psychotic levels of paranoia, instances in which a patient believes, say, that he or she is the personal target of an international spy ring or is receiving covert messages during TV commercials about the incipient end of the world. But I have also heard high-achieving, reality-oriented clients ruminate about whether the fact that someone sat in their usual chair revealed a plot to harass and humiliate them. Incidentally, such clients often do not come across as paranoid in the intake interview, and it can be startling to hear, after several sessions, the emergence of the organizing conviction that everything that happens to them reflects the significance to other people of their personal existence. 这种极性弱的一面，明显体现在恐惧的程度中，偏执者长期生活在一种恐惧之中。他们从来没有感到完全安全，并花费过多的精力在环境中寻找危险。狂妄的一面则很明显地体现在他们的牵连观念中:发生的每件事都与他们个人有关。这在精神病性偏执者中表现得最为明显，比如，患者认为自己是一个国际间谍组织的个人目标，或者在电视广告中收到有关世界末日即将来临的秘密信息。但我也听到过一些成功、注重现实的客户在反复思量，某人坐在他们[指偏执者]通常坐的椅子上，是否透露出了骚扰和羞辱他们的阴谋。顺便说一句，这样的客户在初始访谈中通常不会给人以偏执的印象，但在几次会谈后，治疗师会惊讶地发现他们显现出一种有组织的信念:发生在他们身上的每件事，都反映了他们个人的存在对其他人具有重要意义。[牵连观念，是指将无关的外界现象解释为与本人有关] The megalomania of paranoid people, whether unconscious or overt, burdens them with unbearable guilt. If I am omnipotent, then all kinds of terrible things are my fault. The intimate connection between guilt and paranoia can be intuitively comprehended by any of us who have felt culpable and then worried about being exposed and punished. I notice that when one of my students is late turning in a paper, he or she avoids me whenever possible, as if the only thing on my mind is that transgression and my planned retribution. A woman I was treating who was having an extramarital affair reported with amusement that while she was on a drive with her lover, holding hands in the car, she noticed a police vehicle ahead and pulled her hand away. 妄想症患者的妄自尊大，无论是无意识的还是公然的，都会给他们带来难以承受的罪恶感。如果我无所不能，那么所有可怕的事情都是我的错。罪恶感和偏执密切相关，我们当中任何一个人都可以凭直觉理解，我们觉得自己有罪，然后又担心被揭穿和受到惩罚。我注意到，当我的一个学生迟交论文时，他总是尽可能地避开我，好像我脑子里唯一想的事就是他的违规[指没交论文]和我的惩罚计划[这个例子并不是偏执，仅仅是帮助我们理解犯错后担心受到惩罚的心理]。我接待的一位有婚外恋的女士饶有兴趣地说，当她和情人手拉手在车里开车时，她注意到前面有一辆警车，于是把手抽了回去[这个例子才是偏执。明显的牵连观念，警车跟她并没有关系，而她认为有]。 When an unbearable attitude is denied and projected, the consequences can be grave. A connection between paranoia and disavowed homosexual preoccupations has been noted for some time by clinicians (e.g., Searles, 1961) and was confirmed by some empirical studies (e.g., Aronson, 1964) several decades ago. More recently, Adams, Wright, and Lohr (1996) did a series of experiments that showed that the more a man was aroused by homosexual imagery, the more homophobic he tested. Paranoid people, even the minority of them who have acted on homoerotic feelings, may regard the idea of same-sex attraction as upsetting to a degree that is scarcely imaginable to the nonparanoid. To gay and lesbian people, who find it hard to see why their sexual orientation is perceived as so threatening, the homophobia of some paranoid groups is truly menacing. 当一种无法忍受的态度被否定和投射时，后果可能是严重的。一段时间以来，临床医生(如Searles, 1961)已经注意到偏执和被否认的同性贯注[指满脑子想的都是同性]之间的联系，几十年前的一些实证研究(如Aronson, 1964)也证实了这一点。最近，Adams, Wright和Lohr(1996)做了一系列的实验，这些实验表明，一个男人被同性形象唤起[指性唤起]的越多，他就越害怕同性恋。偏执型的人，甚至是少数有过同性恋行为的人，都会认为同性之间的吸引力会让人感到不安，这种不安的程度对非偏执型的人来说是难以想象的。对于同性恋者来说，他们很难理解自己的性取向为何会被视为如此具有威胁性，一些偏执的群体对同性恋的憎恶确实吓人。 As the brief triumph of Nazism demonstrates (and Nazism targeted gay people, mentally disabled people, and the Roma, as well as the Jews), when paranoid trends are shared by a whole culture or subculture, the most horrific possibilities arise. Students of the rise of Nazism (e.g., Gay, 1968; Rhodes, 1980; F. Stern, 1961) locate its psychological origins in the same kinds of events that clinicians have found in the childhoods of paranoid individuals. The crushing humiliation of Germany in World War I and the subsequent punitive measures that created runaway inflation, starvation, and panic, with little responsiveness from the international community, laid the groundwork for the appeal of a paranoid leader and the organized paranoia that is Nazism (for a description of the role of paranoia in recent American politics, see Welch, 2008). 正如纳粹主义的短暂胜利所表明的那样(纳粹主义的目标是同性恋者、智障人士、罗姆人以及犹太人)，当偏执的趋势被整个文化或亚文化所共有时，最可怕的可能性就会出现。研究纳粹主义崛起的学者（如，Gay，1968；Rhodes，1980；F.Stern，1961）将其心理根源定位于临床医生在偏执型个体的童年时期发现的同样类型的事件。德国在第一次世界大战中受到的极大侮辱和随后的惩罚性措施,创造了恶性通货膨胀,饥饿,和恐慌,国际社会的视而不见,奠定了对偏执型领袖和纳粹主义这种有组织偏执的诉求(有关当代美国政界偏执角色的描述，请参阅Welch，2008)。 At the core of the self-experience of paranoid people is a profound emotional isolation and need for what Sullivan (1953) called “consensual validation” from a “chum” or what Benjamin (1988) later called “recognition.” The main way in which paranoid people try to enhance their selfesteem is through exerting effective power against authorities and other people of importance. Experiences of vindication and triumph give them a relieving (although fleeting) sense of both safety and moral rectitude. The dreaded litigiousness of paranoid individuals derives from this need to challenge and defeat the persecutory parent. Some people with paranoid personalities provide devoted service to victims of oppression and mistreatment, because their disposition to battle unjust authorities and vindicate underdogs keeps them on the barricades far longer than other well-meaning social activists whose psychodynamics do not similarly protect them against burnout. 偏执者的自体体验的核心是一种深刻的情感孤立，他们需要被Sullivan(1953)称之为“朋友的一致认可”的东西，或Benjamin(1988)后来所说的“认可”。偏执者增强自尊的主要方式是对权威人士和其他重要人物施加有效的权力。昭雪[指对所受到的责难或嫌疑的澄清]和胜利的经历给了他们一种安全感和道德正义感上的宽慰(尽管是短暂的)。偏执者令人敬畏地好打官司，这源于他们挑战和打败作为迫害者的父母的需要。有些偏执型人格的人会为遭受压迫和虐待的受害者提供投入的服务，因为他们倾向于与不公正的当局斗争，为弱者辩护，这让他们比其他善意的社会活动家在这一议题上停留的时间要长得多(后者的心理动力无法提供类似的保护以避免精疲力尽)。 TRANSFERENCE AND COUNTERTRANSFERENCE WITH PARANOID PATIENTS [todo]偏执者的移情和反移情 Transference in most paranoid patients is swift, intense, and often negative. Occasionally, the therapist is the recipient of projected savior images, but more commonly he or she is seen as potentially disconfirming and humiliating. Paranoid clients approach a psychological evaluation with the expectation that the interviewer is out to feel superior by exposing their badness, or is pursuing some similar agenda that has nothing to do with their well-being. They tend to strike clinicians as grim, humorless, and poised to criticize. They may fix their eyes relentlessly on the therapist in what has been called the “paranoid stare.” 多数偏执者的移情反应转换迅速、张力十足且负性移情居多。治疗师偶尔会成为他们的救世主，但更常被视作驳斥和羞辱他们的对象。偏执者寻求心理咨询时，要么认为治疗师故意寻找他们的短处，以摆出权威的姿态；或是治疗师有意找茬，但一无所获。他们时常表现出冷漠、泰然、无动于衷的态度来刺激治疗师。甚至，他们会死死盯着治疗师，临床称之为“偏执的凝视”（paranoid stare）状态。 Not surprisingly, interviewers respond with a sense of vulnerability and general defensiveness. Countertransference is usually either anxious or hostile; in the less common instance of being regarded as a savior, it may be benevolently grandiose. In any case, the therapist is usually aware of strong reactions, in contrast to the often subtler countertransferences that arise with narcissistic and schizoid patients. Because of the combination of denial and projection that constitute paranoia, causing the repudiated parts of the self to be extruded, therapists of paranoid patients often find themselves consciously feeling the aspect of an emotional reaction that the client has exiled from consciousness. For example, the patient may be full of hostility, whereas the therapist feels the fear against which the hostility is a defense. Or the patient may feel vulnerable and helpless, while the therapist feels sadistic and powerful. 治疗师的无力感和戒备心自然成了意料之中。他们的反移情通常是焦虑或敌对；偶尔被当成救世主时，反移情又改作慷慨的大度。通常情况下，治疗师对自己强烈的反应会有较为清晰的认识，不像面对自恋者和分裂者时的反移情那样难以捉摸。由于偏执者的主要防御是否认和投射，被偏执者拒绝的自我部分被投射出，因此，治疗师能够在意识层面感受到，自己的情绪反应是由于偏执者有意识的流露而导致。比如，来访者无形中的充满敌意，使治疗师可能感到恐惧，而这种恐惧反移情正说明是来自对方的敌意一—恰恰是来访者对恐惧的防御。再或治疗师感到自己残忍且有力的反移情，可能是来自来访者展现出的脆弱无助一—对自己的攻击冲动的防御。 Because of the weight of these internal reactions in the therapist, and the extent to which they betray to a sensitive person the degree of suffering that a paranoid client is trying to manage, there is a countertransference tendency in most therapists to try to “set the patient straight” about the unrealistic nature of whatever danger the patient believes he or she is in. Most of us who have practiced for any length of time have had at least one client who seemed to be crying out for reassurance and yet, upon receiving it, became convinced that we were part of the conspiracy to divert him or her from a terrible threat. The therapist’s powerlessness to give much immediate help to a person who is so unhappy and suspicious is probably the earliest and most intimidating barrier to establishing the kind of relationship that can eventually offer relief. 治疗师的内心反应十分重要，治疗师异乎寻常的反应正反映出偏执者所努力想摆脱的痛苦。这也说明为什么治疗师普遍具有这样的反应：尽快让来访者“脱离苦海”，无论来访者的想法多么脱离实际。我们在治疗生涯中，大多遇到过迫切需要安抚的来访者，但当他们获得抚慰后，却转而坚信我们正密谋将他们置于险境。对于这种状况下痛苦且多疑的来访者，如果 治疗师不能识别自己的反移情，只是感到无能为力，那么这将成为双方建立信任关系的首要障碍。 THERAPEUTIC IMPLICATIONS OF THE DIAGNOSISOF PARANOID PERSONALITY 诊断的治疗意义 The first challenge a therapist faces with a paranoid patient is creating a solid working alliance. Although establishing such a relationship is necessary (and sometimes challenging) for the successful treatment of any client, it is particularly important in work with paranoid people because of their difficulty trusting. A beginning student of mine, asked about his plan for working with a very paranoid woman, commented, “First I’ll get her to trust me. Then I’ll work on assertiveness skills.” Wrong. When a paranoid person truly trusts the therapist, many years may have passed, and the treatment has been a huge success. But the student was right in one sense: There has to be some initial embrace by the client of the possibility that the therapist is well intentioned and competent. This takes not only considerable forbearance from the therapist, it takes some capacity for comfort talking about the negative transference and conveying that the degree of hatred and suspicion aimed at the clinician is to be expected. The therapist’s unflustered acceptance of intense hostility fosters the patient’s sense of safety from retribution, mitigates fear that hatred destroys, and exemplifies how aspects of the self that the patient has regarded as evil are simply ordinary human qualities. 治疗师的首要任务是建立牢固的治疗联盟。尽管这种关系的建立将有利于所有人格类型的来访者，但对于偏执者而言尤为重要，因为他们具有严重的信任危机，与他们建立关系颇具挑战性。我的一位刚参加工作的学生前来询问如何治疗重度偏执的患者，我让他阐述一下自己的治疗计划，他答道：“首先我必须取得她的信任，然后主要用决断技术进行干预。”这就错了。 偏执者需要耗费很多年才能对治疗师产生真正的信任，如果能经历许多年，那么治疗已然取得了很大的成功。但他有一点倒是说得没错：治疗初期应该让来访者确信治疗师的良好意愿和胜任能力。为此，治疗师不仅要有极大的宽容心，还需要对来访者的负性移情进行友善的探讨，告知他们对治疗师的憎恶与怀疑都在意料之中。这种对敌意的接纳和从容不迫的态度有助于培养来访者的安全感，不再担忧被惩罚，也有助于治疗师帮助来访者认识到，被他们视作十恶不赦的那些自体品格，其实常见于普通人群，并非那般恶劣。 This section will be longer than in other chapters because effective work with paranoid clients differs substantially from “standard” psychoanalytic practice. Although it has in common the goals of understanding at the deepest level, bringing into consciousness the unknown aspects of the self, and promoting the most thoroughgoing possible acceptance of one’s full humanity, it accomplishes these ends differently. For example, interpretation “from surface to depth” is usually impossible with paranoid clients because so many radical transformations of their original feelings have preceded their manifest preoccupations. A man who longs for support from someone of his gender, who has unconsciously misread that yearning as sexual desire, denied that, projected it on to someone else, displaced it, and become overwhelmed with fears that his wife is having an affair with his friend will not have his real concerns addressed if the therapist simply encourages him to associate freely to the idea of his wife’s infidelity. 这一部分将比其他章节相应内容稍多，因为针对偏执者的治疗与“标准的”精神分析治疗具有很大的区别。尽管两者都是对心理进行深层探索、将潜意识的内容意识化、促进来访者尽可能地接受自我，但实现这些目标的方式有所不同。例如，对偏执者“由表及里”地进行解释，并不合适。因为在他们表露出的先占观念背后，是层层叠叠的防御转换。一个渴望得到同性别他人支持的男人会潜意识地将自己的这种渴求误以为是对同性的性欲望，于是潜意识地对此否认，并将之投射于他人，认为是妻子的不忠，并为这种“事实”一蹶不振，这种情况下，如果治疗师只是简单地鼓励他对妻 子的不忠行为进行自由联想，显然无济于事。 “Analyzing resistance before content” can be similarly ill fated. Commenting on actions or statements made by a paranoid client only makes that client feel judged or scrutinized like a laboratory guinea pig (Hammer, 1990). Analysis of the defenses of denial and projection elicits only more Byzantine uses of the same defenses. The conventional aspects of psychoanalytic technique— such as exploring rather than answering questions, bringing up aspects of a patient’s behavior that may be expressing an unconscious or withheld feeling, calling attention to slips, and so forth—were designed to increase patients’ access to internal material and to support their courage to talk more openly about it (Greenson, 1967). With paranoid people, such practices boomerang. If the standard ways of helping clients to open up elicit only further elaborations of a paranoid sensibility, how can one help? “先分析阻抗，再分析潜意识内容”这一方法同样难逃厄运。对偏执者的阻抗言行进行评论只能令他们感到自己像实验室的小白鼠，任由治疗师摆布（Hammer，1990）。对否认和投射防御进行分析只会引出更加复杂的否认和投射。传统精神分析的技术，如探索和联想可诱导来访者暴露潜意识中被压抑的情感，或抓住口误、笔误中的潜意识成分，从而帮助来访者提高识别和表达的能力。但对于偏执者而言，这些技术可能得不偿失。如果精神分析的常规方法只会加剧偏执者的阻抗，治疗师应该如何做呢？ First, one can call on a sense of humor. Many of my teachers advised against joking withparanoid patients lest they feel teased and ridiculed. This caution is warranted, but it does not rule out the therapist’s modeling an attitude of self-mockery, amusement at the world’s irrationalities, and other nonbelittling forms of wit. Humor is indispensable in therapy—perhaps especially with paranoid clients—because jokes are a time-honored way to discharge aggression safely. Nothing relieves both patient and therapist more than glimpses of light behind the gloomy stormcloud that surrounds a paranoid person. The best way to set the stage for mutual enjoyment of humor is to laugh at one’s own foibles, pretensions, and mistakes. Paranoid people miss nothing; no defect in the therapist is safe from their scrutiny. A friend of mine claims to have perfected the “nose yawn,” a priceless asset to the conduct of psychotherapy, but I would bet my couch that even he could not fool a good paranoid. 首先，治疗师可以适当地表现幽默感。许多导师都建议我不要和偏执型来访者开玩笑，以免让他们感到被取笑和戏弄。这种担忧虽不无道理，但并不代表治疗师不应该做出榜样，以自嘲的态度，讽刺世间的荒唐，展现善意的智慧。治疗偏执型来访者时，幽默是不可或缺的，解嘲向来都是消除戒备的良方。拨开笼罩在偏执者周围的乌云，透进一缕阳光，足以让咨访双方都备感轻松。治疗师的自嘲是最好的方式，因为偏执者的观察力特别敏锐，对治疗师的缺陷了然在目。我有个治疗师朋友声称可以做到完全不动声色地 “用鼻子打哈欠”，还觉得他的这种不露声色是心理治疗的有用一招，但我敢用自己的躺椅打赌，无论如何他也别想糊弄一个偏执的来访者。 The woman whose history I described earlier in this chapter has never failed to notice my yawning, no matter how immobile my face. I reacted to her initial confrontations about this with apologetic admissions that she had found me out again, and with whining self-pity about not being able to get away with anything in her presence. This kind of reaction, rather than the heavy, humorless exploration of what her fantasy was when she thought I was yawning, has deepened our work together. Naturally, one stands ready to apologize if one’s wit is mistaken for ridicule, but the idea that work with hypersensitive patients must be conducted in an atmosphere of oppressive seriousness seems to me unnecessarily fussy and somewhat patronizing. Especially after a reliable alliance has been established, something that may take months or years, judicious teasing, in an effort to make omnipotent fantasies ego alien, can be helpful to a paranoid person. Jule Nydes (1963), who had a gift for working with difficult clients, cites the following interventions: 无论我在打哈欠的时候脸部多么纹丝不动，前面提到的那位女性来访者从来都没有遗漏过一次。当她毫不客气地指出时，我会抱歉地承认再次被她抓住，并且羞愧地感叹什么都瞒不过她的眼睛。我选择这种回应方式，而不是沉闷地探究她看到我打哈欠时脑中产生何种幻想，这样反而可促进治疗进一步深入。当然，也应注意不要开玩笑过头，但若认为治疗十分敏感的来访者就必须不苟言笑，未免有些小题大做。尤其当建立起稳固的治疗联盟之后，适当的挪输可以促进偏执型来访者的全能幻想转化为自我不协调性。Jule Nydes（1963）十分擅长与难治性来访者打交道，他将挪榆举例如下： One patient ... was convinced that his plane would crash while en route to a well earned vacation in Europe. He was startled and relieved when I remarked, “Do you think God is so merciless that He would sacrifice the lives of a hundred other people simply to get at you?” 一位来访者……好不容易争取到一次欧洲旅行的机会，但他坚信自己乘坐的航班会中途坠毁。我这样说道，“你觉得上帝会这样冷酷无情，为了你而牺牲上百条性命吗？”他听后十分震惊，但随之有所感悟。 Another such example is that of a young woman ... who developed strong paranoid fears shortly before her forthcoming marriage which she unconsciously experienced as an outstanding triumph. This was at the time the “mad bomber” was planting his lethal weapons in subway cars. She was certain that she would be destroyed by a bomb, and so she avoided the subway. “Aren’t you afraid of the ‘mad bomber’?” she asked me. And then before I could reply she sneered, “Of course not. You ride only in taxicabs.” I assured her that I rode the subways and that I was unafraid for the very good reason that I knew the “mad bomber” was out to get her, not me. (p. 71) 另一位年轻的女性……潜意识中对自己将步入婚姻殿堂视作万人瞩目，但就在婚礼即将到来之际，她却产生了强烈的偏执恐惧。当时正是“炸弹狂人”扬言要在地铁中安放炸弹的时期，于是她确信自己会在爆炸中身亡，并尽量避免乘坐地铁出行。“你难道不怕那个疯子吗？”她还没等我回答，又冷笑道，“你当然不会怕，你只坐出租车的。”我向她保证自己常坐地铁，而且不怕“炸弹狂人”，反正他要追杀的是她，又不是我。（p.71） Hammer (1990), who stresses the importance of indirect, face-saving ways of sharing insights with paranoid patients, recommends the following joke as a way to interpret the drawbacks of projection: Hammer（1990）强调与偏执者分享内心体验时，应该迁回婉转、因势利导，并推荐下面这个段子，用于示范如何解释投射： A man goes toward his neighbor’s house to borrow a lawnmower, thinking how nice his friend is to extend him such favors. As he walks along, however, doubts concerning the loan begin to gnaw at him. Maybe the neighbor would rather not lend it. By the time he arrives, the doubts have given way to rage, and as the friend appears at the door the man shouts, “You know what you can do with your damn lawnmower; shove it!” (p. 142) 一个人去邻居家借割草机，心想他的朋友帮了他这么大的忙，真是太好了。然而，当他继续前行时，对这个出借的疑虑开始咬噬他。也许邻居不愿意出借。当他到达的时候，疑惑已经让位于愤怒，当他的朋友出现在门口的时候，他喊道:“你知道你可以用你那该死的割草机做什么;快点把它推出来!”（p.142）[在这个例子中，应该是把“内化的批判性客体”投射到了朋友身上。非常类似第五章患者A、患者B那个例子] Humor, especially willingness to laugh at oneself, is probably therapeutic in that to the patient it represents being “real,” rather than playing a role and pursuing a secret game plan. The histories of paranoid people may be so bereft of basic authenticity that the therapist’s direct emotional honesty comes as a revelation about how people can relate to each other. With some reservations cited below, having to do with maintaining clear boundaries, I recommend being quite forthcoming with paranoid clients. This means responding to their questions honestly rather than withholding answers and investigating the thoughts behind the inquiry; it is my experience that when the manifest content of a paranoid person’s concern is respectfully addressed, he or she becomes more rather than less willing to look at the latent concerns represented in it. 首先，幽默，尤其是自嘲反映的是“真实”感受，它既非装模作样，也不是诡计多端，因此很可能对来访者具有治疗效用。偏执型来访者既往一直缺乏这种基本的真实感，而治疗师流露出的明白无误的真实情感，将为他们做出人际互动的榜样。为了促进偏执型来访者清晰认识人际边界，我建议对他们直言相告。这意味着治疗师要诚实地回答他们的问题，不能顾左右而言他，也无须刻意探寻其背后的心理意义。根据我的经验，如果偏执者意识中的担忧得到了妥善处理，他们反而会主动寻求这些担忧的象征意义。 Second, one can “go under” or “sidestep” or “do an end run around” (depending on one’s favored metaphor) the complex paranoid defense and into the affects against which it has been erected. In the case of the man consumed with ruminations about his wife’s possible infidelity, one could be helpful by commenting on how lonely and unsupported he seems to feel. It is startling to see how fast a paranoid rant can disappear if the therapist simply lets it run its course, avoiding all temptations to deconstruct a convoluted defensive process, and then engages empathically with the disowned, projected feelings from which the angry preoccupation originally sprang. 其二，治疗师可以运用“暗渡陈仓”、“迂回包抄”（根据个人喜好）等方法化解复杂的偏执型防御，掀开其隐藏于后的情感的面纱。在丈夫反复纠结妻子是否出轨的那个案例中，治疗师如果指出他内心的孤立无援，会对他颇有帮助。若静观其变，避免对那些复杂的防御过程进行分析，并以共情的方式指出他否认和投射愤怒的真正原因，我们会惊讶地发现，来访者咆哮而 出的怨气竟会顷刻之间烟消云散。 Often the best clue to the feeling being defended against is one’s countertransference; paranoid people are usefully imagined as actually projecting their unacknowledged attitudes physically into the therapist. Thus, when the patient is in an unrelenting, righteous, powerful rage, and the therapist feels resultingly threatened and helpless, it may be deeply affirming for the client to be told, “I know that what you’re in touch with is how angry you are, but I sense that in addition to that anger, you’re coping with profound feelings of fear and helplessness.” Even if one is wrong, the client hears that the therapist wants to understand what is creating such severe upset. 一般来说，反移情是判断治疗师遭受到防御的最佳线索；我们通常认为偏执者会将他们无法理喻的态度投射到治疗师身上，引起治疗师的相应反应。因此，每当他们理由十足地发泄不可遏制的狂怒时，会使治疗师感到手足无措，这时，根据自身的感受，我们就应该十分肯定地告诉来访者，“我能体会现在你有多愤怒，但我感到除了这种怒气，似乎你还感受到了深深的恐惧和无助。”即便这种判断可能失误，来访者也能理解治疗师试图理解他们的良好动机。 Third, one can frequently help patients suffering from an increase in paranoid reactions by identifying what has happened in their recent experience to upset them. Such triggers often involve separation (a child has started school, a friend has moved away, a parent has not answered a letter), failure, or—paradoxically—success (failures are humiliating; successes involve omnipotent guilt and fears of envious attack). One of my patients tends to go on long paranoid tirades, during which I can usually figure out what he is reacting to only after 20 or 30 minutes. If I assiduously avoid confronting his paranoid operations and instead comment on how he may be underestimating how bothered he is by something that he mentioned in passing, his paranoia tends to lift without any analysis of that process at all. Educating people to notice their states of arousal and to look for triggers often preempts the paranoid process altogether. And I have found that especially if one cantap into underlying grief and bear gentle witness to the client’s pain, paranoia may evaporate. 其三，治疗师能够通过识别近期刺激性事件，识别来访者偏执状态加重的原因。这类触发因素通常涉及分离（孩子入学，朋友迁居，父母矛盾），挫败或成功（受到羞辱；成功后的内疚，担心受嫉妒）。我的一位来访者时常在治疗时段长时间抱怨别人，我很快便可判断出他真正的攻击行为。如果此时我能做到不与他的偏执针锋相对，而是着重向他表达理解别人如此对待他而导致他的愤藏情绪，那么即使没有细致的分析过程，他的怨气也会消散。指明他的情绪唤醒状态并积极寻找导火索，通常可以制止偏执行为。我甚至发现，如果治疗师能够深度体察来访者的伤痛，并给予温柔抚慰，那么偏执的阴霾或许会云开日出。 One should usually avoid direct confrontation of the content of a paranoid idea. Paranoid people are acutely perceptive about emotion and attitude; where they get mixed up is on the level of interpretation of the meaning of these manifestations (Josephs & Josephs, 1986; Meissner, 1978; D. Shapiro, 1965; Sullivan, 1953). When one challenges their interpretations, they tend to believe that one is telling them they are crazy for having seen what they saw, rather than suggesting that they have misconstrued its implications. Hence, although it is tempting to offer alternative interpretations, if one does this too readily, the patient feels dismissed, disparaged, and robbed of the astute perceptions that stimulated the paranoid interpretation. 我们应该尽量避免与来访者的偏执内容对峙。他们能敏锐地觉察他 人的情感和态度，但对觉察到的表现的理解却时常容易混淆（Josephs和Josephs，1986；Meissner，1978；D.Shapiro，1965；Sullivan，1953）。当人们质疑其理解时，偏执者会认为被指责自己不正常，而不是他人正在反驳自己的误解。因此，如果治疗师急于纠正他们的理解偏差，会令来访者感到被诋毁和蔑视，是对自己敏锐的洞察力的掠夺。 When a paranoid client is brave enough to ask outright whether the clinician agrees with his or her understanding of something, the therapist can offer other interpretive possibilities with suitable tentativeness (“I can see why you thought the man intended to cut you off, but another possibility is that he’d had a fight with his boss and would have been driving like a maniac no matter who was on the road”). Note that the therapist in this example has not substituted a more benevolent motive for the paranoid person’s self-referential one (“perhaps he was swerving to avoid hitting an animal”) because if paranoid people think one is trying to pretty up intentions that they know are debased, they will get more anxious. Note also that the comment is made in the tone of a throwaway line, so that the patient can either take it or leave it. With paranoid patients one should avoid asking them to explicitly accept or reject the therapist’s ideas. From their perspective, acceptance may equal a humiliating submission, and rejection may invite retribution. 若偏执型来访者鼓足勇气询问治疗师是否同意他们对某事的理解，我们可以借机用委婉的语气提供其他可能的答案（“我明白你为什么会觉得那人不讲理，但他也有可能刚与领导吵过架，无论遇到谁，他都会这样蛮不讲理”）。注意，在上述例子中，治疗师并没有用更加良性的假设去替代偏执者 原先的猜测（比如告诉他，“或许那人其实并没有不讲理”），因为偏执者会认为治疗师是在粉饰敌人卑劣的行为，因而更加焦虑。治疗师委婉的语气，也使来访者即便不以为然，也不至于与你针锋相对。我们还应避免要求偏执者直接对反馈意见表态，对于偏执者来说，接受意味着降服，拒绝则可能招致报复。 Fourth, one can make repeated distinctions between thoughts and actions, holding up the most heinous fantasies as examples of the remarkable, admirable, creative perversity of human nature. The therapist’s capacity to feel pleasure in hostility, greed, lust, and similar less-than-stellar tendencies without acting them out helps the patient to reduce fears of an out-of-control, evil core. Lloyd Silverman (1984) stressed the general value of going beyond interpretation of feelings and fantasies to the recommendation that one enjoy them, a particularly important dimension of work with paranoid people. Sometimes without this aspect of treatment, patients get the idea that the purpose of therapy is to get them to expose such feelings and be humiliated, or to help them purge themselves of them, rather than to embrace them together as part of the human condition. 其四，人们的思维与行动之间的有着本质的区别，大脑可以反复思虑憎恶的念头，但并不妨碍人性中充满卓越、高尚和创造力。治疗师如果能从敌意、贪婪、和缺乏人性等倾向中读出积极的感受，而非将这些观点引起的厌恶感付诸行动，会有助于偏执者降低对失控感和罪恶感的恐惧。Lloyd Silverman（1984）提议，要超越分析解释的局限性，欣赏来访者的思维与行为的不对称性。这也是治疗偏执者的十分重要且效果显著的一个环节。如果缺少这种超越和欣赏，分析治疗会让来访者觉得只是让他们出乖露丑，自己需要脱胎换骨，而无法感受到自己被当作完整的人性来对待。 When my older daughter was about 3, a nursery school teacher promulgated the idea that virtue involves “thinking good thoughts and doing good deeds.” This troubled her. She was relieved when I commented that I disagreed with her teacher and felt that thinking bad thoughts is a lot of fun, especially when one can do good deeds in spite of those thoughts. For months afterward, especially when she was trying not to abuse her infant sister, she would get a mischievous expression on her face and announce, “I’m doing good deeds and thinking very bad thoughts!” Although she was a much quicker study than a person with a lifetime of confusion about fantasy and reality, what I was trying to teach her is the same message that is healing to paranoid clients. 我的大女儿3岁的时候，托儿所的一位老师解释美德就是“想好事，做好事。”这令她十分沮丧。我告诉她我不同意这位老师的观点，想歪念显然乐趣更多，尤其是想着歪念但干着好事，岂不美妙！她听后松了一口气。几个月后，当她克制住想要捉弄妹妹的想法时，便会做个鬼脸说道，“瞧我做得多棒！其实我想得很坏哦！”有人缺乏这样的教导，所以终其一生都难以分清幻想和现实的区别，这种教导的原理与治疗偏执者所表达的信息并无二致。 Fifth, one must be hyperattentive to boundaries. Whereas one might sometimes lend a book or spontaneously admire a new hairstyle with another kind of patient, such behaviors are rife with complication when enacted with a paranoid person. Paranoid clients are perpetually worried that the therapist will step out of role and use them for some end unrelated to their psychological needs. Even those who develop intensely idealizing transferences and insist that they want a “real” friendship with the therapist—perhaps especially these clients—may react with terror if one acts in a way that seems uncharacteristically self-extending. 其五，治疗师必须高度注意界限问题。对其他类型的来访者，我们可以称赞他们的发型，借书给他们。但这类行为却会对偏执者产生复杂的效果。因为他们时刻都戒备治疗师会跨越边界，谋取某些与治疗无关的利益。有些偏执者会发展出强烈的理想化移情，并坚称要与治疗师建立“真正的”友谊，但也正是这样的来访者，如果治疗师果然表现出不够专业的行为时，他们将产生极度的恐惧。 Consistency is critical to a paranoid person’s sense of security; inconsistency stimulates fantasies that wishes have too much power. Exactly what the individual therapist’s boundaries are (e.g., how missed sessions or phone calls to the therapist’s home are handled) matters less than how reliably they are observed. It is much more therapeutic for a paranoid person to rage and grieve about the limits of the relationship than to worry that the therapist can actually be seduced or frightened out of his or her customary stance. While a surprising deviation that speaks for the therapist’s caring can light a spark of hope for a depressive person, it may ignite a blaze of anxiety in a paranoid patient. 保持一致性对于维护偏执者的安全感极为重要；缺乏一致的情境将诱 发他们更加确认内心想法有可能成真。治疗设置的设定（比如，怎样处理爽约；应对治疗时段以外的电话）固然重要，但执行设置将更具决定意义。偏执者可以因设置所限而愤怒或悲伤，治疗师不应受诱使或恐吓而偏离立场。治疗师打破设置的额外关注可能会点燃抑郁者的希望，但对偏执者却会弄巧成拙，激发他们的恐惧。 On this topic, I should mention the risk of pseudoerotic transference storms in paranoid clients. Same-sex therapists may have to be even more carefully professional than opposite-sex ones, on account of the vulnerability of many paranoid people to homosexual panic, but both may find themselves suddenly the target of an intense sexualized hunger or rage. The combination of extreme psychological deprivation and cognitive confusion (affection with sex, thoughts with action, inside with outside) often produces erotized misunderstandings and fears. The best the therapist can do is to restore the therapeutic frame, tolerate the outburst, normalize the feelings behind the eruption, and differentiate between those feelings and the behavioral limits that make psychotherapy possible. 在此我必须强调偏执型来访者假性性欲移情（pseudoerotic transference） 的风险。由于许多偏执者具有恐惧同性恋的特质，因此同性别的治疗师应该比异性治疗师更为谨慎，但治疗师都有可能成为他们强烈的性欲或愤怒的发泄对象。强烈的心理剥夺和认知混乱（伴强烈情绪的性冲动、伴行为的思维、伴外部刺激的内部冲动）结合在一起，造成偏执者对自身性欲的误解和恐惧。此时治疗师应该调整治疗框架，承受来访者的情感爆发，引导情绪背后的冲动，协助来访者区分这些感受和行为之间的差异，从而使心理治疗得以继续进行。 Finally, it is critical that one convey both personal strength and unequivocal frankness to paranoid clients. Because they are so full of hostile and aggressive strivings, so confused about where thoughts leave off and actions begin, and so plagued with feelings of destructive omnipotence, their greatest worry in a therapy relationship is that their evil inner processes will injure or destroy the therapist. They need to know that the person treating them is stronger than their fantasies. Sometimes what matters more than what is said to a paranoid person is how confidently, forthrightly, and fearlessly the therapist delivers the message. 最后，治疗的关键在于治疗师应明确无误地、坦率地表达个人态度。偏执者既充满敌意和攻击欲望，又难以辨别思维和行动的边界，还具有强烈的消极全能感，所以他们十分担心自己的恶念会在治疗中对治疗师造成伤害甚至毁灭。他们需要确定治疗师的足够强大。有时候治疗师的自信、直率和无畏的态度，比这种态度下所传达的信息内容更为重要。 Most people who have written about the actual experience of treating paranoid people (as opposed to the much larger literature theorizing about the origins of paranoid processes) have stressed respect, integrity, tact, and patience (Arieti, 1961; Fromm-Reichmann, 1950; Hammer, 1990; Karon, 1989; MacKinnon et al., 2006; Searles, 1965). Some, especially those who have worked with psychotic clients, have recommended joining in the patient’s view of reality, in order to create enough affirmation that the patient can start shedding the paranoid constructions that therapist and client now seem to share (Lindner, 1955; Spotnitz, 1969). Most writers, however, feelone can convey respect for the client’s view of the world without going that far. 许多实际治疗偏执者的治疗师都认识到尊重、真诚、机智与耐心在 治疗过程中的作用（尽管他们写作的大部分文献只注重阐述偏执机制的起源）（Arieti，1961；Fromm-Reichmann，1950；Hammer，1990；Karon，1989；MacKinnon等，2006；Searles，1965）。尤其是那些治疗精神病性来访者的治疗师会提倡引导患者的现实检验能力，以便于营造足够的现实氛围，让来访者逐渐卸除精心编织的偏执外衣（Lindner，1955；Spotnitz，1969）。然而，多数作者认为，治疗师只要表达对来访者对世界的观点的尊重就可以了，不一定要走得那么远。 Because of their excruciating sensitivity to insult and threat, it is not possible to treat paranoid patients without some debacles. Periodically, the therapist will be made into a monster (Reichbart, 2010), as the client makes what Sullivan (1953) called “malevolent transformations” and suddenly experiences the therapist as dangerous or corrupt. Sometimes the therapy work seems like an endless exercise in damage control. In the short run, one has to tolerate a protracted feeling of standing alone, since people with paranoid psychologies are not inclined to confirm, by verbal acknowledgment or visible appreciation, one’s exertions in the service of understanding. But a devoted, reasonably humble, honest practitioner can make a radical difference over the years with a paranoid person, and will find beneath all the client’s rage and indignation a deep well of warmth and gratitude. 偏执者对羞辱和威胁极度敏感，有时会造成治疗的波折。他们时常会 不自觉地将治疗师视作洪水猛兽（Reichbart，2010），偏执者会突然感到治疗师十分危险或品质恶劣，Sullivan（1953）称之为“恶意调转”（malevolent transformation）。有时，心理治疗不得不演变成对来访者消除创伤的过程。 出于偏执型心理，来访者不愿用语言或行动对治疗师的努力进行肯定和赞许，所以治疗师常常必须旷日持久地忍受孤立无援的感受。但一个热忱、谦逊且诚恳的治疗师，确实能够在数年的治疗过程中让偏执者面貌一新，并发现他们深埋于狂怒和愤慨之下的温情和感激。 DIFFERENTIAL DIAGNOSIS 鉴别诊断 The diagnosis of paranoid personality structure is usually easy to make, except, as noted previously, in instances in which a person is high functioning and trying to keep the extent of his or her paranoia hidden from the interviewer. As with schizoid clients, attention to the possibility of psychotic processes in a manifestly paranoid patient is warranted. 偏执型人格结构的诊断通常很容易，但如前所述，在某些情况下是个例外，例如一个人是高功能的，并试图向治疗师隐藏他的偏执程度。就像对待有分裂症状的患者一样，注意明显偏执的患者可能的精神病性过程是必要的。 Paranoid versus Psychopathic Personality 偏执型入格vs.精神变态人格[即反社会人格] In Chapter 7 I commented on the differential importance of guilt as a central dynamic in the respective psychologies of paranoid and antisocial people. I should also mention love. If a paranoid person feels that you and he or she share basic values, and that you can be counted upon in adversity, there is virtually no limit to the loyalty and generosity of which the person may be capable. Projective processes are common in antisocial people, but where psychopaths are fundamentally unempathic, paranoid people are deeply object related. The main threat to longterm attachment in paranoid people is not lack of feeling for others but rather experiences of betrayal; in fact, they are capable of cutting off a relationship of 30-years’ duration when they feel wronged. Because they connect with others on the basis of similar moral sensibilities and hence feel that they and their love objects are united in an appreciation of what is good and right, any perceived moral failing by the person with whom they are identified feels like a flaw in the self that must be eradicated by banishing the offending object. But a history of aborted relationships is not the same thing as an inability to love. 我在第七章曾指出，内疚作为一种核心动力对于偏执者和反社会者具有不同的作用。爱的作用同样如此。如果偏执者认为你和他价值观相同，且能够在困难时对你有所依靠，那么便会对你表现出无比的忠诚和慷慨。精神变态人格善用投射机制，却基本不具备共情的能力，而偏执者则具有良好的客体依恋。对于偏执者而言，威胁长期依恋关系并非由于缺乏感觉，而是遭到背叛；实际上，他们甚至会因为感到委屈而结束多年的感情联系。他们与人建立关系是基于相似的道德敏感性，因此，理所当然地觉得可以与他人分享世事的善与恶，当他们觉察出他人的道德缺陷时，便仿佛自身受到了玷污，必须通过驱逐他人来达到肃清自身的目的。这种心理支配下的关系天折并不等同于缺乏爱的能力。 Paranoid versus Obsessive Personality 偏执型入格vs.强迫型人格 Obsessive people share with paranoid individuals a sensitivity to issues of justice and rules, a rigidity and denial around the “softer” emotions, a preoccupation with issues of control, avulnerability to shame, and a penchant for righteous indignation. They also scrutinize details and may misunderstand the big picture because of their fixation on minutia. Further, obsessional people in the process of decompensating into psychosis may slide gradually from irrational obsessions into paranoid delusions. Many people have both paranoid and obsessional features. 强迫者与偏执者都对公平和规则十分敏感，对“细腻”的情感也都持刻板和排斥的态度，他们都专注于控制，难以忍受羞耻，对缺乏正义会义愤填膺。他们关注细节，经常因事无巨细而顾此失彼。此外，强迫者从逐渐失代偿发展至精神紊乱的过程中，强迫观念可能会逐渐带有偏执色彩。因此许多人会同时具有偏执和强迫两种特征。 People in these respective diagnostic categories differ, however, in the role of humiliation in their histories and sensitivities; the obsessive person is afraid of being controlled but lacks the paranoid person’s fear of physical harm and emotional mortification. Obsessive patients are more likely to try to cooperate with the interviewer despite their oppositional qualities, and therapists working with them do not suffer the degree of anxiety that paranoid patients induce. Standard psychoanalytic technique is usually helpful to obsessive clients; rage reactions to conventional clarifications and interpretations in a patient one has believed to be obsessional may be the first sign that his or her paranoid qualities predominate. 但这两种不同特征类型的来访者对羞耻感的敏感性和既往经历存在差异；强迫者害怕受到控制，而偏执者却对躯体伤害和情感屈辱更加在意。强迫者虽然具有对抗特质，但多少愿意试着与治疗师合作，因此治疗师较少有焦虑感受。精神分析技术对于强迫性患者疗效显著；但如果治疗中强迫者开始对澄清和解释勃然大怒时，很可能说明他们的偏执倾向已经占据了主导地位。 Paranoid versus Dissociative Psychology 偏执型心理vs.解离心理 Many people with dissociative identity disorder have an alter personality that carries the paranoia for the personality system and may impress an interviewer as representative of the whole person. Because emotional mistreatment is implicated in the etiologies of both paranoia and dissociation, the coexistence in individual people of these processes is common. In Chapter 15 I discuss the diagnosis of dissociative disorders thoroughly enough that it will be clear how to discriminate an individual with a paranoid personality from a dissociative person with a paranoid alter personality or paranoid tendencies. 许多解离型身份障碍的个体会同时具备偏执人格，有时治疗师会以偏概全，误以为偏执是个体的全貌。偏执和解离人格的起源都包含有对情感的错误理解，因此个体兼具偏执和解离倾向就十分普遍。我将在第十五章对解离障碍给予充分讨论，以便于读者鉴别偏执人格与伴有偏执倾向的解离人格。 SUMMARY 小结 I have described the manifest and latent qualities of people whose personalities are predominantly paranoid, stressing their reliance on projection. Possible etiological variables include innate aggressiveness or irritability, and consequent susceptibilities to fear, shame, envy, and guilt. I considered the role of formative experiences of threat, humiliation, and projective processes in the family system, and anxiety-ridden, contradictory messages in the development of this type of personality organization, and I described the paranoid person’s sense of self as alternately helplessly vulnerable and omnipotently destructive, with ancillary preoccupations resulting from a core fragility in identity and self-esteem. Finally, I discussed the intensity of transference and countertransference processes, especially those involving rage. 本章描述了偏执型人格者的外显和内隐特征，强调了他们对投射防御机制的依赖。其病因还包括先天的攻击性或易激惹性，和随之而起的对恐惧、羞耻、嫉妒和愧疚的高度敏感。我描述了家庭环境对偏执个体形成恐惧、 羞耻和投射的影响，以及焦躁不安、矛盾信息对偏执人格形成的作用，我还描述了偏执者无助的脆弱感与全能控制感交替出现的状态，以及与这种状态伴随而行的认同和自尊的脆弱而导致的优势观念。最后，我讨论了治疗偏执者过程中的移情和反移情，对涉及愤怒情绪的部分给予了特别强调。 I recommended that therapists of paranoid patients demonstrate a good-humored acceptance of self and an amused appreciation of human foibles; work with affect and process rather than defense and content; identify specific precipitants of symptomatic upset, avoiding frontal assaults on paranoid interpretations of experience; distinguish between ideas and actions; preserve boundaries;and convey attitudes of personal power, authenticity, and respect. Finally, I differentiated people with predominantly paranoid psychologies from those with psychopathic, obsessive, and dissociative types of personality organization. 我建议治疗师向偏执型来访者展现对自我的悦纳和对缺点的赏识；对情感加以分析，但非着眼于防御；识别症状性愤怒的特定病因，避免对来访者的偏执性解释给予正面攻击；分辨思维和行动的差异；保持咨访界限；展现治疗师的坚定、真诚和尊重。最后，我对偏执者和精神变态、强迫人格及偏执倾向的解离性人格进行了区分。 SUGGESTIONS FOR FURTHER READING 进一步阅读的建议 The most comprehensive book on paranoia may be Meissner’s The Paranoid Process (1978). But D. Shapiro’s (1965) chapter on the paranoid style is better written, shorter, and livelier. Much recent psychoanalytic writing on paranoia has addressed social justice issues or commented on political phenomena, as paranoia is central to the process by which groups achieve cohesion by exploiting fears of other groups. The journal Psychoanalytic Review recently devoted an interesting issue (2010, vol. 97[2]) to this topic, in which I have an essay. 介绍偏执最为全面的著作当属Meissner的《偏执状态》（The Paranoid Process，1978）。但D.Shapiro（1965）的书中对偏执的描写，文字流畅、简洁生动。近期有关偏执的精神分析文献普遍提到社会公平问题，有些还对政治现象进行了评论，表明利用公众的恐惧心理来达成群体凝聚力的过程，偏执因素在其中占据主要地位。《精神分析评论》杂志（Psychoanalytic Review， 2010，vol.97[2]）对此专门做了一个有趣的专题，我的文章也位列其中。