思想起心理治療中心 (松德院區) ------ Taipei Psychotherapy Center

關於部落格
SpaceToThink-WayToTalk-FutureToHope
中心位於北市聯合醫院松德院區(原:北市療)第五院區。以"精神分析取向心理治療師"的培訓與個案治療為目的。培訓課程則擁有相當豐富的精神病理學理論,精神分析理論閱讀課程,以及多種臨床案例的工作坊。思想起心理治療中心並與臺灣精神分析學會密切合作。。
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(思想起論壇第六想)自閉症的觀察

(僅呈現power point的文字部分做為參考,圖樣部分未能呈現) 1920s, Paris:Paul Valéry (the poet and writer):[ Mr. Einstein, what do you do whenever an idea comes into your head? Do you make a note of it right away?] Albert Einstein: [Oh, you know, ideas….Not many of them about!]” ****************** Ideas Treatment skills Emotion, body feels and thinking:psychoanalysis the treatment models of Tavistock Autistic Workshop ******************* “The Cradle of Thought”- Peter Hobson the seventeenth century, Aristotlethought (cognition), affect (feeling) conation (the will) ********************** F84 廣泛性發展障礙症 Pervasive Developmental Disorders F84.0 兒童期自閉症 F84.1 非典型自閉症 F84.2 雷特症候群 F84.3 其他兒童期崩解症 F84.4 有智能不足與重覆動作之過動症 F84.5 艾斯伯格症候群 ***************** 自閉症的認知神經心理功能缺損 *心智理論缺陷假說(Theory of Mind Deficit; Baron-Cohen, 1995 ): first order or secondary order *中心聚合缺陷假說( Central Coherence Deficit; Francesca Happé, Uta Frith, 1989) *執行功能缺陷的假說(Executive function theory ;Ozonoff, Rogers and Pennington, 1991): working strategy/attention, impulse control *交互主體性/情感缺陷假說 (Intersubjectibility;Colwyn Trevarthen)(Affect Deficit :social perception deficit ;Interpersonal Relatedness; Peter Hobson):emotional based social learning Resonance Behaviors (補充閱讀:A first order theory of mind requires a person to predict another’s mental state(“ I think that John thinks….”). Second order theory of mind, on the other hand, allows the process of one’s understands of another’s mental state (“Jane thinks that John think…..”). Executive function theory (Ozonof, Rogers and Pennington, 1991) The executive functioning consists of processes such as planning, complex cognitive tasks, impulse control and flexibility of thought and action. It may indicate the more basic information processing deficits which may lead to difficulties presenting in theory of mind. The basic frontal lobe function also existed in other psychiatric illness such as ADHD, OCD, and schizophrenia, not specific to the ASD. In normal information processing, information is gathered from different situations and levels. To the end, the overall impression is formed--the gist of the circumstances. If some extreme style in the spectrum of continuum happens, too weak or too extreme central coherence functions, it can explain the communication and social abnormality of autism in that they can’t take all contextual information into relevant account. It also accounts for their extreme abilities such as remember unrelated detail information. According to the work of Trevarthen, the “primary intersubjectivity”, in which immediately emotional communication between mother and baby, precedes the later joint attention to objects that characterizes “secondary intersubjectivity”. This is very much a “two-person” theory, contrast to “theory of mind” which could be viewed as “one-and-a-half-person psychology” (They do focus on understanding others on the level of cognition or rational inference, but without addressing the affection of relationships.) The ability of autism to recognize emotion in others-a core component of intersubjectibility-may underdeveloped. ) ****************** Intersubjectibility (C. Trevarthen) : “primary intersubjectivity” joint attention, “secondary intersubjectivity” Interpersonal Relatedness (Peter Hobson): theory of “affective interpersonal awareness and relatedness” (補充閱讀:Peter Hobson, at the Tavistock Clinic, has proposed the theory of “affective interpersonal awareness and relatedness”. In normal developmental stage, infants develop the sense of self from sharing the experience with other person (not on locating in one person and communicate to the other). Then through the observation and monitoring of the bodily expressions of the relatedness, the infants can understand their relatedness to others. Finally they can recognize the relationship between their own subjective experiences and the bodily appearance of other people. In order to this, infants must be born with “pre-wired capacities” as precursors to the relational relatedness. According to the work of Trevarthen, the “primary intersubjectivity”, in which immediately emotional communication between mother and baby, precedes the later joint attention to objects that characterizes “secondary intersubjectivity”. This is very much a “two-person” theory, contrast to “theory of mind” which could be viewed as “one-and-a-half-person psychology” (They do focus on understanding others on the level of cognition or rational inference, but without addressing the affection of relationships.) The ability of autism to recognize emotion in others-a core component of intersubjectibility-may underdeveloped. ) ************************ 自閉症的神經缺損-Christopher Gillberg 2004/8 第一類:小腦或腦幹,低功能無語言,注意力缺損 第二類: mid-trimester,兩邊顳葉,典型自閉症,可能有些片語、詞彙能力。 第三類: 單邊或雙邊之額葉/顳葉損傷,艾斯伯格症 第四類: 多重、嚴重損傷如嚴重自閉症、極重度智能不足或不典型個案。 ******************** 精神疾病: 認知或情緒缺陷兒童精神病理: 意圖(intention)問題 自閉症的心理運作機制認知發展有缺陷(如theory of mind, executive functioning theory)極端偏差(如central coherence, extreme male brain theory) ************************ *認知理論無法解釋社會性主動互動及溝通缺損的核心症狀 *交互主體性(Intersubjectivity)解釋一部分嬰兒早期的動機及學習模式。 *克萊恩學派及客體關係理論則進一步探討以關係及情緒為基礎的心智學習模式。 *********************** 美國的自閉症療育模式 *除了傳統的ABA TEACCH地點 大部分都在整合不同訓練內涵 *醫療模式漸弱 教育模式漸增 *早療模式的深刻探索的被重視 *青少年以上的服務模式仍少 *療育模式公司化 全球化的發展 ******************* S. Freud *The past *The sexual content of phantasies *The powerful repressive forces Anna Freud: defences as achievements ************************ Melaine Klein *Paranoid-schizoid/ depressive position *Primitive state of persecutory anxiety/ terror of annihilation *Anxiety related to fear/guilt *Projection/ Projective identification ************************* Wilfed Bion:1897-1979 *Containment: enable a thought to become thinkable *Grid ***************************** Bion’s Grid *Beta elements *Alpha elements *Dream thought (psychic reality)‏ *Preconception (empathy thought)‏ *Conception(personal idea)‏ *Concept(abstract general thought)‏ *Scientific system *Algebra calculus ************************* W. Winnicottepreventive psychiatry *1935-1944: Environment-Individual Set up *1945-1959:Transitional Phenomenon *1960-1971:Use of an Object ***************** 自閉症理解與療育 —倫敦塔菲斯塔克模式 (Tavistock Clinic Autistic Workshop: psychodynamic-oriented relationship ) (補充閱讀:塔非史塔克中心是世界知名以精神分析導向心理治療為主的訓練重鎮之一,也是目前英國國家級公立機構之一,主要以克萊恩學派為主(Kleinlian)。除了有一個直接服務病患的門診部門外,它的主要角色是提供從事精神健康、社會照顧專業人員的再教育與訓練。過去半個多世紀來,許多領導性文章由此誕生,並進而衍伸成各自重要系統理論。 塔非史塔克創建於1920年代,初始的目的是針對大戰中有創傷經驗的士兵,在他們接受軍事制裁前予以人道性的協助,並以心理治療模式如:談話、傾聽及理解去了解受苦於[彈殼症候群]士兵的精神病理基礎。二次世界大戰期間多位專業人員(如有名的Dr Wilfred Bion)直接參與了治療的工作並發展出特殊的治療技巧(如leaderless group),今日[創傷中心]已有它一系列的理論與治療技巧的訓練課程。 1950年代許多重要的臨床研究結果改變了後續的臨床處置。Dr Michael Balint 針對醫病關係的探討改變了一般家庭醫學科的訓練養成過程。Dr John Bowlby 的依戀理論更影響後續相關發展心理學甚至認知神經科學的研究走向, 更進一步改變醫療及社會系統中專業人員針對孩童的態度。系統家庭治療的發展亦自當時之後成為英國非常重要的醫療政策之一。1948年機構的臨床及照會工作已納入國家健康照護的醫療給付機構之一。 倫敦的兒童指導訓練中心(The Child Guidance Training Centre ) 成立於1929年,並自1967納入塔非史塔克兒童與父母部門(1985年更名為兒童與家庭部門)。國家證照制度認可的專業兒童治療師認證訓練始自1948年,1994年始除證照外並授予東倫敦大學的碩士學位,修業自四到七年不等。目前全國有六家可訓練專業兒童治療師,塔非史塔克是創始及最大的中心。) ************************* 全能幻想 *extreme psychic pain:manipulation and projection, not for symbolic thinking. * Omnipotent narcissism:the libidinal part the destructive part ( Rosenfeld, 1971). *The autistic child can show the extreme form of narcissistic withdrawal, as if mindlessness. ***************************** *Treatment philosophy :“Feeling understood and coming to understand themselves ( M. Rustin)” *organic etiology :irreducible primary handicap, *psychological approach reduce the emotional-experience-based secondary handicapthe learning ability can be augmented ******************************* New treatment skills *Neutrality (Freud)the real deep change, rather than superficial *Containment (Bion) *Reclamation (Alvarez) (補充閱讀:1. Neutrality, Freud pointed out that the analyst’s taking over of repressive, guiding or encouraging functions, these could interfere the process of self-knowledge, self-realization in the patient (Freud 1912). Because of the powerful nature of transference, the analyst is in a highly privileged, therefore extremely responsible position. Only from the patient himself explore his truly inner imaginative world, however cruel and devastating, the real deep change, rather than superficial, could happen. The key point is the static state of the analyst’s affairs. 2. Containment, Bion stresses what the attitude should be than what it should not be. Underpinning the object-relation ones, containment indicates a more dynamic notion, referring to the holding of a balanced play of forces, and also to the method by which balanced holding is achieved. So that the thoughtful emotionality and emotional thoughtfulness, both could be done during the analysis, between the analyst and analyze. Bion related this to a state of maternal reverie. The beta elements were evacuated out to the mother-infant dyad relation, transformed under the process of alpha function, changed to alpha elements which could be let out by verbal thoughts in meaningful symbolic frames. In the consulting room, away from the neutral mirror (classical Freudian), the thoughtful reverie seems stressing on the receptive role which the therapist could be opening to feeling the impact of patient’s projections. The receptive, sometimes passive implications of the function of containment seemed leave something to be desired. How about the vegetative-like, no active outreaching patients? Let’s have a look about Reclaiming. 3. Reclamation, from James Strachy’s view (Strachy 1934), for some patients who give up, abandon hope rather than project it, not just lost of the will to live but rather have no knowledge that they do exist in the real human world, the therapist should act as an auxiliary superego - that is, as a non-judgmental and non-seductive figure who eventually be seen to be different from more extreme inner parental imagoes and voices - help the patients to be free from deeply inner fear, guilt and illusions. Rosenfeld extended and stressed the functions of the therapist as the auxiliary self, performing some ego functions such as perceiving, introjecting, and verbalizing which the patient cannot manage (Rosenfield 1972). Yet, in cases of chronic mental illness, or chronic depression or chronic apathy, the depersonalization is deeply chronic, who is as burn-out, long-forgotten by himself, at this critical point, the therapist may be temporarily functioning as almost the whole of the patient’s self –that is, not only the rational thinking, sorting ego, and not just the infantile dependent self either, but as something prior to both: the very sense of been alive. For years of withdrawal, mental starvation is different from mental hunger. The early psychoanalytic notions as an uncovering, unmasking activities seems fairly irrelevant to such chronicity of starvation. ) ********************************* Emotion, body feels and thinking *Anne Alvarez: premier social interaction leads to intellectual deficits and stereotypical behaviors. *intellectual deficit: from child’s native endowment, also from child’s identification of someone he doesn’t experience lively and imagine as a object-like person with his own restricted view. (補充閱讀:Anne Alvarez invokes Trevarthen’s stages of intersubjectibility. She argues the problems of autism would be in premier social interaction which leads to the consequence of intellectual deficits and stereotypical behaviors. The intellectual deficit is not only from the child’s native endowment (view from biochemistry or one-person psychology), it also from the child’s identification of someone he doesn’t experience lively and imagine as a object-like person with his own restricted view (from development and two-person psychology). Alvarez integrates psychoanalytic theory and developmental psychology: she stresses that therapist needs to be aware of issues of deficit and defense, to gear any intervention to the developmentally stage at any moments of treatment, to make verbal or non-verbal messages across. She introduces the techniques in treating autistic children: reclamation.) **************************** Treatment models of Tavistock Autistic Workshop *去人格化診斷與分類? *自閉症︰1.subtype(Wing, Attwood)2.嚴重程度不同3.慢性化程度不同(Alvarez) *多層次描述模式(五級) *個別人格、需求、傾向、慾望以及要求各不相同。 (補充閱讀:病人及家屬,面對一種去人格化的診斷與分類是困難與不堪的經驗,然而清楚的描述確實有助於我們對他們的理解。 自閉症之間有subtype(Wing & Attwood 1987)或 sub-sub-types (Alvarez & Reid, 1999b)的差異,嚴重程度的不同(ADI, Rutter et al., 1988),慢性化程度不同(Alvarez 1992) 一種多層次描述方式(五級分層) 個別性的人格、需求、傾向、慾望及要求各不相同,次分類本身是需有彈性,不同的時機可有相異的介入觀點。) ******************************* 初級疾病(primary deficits/disorders) *根本主要缺陷或疾病︰1.對別人好奇意圖有缺陷(Alvarez和Reid)2.心智理論(Theory of mind)3.警覺系統失調(dys-regulation of arousal level)4.認知整合問題(Frith)5.相互主體協調性問題(Trevarthen) *一種神經學上易致病性。 一種認知心理學上缺陷。 (補充閱讀:大部分講述ASD三種核心症狀的學者,現今多傾向有一根本的主要缺陷或疾患。 對他人的好奇、慾望有缺陷(Alvarez & Reid, 1999b) 心智理論(Theory of mind, Baron-Cohen,1988); 覺醒系統的失調(dys-regulation of arousal level, Dowson and Lewy) ; 認知整合問題(Frith) 相互協調性問題(Trevarthen,Aitken et. al.,1996) 都強調有一種基本神經學上的易致病性。 或可說是有一種認知心裡學上的缺陷。但在動力分析式心理治療的觀點,嚴重精神病狀態,精神病或自閉症,著重的觀點皆在其情緒狀態的理解有困難,自我功能在整合內在或外在現實時有困擾。)) *************************** 二級疾患(secondary disorder) *上述的初級疾患呈現在社交、溝通及想像力上的缺陷狀態即是二級疾患。 *特殊的二級疾患形式:重複行為與先佔性(repetitive behavior and preoccupation) ************************** 三級疾患(tertiary autism) :偏頗deviance *如同上癮的行為之後呢?避難所變成監獄之後呢? *一旦陷入怪誕、瘋狂的重複興奮刺激行為時,他們必須得完成它。需得有一種好的戰爭去釋放攻擊的慾望,一些友善的、幽默但確實傳達毀滅性意涵的攻擊需得承受。活著有時需要一種興奮感 *由堅定的面質與挑戰將怪異的呈現修飾成半遊戲方式。 (補充閱讀:當行為持續多年,已發展出一種先佔性、強迫性,如同上癮的行為之後呢?當避難所變成監獄無法脫離之後呢? 彷彿藥物上癮,當充滿強大力量的強迫性行為即將發生前,最好的方式是在行為發生前面質那種力量。有時一旦陷入一種怪誕、瘋狂的重複興奮刺激行為時,他們必須得完成它。人生中的某一些時刻需得有一種好的戰爭去釋放攻擊的慾望,一些友善的、幽默但確實傳達一種毀滅性意涵的攻擊我們需得承受。彷如活著有時亦需要一種興奮感,此時一些好的技巧可以將怪異的呈現方式修飾成半遊戲方式,但是確實是經由我們堅定的面質與挑戰使它改變的。 尤其到了青春期之後,AS病人無法有正常青少年人際間的挑逗、嚼舌及性經驗,而該死的感覺又如河流般泊泊流出,於是很可能如漩渦般懸繞在不恰當的物品或主題,猶如一種戀物癖(fetishism)。有時AS病人會以純口語方式來呈現其對性的不尋常幻想。Joseph 曾以”chuntering”來描述一些憂鬱狀態病人重複不斷抱怨自身的一種絕望時,治療者感受到的不是無望,反倒是刺激。任何主題被揮舞著擅場演出時,重點不在其內容,而在它是以怎麼樣的一種形式被傳遞,由最嚴重儀式化自閉行為到AS病人不斷的強迫性對話,都有可能觸發我們的憤怒或自戀的不堪(narcissistic moments)。 ) **************************** 三級疾患(tertiary autism):偏頗deviance *青春期,無法有正常青少年人際間的挑逗、嚼舌及性經驗,而感覺又如河流般泊泊流出,於是很可能如漩渦般懸繞在不恰當的物品或主題,猶如一種戀物癖(fetishism)。 *Joseph 以”chunttering”來描述一些憂鬱狀態病人重複不斷抱怨自身的一種絕望時,治療者感受到的不是無望,反倒刺激。 *Proust: consenting to be robbed, so not to be murdered ******************* 第四種因素:非症狀其他人格部分(fourth factor:the non-Asperger’s part of the personality) *發展的主題是持續且巨大的,病患其他人格正常的部分,常常被嚴重自閉儀式化行為掩蓋或被限制、或延遲發展或以另外的方式演出。 *仔細評估此部分的強處或優勢,將有助於協助病患克服其本身的困境。 ********************* 第五種因素:孩子本身自然人格的部分 講述的是每個人先天的自然生理狀態及氣質。 ************************** 自閉症治療: Anne Alvarez-Live Company *臨床個案分析:一種長期陷落的狀態、覺醒、成形、翻鬆固著到伴他活著1. understanding the long fall, 2.vegetable life and awakening, 3. growth of a mind (containment)4. reclamation5. live company and making the thought thinkable. (補充閱讀:Anne Alvarez將其長期經驗寫成書[Live Company]。由臨床個案著手逐步分析自閉狀態的精神病理學,如:一種長期陷落的狀態、覺醒、成形、翻鬆固著到伴他活著,一步步指出治療的依據及新技法,此種不過度強調訓練矯正,而是視之為有著嚴重困難個體,要協助他走出深層自閉,與人發展一種特殊需予以尊重的[他特有的形式且別人也可以體會]的人際社會關係,這種治療哲學是筆者深深認同的。固筆者特選了這個主題加以研讀,並試圖翻譯相關文獻。) ************************** When he realized his own ability to love and hate the parents, the psychic pain, depressive anxiety, is so great that it leads to defensive characters including manic or obsessional reparation, or totally denial of damage or contempt.(一人自閉) ******************* As the child can perceive the parents were the one who have their own thinking and feeling ( having a ‘theory of mind’), they begin developing and achieving separateness and independence (close to Mahlerian model of separation-individuation).(兩人關係) *********************** Once the child separating, he perceives the whole object as integration of both love and hate, that is, she has her feeling about the ‘third’, for example father or siblings, the child inevitably has to face the oedipal conflict.(三人關係)
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