Chessick R D
Northwestern University, Evanston, IL.
Am J Psychother. 1993 Spring;47(2):206-27. doi: 10.1176/appi.psychotherapy.1993.47.2.206.
This paper discussed common problems in the outpatient psychotherapy of borderline patients, especially their rage, seductiveness, and abrupt negative shifts. The definition of "borderline" is not settled. Even DSM-III-R mixes it up with other personality disorders. There are no pathognomonic symptoms, no specific personality constellations, and no compelling evidence for a definitive stage in infant development when this disorder is fixed; all stages are involved, from faulty foundational to oedipal periods. It is a descriptive diagnosis and typical presentations of such patients are reviewed. In the psychotherapeutic approach, limits must be set first, but these must be flexible and reasonable. Medications are used rarely and with care. We attempt to form an alliance by (a) getting the patient to join us in a study of himself or herself, especially a study of when rage and maladaptive behavior emerges, and (b) providing a consistent and reasonable ambience. The ultimate aim is uncovering and interpreting when the patient is ready for it, more and more approximating psychoanalytic treatment as the patient's pathology permits. The special phenomena of the self-object (Kohut), transitional object (Modell), and disruptive extreme erotic or raging (Kernberg) transferences were reviewed, as well as the pitfalls of therapist anxiety and impatience in dealing with them. While archaic transferences predominate, we serve as an auxiliary microscopic ego and appeal to the rational adult part of the patient's ego in a phenomenological investigation. We interpret early only if we cannot get the patient to examine what has led to the explosions and when distortions or projection without insight continues to predominate. The dangers of early transference interpretations are discussed. Therapy is long, tedious, and requires the willingness to patiently catalyze the patient's resumed development and endure the periodic disruptions. Countertransference problems and what to do about them are reviewed.
本文讨论了边缘型患者门诊心理治疗中的常见问题，尤其是他们的愤怒、诱惑性和突然的负面转变。“边缘型”的定义尚未确定。甚至《精神疾病诊断与统计手册第三版修订本》（DSM - III - R）也将其与其他人格障碍混淆。没有特征性症状，没有特定的人格组合，也没有确凿证据表明在婴儿发展的某个特定阶段这种障碍就已确定；从有缺陷的基础期到俄狄浦斯期的各个阶段都有涉及。这是一种描述性诊断，并对这类患者的典型表现进行了回顾。在心理治疗方法中，首先必须设定界限，但这些界限必须灵活且合理。药物使用很少且需谨慎。我们试图通过以下方式建立联盟：（a）让患者和我们一起研究他或她自己，特别是研究愤怒和适应不良行为何时出现；（b）提供一个一致且合理的氛围。最终目标是在患者准备好时进行揭示和解释，随着患者病情允许，越来越接近精神分析治疗。文中回顾了自我客体（科胡特）、过渡性客体（莫德尔）以及破坏性的极端色情或愤怒（克恩伯格）移情的特殊现象，以及治疗师在处理这些现象时焦虑和不耐烦的陷阱。虽然古老的移情占主导，但在现象学调查中，我们充当辅助的微观自我，诉诸患者自我中理性的成人部分。只有当我们无法让患者审视导致爆发的原因以及缺乏洞察力的扭曲或投射持续占主导时，我们才会尽早进行解释。文中讨论了早期移情解释的风险。治疗过程漫长、乏味，需要有耐心促进患者恢复发展并忍受周期性的干扰。文中回顾了反移情问题以及应对方法。
