Breaking The Clouds

Helping you to get help, bilingual mental health info

Projection

最近恶补了一些心理学基本概念,上次转贴了一篇关于 transference 的文章,这次转述一下学到的 projection 的概念。

字典上对 projection 的定义是: the attribution of one’s own ideas, feelings, or attitudes to other people or to objects; especially: the externalization of blame, guilt, or responsibility as a defense against anxiety.

这是啥意思呢?就是说,一个人,当他感受处于不愉快的有压力的处境时,把自己内心的负面想法和感情投射在别人身上。这是一种心理防御 (defense mechanism) 的手段之一,过程一般在意识之下进行,大脑皮层不会有意地想: “我要把不愉快或者焦虑的想法投射到别人身上”,而是通过皮层下的 limbic system 之类的线路低空飞行更快地通过潜意识达到。 (旁白:潜意识就是意识思想之下进行的大脑活动,所谓本能、直觉,以及感情线路的活动,没有弗洛伊德形容得那么神奇,但是确实存在,而且意识本身可以收集线索间接地观察到自己的潜意识。)

举个例子哈,甲先生在工作上失手犯错,感到十分焦虑和羞愧,认定“老板要开除我了,同事都瞧不起我,他们都认为我一钱不值”。事实是,他又不会读心术,也没有跟老板谈话交换意见,怎么能确认别人的实际想法呢?但是甲先生非常肯定公司里的人都认为他很差,没本事。实际上,是他自己认为自己很差,没本事,认为自己一钱不值,应该被开除,但是这个想法(虽然也许他很习惯这样的思路)带来强烈的焦虑和沮丧,所以他并没想到这是自己的想法,而是将之投射到别人身上,这样弱化了焦虑感情。

另举一个例子,乙太太想跟丈夫离婚,她已经不爱他了,看见他就心烦和厌恶,但是离婚的前景让她感到害怕和紧张,所以不能直白地向自己承认“我想离开他”。作为 defense mechanism ,她把这个愿望投射在对方身上,下意识地将丈夫的言行(这时候他们的关系多半好不到哪里去)解释为“他不爱我了,他想跟我离婚。” 实际上是她自己想离婚,但是无法忍受和接受这样的来自本人的愿望,所以将此心投射在对方身上,不仅缓解了自责和焦虑感,而且更方便为自己建立一个“战斗”或者“受害者”的立场,给自己提供反感对方更多的理由和借口。

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Projection 是一个颇常见的天然现象,本身并不一定是病态,只要是人都有且使用 defense mechanism 。只不过,在不同的人身上发生的频率和程度深浅不同而已。推到一定的极端程度,则有可能影响到客观认知,把他人和自己的思想混淆起来。

在大脑发育过程中,婴儿逐渐学会区分我与他,我和他是不同的人,我感到热或者痛,他不能同时感到,世界不等于我。别看这个现象微不足道,似乎天经地义,其实非常复杂非常神奇,而且不是每次都能够完美地完成发育任务。人脑还有另一个本事,empathy, 身感同受,婴儿看见旁边的孩子哭,自己也哭了;我们看见别人钉钉子砸了手,会不由自主地缩起手好像自己也痛到。通过设身处地的想象而揣摩别人的思想感情,这也是天然的本领在早期发育过程中建立,也很神奇,但也偶尔会出错没长好 (例如未能建立同情能力的 psychopathic/antisocial personality disorder )。

上面这段儿跟 projection 有什么关系呢?我想的是,区分你我,区分主观与客观,真是一个复杂而模糊的事情,每个人的你我界限和认知似乎都有一定程度的不同。有些人情绪特别容易受到周围人的影响,也有人过度将自己的情绪投射到别人身上分不清人与我,另外有些人生活在自己的硬壳里,对别人的情绪完全隔离。

社交上过度紧张害羞的人,常常在社交场合之前想象别人会如何鄙视自己,过程中想象别人如何关注和批评自己,过后还想象别人在背后讥笑自己,其实所有这些贬低自己的想象都来自内心,来自本人最根深蒂固的自我意象 (self image) ,但是当事人认定主观的焦虑和恐惧是客观的存在,来自外界的威胁。

过度投射自己的焦虑自卑和恐惧怎么办呢?我觉得可以重新审视很多根深蒂固,自动不经大脑的 knee jerk 反应。每次脑子里跳出“他讨厌我”,“他瞧不起我”,“他们都认为我是傻瓜”之类想法的时候,不如停下来反问自己,这是客观现实呢?还是我的主观心理投射?

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June 4, 2009 - 7:20 PM No Comments

In Treatment 第二季

前阵子我推荐过一个 HBO 电视剧 In Treatment,当时看了第一季里面的前几集,觉得不错。后来看了第一季的全部,态度就有点动摇了。主要问题在于,这部电视剧讲的是精神分析学流派的过程,主角进行的是精神分析法。在美国,精神分析法已经颇为衰落,在英国,分析师人数和研究者仍然不少,但也仅限于小圈子里使用。现在的心理咨询与治疗方法,主流是 CBT,认知行为治疗法,同时还有其他几种经过临床研究考验的疗法,例如 interpersonal therapy,problem-solving therapy。过去我对精神分析学有很大的偏见,认为完全无效(至少不能在临床研究里证明有效)。但是随着对心理学的了解加深,现在我不认为 psychoanalysis 无效了,实际上其中很多成分和理论对其他心理治疗流派有很深的影响和帮助。我的个人观点是,纯精神分析疗法只适用于一小部分病人,如果要达到对大多数人的显著疗效,则不能只依赖它。

一部分是因为我个人比较偏向临床数据,所以 In Treatment 第一季里面的 psychoanalytical 的态度让我很不耐烦。现代心理治疗不是这样看似漫无目的,每周见面治疗师让病人想说什么就说什么,而是在谈话过程中有明确的目标和主旨。当然不能太过拘泥,病人说“我的问题是嫁不出去”,治疗师就专门解决这个问题,帮病人结婚成功。大部分时候,嫁不出去,或者工作受挫,或者家庭关系问题,这些是症状而不是病根,所以需要一定程度的挖掘 explore,但是找到问题症结,心理治疗师一般会集中火力引导病人一个一个地打开死结,有很明确的目标和终点 endpoint,而不是没有方向地探索挖掘下去。

另一个让我颇不满意的地方是关于治疗师和病人之间的界限 (boundaries) 问题。电视剧里为了达到戏剧效果,把这个界限描绘得模棱两可。还好,编剧借用其中一个人物 Gina 提供了目前已被广泛接受的行医标准:治疗师和病人不能越过界限进行恋爱关系。这是不符合行医道德的,医生本人需要严格避免。电视剧里主角的态度几乎抵抗不了病人的诱惑,这种态度有点过时。当然,这不等于说,现在正在工作行医的治疗师里没有违反职业道德标准,甚至不把职业标准当回事儿的人 — 有,我都听说过不少反例,而且二三四十年前,这个标准比现在松得多。但是毕竟现在的标准严格很多了,所以我的期望值也比较高。

最近偶然看到第二季中的两三集,大失所望。本来,其实也不应该把文艺作品当作真实的教材和范例,但是第一季至少还有一点精神分析学的真实感,虽然不太符合现在的职业标准。第二季就太糟糕了,主角表现得象一个刚出道的学徒,不象一个有二十年经验的精神分析师,净说一些很初级的话,犯些初级的错误,有初级的烦恼。也许主要原因是,第二季的 show runner,剧本总监,换了个人,而这位老兄看上去是个不太了解心理治疗专业的外行,直奔戏剧情节和煽情去了。

所以,我郑重收回对这个电视剧的推荐,特别是第二季。现实中的心理治疗不是这样的,治疗师也(绝大多数)不是这样的。

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June 3, 2009 - 8:31 PM No Comments

做一次偷书人:Transference and Computers

Mom, Dad, Computer

(Transference Reactions to Computers)


Let’s do a quick exercise.

Think of your husband or wife, or your romantic relationship, or a close friend. Think about some important characteristic of that individual’s personality - a characteristic or trait in that person to which you have a strong emotional reaction, positive OR negative…. Now think about one of your parents, or perhaps a sibling. Do they have that very same characteristic, and are the reactions you have to that aspect of them similar to those concerning your current close relationship?

The phenomenon of “transference” is one of the cornerstones of psychoanalytic theory. Rows of bookshelves could be filled with what has been written about it. The basic premise is that we tend to recreate in our current relationships the patterns of thinking, feeling, and behaving that were formed early in our life, most importantly in the relationships with our parents and siblings when we were children.

Critics challenge this idea. They accuse psychoanalytic theory of dwelling too much on the effects of childhood and family dynamics on the evolution of one’s personality. Surely, one’s personality does develop and change throughout the course of one’s life as a result of our friends, lovers, and new life experiences. It is not solely determined by how our parents raised us as children.

I think this is a perfectly valid criticism. We are not SIMPLY the products of our families. Nevertheless, our parents (or other parental figures) and siblings did indeed spend a great deal of time with us during those formative years, when our minds were young, impressionable, and eager to learn about how we humans relate to each other. Based on our relationships with them, we created models or templates in our mind about what constitutes the expected ways in which people will behave in relationships. We formed basic impressions about the kinds of needs, wishes, fears, and hopes that shape relationships and our image of ourselves in those relationships. Often we don’t realize these are OUR OWN models. They may be very different than the models taking shape in the heads of other people. Think of a time when, as a young person, you went to a friend’s house and were totally surprised, maybe even shocked, at how differently that family behaved as compared to your own family.

As we grow up we take these models with us. Often operating at an unconscious level, they affect the choices we make in the kinds of people we get involved with as well as how we experience those people. For example, think of your first boyfriend or girlfriend, and how similar that person might have been to one of your parents (usually your opposite sex parent). How often have young men said to their girlfriends “You’re just like my mother!”… or vice versa.

These models also shape how people select and experience things in their lives that are NOT human, but so closely touch our needs and emotions that we want to imbue them with human characteristics. We humans can’t help but anthropomorphize the elements in the world around us. It’s in our blood. We use our internal models to humanize and shape our experience of cars, houses, pets, careers, the weather…. and COMPUTERS.

Yes, computers can be a prime target for transference because they may be perceived as human-like. They are complex machines that almost seem to “think” like humans think. In fact, some people say they WILL someday be able to “think” like us. Unlike TV, movies, or books, they are highly interactive. We ask them to do something and they do it - at least, they usually do (like humans they sometimes disobey and surprise us). With the new generation of highly visual, auditory, and customizable operating systems and software applications, we also have a machine that can be tailored to reflect what we expect in a companion. The science fiction fascination with robots and androids is the culmination of this perception of machines as being almost like one of us.

What makes computers especially enticing targets for transference is that they are VAGUELY human and PROGRAMMABLE to be whatever we make them out to be. Psychoanalysts discovered that if they remain relatively ambiguous and neutral in how they behaved with their clients, the clients would begin to shape their perceptions of the analyst according to their internal models from childhood. When faced with an indistinct, seemingly malleable “other”, we instinctively fall back on our familiar mental theories about relationships and use those theories to shape how we think, feel, and react to this new, somewhat unclear relationship. This whole process often is unconscious. We are so used to these old templates that they automatically start to mold our perceptions and actions without our really thinking about it.

So now we go back to the exercise at the beginning of this article. Only now we substitute in “computer” for husband, wife, lover, or friend. Do we unconsciously experience the computer as being like our mother or father, or sibling? At first glance the question may seem silly. Keep in mind, though, that I am not saying that we think the computer IS our parent or sibling, but rather that we recreate in our relationship with the computer some ASPECT of how we related to our family members. Still, even if you apply the exercise to an important person in your life or to your computer, you may insist that they are nothing like your mother or father! Here’s where we need to examine the process of transference more carefully - for there are curious twists and turns in this phenomenon that make it considerably more complex than what I have described so far. We’ll see that the same pattern of relating to a family member can be played out in various ways in one’s relationship to the computer. In the descriptions that follow, I’ll focus mostly on relationships with parents, though these also could apply to other family members.


You as You, Computer as Parent

This is the most basic, obvious type of transference - the type I’ve already described. You experience the other as being like your parent and yourself as the child you once were.

So let’s say Leonard had a mother who had many rules for how he should behave as a child, but the rules always seemed to be changing. Even though he tried to figure out and obey his mother’s requests, he never quite succeeded and never satisfied her. He could never seem to do anything right. As a result, he felt frustrated, helpless, and defeated whenever he tried his best but ultimately failed in the eyes of his mother. As an adult, Leonard experiences his computer in the same light. He is intimidated by it, is never quite sure how to please it. When he tries to accomplish something, the computer doesn’t seem to like what he does. It won’t respond. He gets error messages. He has failed once again. His computer makes him feel frustrated, helpless, and defeated. Maybe he even tries to avoid it, just like he did with his mother.

Jenny had a father who was frail and not quite competent as a person. She loved him, and so took care of him and was very attentive to his needs. Perhaps she sometimes sacrificed her own needs in order to attend to his. As an adult, she perceives her computer as something that is a bit fragile and vulnerable. She is very careful about how she uses it because she doesn’t want to cause damage. She is very conscientious about running diagnostics and anti-virus programs. The health and well-being of her computer, she feels very earnestly, is in her hands. Some might even say she is bit over-protective of her machine.

Leonard and Jenny are only two examples. This first type of transference can take many different forms. Traditional psychoanalysis (”Freudian” theory) often described it in terms of sexual wishes and fantasies towards the parent. The child hopes to possess the opposite sex parent as someone to satisfy their sensual/emotional desires. Later, after resolving the conflicts associated with these wishes, the child learns to identify with the sexuality of the same sex parent. In his article “The Internet Regression,” Norman Holland focuses on these types of transferences towards computers. The computer is seen as seductive, as a sex object, a satisfier of desire, as a symbol of sexual power and prowess. As an illustration, consider this real conversation from a cyberspace chat room in which the members are discussing how one of their friends “Suzy” on CUseeme (internet video conferencing) was flashed by a exhibitionist.

Daisy: so all she sees is a big penis on her screen! lol!
Hawkeye: lol
Daisy: I can’t figure out why he wanted to see *Suzy’s* penis!
Dragon: next ur gonna say she has a 15 inch monitor, right?
Daisy: 20 inch, Dragon
THR: geez and black and white haha
Mr. Tops: 17 in rotating
Daisy: hahahahhahah
Tweety: bigger is… bigger!
Dragon: wow, no wonder you gals like macs so much
Daisy: doesn’t have to be bigger, just better
Daisy: and rechargeable
Tweety: or plugged in the wall…
Hawkeye: what about bigger AND better?
Mr. Tops: its not the size of the monitor, but the driver behind it
Tweety: with loads of amps
Hawkeye: as one of my friends like to say, “How hard is your big drive?”
Daisy: lol!
Dragon: more importantly, Hawkeye, is it compressed?
Daisy: more importantly, is it unzipped
Hawkeye: and how often do you optimize it?
Lola: or is it backed up?
Dragon: only in san francisco
Daisy: LOL!

Freud would have a field day with this dialogue. It’s not too difficult to detect themes about phallic power, penis envy, castration fears, and a miscellaneous collection of heterosexual and homosexual issues. However, I don’t want to dwell on the idea of computers as powerful (parental) sex objects. This type of transference applies to some people, but not all. I’m not even convinced that it is a prominent type of transference. The language of classical Freudian theory also gets downright sexist and culturally biased.

What I think is most important about this “erotic” transference is not the sexual feelings towards computers, but rather the perception of the computer as POWERFUL, perhaps in ways similar to how parents are perceived as powerful. This perception of power is obvious in the dialogue from the chat room. The computer can think faster than us, often has more knowledge on a subject, can perform tasks that we couldn’t do alone… and now, in the age of the internet, is a link and guide to a vast, wondrous “outside” world. For some people, these qualities may stir up feelings of admiration, awe, fear, competition - not unlike transferential feelings towards any authority figure.


You as Parent, Computer as You

In this type of transference, a person’s mind reverses the roles played by the child and parent. A clearly visible, and pathological, example of this is when the abused child grows up to become a child abuser. This is a process of “turning the passive into the active” where the child’s feelings of helplessness and anxiety in the face of being controlled, manipulated, and used is warded off in adulthood by assuming the role of one who is powerful and in command.

It’s possible that some users might abuse their computers just as they might have been abused, to a greater or lesser extent, within their family of origin. But computers are expensive. For most people, the possibility of damaging them would not be very satisfying in the long run. On a more subtle level, people who once were controlled, dominated, and manipulated within their family - as if they were not really people at all, but just objects to be used - may very well as adults treat their computers in the same manner. Anger and outright rage at the computer, when it doesn’t behave the way YOU want it to, may be a symptom of this kind of transference. This may have been the same emotional reaction of the disappointed, “betrayed” parent.

The computer also can be perceived, almost lovingly, as one’s baby. You attend to it’s needs, nurture it, help it develop and grow (by adding software and hardware). Not unlike Jenny, who assumed a parental role towards her father, you feel protective and responsible for the computer’s well-being. You become invested in it’s strivings and achievements, even taking pride in the new things it can do. With delight and wonder, you take part in the creation of a new individual with it’s own unique abilities and personality. It is a reflection of you, YOUR abilities and personality, but you also realize that much of what you have done is to direct and shape the raw qualities and potentials that already existed inherently in your “baby.” And quite unlike real life babies, this silicone substitute will never become independent and leave you. For some people, that may be a very attractive proposition.


You as You, Computer as Wished-For Parent

Many people wish, consciously or unconsciously, that their parents could have been different in some way. That wish may shape their perception of the computer as possessing those desired characteristics.

Sam’s mother was, to use a less than technical term, “crazy.” Her behavior and emotions were unpredictable. One moment she would be caring and loving, and the next harsh, critical, and punishing. Never being able to tell what was coming his way next, Sam became a hypervigilant, paranoid child. He needed always to be on the lookout for subtle cues indicating how his mother would behave. He tried to anticipate her moves, but often was not successful. Feeling helpless and angry (in some ways similar to Leonard), he experienced life as unpredictable, dangerous, and beyond his control.

As an adult, Sam takes comfort in his computers. They possess the qualities he wished his mother had - predictable, reliable, non-judgmental, and no unexplained emotional outbursts. If he applies his hard-earned skills at analyzing the subtle details of how it behaves, almost all of the time he CAN predict and control how it will behave. There is very little intimacy and “loving” feelings towards his computer. But that’s quite OK by him. Those things only got him entangled in trouble with his mother. In fact, he takes some pleasure in his cold dominance over the submissive machine.

Lorna experiences her computer quite differently. She sees it as a benign presence. It is always there, waiting for her. It pays attention to what she wants and gives immediate feedback. It allows her to express her thoughts, her feelings, her creativity. It takes and accompanies her wherever she wants to go on the internet. She almost sees it as a very responsive, compassionate companion who recognizes her value and individuality as a person. It even HELPS her develop her individuality…. How unlike her parents who were so busy and preoccupied that they often neglected to show an interest in her life.


You as Wished-For Parent, Computer as You

In this last type of transference, a reversal once again occurs - only this time the user acquires the wished-for parental qualities and the computer becomes like the child. Often people strive for the benign qualities that were missing in their parents - which is often a matter of reversing some characteristic of the parent. Sometimes that reversal may go too far. If your parents were too strict, you may become too liberal with your child. If your parents were uninvolved in your life, you may become too intrusive in your child’s life.

Becoming the wished-for parent of one’s computer may follow the same pattern. Users strive to be “good” to their computer in ways that their own parents were not “good” to them. In some cases they carry that effort too far. One user is careful about making sure her computer is safe and healthy. Another becomes so worried about viruses and possible damage to his machine that he refuses to explore the internet, is wary of installing new software, and rarely lets anyone else use it. One user takes interest in what goes on “inside” his computer and so tries to learn about its hardware and software. Another becomes so invested in the technology of her machine that it becomes an obsession that rules her life.


You are Me, I am You, We are All Together

Some type of transferences (called “selfobject” transferences) involve a bolstering and enhancing of one’s sense of self. When the parent admires the child’s painting, acknowledges her thoughts about a TV program, or empathizes with her feelings of anger, sadness, and delight, the child’s identity is fortified through this “mirroring.” When a boy imitates his father mowing the lawn, or a girl plays with Mommy’s briefcase, this identifying with the parent in an “idealizing” relationship augments their self-esteem and sense of self. So too in a “twinship” relationship when siblings play and work with each other. The feeling that “we are doing this together” satisfies their thirst for knowing who they are by what they do with others. In these forms of transference, there is a blending of oneself with the other, so that the other person is not necessarily experienced as a separate person, but as part of oneself.

Users may rely on their computers to clarify and strengthen their sense of identity. The computer is attentive and accommodating to their needs. It mirrors them. As users customize its hardware and software, the computer becomes more and more like a responsive reflection of their needs, feelings, and ambitions. It is part of them, a reflection of who they are, a world created from within themselves. By idealizing it, by participating in all the amazing, powerful things a computer can do, users strengthen their own confidence and feelings of success. By spending time together with their computer, it becomes a reassuring extension of their motivations, personality, and inner psychological life - like a good buddy, a sibling…. a twin.

But there is a danger in relying too heavily on the computer as a support to one’s identity. Placing all your eggs in one basket is never a good idea. The system may crash at exactly the wrong moment. The hard-drive may fail. For any of a wide variety of reasons, your treasured machine may be taken from you. The rug has been pulled out from under your feet. You feel betrayed, abandoned, lost….. resulting in anger and depression.

Perhaps all computer transferences involve a blending of the user’s mind with the “cyberspace” created by the machine. Cyberspace indeed is a psychological space, an extension of the user’s intrapsychic world. Using psychoanalytic terms, we would say that computers create a transitional space - an intermediate zone between self and other - where identifications, partial identifications, internalizations, and introjects interact with each other. In more plain language, we would say that cyberspace is a zone where the big and little bits of our parents and siblings that we’ve taken into our own minds and personalities become free to express themselves, to play, work, fight, and, ideally, make peace with each other.


How Do You Know It’s Transference?

Psychological reactions to one’s computer (and any significant “other”) may be a complex combination of some or all of the types of transference described above. Mother, father, and sibling transferences can interact and change over time. It’s often difficult detecting the interpersonal origin of one’s thoughts or feelings towards the silicone-other. When thinking about transferences in real life, clinicians often ask themselves, “Who is doing what to whom?”

So how do you know when you’re having one of these transference reactions to your computer? …. There are some tell-tale signs. When you want to throw the damn thing against the wall. When it “makes you” feel betrayed and disappointed. When you feel lonely and empty because you have not had enough time to spend with it. When you often want to be at your keyboard more than you want to be with family and friends, or when those people comment on how attached or emotional you get towards it. Any seemingly exaggerated or “inappropriately” strong feelings towards your machine probably means you think of it as more than just a machine.

Transference also may be rearing its head whenever one feels addicted (see “Why is This Thing Eating My Life”). Computer addictions often mean that the user is attempting to use the cyberworld to satisfy some strong internal need, but the strategy never quite works. One never feels fully satisfied or complete because the frustrated need arises from something that was or is missing from one’s relationship to real world people. The computer has become an inadequate substitute target for that unfulfilled need.


Adult and Machine

Growing up into a mature adult is a gradual process of realizing how the mental models from our childhood have shaped our relationships and our lives. Sometimes these models steer us in the right direction - towards the right people and activities - and thereby enrich our lives. Sometimes not. We may need to challenge, develop, or outright abandon some of them. In all cases, the enlightening path is to see these models for what they are - simply models. After all, the computer is not Mom, Dad, Sister, or Brother. It’s just a computer.


Online Others in the Machine

All of the transference reactions described in this article also can explain how the user reacts to other people that he or she encounters in cyberspace. Communicating only by typed text in e-mail, chat rooms, and newsgroups results in a highly ambiguous environment. We can’t see or hear other people. They become a shadowy figure, a screen onto which we may launch any of the variety of transference reactions.

Because we experience online others THROUGH the computer, it’s also possible that the transference reactions to them may interact with the transference reactions to the computer. Transference to the computer may spill over to, amplify, or be contradicted by the perception of the online other. For example, if William perceives the computer as a passive thing to be manipulated (like Dad manipulated him), he might extend that perception to other people he meets online, treating them as weaker people to be controlled. If they happen to say something that sounds passive, or if their personality style is indeed a bit passive, William may greatly amplify in his own mind how passive they seem to be. As a result, his reactions to them may be inappropriate. If others do something that grossly contradicts William’s perception of the computer as passive - if they act assertive or independent - William may react with severe disappointment or anger at the perceived “betrayal.”

Healthy online relationships are those in which we realize that our perceptions are not always accurate. Other people are other people, not extensions of our beliefs or ghosts in our machine. Given the complexities of transference reactions, this isn’t always easy to do. As Otto Kernberg was fond of saying about unraveling transference in psychotherapy, one must continually ask, “Who is doing what to whom?” Once we fully realize that the computer AND online others aren’t our Moms, Dads, Sisters, or Brothers, we become free to enjoy cyberspace in the ways that we wish, without any unconscious strings attached.


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June 1, 2009 - 7:06 PM No Comments

漫谈:网络与脑(5)

今天正巧看到一篇有意思的文章,转过来给大家看看。文章是英文的,但是不专业,很好懂,是 New Jersey 的一个大学心理学教授写的,虽然是1996年的文章,但是对今天如火如荼的网上人生仍然适用。

Transference to Computers by John Suler

其中 transference 是心理学上专用的一个术语,指一个人在无意识中把自己跟亲密关系者(主要是父母和兄弟姐妹)的关系(即幼年时期建立的关系)转移到陌生人(例如新认识的同事朋友上司或者心理治疗师)身上。如果这个陌生人让你回忆起你的母亲(例如她的地位和身份甚至容貌让你产生代入感),那么你对于她的态度和相处方式会不自觉地模仿你跟母亲相处的方式。

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May 27, 2009 - 10:01 PM Comment (1)

“They would do it somewhere else.”

上星期听了一个讲座,关于 San Francisco 旧金山的金门大桥自杀防护栏工程。金门大桥在完工后三个月就有人从上面跳海自杀,直至今日,成了一个吸引自杀者的“热门地点”。一直有人建议和推动在金门桥上设置围栏或其他防护措施,因为现在的栏杆太低,普通身高的成年人都可以跨过去,也是吸引自杀者的原因之一。但是这个建议一直没有施行,原因是反对者甚众,而且立场特别强硬,理由是:第一,金门桥现在这样是经典建筑,完美无缺,加高栏杆或者其他护栏之类会破坏其美观;第二,自杀的人么,你堵了他从这里跳海的机会,他还是会跑到别处去,或者用其他方法自杀的,白费劲。另外,虽然无人公开这么说,想必加建护栏的费用也在某些人的顾虑之中。

金门桥不属于政府财产,而是属于一个私人组织,所以民间组织集团的呼声并不能拿他们怎么样。护栏运动已经进行多年至今桥上的栏杆仍然很低,周围仍未有防护措施。

让我惊奇的是,怀有“想自杀的人拦也拦不住”的信念者甚众,包括很多心理医学工作者都有这个误解。实际上这个问题早有答案,而答案是“非也,自杀时拦住了救下来,大部分人不会再次自杀。” 1978年,加州大学 Berkeley 的公共卫生研究学者 Richard Seiden 做过一个划时代的研究,他追踪收集了515个试图从金门桥跳海自杀而未遂者的医学记录,发现平均26年之后,只有 6% 的人已经再次自杀而死,其他 94% 的人不是还活着就是死于自然原因。这个发现之后又有许多世界各地的研究得出类似的结论,提出了很多支持的旁证。例如华盛顿地区有一个以爵士作曲家 Duke Ellington 命名的桥,风景甚美,过去每年总有很多人跳下去,但是附近的一个以 Taft 命名的桥,两座桥很近,就极少人从那里跳下去。后来政府在 Ellington Bridge 上面竖起栏杆,杜绝了从那里自杀的人数,有意思的是,从 Taft 桥上自杀的人完全没有增加。

2007年发行了一部叫做 The Bridge 的纪录片。拍摄者在金门桥附近埋伏着抓拍了很多试图自杀甚至跳了下去的真人真事。他们也访问了一个跳下去而幸存的人。跟很多其他自杀未遂被救回来的人一样,他说,在下落的过程中,他已经后悔不想死了。

在研究自杀行为的 suicidology 学科里,这已经是一个公认的事实:绝大多数的自杀不是合乎逻辑、理智思维下的现象,情绪极不稳定,已经失去了平时正常思考的能力。虽然,自杀未遂者将来自杀的机率要比普通未自杀人群高很多—特别是如果 underlying 的精神疾病没有得到有效及时的治疗,但是这个机率离 100% 很远很远,自杀的人,成功了也好,不成功也好,如果给他换一个时间地点,大多数都会后悔,而且不会再干。在医学上,自杀行为仍然是一个难以预料因而难以防止的现象,但是社会主流观念对自杀的各种误解和偏见 (stigma) 很不利于有危险的人求助也不利于关心他们的人有效地防止,让事情更糟。

听到两个精神医生说到自己病人的一手经历,男性精神疾病患者被长期失眠困扰是最最危险的一类人。即使是没有精神疾病的人,在长期失眠状况下会精神压力极大和产生幻觉(所以 sleep deprivation 本身就是 torture),如果原本就有 mood disorder,躁郁症,带有焦虑症状或者幻觉 (psychosis) 的抑郁症,自杀的危险就非常高。似乎纯抑郁症的症状,例如情绪低落,人生失去乐趣,起不了床,这些还不是诱发自杀的关键因素,比较危险的因素是冲动性格(impulsivity) 以及攻击性 (aggression) 倾向,就是所谓脑子一热就干出了糊涂事。所以,抑郁症或躁郁症加上滥用药物特别是兴奋剂,也是非常危险的组合,因为滥用药物的后果常常是降低大脑前额叶的思考判断能力,让感情中枢全面控制行为,特别冲动。另外一个现象是,在这种糊涂的思想状态下,有很多人把自杀的地点环境盯死在某一个著名的建筑,所以有很多人千里迢迢跑到金门大桥跳下去。如果他们 fixated 建筑不能让他们方便地执行计划,几乎每个人都不会另外在附近随便找个高楼就跳了下去。

让我觉得最匪夷所思的是,金门大桥的主人们,面对这么多医学证据,直到2008年才投票赞成修建一个防护网,挂在桥外的下面以阻止想跳的人。这是在 Seiden study 发表后三十年!才做出的决定。为了绝不让心爱的建筑产生一点改变,所以爱死多少人就死多少人,可以救下人命也不愿意—原来求生心理很强的所谓正常人里面有不少是这么想的。有很多人总是拿“反正这里拦住了,他们还会到别处自杀”这个借口来推搪公共安全措施,对于这种说法,在讲座中 Marine County (离金门桥最近的县,就在旧金山市的对面)Coroner’s office 的医生说,我检查跳桥尸体已经三十年了,从来没有见过谁被人在桥上拦下来之后扑到桥上的汽车轮子下的。他们在桥上离那些飞速行驶的汽车只有四五尺那么远,又抱了必死之心,但是一个也没有冲进 traffic 里面自杀的。

推荐一下 The Bridge 这部电影,更推荐有兴趣的读者到 这个网站 上看一看资料。

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May 23, 2009 - 10:45 PM Comments (2)

关于抗忧郁症药物的一些看法

上面一篇文章后面有位留言者说:

其实还有一个很关键的理由,就是人有一个自我恢复的能力,即使不经过治疗,人通过一定程度的自我调整,会有相当高的一个自愈率的,而这个自愈率很可能就被统计进药物治疗的有效率里了.

关于这个问题,我觉得很复杂,很难一概而论,而且其中有一些”地雷区“,容易形成误解,所以再深入地说一说我的想法。

在美国的医疗和社会现状情况下(注意,与中国国情不相同),抗抑郁症药物大多数为家庭医生或内科医生开处方,这个现象有好处也有弱点;加上美国医疗保险制度的不平等(穷人,失业者,自由职业者,等等无健康保险),造成了一定使用抗抑郁症药物的不均衡不合理的现象。虽然很多家庭医生是很仔细地诊断,合理地开药,也有一些不恰当的或者处理心理健康方面问题经验不足的 primary care 医生。有些精神科医生和研究人员认为,现在美国使用抗抑郁药物的状况是有些不需要服药的病人(症状轻微,暂时性)被随便开药,但是另一些病情严重需要长期药物治疗的人却因为不能工作,没有医疗保险,而得不到应有的药物和全面的治疗。

自愈的过程,在 mild to moderate depression 病患中并不罕见,在某些人当中,暂时的情绪低落和持续悲伤事出有因(例如失去亲人或者其他严重的生活打击),另一个现象是 depression 疾病的自然演变过程,mood 会上下起伏,特别是第一次的 depressive episode,相当一部分的人会在一定时间内(几个月到一年多)自然好转,但是另一部分病人会过一段时间后再次跌入低谷,而且,陷入 depression 的次数(被称为 depressive episodes)越多,后面的病发就越难治疗。所以,即使是第一次的 major depressive episode,也不应该掉以轻心。

另一个现象是 placebo effect,这个现象在药物的临床试验中非常明显,在病人不知道自己是吃药物还是对照组用的糖片儿的情况下(所谓“双盲”试验),吃糖片儿的病人常常有30%或更多的人产生疗效甚至痊愈。但是,这跟“自愈”是不同的概念,placebo effect 不是虚无缥缈的东西,糖片儿虽然不含药物成分,但是病人的期待和希望本身就对大脑活动产生一定作用。另一个重要的因素是,吃糖片儿的病人仍然需要每月或者每两周与医务人员研究人员见面,回答很多问题,等于与人交流甚至类似被人嘘寒问暖。这个交流的过程本身对抑郁症也有缓解作用,因为忧郁症的一个重要症状是孤立与隔绝,而孤立与隔绝的行为本身又会加重忧郁症,而社交,即使是非常表面非常无心的跟陌生人交流也有作用,几乎类似非正式低强度的行为治疗。

需要强调的是,虽然现有的抗抑郁症药物不能治愈所有的病人,但是大家都知道我的态度是看病要紧,不应该讳疾忌医。让我担心的是一些人对心理问题和精神疾病的偏见和恐惧转化成对药物的恐惧和抵触,因此而拒绝寻求帮助。看医生并不等于一定要吃药,治疗方法不一定限于药物,药物也不是唯一的治疗手段,即使是每月跟一个关心病人并且业务强的医生见一次面,讨论自己的情绪和障碍,本身也是治疗的一部分,谈话治疗和行为治疗法的效果常常跟药物相仿并且疗效持久,又没有副作用。当然,有不少因为暂时而明显的诱因而情绪低落甚至沉湎忧郁中的人可以不治而愈,但是因为盲目相信自己可以自愈而拖延了宝贵的治疗时机(特别是青少年,心理不稳定或疑似 bipolar disorder 的人,自己或家人有 mood disorder 历史的人),是很危险的。如果你怀疑自己有抑郁症,不应该关门在家坐等自愈,因为孤独是最糟糕最不利心理健康或者自愈的环境。

我想提醒大家的是,吃药而未能痊愈的病人数目很多,吃了药而不能痊愈的病人,极少能自愈。所以一个好医生不仅需要精通药理,而且应该能够判断病患的轻重,深入了解和积极推行其他治疗方法,帮助重病人尽量减轻痛苦;同时,对病情较轻又没有家庭或本人病史的患者,考虑从 psychotherapy 着手 ,包括生活习惯和行为方面的修改,从睡眠到饮食习惯到打开社交范围。而不是病人一说“我心情不好长达两个星期” 就啪啪开一张 Prozac 处方打发回家。如果你遇到的医生,没等你三句话说完,也不细问,就武断开药,你应该另请高明。

另一个我想表达的观点是,现在的抗抑郁症药物还很不先进,还有很大很大的进步和发展的余地,我们非常非常需要更多更有效的新药和新治疗方法,我们也更需要消除一些病人和家属对 psychotherapy 的疑虑和偏见,更多采用高质量的谈话和行为疗法帮助病人减轻症状,防止病情复发。比较棘手的问题是 psychotherapy 的应用和 therapists 的水平不齐所以效果因人而异,还有不少人误以为谈话治疗就是批评教育甚至道德评判。

不过即使是吃药无效果或者效果不好的病人也不需要失去信心,现在的医学研究正在如火如荼地研究开发新药和治疗严重抑郁症的新手段,包括一些电磁仪器和手术方法,有希望涌现更多的治疗武器。另外,不要小看了 electroconvulsive therapy,就是电痉挛疗法,虽然仍然有很多偏见,但是实际上效果很强,即使是吃药无效的病人,也有70% 到80%的疗效。缺点在于价格昂贵,需要医护人员受过专门训练,有一定的副作用(例如记忆问题),而且有一半病人无法达到长期治愈效果。关于这个疗法,以后找时间细说,但也是严重病人的希望之一。

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May 23, 2009 - 12:15 AM No Comments

世界卫生组织对抑郁症的一点调查资料

根据世界卫生组织的数据,全球有一亿两千万人(121 million)抑郁症患者。最新发表的2004年全球疾病负担报告说,抑郁症是全球第一慢性病,是疾病负担 (disease burden) 最高的一项,超过心绞痛和呼吸道阻塞病 (COPD) 带来的长期负担。所谓疾病负担,是按照 disability-adjusted life years (DALY) 来计算,相当于“因为得病而失去的健康生命时间”,是公共卫生学中统一计算不同疾病带来的后果的一个指标。

这个WHO网页上关于治疗有效率的估计(60%-80%) 我个人觉得过于乐观了一点。第一,有效不等于无症状,对于很多抑郁症病人来说,即使吃药治疗有效减轻症状或者消灭某些症状,仍然不能达到完全无症状,跟得病前一样的程度。第二,抗抑郁症药物的疗效一般是从临床药物试验里计算的,但是临床试验常常集中在只患有一个病的病人中,而大量患有抑郁症和其他并发症的人没有被算在其他,但他们是最难治的,疗效也相对比较低。第三,药物+谈话治疗的疗效最好,但是谈话治疗的推广性还很低,质量也比较参差不齐,令很多病人无处求医。第四,全球各地由于文化和社会和经济状况的差异,在有些地区精神医学卫生特别不容易被大众接受,而医药资源也非常不够。所以 WHO 的数据说大约只有四分之一的患者能得到应有的治疗。

这个2004全球统计报告还有中文版

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May 10, 2009 - 7:27 PM Comment (1)

不惑

一个大学同学出差到本地,今天跟她吃饭叙旧。我们已经七年没有见面了。毕业以后她在学术界的阶梯上越走越高,是聪明加勤奋的成功例子。一般的观念是人成年之后,特别是离开学校工作之后,性格思想都已定型,不会有大的改变了。我发现事实不一定如此,七年之后的老同学,跟记忆里的她有明显的不同。上一次见面,她已经开始当上了助理教授,但是言谈之间仍然有战战兢兢的语气。在大学里乃至毕业后,她给人的印象一直是能力很强但是自信不足,开始给人感觉是过度谦虚,深交之后就发现她是发自内心地习惯扬他人之长,暴自己之短,容易自我怀疑。也许是亚洲女性的传统文化,也许是她的性格所致。

七年之后,谈到她的工作和经历,发现她神采飞扬洒脱,语气充满自信,好像变了个人。评论曾被她十分仰视和敬畏的诸位老教授和现在共事的医学专家,口气也变得客观和老练,一针见血,甚至有点儿无情。

这个故事的教训?虽然人脑线路最大的重整和变化有两个阶段:零到五岁和青春期到二十出头,而性格脾气更是先天决定一半,头一年决定三分之一,但也不是铁板一块,永无调整。三十以后,人仍会继续变化,大脑神经细胞在一生过程中仍然保持一定程度的弹性,每天每时输入的新记忆能够做出微小的修改,日积月累,倒也颇可观。

这并不是说每个人都越变越有智慧,越通达,越成功,越自信。当然每个人的变化速度和方向都有极大的不同。人生经历和记忆的积累,放在某些人身上的结果是增加自信、智慧、宽容、适应逆境的能力,放在另一些人身上可能结果是增加焦虑、恐惧、不安全感、失败感、依赖感、固执僵硬、更需要控制。

这位朋友本来是一个充满热情但缺乏自信的丑小鸭,这几年忽然长成潇洒自信,事业蒸蒸日上的白天鹅,我又听又看了半天,觉得原因主要是她的主要性格没变,工作努力不说,做人一直都非常大方,随时愿意伸手帮别人一把,宁可自己多做一点,不斤斤计较回报。过去她的朋友(包括但不限于我)都觉得她太无私奉献了,太不设防了,很容易被人占便宜白吃白拿,但是她的大方性格吸引了人心向善的一面,世界上能硬着心肠只拿不给的人终究是少数,她的周围有很多敬佩喜欢或者只想还她人情的人。所以她在事业上一路得到很多良师益友的扶持和帮助。当然也有特别自私和厚脸皮的例子,有少数甚至过河拆桥。不过她只是心地善良,又不是傻子,吃一堑长一智,拿眼睛看清楚了,以后注意这种人就好了,不需要一朝被蛇咬十年怕井绳,不需要因为一个烂人而不信任所有的人。追求事事占人上风,一点亏也不吃的人,我见过很多,个个生活在焦虑之中,没一个成大器。

另一个让她人生之路越走越宽的原因,我发现,是她的 open mind。也许跟性格善良有关系,也许跟结交人多有关系,又或许 open mind 是善良和多友的基础。一方面她颇有事业野心,这些年力争把自己的专业知识和能力做到最好,另一方面对份外的事情也有兴趣参与,哪怕花费自己的时间精力,例如回到越南给学校义务讲课。因为对人保持开放而不是设防的态度,所以能够建立一个庞大的朋友同事关系网,因为对环境保持开放而不是悲观或不屑的态度,所以遇到新鲜事物和机会能够好奇地尝试而不会局限自己。

一个有趣的现象,民间传说,流传最广的原始故事,一般都是讲述主人公的成年过程,男孩子女孩子离家探险,故事总是讲到他们跨过了成年的门槛就结束,”王子与公主从此幸福地生活在一起”。我们的社会观念也非常强调成年之前的选择,上什么大学,学什么专业,第一个工作入门,以及找一个”对“的人结婚,好像从此之后的人生就是一成不变日日重复直到退休或者老死。其实不是的。人生很长,二十五岁三十岁之后还有大半道路没走。有人经历五光十色的事件,有人一日三省从内心观察和调整自己,有人喜欢学习新东西,有人喜欢接触认识陌生人,有人喜欢探索陌生的地方,这些探险过程都在记忆中留下痕迹,积累的多了,对世界和自己的定位也在不知不觉中变化了。所有的经历都不是浪费,人生没有弯路,除非禁锢自己原地踏步。

儿童和青少年时期大脑变化很快很大,但是现有的教育体系却过分强调统一规范的环境和观念,制造一种世界很单调很局限很小,人生有统一规律的假象,特别是青春期。很多人以为这就是世界,考试升学就是人生的一切标准,考试失败或者不合群被其他孩子鄙视讥笑,人生就会永远如此。成年人没能很好地教给儿童少年们,世界很大很大,人生很长很长,一个人有巨大的空间长成一个独特的人,长成你自己。

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忽然发觉这篇 entry 有点歧义的可能,所以解释一句。我的意思并不是宣扬“大家都努力变成这样的人吧”。说到底,一个人并不是想变成另一个人就能变成另一个人的,而且也没有必要把自己变成另一个人。我想说的是,痛痛快快地过日子的人,自然而然就在人生经历中,不知不觉地发生了变化。Some things change. Some stay the same.

May 3, 2009 - 7:16 PM Comments (11)

压力和焦虑

最近两三个朋友跟我说起压力大,心情焦虑持续不断,身心健康都受到影响。恰好我自己也刚忙过一段,加上连续出差,生活不规律,也觉得有点疲倦。一个让很多人觉得压力大的因素是过去几个月的经济情况不好,失业人数增长,坏消息一个接一个,难免有人人自危的感觉。另一个因素是,春天让很多人睡眠不好,心情波动大 — 这个现象是小样本观察来的,我跟周围的人聊天的印象(我自己也睡得不好),倒没有理论研究的根据。不过春天时自杀率突然上涨倒是有医学数据记载的,一些科学家认为日照长容易引发烦躁焦虑的情绪,另一些研究人员认为可能跟花粉过敏、免疫系统紊乱除非神经系统失调有关。总之不得不防。

Stress 对身体各个器官系统的长远影响已经有很多研究证实,还有更多的数据涌现出来。遇到压力大的环境时,人类身体天然会产生一系列生理化学反应进行对抗,焦虑和紧张是自然而快速的反应,非常直接地通过植物神经系统就产生了,而无需经过大脑意识的考虑和决定。这也很自然,在漫长的进化过程中,人类常常会遇到危险状况(捕猎或者应敌),就是大家都熟悉的 fight or flight 反应。这时无需思考,肾上腺激素就哗哗地流进血液循环,corticosteroid 也大量分泌出来,血液集中流向四肢,心跳加快,警觉性大大提高。

我们现在的生活环境,特别是谋生环境已经从古代人类的环境大变了,每日激起我们肾上腺和 corticosteroid 分泌的也不是狮子老虎而是工作和生活中的各种责任和突发事件,我们现在的环境和行为都比古代复杂得多,外界的信号和刺激也密集复杂的多,我们随身携带的身体功能自然而然地把这些信号当成类似洪水猛兽的威胁,继续哗哗地分泌应付威胁的化学和电神经信号。问题是,我们的身体/自然功能/器官系统不适合持续处在 fight or flight 的状态之下,暂时的应急变化有利于逃避老虎狮子,对生存很重要,但是如果身体长期持续地处于紧张状态,各器官的平衡就被打乱了。就是俗话说的,橡皮筋绷紧太久就失去了弹性。

压力和焦虑虽然是主观现象,却不受意识和理智控制,而是直接的生理功能,所以不容易缓解。好像睡眠一样,放松也不是越努力越管用,甚至可能适得其反。缓解压力和放松心情,不是容易的事,特别是在千变万化,时刻出问题,时刻要解决的环境里。说实在的,我也仍在摸索寻找有效手段中,没有灵丹妙药。而且,每个人的性情和环境各有不同,缓解方法和效果肯定因人而异,对甲有用的方法不一定适合乙。最主要的是,我觉得哈,应该花些时间和精力观察下自己的生活规律,那些责任和事件带来最大的压力,然后集中寻找办法处理最严重的那几个,或者消灭或者减轻。

建议:

1. 这本 Stress Management for Dummies 我没看过,但是 For Dummies 系列一般质量不错,过去翻过几本其中跟心理学有关的,觉得挺有用,所以拿出来推荐一下,可以参考参考。里面有很多不同的方法,可以翻阅之后挑些适合自己的手段施行。

2. 学习瑜伽和冥想。有不少试验表明 meditation 真的有用,对神经系统有一定的调整作用,虽然科学家还不明白到底是什么生理机制。这的确不是封建迷信。

3. 我又要老调重弹了,精神上的孤立能强化焦虑感,而跟他人分享交流感情,哪怕是没有任何明确意义和目的的闲聊废话,都有助于缓解心情,提高情绪。具体的生理机制没人知道,但是人类确实是社会动物,我们的脑子就是被倾向社会的基因控制。一个人孤立的时候,原始的脑子本能可能会以为自己是落了单的个体,在荒蛮丛林里危险很大,而与人交流和建立纽带告诉我们古旧的本能我们还在部落里,有很多人扶持。而且很多时候,遇到难题求人帮助是最好最快的解压手段。

4. 如果你觉得每天都有做不完的事,累得半死,我觉得可以弄个笔记本或者小录音机,记录一下每天都在忙什么,然后回顾一下,看看有什么地方可以精简。例如,能不能请钟点工来家里打扫卫生洗衣服,如果这些是你最憎恶的家务事?能不能跟邻居商量请他们捎带孩子上学放学,你贴补一下他们的汽油费?每周或者每两周请一次 babysitter 看孩子一晚上或者周末半天?天天开车送孩子上芭蕾课中文课足球队等等,能不能砍掉一两项?记住,妈妈开心,孩子才开心,否则课外活动再丰富也没用。如果用钱可以买到一定的休息时间,要好好考虑使用。

这方面我自己也很不高明,经常失去平衡,拿出来跟大家交流,欢迎提出更多建议分享。

总之,长期的压力和焦虑有害健康,增加糖尿病,心血管疾病,免疫系统疾病,精神疾病,肥胖等等的危险,都是已经被医学研究发现证实的后果。不要死撑下去哦。

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April 23, 2009 - 8:34 PM No Comments

请教蔡医生(10)

10) 问:医疗保险一般包括心理和精神治疗吗?一般看医生或者治疗师要花多少钱?

答:首先,根据不同的心理和精神疾病以及不同的严重程度,治疗方式各有不同。常见的治疗方法主要是药物和精神疗法 (psychotherapy),稍微少见的有电休克治疗 (electroconvulsive therapy, or ECT),精神分析,催眠疗法等等。有些疗法需要住院,但大多是门诊治疗。有时候,几种治疗方法可以双管或多管齐下,增加疗效。常见的药物和精神疗法就经常合起来使用(见问答#4,6,7)。如果一个医生只采用药物治疗和调整,一般每次诊治15-20分钟,但费用跟专门的精神疗法差不多;不包括开药的精神疗法每次诊治要花45-50分钟。如果你的医生兼顾处方药和精神疗法两方面的咨询,每次诊治差不多30-45分钟,费用跟前两种差不多,或者贵一点。不过要注意,不同的医生, 不同的地区收费有所不同。而且费用也可能随时间/年度而变。 

第二,据我所知,大部分的医疗保险会支付一部分的药物治疗和精神疗法。但是,很多保险控制你看医生的次数,例如一年内不得超过多少多少次,看医生的次数包括精神疗法或药物疗法都算在内。和看其他科目的医生一样,即使有保险,每次门诊仍然要付少量的合款(copay)或者费用总数的一个百分比。开始治疗期间,病人可以同医生商量门诊看病次数的限制和治疗计划,有时候治疗需要每周一次甚至更多。 一般门诊次数很可能超过保险公司的年限。就是说,自己掏钱付一部分的门诊费是很常见的。你的医生可以帮你安排治疗计划,尽量配合你的支付能力和需要。虽然精神分析疗法对于某些病人还是有效的,但是在美国几乎没有保险公司愿意支付。这是精神分析疗法在近三十年来在此风行程度极剧下降的原因之一。大多数精神分析师们现在提供其他形色的心理疗法。

第三,就象看内科或其他专科的医生,保险公司常常有一个指定的医疗网,在医疗网内(也就是跟保险公司签了合同的医生和医院)看病的价钱跟看网外医生的价钱不同。如果你负担不起看网外医生的费用,务必先问清楚你的保险计划以及找网内的医生。可惜,很多医师和心理师,包括一些特别好的,因为保险公司限制多、手续烦、付费低而不加入保险医疗网。

一般情况下,精神科医生(psychiatrists)的收费会比心理学家(psychologists)或者社会工作人员(clinical social workers)高一些,但是费用的差别还有很多其他因素,例如专业人员的经验和资历,找他看病的人数,所处地点,以及是为医院工作还是独立开业。

仍在临床实习或训练中的专业人士常常收费比较低,但因为他们看病人的治疗过程需要在教授指导下进行,他们的能力和治疗质量未必不如有正式执照的人。有些医院在经过病人同义下,还把实习医生看病人的过程录影下来,由他们的教授监督和指导。而且, 实习中的医生常常特别小心和仔细,知识也比较新。所以,在教学医院里看病,常常能用较少的费用收到质量颇高的治疗。社区医院中的治疗师,常常会采取一种渐进式的收费方式,根据病人的需要,病情和收入收费。 低收入的病人,收费按照收入水平酌情减免。最后,同一个医生的费用也常会根据通货膨胀率而每年上涨一点。

因为牵涉到的因素太多,我不能提供一个具体的费用数目。但是记住,不要害怕跟医生或者心理师地讨论治中的任何问题, 包括疗费用的事宜。 与其他科目不同,即使是讨论费用,也对医生与病人之间的交流和精神心理方面的治疗有重要的关系。大多数的医生有职业操守,合理收费,不会欺诈病人。

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March 11, 2009 - 8:10 PM No Comments

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