心智化的方法與技術(shù)：第5講課件

MENTALIZINGFAILURESINATTACHMENTTRAUMA

依戀創(chuàng)傷中的心智化失敗

JonG.Allen,Ph.D.Thesis

論點Theexperienceofbeingleftpsychologicallyaloneinunbearableemotionalstatesispotentiallytraumaticowinginparttotheabsenceofmentalizingandtheexperienceofbeingpsychologicallyinvisibleinthesestates.Treatmententailscreatingasecureattachmentcontextbymeansofmentalizinginwhichpreviouslyunbearableemotionalstatescanbeexperienced,expressed,reflectedupon,andunderstood—andthusrenderedmeaningfulandbearable.心理上被獨自留在無法承受的情緒狀態(tài)中，這種體驗可能是創(chuàng)傷性的，部分原因在于缺乏心智化和在這些狀態(tài)下心理上未被看到的體驗。治療需要通過心智化來創(chuàng)造安全的依戀情境，在治療中可以體驗、表達、反思和理解那些先前難以承受的情緒狀態(tài)，從而使其變得有意義和可以忍受。CoreConcepts

核心概念Trauma:Lastingadverseimpactofstressfulevents創(chuàng)傷：壓力事件帶來的持續(xù)不利影響Twosensesofattachmenttrauma依戀創(chuàng)傷的兩種意義traumaticeventsinattachmentrelationships(child&adult)依戀關(guān)系中的創(chuàng)傷事件（兒童和成人）impact:underminescapacityforattachmentandmentalizing影響：破壞依戀和心智化的能力Evidentindisorganizedattachmentininfancy(e.g.,frightened,dissociativebehavior,extremelycontradictoryinteractions)在嬰兒時期的紊亂型依戀（例如，受驚嚇的，解離的行為，極其矛盾的互動）中很明顯Typesofattachmenttrauma依戀創(chuàng)傷的類型physicalabuse身體虐待sexualabuse性虐待antipathy(rejection,harshcriticism)憎惡（拒絕，嚴厲的批評）psychologicalabuse(cruelty,terrorizing,humiliating)心理虐待（殘忍，恐嚇，侮辱）physicalneglect身體的忽略psychologicalneglect心理的忽略witnessingdomesticviolence目睹家庭暴力Tripleliabilityassociatedwithattachmenttraumainchildhood

與兒童時期依戀創(chuàng)傷相關(guān)的三重不利因素1）provokesextreme,repeatedstress引發(fā)極端的、反復(fù)的壓力2）underminesthedevelopmentofthecapacitytoregulatedistress(viainsecureattachment,impairedmentalizing)破壞調(diào)節(jié)痛苦的能力的發(fā)展（通過不安全的依戀，損害心智化）3）compromisesthedevelopmentofepistemictrust:干擾認知信任的發(fā)展：Epistemictrust,trustinanotherperson’sknowledge,mediatesopennesstosocialinfluence,insideandoutsidetherapy.Epistemictrustispromotedbymentalizingintherapy.Thetherapistmustbecomeacrediblesourceofpersonal(social)knowledgeforthepatient(seeFonagy&Allison;Allen&Fonagy).認知信任，信任他人的知識，在治療中以及在治療之外調(diào)節(jié)對社會影響的開放度。通過治療中的心智化促進認知信任。治療師必須成為病人個人（社會）知識的可靠來源（參見福納吉＆艾利森；艾倫＆福納吉）。AttachmentTrauma:FrightwithoutSolution

依戀創(chuàng)傷：沒有解決方案的恐懼relatedness(effectivedependence)關(guān)聯(lián)性（有效的依賴）self-definition(autonomy)自我定義（自治）secureattachment/psychologicalsecurity安全型依戀/心理安全BALANCE平衡excessivedependency過度依賴diminishedautonomy自治性降低Ambivalent矛盾型diminishedrelatedness關(guān)聯(lián)性降低excessiveautonomy過度自治Avoidant回避型diminishedrelatedness關(guān)聯(lián)性降低diminishedautonomy自治性降低Disorganized紊亂型non-mentalizingparent-infantinteractions非心智化的父母-嬰兒互動Non-mentalizingintheintergenerationaltransmissionofattachmenttrauma(begetsnon-mentalizing)

依戀創(chuàng)傷的代際傳遞中的非心智化（會帶來非心智化）infantattachmentdisorganization嬰兒的紊亂型依戀（無組織）impairedmentalizingcapacityinchildhood童年時期心智化能力受損parentalattachmentinsecurity?impairedparentalmentalizingcapacity父母的不安全依戀?父母的心智化能力受損infantaffectivedysregulation嬰兒情感失調(diào)“Trauma”broadlyconstrued

“創(chuàng)傷”的寬泛定義AFRAIDunbearableemotionalstates害怕無法忍受的情緒狀態(tài)+ALONE

absenceofexperienceofbeingmentalizedfeelingabandonedneglected,unloved,invisible孤單缺乏心智化的體驗

被拋棄、被忽視、不被愛的感覺，隱形的感覺IMPAIREDMENTALIZINGCAPACITY心智化能力受損MaryMainInitiallyidentifieddisorganizedinfantattachmentwithmaltreatmentandthenmorebroadlyidentifiedfrighteningorfrightenedparentalbehavior(e.g.,associatedwithparents’historyoftraumaorloss).瑪麗·梅因首次識別出嬰兒的紊亂型依戀與虐待的關(guān)聯(lián)，然后更廣泛地識別出和令人害怕的或被嚇壞了的父母的行為的關(guān)聯(lián)（例如，與父母的創(chuàng)傷或喪失歷史相關(guān)）。KarlynLyons-RuthParallelingMain’sfrightening-frightenedpattern,identifiedhostile-helplessbehaviorsaswellasabroaderpatternofdisruptedemotionalcommunication,forexample,negative-intrusivebehavior,roleconfusion(e.g.,seekingreassurancefromtheinfant),withdrawal,contradictorybehaviors(e.g.,verbalencouragementtocomeclosecoupledwithphysicaldistancing),anddisorientation(e.g.,dissociativestates).Disruptedcommunicationpredictsdisorganizationevenintheabsenceoffrighteningbehavior.卡林·萊昂-魯斯和梅因的令人害怕-嚇壞了的模式平行，識別出敵對-無助行為也是一種更廣泛的會打斷情緒溝通的模式，例如，負面-侵入性的行為，角色混亂（例如，向嬰兒尋求安慰），退縮，矛盾行為（例如，言語上鼓勵靠近，但身體上遠離），和迷失方向（例如，解離狀態(tài)）。即使沒有令人害怕的行為，溝通的干擾也會導(dǎo)致紊亂型依戀。AriettaSladePoormaternalmentalizingintheParentDevelopmentInterviewindicatedbyobliviousnesstochild’sfeelings,malevolentattributions,lackofself-awarenessoffeelings.Poormentalizingintheinterviewisassociatedwithdisruptedemotionalcommunicationininteractionsaswellasdisorganizedattachmentininfants.阿莉埃塔·斯萊德在父母發(fā)展訪談中心智化表現(xiàn)不佳的母親，無視孩子的感受，惡意歸因，缺乏對情感的自我覺察。訪談中心智化不良與互動中的情緒溝通干擾以及嬰兒的紊亂型依戀有關(guān)。Fillingthetransmissiongap:disorganizedattachment填補傳遞的空檔：紊亂型依戀（無組織）StillFace(Google:Tronick,YouTube,StillFacetoseevideo)Briefseparation-reunionexperience(e.g.,3,6,9months):afterperiodoffreeinteractiveplay,motherremainsexpressionlessfor3minutes,thenresumesinteraction.Anexperimentalmodelofemotionalneglect.Infantsmakeeffortstoengagemother,averttheirgaze,showsignsofemotionaldistressandphysiologicalstress,loweredpositiveemotion,increasednegativeemotion;ultimatelywithdraw;canbedifficulttore-engage靜止的臉（搜索：特羅尼克，《靜止的臉》視頻）短暫的分離–重聚的體驗（例如，3個月，6個月，9個月）：在一段自由的互動玩耍之后，母親保持面無表情3分鐘，然后恢復(fù)互動。情感忽略的實驗?zāi)Ｐ汀雰号ξ赣H參與，移開他們的視線，體現(xiàn)出情緒困擾和生理壓力的跡象，積極情緒降低，消極情緒增加；最終退縮；可能很難重新參與Levelsofstressinthetransmissiongap:Tronick傳遞空檔中的壓力水平：特羅尼克SimulateddepressionInfantsarelesssociallyengaged,moredistressandmoredisengagedthaninthestill-faceparadigm;alsolessengagedwithobjects模擬的抑郁癥與靜止的臉范式相比，嬰兒更少參與社交活動，更多的痛苦和更多的不參與;也更少與客體互動Levelsofstressinthetransmissiongap:Tronick傳遞空檔中的壓力水平：特羅尼克SymptomaticdepressionMothers:lesspositivesocialplay,morelookingaway,moreangryandintrusive,lesspositiveaffect.Infants:lesssocialplay,lessfocusonobjects,lessattentiontomother,moreprotest,becomemorepassiveanddepressed;respondinawaythatmirrorsmother’slackofengagementanddecreasedrangeofaffect癥狀性抑郁癥母親：社交玩耍不太積極，更多的看向別處，更多的憤怒和侵入，更少的積極情感。嬰兒：減少社交玩耍，減少對客體的關(guān)注，減少對母親的關(guān)注，抗議增多，變得更加被動和有挫折；以一種映照出母親缺乏參與度的方式作出反應(yīng)，情感的范疇縮小。TraumaNosingleeventbutratherprolongedinteractivefailureandnegativeemotion;lessrepairandthuslessmovementcontinuallyfromnegativetopositiveemotion.Neglectismorecompromisingthanabuse.Traumaexceedstheinfant’sresourcesforcoping,incontrasttothe30:70ratiothatpromotesresilience.創(chuàng)傷不是單一的事件，而是長期的互動失敗和負面情緒；較少修復(fù)，從而較少從負面到積極情緒的連續(xù)運動。忽略比虐待更有傷害。創(chuàng)傷超過了嬰兒的應(yīng)對資源，而30:70的比例則促進韌性。gazedawayfromtheirinfant’sfacemoreoftenandunpredictably更頻繁和不可預(yù)測地把視線從嬰兒的臉上轉(zhuǎn)開loomedintotheinfant’sfacemoreoftenandunpredictably更頻繁和不可預(yù)測地迫近嬰兒的臉didnotrespondtotheirinfant’sself-touchwithcomplementaryaffectionatetouch不以互補的帶著情感的觸摸來回應(yīng)嬰兒的自我觸摸showedlessvariableemotionalresponsiveness,thatis,relativelyrigid,closed-upfacialexpressions較少表現(xiàn)出有變化的情緒反應(yīng)，即相對僵硬、封閉的面部表情werelesslikelytofollowtheinfant’sshiftsbetweenpositiveandnegativeemotions,forexample,lessableto“emotionally‘enter’and‘gowith’infantfacialandvocaldistress”不太能夠跟隨嬰兒在積極和消極情緒之間的轉(zhuǎn)變，例如，不能“帶著情緒地‘進入’和‘伴隨’嬰兒面部和聲音中的痛苦”showeddiscordantemotionalresponses,respondedtotheirinfant’sdistresswithsurpriseorpositiveemotion.Discordantresponsesareindicativeofdenialoftheinfant’semotionaldistress,attemptingtoridenegativeintopositive,e.g.,“Don’tbethatway”or“Nofussing,nofussing,youshouldbeveryhappy”表現(xiàn)出不和諧的情緒反應(yīng)，以驚訝或積極情緒回應(yīng)嬰兒的痛苦。不和諧的反應(yīng)提示出對嬰兒情緒痛苦的否認，試圖以積極的情緒覆蓋消極的情緒，例如“不要那樣”或“別難過，別難過，你應(yīng)該非常高興”Beebe:Maternalbehaviorat4monthspredictingdisorganizedattachmentat12months畢比：4月齡時的母親行為預(yù)測12月齡時紊亂的依戀highlevelsofemotionaldistress(facialandvocal)程度強烈的情緒痛苦（面部和聲音）discordantresponses,e.g.,oneinfantjoinedsweetmaternalsmileswithsmilesofhisown,butmeanwhilehewhimperedashismotherpushedhisheadbackandroughlysmackedhishandstogether不和諧的反應(yīng)，例如，一個嬰兒微笑著呼應(yīng)了母親的甜蜜微笑，但同時他嗚咽著，因為他的母親把頭往后推，太過毛躁地讓他雙手擊掌behaviorerraticandunstable,moment-to-moment,potentiallymakingitmoredifficultformotherstomentalize行為易變、不穩(wěn)定，時刻刻刻都是如此，可能導(dǎo)致母親更難心智化lowlevelsofself-soothing,emotion-regulatingself-touch低水平的自我安撫性質(zhì)、情緒調(diào)節(jié)性質(zhì)的自我觸摸Mentalizingcommentary:“I’msoupsetandyou’renothelpingme.I’msmilingatyouandwhimpering;don’tyouseeIwantyoutoloveme?WhenI’mupset,yousmileorcloseuporlookaway.Youmakemefeelworse.IfeelconfusedaboutwhatIfeelandaboutwhatyoufeel.Ican’tpredictyou.Idon’tknowwhatisgoingon.WhatamIsupposedtodo?Ifeelhelplesstoaffectyou.Ifeelhelplesstohelpmyself.Ifeelfrantic.”心智化的評論：“我很難過，你沒有幫助我。我對你微笑又嗚咽；你看不到我希望讓你愛我嗎？當(dāng)我心煩意亂時，你會微笑或封閉或移開視線。你讓我感覺更糟。我對自己的感受和你的感受是什么感到困惑。我無法預(yù)測你。我不知道發(fā)生了什么事。我應(yīng)該做些什么？我感到?jīng)]有辦法影響你。我感到?jīng)]有辦法幫助自己。我感到很瘋狂?！盉eebe:infantbehaviorat4monthspredictingdisorganizedattachmentat12months畢比：4月齡時的嬰兒行為預(yù)測12月齡時紊亂的依戀ClinicalExample:depersonalization

臨床實例：去人格化History背景Womeninherfortieswithextremeandpervasivetraumahistory:manytypesofabuseandneglectbyfatherandabusiveolderbrother;abusecontinuedintoearlyadulthood有著極端且廣泛的創(chuàng)傷史的四十多歲的女性：遭受父親和虐待人的哥哥的多種類型的虐待和忽略；虐待持續(xù)到成年早期Centraltoalltraumawaslackoffeelingvalidatedandunderstood所有創(chuàng)傷的核心元素都是缺乏得到確認、被理解的感覺SeverePTSD+anddissociation嚴重的PTSD+解離Pervasiveabsorptioninfantasy,livinginadream嚴重沉浸在幻想中，生活在夢里Dissociativedetachmentwasprimaryproblem:felt“spacy,”likerobot,non-human,lightasafeatherthatcouldblowawayinthewind;worriedshewasmakingupherproblems,whichherhusbandreinforced解離型的脫節(jié)是主要問題：感覺“空白感”，像機器人，非人類，輕如羽毛，可以被風(fēng)吹走；擔(dān)心自己的問題是自己編造出來的，而她丈夫強化了這一點Nonsuicidalself-injurytomakeherselffeel“real.”非自殺性的自我傷害使她自己感覺“真實”。ClinicalExample,continued

臨床實例，續(xù)Therapy治療Patientfeltshewaslivinginadreamandwantedto“wakeup”病人覺得她生活在夢中，想要“醒來”Positiveexperienceofbeingabletoexpressherself,feltunderstood,feltmorestablyreal(illnessaswellastalentsandprofessionalachievementstakenveryseriously)能夠表達自己，感受到被理解，感覺更加穩(wěn)定且真實（疾病、天賦以及專業(yè)成就得到認真看待）的積極體驗Tookupthehobbyofmakingpottery,helpedherfeelgrounded.有了制作陶器的愛好，幫助她感受到有了根基。Towardendoftherapy,usedmetaphorofbeing“pluggedin”and“synced”insteadofbeinginadreamworld接近治療結(jié)束時，使用“插入”和“同步”的比喻，而不再是生活在夢境中Couplestherapyhelpedherhusbandtakeherillnessmoreseriouslyinsteadofcallingheran“airhead”;shefeltvalidatedandmoreconnectedtohim;helpedhersenseofreality.夫妻療法幫助丈夫更嚴肅地對待她的病，而不是稱她為“沒腦子”；她感到得到確認，與他有了更多連接；幫助她的現(xiàn)實感。Familyworkalsoledtosomebettersenseofconnectionwithhusband家庭工作也帶來了一些與丈夫更好的連接感Positivefollow-up積極的后續(xù)發(fā)展References參考文獻AllenJG(2013).Mentalizinginthedevelopmentandtreatmentofattachmenttrauma.London:Karnac.AllenJG&FonagyP(2014).Mentalizinginpsychotherapy.InREHalesetal.(Eds.).TextbookofPsychiatry:DSM-5Edition.Washington,