追寻记忆的痕迹 9.0分
读书笔记 第27章:生物学与精神分析思想的复兴
北公爵
精神分析学派出现在20世纪的第一个10年的维也纳,是一种全新的关于意识和精神障碍的理论。直到20世纪中,这种无意识心理加工理论带来的兴奋感都在持续升温;精神分析学也从德国和维也纳传到了美国。 …… 但是到了1960年我开始精神病学的临床实习时,我的热情减退了。我与实证主义社会学者Denise的婚姻,和我的研究经历——先是在哥伦比亚大学的Harry Grundfest实验室,后是在国家心理健康研究所的Wade Marshall实验室,都使我对精神分析的狂热趋于平静。在我仍然非常钦佩精神分析关于意识的丰富又敏锐的观点时,却失望地在临床中发现精神分析的作用几乎无法通过实证的方法进行验证。我也对哈佛的许多老师感到失望,还有那些忽视人文思考进入精神分析领域的医生,他们对科学毫无兴趣。我感觉到精神分析正在退回到一个非科学的时代,同时也把精神病学带回那个时代。 在精神分析学派的影响下,第二次世界大战后的精神病学从一个与神经病学相关的实证医学学科转变为一个以精神治疗为中心的非实证学科。在20世纪50年代,学院派精神病学放弃了原有的生物学和实验医学的根基,逐渐变成一个治疗性的学科。这样,它就完全不考虑实证或者心理活动的脑机制。相反地,在这个阶段,受到从生物化学到分子生物学的还原论的影响,医学却从一门以治疗为中心的人文学科转变为治疗科学。在医学院的时候,我见证并感受到了这次革命。那时我虽然无能为力却很清楚精神病学在医学中的特殊地位。 精神分析使用自由联想与合理解释的方法检查病人的心理状况。弗洛伊德教导精神分析师认真倾听病人的谈话,并且学会敏感地发现病人谈话下面隐藏的信息。他也建立了针对无关或者语无伦次谈话的解释图式。 这种方法如此强大神奇,以至于多年来,弗洛伊德及其他睿智的精神分析学家都一词宣称精神分析疗法提供了意识最好的科学解释,满足了病人和治疗师之间的需求,特别是在无意识的心理加工方面。实际上,早期精神分析学家的确提出了很多有效的观察方法,通过倾听病人描述以及通过检验这些精神分析法的观点(比如在儿童发展中观察研究童年性欲),可以帮助我们增加对意识的了解。当然还包括集中潜意识和前意识的心理加工、动机的复杂性、移情(转移过去经验对病人当前生活的影响)和阻抗(病人出现无意识地对抗治疗师得治疗方案的行为)。 在这些出现60年后,精神分析的威力就快耗尽了。1960年,连我都发现通过观察病人和倾听再也无法获得更多的新知识和观点了。尽管精神分析学一直希望自己是一门关于意识的可重复检测的实证科学,但是它的方法却没什么科学性。经过几十年的努力,人们试图将它的理论假设转换为可重复的实验,但还是失败了,事实证明它的理论性高过实证性。因此,精神分析并没有取得像心理学和医学等其他领域那样的进步。在我看来,精神分析学已经迷失了方向,精神分析学不该致力于那些可以重复检测的领域,研究那些心理和身体的障碍,因为这些并不是它的最佳治疗对象。 起初精神分析学用来治疗当时被称为神经官能症的疾病,包括恐惧症、强迫症、歇斯底里症及焦虑症等。然而,神经分析疗法逐渐将治疗对象扩展到大部分的心理疾病,包括精神分裂症、抑郁症等。20世纪40年代,对第二次世界大战后受战争创伤影响的士兵的成功医治,大大鼓舞了许多精神分析学家,他们相信精神分析的观点对那些药物无法治疗的身体疾病也是有效的,像高血压、哮喘、胃溃疡、溃疡性结膜炎等,都被视为与心理相关的疾病,是无意识冲突的结果。因此,到1960年,精神分析理论成为许多精神分析学家,尤其是美国东岸和西岸的那些精神分析学家治疗所有心理和部分生理疾病的主要模型。 这种不断扩展的治疗范围表面上是增强了精神分析学的解释力和临床实用性,但实际上却减弱了精神病学的效力,阻碍它成为一个与生物学相结合的实证学科。弗洛伊德首次用无意识心理加工解释行为是在1894年,他努力将其发展为实证心理学,并试图寻找行为的神经模型,但是由于当时脑科学不够成熟,他才放弃了基于主观报告的生物学模型。到我进哈佛学习精神病学的时候,生物学已经对意识进行了一些重要的研究,但是许多精神分析学家却置之不理,极端地认为生物学与精神分析学无关。 在我做驻院医生期间,生物学遇到的不是漠然就是轻视。更严重的问题是,精神分析学家根本没有意识到自己的研究结果缺乏严格控制,甚至不控制研究者的偏见。别的医学分支已经学会用双盲实验控制这种偏差。然而,精神分析案例收集的数据却一向是保密的。患者的意见、联想、沉默、姿势、动作及其他行为都是优先尊重的。当然,不能否认隐私是对治疗师信任的核心,但是这也导致了在几乎所有案例中,唯一的记录都是治疗师的主观判断报告。正如研究精神分析的学者Hartvig Dahl一直所说的,这种主观报告不足以成为科学证据。精神分析学家却很少考虑这个问题。
When psychoanalysis emerged from Vienna in the first decades of the twentieth century, it represented a revolutionary way of thinking about mind and its disorders. The excitement surrounding the theory of unconscious mental processes increased as the century reached its midpoint and psychoanalysis was brought to the United States by émigrés from Germany and Austria. …… But by 1960, when I began clinical training in psychiatry, my enthusiasm had stalled. My marriage to Denise, an empirical sociologist, and my research experiences—first in Harry Grundfest's laboratory at Columbia and then in Wade Marshall's laboratory at the National Institute of Mental Health—tempered my enthusiasm for psychoanalysis. While I still admired the rich, nuanced view of mind that psychoanalysis had introduced, I was disappointed during my clinical training to see how little progress psychoanalysis had made toward becoming empirical, toward testing its ideas. I also was disappointed in many of my teachers at Harvard, physicians who were motivated to enter psychoanalytic psychiatry out of humanistic concerns, as I was, but who had little interest in science. I sensed that psychoanalysis was moving backward into an unscientific phase and, in the process, was taking psychiatry with it. Under the influence of psychoanalysis, psychiatry was transformed in the decades following World War II from an experimental medical discipline closely related to neurology into a nonem-pirical specialty focused on the art of psychotherapy. In the 1950s academic psychiatry abandoned some of its roots in biology and experimental medicine and gradually became a therapeutic discipline based on psychoanalytic theories. As such, it was strangely unconcerned with empirical evidence or with the brain as the organ of mental activity. In contrast, medicine evolved during this period from a therapeutic art into a therapeutic science, based on a reductionist approach derived first from biochemistry and later from molecular biology. During medical school, I had witnessed and been influenced by this evolution. I therefore could not help but note the peculiar position of psychiatry within medicine. Psychoanalysis had introduced a new method of examining the mental life of patients, a method based on free association and interpretation. Freud taught psychiatrists to listen carefully to patients and to do so in new ways. He emphasized a sensitivity to both the latent and the manifest meaning of the patient's communications. He also created a provisional schema for interpreting what might otherwise appear as unrelated and incoherent reports. So novel and powerful was this approach that for many years not only Freud but other intelligent and creative psychoanalysts as well could argue that psychotherapeutic encounters between patient and analyst provided the best context for scientific inquiry into mind, particularly into unconscious mental processes. Indeed, in the early years psychoanalysts made many useful and original observations that contributed to our understanding of mind simply by listening carefully to their patients and by testing the ideas that arose from psychoanalysis—such as childhood sexuality—in observational studies of normal child development. Other original contributions included the discovery of different types of unconscious and preconscious mental processes, the complexities of motivation, transference (the displacing of past relationships onto the patient's current life), and resistance (the unconscious tendency to oppose a therapist's efforts to effect change in the patient's behavior). Sixty years after its introduction, however, psychoanalysis had exhausted much of its novel investigative power. By 1960 it was clear, even to me, that little in the way of new knowledge or insights remained to be learned by observing individual patients and listening carefully to them. Although psychoanalysis had historically been scientific in its ambitions—it had always wanted to develop an empirical, testable science of mind—it was rarely scientific in its methods. It had failed over the years to submit its assumptions to replicable experimentation. Indeed, it was traditionally far better at generating ideas than at testing them. As a result, psychoanalysis had not made the same progress as some other areas of psychology and medicine. Indeed, it seemed to me that psychoanalysis was losing its way. Rather than focusing in on areas that could be tested empirically, psychoanalysis expanded its scope, taking on mental and physical disorders that it was not optimally suited to treat. Initially, psychoanalysis was used to treat what were called neurotic illnesses: phobias, obsessional disorders, and hysterical and anxiety states. However, psychoanalytic therapy gradually extended its reach to almost all mental illnesses, including schizophrenia and depression. By the late 1940s, many psychiatrists, influenced in part by their successful treatment of soldiers who had developed psychiatric problems in battle, had come to believe that psychoanalytic insights might be useful in treating medical illnesses that did not respond readily to drugs. Diseases such as hypertension, asthma, gastric ulcers, and ulcerative colitis were thought to be psychosomatic—that is, induced by unconscious conflicts. Thus by 1960 psychoanalytical theory had become for many psychiatrists, particularly those on the East and West coasts of the United States, the prevailing model for understanding all mental and some physical illnesses. This expanded therapeutic scope appeared on the surface to strengthen psychoanalysis's explanatory power and clinical insight, but in reality it weakened psychiatry's effectiveness and hindered its attempt to become an empirical discipline aligned with biology. When Freud first explored the role of unconscious mental processes in behavior in 1894, he was also engaged in an effort to develop an empirical psychology. He tried to work out a neural model of behavior, but because of the immaturity of brain science at the time, he abandoned the biological model for one based on verbal reports of subjective experiences. By the time I arrived at Harvard to train in psychiatry, biology had begun to make important inroads in understanding higher mental processes. Despite these advances, a number of psychoanalysts took a far more radical stance—biology, they argued, is irrelevant to psychoanalysis. This indifference to, if not disdain for, biology was one of the two problems I encountered during my residency training. An even more serious problem was the lack of concern among psychoanalysts for conducting objective studies, or even for controlling investigator bias. Other branches of medicine controlled bias by means of blind experiments, in which the investigator does not know which patients are receiving the treatment being tested and which ones are not. However, the data gathered in psychoanalytic sessions are almost always private. The patient's comments, associations, silences, postures, movements, and other behaviors are privileged. Of course, privacy is central to the trust that must be earned by the analyst—and therein lies the rub. In almost every case, the only record is the analyst's subjective accounts of what he or she believes happened. As research psychoanalyst Hartvig Dahl has long argued, such interpretation is not accepted as evidence in most scientific contexts. Psychoanalysts, however, are rarely concerned about the fact that accounts of therapy sessions are necessarily subjective.

我相信这段描述是比较中肯且客观的对于精神分析的回顾和评价。

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