It is hard for me to recapture(再现) now the motivation and understanding with which I entered the field of psychiatry fifteen years ago. Certainly I wanted to “help” people. The process of helping people in the other branches of medicine involved technology with which I was uncomfortable and which in other ways seemed too mechanical to suit my tastes. I also found talking to people more fun than poking(刺) and prodding(刺激) them, and the quirks of the human mind seemed inherently more interesting to me than the quirks of the body or the germs infesting(寄生于) it. I had no idea how psychiatrists helped people, except for the fantasy that psychiatrists were the possessors of magical words and magical techniques of interacting with patients which would magically unscramble(使恢复原状) the knots of the psyche(心智). Perhaps I wanted to be a magician. I had very little notion(概念) that the work involved would have something to do with the spiritual growth of patients, and certainly I had no notion whatsoever that it would involve my own spiritual growth.
During my first ten months of training I worked with highly disturbed(有精神病的) inpatients(住院病人) who seemed to benefit much more from pills or shock(电击) treatments or good nursing care than they did from me, but I learned the traditional magical words and techniques of interaction. After this period I began to see my first neurotic patient for long-term outpatient psychotherapy. Let me call her Marcia. Marcia came to see me three times a week. It was a real struggle. She wouldn’t talk about the things I wanted her to talk about, and she wouldn’t talk about them in the way I wanted, and sometimes she just wouldn’t talk at all. In some ways our values were quite different; in the struggle she came to modify hers somewhat and I came to modify mine somewhat. But the struggle continued despite my storehouse of magical words and techniques and postures, and there was no sign that Marcia was improving. Indeed, shortly after she started to see me she began a pattern of almost outrageous(令人惊讶的) promiscuity(混乱), and for months she recounted(叙述) unabatedly(不衰退地) innumerable(数不清的) incidents(事件) of “bad behavior.” Finally, after a year of this, she asked me in the middle of a session “Do you think I’m a bit of a shit?”
“You seem to be asking me to tell you what I think of you,” I replied, brilliantly stalling(暂缓) for time.
That was exactly what she wanted, she said. But what did I do now? What magical words or techniques or postures(姿势) could hep me? I could say, “Why do you ask that?” or “What are your fantasies about what I think of you?” or “What’s important, Marcia, is not what I think of you but what you think of yourself.” Yet I had an overpowering(无法抵抗的) feeling that these gambits(话题) were cop-outs(站不住脚的借口), and that after a whole year of seeking me three times a week the least(最少) Marcia was entitled(有资格的) to was an honest answer from me as to what I thought of her. But for this I had no precedent(先例); telling a person honestly face to face what you think of him or her was not one of the magical words or techniques that any of my professors had taught me. It was an interaction that had never been suggested or recommended in my training; the very fact that it had not been mentioned indicated to me that it was an interaction that was disapproved of, a situation that any reputable(声誉好的) psychiatrist would not allow himself to fall into. How to act? With my heart pounding I went out on what seemed to be a very shaky(颤抖的) limb(肢体) indeed. “Marcia,” I said, “you have been seeing me now for over a year. During this long period of time things have not gone smoothly for us. Much of the time we have been struggling, and the struggle has often been boring or nerve-wracking(极端令人头疼的) or angry for both of us. Yet despite this you have continued to come back to see me at considerable effort and inconvenience to you, session after session, week after week, month after month. You wouldn’t have been able to do this unless you were the kind of person who is determined to grow and willing to work very hard at making yourself a better person. I do not think I would feel that someone who works as hard on herself as you do is a bit of a shit. So the answer is, No, I do not think you are a bit of a shit. In fact, I admire you a great deal.”
From among her dozens of lovers Marcia immediately picked one and established a meaningful relationship with him which eventually led to a highly successful and satisfying marriage. She was never again promiscuous(混杂的). She immediately began to speak about the good things in herself. The sense of unproductive struggle between us instantly(立刻) vanished, and our work became fluent and joyful, with incredibly(难以置信地) rapid progress. Strangely, my going out on a limb(我的冒险) by revealing my genuinely positive feelings for her-something I felt I was really not supposed to do-rather than seeming to hurt her, apparently was of great therapeutic benefit and clearly represented the turning point in our work together.
What does this mean? Does it mean that all we have to do to practice successful psychotherapy is to tell our patients that we think well of them? Hardly. First of all, it is necessary to be honest in therapy at all times. I honestly did admire and like Marcia. Second, my admiration and liking was of real significance(含义) to her precisely(准确地) because of the length of time I had known her and the depth of our experiences in therapy. In fact, the essence of this turning point did not even have to do with my liking and admiration; it had to do with the nature of our relationship.
A similarly dramatic turning point came in the therapy of a young woman I will call Helen, whom I had been seeing twice weekly for nine months with a noticeable(显而易见的) lack of success and for whom I did not yet have much positive feeling. Indeed, after all that time I did not even have much of a feeling of who Helen was at all. I had never before seen a patient for such a length of time without having gained some idea of who the individual was and the nature of the problem to be resolved. I was totally confused by her and had spent the better part of several nights attempting without any success whatsoever to make some sense out of the case. About all that was clear to me was that Helen did not trust me. She was vociferous(喧嚷的) in her complaints that I did not genuinely care for her in any way, shape or form and was interested only in her money. She was talking in this fashion during one session, after nine months of therapy: “You cannot imagine, Dr. Peck, how frustrating(令人沮丧的) it is for me to attempt to communicate with you when you are so uninterested in me and therefore so oblivious(不在意的) to my feeling.”
“Helen,” I replied, “it seems to be frustrating for both of us. I don’t know how this will make you feel, but you are the single most frustrating case I have ever had in a decade(十年) of practicing psychotherapy. I have never met anyone with whom I have made less headway(前进) in so long a time. Perhaps you are right in believing that I am not the right person to work with you. I don’t know. I don’t want to give up, but I sure as hell(确实) am puzzled about you, and I wonder until I’m almost crazy as to what the hell is wrong in our work together.”
A glowing(热情洋溢的) smile came over Helen’s face. “You really do care for me after all,” she said.
“Huh?” I asked.
“If you didn’t really care for me you wouldn’t feel so frustrated,” she replied, as if it were all perfectly obvious.
At the very next session Helen began to tell me things that she had previously either withheld or actually lied about, and within a week I had a clear understanding of her basic problem, could make a diagnosis, and knew generally how the therapy should proceed.
Again, my reaction to Helen was meaningful and significant to her precisely because of the depth of my involvement with her and the intensity(强度) of our struggle together. We are now able to see the essential ingredient(要素) that makes psychotherapy effective and successful. It is not “unconditional positive regard,” nor is it magical words, techniques or postures; it is human involvement and struggle. It is the willingness of the therapist to extend himself or herself for the purpose nurturing the patient’s growth-willingness to go out on a limb, to truly involve oneself at an emotional level in the relationship, to actually struggle with the patient and with oneself. In short, the essential ingredient(要素) of successful deep and meaningful psychotherapy is love.
It is remarkable(引人注目的), almost incredible(不可思议的), that the voluminous(长篇的) professional literature in the West on the subject of psychotherapy ignores the issue of love. Hindu gurus frequently make no bones about(对……毫不犹豫) the fact that their love is the source of their power.
But the closest Western literature comes to the issue are those articles that attempt to analyze differences between successful and unsuccessful psychotherapists and usually end up mentioning such characteristics of successful psychotherapists as “warmth” and “empathy.” Basically, we seem to be embarrassed(尴尬的) by the subject of love. There are a number of reasons for this state of affairs. One is the confusion between genuine love and romantic love which so pervades(遍及) our culture, as well as the other confusions that have been dealt with in this section. Another is our bias(偏见) toward the rational(基于理性的), the tangible(明确的) and the measurable in “scientific medicine” that the profession of psychotherapy evolved(逐渐形成). since love is an intangible, incompletely measurable and suprarational(超国家的) phenomenon, It has not lent(借给) itself to scientific analysis.
Another reason is the strength of the psychoanalytic(精神分析的) tradition in psychiatry of the aloof(冷漠的) and detached(不带感情的) analyst, a tradition for which Freud’s followers more than Freud himself seem to be responsible. In this same tradition, any feeling of love that the patient has for the therapist are generally labeled “transference” and any feelings of love that the therapist has for the patient “countertransference,” with the implication(暗指) that such feelings are abnormal, a part of the problem rather than its solution, and are to be avoided. This is all quite absurd(荒谬的). Transference, as mentioned in the previous section, refers to inappropriate feelings, perceptions and responses. There is nothing inappropriate about patients coming to love a therapist who truly listens to them hour after hour in a nonjudgmental(无偏见的) way, who truly accepts them as they probably have never been accepted before, who totally refrains(避免) from using them and who has been helpful in alleviating(缓解) their suffering. Indeed, the essence of the transference in many cases is that which prevents the patient from developing a loving relationship with the therapist, and the cure(治疗) consists of working through the transference so that the patient can experience a successful love relationship, often, for the first time. Similarly, there is nothing at all inappropriate in the feeling of love that a therapist develops for his or her patient when the patient submits to the discipline of psychotherapy, cooperates in the treatment, is willing to learn from the therapist, and successfully begins to grow through the relationship. Intensive psychotherapy in many ways is a process or reparenting. It is no more inappropriate for a psychotherapist to have feelings of love for a child. To the contrary, it is essential for the therapist to love a patient for the therapy to be successful, and if the therapy does become successful, then the therapeutic relationship will become a mutually loving one. It is inevitable that the therapist will experience loving feelings coincidental(巧合的) with the genuine love he or she has demonstrated toward the patient.
For the most part, mental illness is caused by an absence of or defect(缺陷) in the love that a particular child required from its particular parents for successful maturation(成熟) and spiritual growth. It is obvious, then, that in order to be healed through psychotherapy the patient must receive from the psychotherapist at least a portion(一部分) of the genuine love of which the patient was deprived(丧失的). If the psychotherapist cannot genuinely love a patient, genuine healing will not occur. No matter how well credentialed(有资格的) and trained psychotherapists may be, if they cannot extend themselves through love to their patients, the results of their psychotherapeutic practice will be generally unsuccessful. Conversely, a totally uncredentialed(无资质的) and minimally trained lay(外行的) therapist who exercises a great capacity to love will achieve psychotherapeutic results that equal those of the very best psychiatrists.
Since love and sex are so closely related and interconnected, it is appropriate to mention here briefly the issue of sexual relationships between psychotherapists and their patients, and issue that is currently receiving a good deal of attention in the press(新闻界). Because of the necessarily loving and intimate(亲密的) nature of the psychotherapeutic relationship, it is inevitable that both patients and therapists routinely(毫不意外地) develop strong or extremely strong sexual attractions to each other. The pressures to sexually consummate(完成) such attractions may be enormous. I suspect(猜想) that some of those in the profession(职业) of psychotherapy who cast(投掷) stones at a therapist who has related(联系) sexually with a patient may not themselves be loving therapists and may not therefore have any real understanding of the enormity of the pressures involved. Moreover, were I ever to have case in which I concluded(作结论) after careful and judicious(明智的) consideration that my patient’s spiritual growth would be substantially(大量地) furthered by our having sexual relations, I would proceed to have them. In fifteen years of practice, however, I have not yet had such a case, and I find it difficult to imagine that such a case, and I find it difficult to imagine that such a case could really exist. First of all, as I have mentioned, the role of the good therapist is primarily that of the good parent, and good parents do not consummate sexual relationships with their children for several very compelling(令人信服的) reasons. The job of a parent is to be of use to a child and not to use the child for personal satisfaction. The job of a therapist is to be of use to a patient and not to use the patient to serve the therapist’s own needs. The job of a parent is to encourage a child along the path toward independence, and the job of a therapist with a patient is the same. It is difficult to see how a therapist who related sexually with a patient would not be using the patient to satisfy his or her own needs or how the therapist would be encouraging the patient’s independence thereby.
Many patients, particularly those likely to be most seductive(有魅力的), have sexualized attachments to their parents which clearly impede(妨碍) their freedom and growth. Both theory and the scant bit of(很少的) evidence available strongly suggest that a sexual relationship between a therapist and such a patient is far more likely to cement(巩固) the patient’s immature attachments than to loosen them. Even if the relationship is not sexually consummated, it is detrimental(有害的) for the therapist to “fall in love” with the patient, since, as we have seen, falling in love involves a collapse of ego boundaries and a diminution(缩小) of the normal sense of separation that exists between individuals. The therapist who falls in love with a patient cannot possibly be objective about the patient’s needs or separate those needs from his or her own. It is out of love for their patients that therapists do not allow themselves the indulgence(沉溺) of falling in love with them. Since genuine love demands respect for the separate identity of the beloved, the genuinely loving therapist will recognize and accept that the patient’s path in life is and should be separate from that of the therapist. For some therapists this means that their own and the patient’s paths should never cross outside of the therapeutic hour. While I respect this position, for myself I find it unnecessarily rigid(严格死板的). Although I have had one experience in which my relating to an ex-patient seemed to be definitely(肯定地) detrimental(有害的) to her, I have had several other experiences in which social relationships with ex-patients seemed clearly beneficial to them as well as to myself. I have also been fortunate enough to successfully analyze several very close friends. Nonetheless, social contact with the patient outside of the therapeutic hour, even after therapy has been formally terminated, is something that should be entered into only with great caution and stringent self-examination as to whether the therapist’s needs are being met by the contact to the detriment(损害) of the patient’s.
We have been examining the fact that psychotherapy should be(must be, if successful) a process of genuine love, a somewhat heretical(异端的) notion in traditional psychiatric circles. The other side of the same coin is at least equally heretical: if psychotherapy is genuinely loving, should love always be psychotherapeutic? If we genuinely love our spouse, our parents, our children, our friends, if we extend ourselves to nurture their spiritual growth, should we be practicing psychotherapy with them? My answer is: Certainly. From time to time at cocktail parties someone will say to me, “It must be difficult for you, Dr. Peck, to separate your social life from you professional life. After all, one can’t go around analyzing one’s family and friends, can one?” Usually the speaker is only making idle conversation and is neither interested in nor ready to assimilate(理解) a serious reply. Occasionally, however, the situation gives me the opportunity to teach or practice psychotherapy there and then(当时当地), on the spot, explaining just why I do not even attempt, or would want to attempt to separate my professional and my personal lives. If I perceive my wife or my children or my parents or my friends suffering from an illusion(错误的观念), a falsehood(谬误), an ignorance(无知) or an unnecessary impediment(障碍), I have every bit as much obligation to extend myself to them to correct the situation insofar as possible, as I do to my patients, who pay me for my services. Am I to withhold my services, my wisdom and my love from my family and my friends because they have not specifically contracted and paid me for my attention to their psychological needs? Hardly. How can I be a good friend, father, husband or son unless I take the opportunities that are available to attempt, with whatever artistry(艺术性) I can command, to teach my beloved what I know and give whatever assistance is in my power to give to his or her personal journeys of spiritual growth? Moreover, I expect the same services from my friends and family to the limits of their ability. Although their criticism of me may be unnecessarily blunt(直言不讳的) at times and their teaching may not be as thoughtful as an adult’s, I learn much to help me from my children. My wife guides me as much as I guide her. I would not call my friends friends were they to withhold from me the honesty of their disapproval(不赞同) and their loving concern as to the wisdom and safety of the directions of my own journey. Can I not grow more rapidly with their help than without it? Any genuinely loving relationship is one of mutual psychotherapy.
I have not always seen it this way. In years past I was more appreciative of my wife’s admiration than of her criticism, and did as much to foster(促进) her dependency as I did her power. My self-image as a husband and father was that of provider; my responsibility ended with bringing home the bacon. Home I wanted to be a place of comfort, not challenge. At that time I would have agreed with the proposition(观点) that it would be dangerous and unethical and destructive for a psychotherapist to practice his art upon his friends and family. But my agreement was motivated as much by laziness as it was by fear of misusing my profession. For psychotherapy, like love, is work, and it’s easier to work eight hours a day than it is to work sixteen. It’s also easier to love a person who seeks out your wisdom, who travels to your territory to obtain it, who pays you for your attention and whose demands upon you are strictly limited to fifty minutes at a time than it is to love someone who regards your attention as a right, whose demands may not be limited, who does not perceive you as an authority figure and who does not solicit(请求) your teaching. Conducting psychotherapy at home or with one’s friends requires the same intensity of effort and self-discipline as it does in the office but under much less ideal conditions, which is to say that at home it requires even more effort and love. I hope, therefore, that other psychotherapists will not take these words as an exhortation(道词) to immediately begin practicing psychotherapy with their mates and children. If one remains on a journey of spiritual growth, one’s capacity to love grows and grows. But it is always limited, and one dearly should not attempt psychotherapy beyond one’s capacity to love, since psychotherapy without love will be unsuccessful and even harmful. If you can love six hours a day, be content(满意的) with that for the moment, for your capacity is already far greater than most; the journey is a long one and it requires time for your capacity to grow. To practice psychotherapy with one’s friends and family, to love one another full time, is an ideal, a goal to be striven(努力) toward but not instantly achieved.
Since, as I have indicated, laymen can practice successful psychotherapy without great training as long as they are genuinely loving human beings, the remarks(言论) I have made concerning(关于) the practice of psychotherapy on one’s friends and family do not apply solely to professional therapists; they apply to everyone. Occasionally when patients ask me when they will be ready to terminate their therapy, I will reply, “When you yourself are able to be a good therapist.” This reply is often most usefully made in group therapy, where patients of course do practice psychotherapy on each other and where their failures to successfully assume the role of psychotherapist can be pointed out to them. Many patients do not like the reply, and some will actually say, “That’s too much work. To do that means that I would have to think all the time in my relationships with people. I don’t want to think that much. I don’t want to work that hard. I just want to enjoy myself.” Patients often respond similarly when I point out to them that all human interactions are opportunities either to learn or to teach(to give or receive therapy), and when they neither learn nor teach in an interaction they are passing up an opportunity. Most people are quite correct when they say they do not want to achieve such a lofty(崇高的) goal or work so hard in life. The majority of patients, even in the hands of the most skilled and loving therapists, will terminate their therapy at some point far short of completely fulfilling their potential. They may have traveled a short or even a goodly(优秀的) distance along the journey of spiritual growth, but the whole journey is not for them. It is or seems to be too difficult. They are content to be ordinary men and women and do not strive to be God.