I wish to present my work with a patient who discovered she had developmental prosopagnosia(facial blindness) after several years of psychoanalysis. Though as much as 2% of the population may have this, there is little if anything in the psychoanalytic literature about this condition, or it’s effects on development or treatment. I wish to highlight that many patients are unaware they have this condition or their therapist, including myself, don’t consider it.
我想呈报一个我的个案，案主在与我进行了数年精神分析工作之后察觉到自己患有发展性面部失认症[1]（脸盲）。尽管有近2%的人口患有这类疾病，但精神分析文献中却很少提到这一点，也很少提到它对发育或者治疗的影响。我想强调的是，很多病人没有觉察到他们有这种情况，甚至他们的治疗师也没有察觉，这其中也包括我。
[1] 失认症（agnosia）这个术语正是由Sigmund 创造，取自希腊语a-（“没有”）和gnosis（“知识”）。失认的意思是提取知识或再认的失败。（译者注。Michael S. Gazzaniga (2015),《认知——关于心智的生物学》第三版，北京：中国轻工业出版社，p.179.）
Facial blindness or developmental prosopagnosia (DP), was considered extremely rare in my training and as recently as the 2003 review by Kress and Daum (1). Since then there has been a surge in research findings that have greatly expanded our understanding. It is now estimated that 1.5 to 2% of the population is affected. An example is a 2008 study with Hong Kong medical students by Kennerknecht and Wong(2), showing a 1.9% distribution, demonstrating the universality of this condition.
在我的受训背景中，脸盲或称面部失认症是很少被提及的，这一点正如Kress和Daum在2003年的综述中提到的那样。自那以后便涌现了大量与此相关的研究，这极大地拓展了我们对此的理解。目前的估计是约1.5-2%的人口受此影响。例如香港医学院学生Kennerknecht和Wong 所做的研究显示有1.9%的流行率，这说明这一疾病有一定的普遍性。
Numerous publications in the popular press have appeared. Several prominent people have reported to suffer from it, Oliver Sachs (3), Brad Pitt, and the artist Chuck Close, to name a few. Jane Goodall, the famous chimpanzee researcher, describes her own experience as follows: I used to think it was due to some mental laziness, and I tried desperately to memorize the faces of people I met so that, if I saw them the next day, I would recognize them. I had no trouble with those who had obvious physical characteristics—unusual bone structure, beaky nose, extreme beauty or the opposite. But with other faces I failed, miserably. Sometimes I knew that people were upset when I did not immediately recognize them—certainly I was. And because I was embarrassed, I kept it to myself. (Goodall and Berman1999).
相关的书籍报道大量出现。一些杰出人士也报告说他们遭遇此类疾病，例如奥利弗·萨克斯，布拉德·皮特和艺术家查克·克洛斯。Jane Goodall， 一位著名的黑猩猩研究者，就描述过她的亲身经历：我曾经以为这是心智惰性导致的，我试图拼命地记住我曾经遇到过的人的脸，这样我下次再见到他们时就可以认出他们。对于那些有明显生理特征的人——比如有不同寻常的骨结构，鹰钩鼻，特别漂亮或非常丑的人我是可以记住的。但可悲的是，对于其他脸我就完全不记得了。有时候我知道那些我没能马上认出的人是不高兴的——对此我也不高兴。我因此而感到尴尬，因此只能把这件事当做一个我自己的秘密。
The author Heather Sellers has written a well-received book “You Don’t Look Like Anyone I Know: A True Story of Family, Face Blindness, and Forgiveness” describing her own experiences. The observed effects on children’s behavior is described and well expressed in the title of Dalrymple and Duchaine’s paper (4)“A room full of strangers every day”.
作家Heather Sellers写过一本很受欢迎的书《你看起来不像任何一个我认得的人：一个关于家庭，脸盲和原谅的真实的故事》，书中描述了她的亲身经验。Dalrymple和Duchaine合著的的《一个每天都充满陌生人的房间》一文，就将此病对于行为的影响进行了详尽描述。
Facial recognition is a complex phenomena, that apparently involves several cortical areas. Some recent work suggests the defect in DP involves reduced connections between the occipital and visual areas. It appears to run in families and involve multiple genes. I defer to those better qualified in understanding this complex and now extensively studied area of cognitive research. See a current review by Bates and Tree(5).
面部识别是一个复杂的现象，它涉及到好多个大脑皮层区。近期的一些工作表明发展性面部失认症与枕叶和视觉区的联系减弱有关。它似乎与家族遗传有关并且涉及到很多。在此，我听从那些在这个热门的认知研究领域里，更有资格理解和研究这一现象的人的意见。可参见Bates 和Tree近期的综述。
I want to present a patient, who discovered she had DP in the course of a long standing analysis, surprising us both, and forcing some new understanding of our work together.
我想呈报一个病人。她在经历了长期的分析之后发现自己实际上患有发展性面部失认症， 这一点令我们双方都很吃惊，并促使我们对于我们共同的工作有了新的理解。
The pt. L is African American single professional woman in her late 50’s. She has been in some form of ongoing therapy most of her adult life. I remember my first impression of her as she came for her initial session. She was referred to me by another analyst, who was relocating out of state. She was a tall, awkward woman with masculine gestures yet still attractive, with a shy smile like a little girl trapped inside, her manish gestures and bearing. Her presenting symptoms were depression, difficulty in relationships, sexual preference, and episodes of transient dissociation described as “spacing out”.
病人L，是一个非裔美国人，50多岁的职业。在她成年之后的大部分时间里，都在接受某些形式的持续治疗。我还记得初始访谈之际她留给我的第一印象。她是一个搬去其他州的分析师转介给我的。她个子高挑，带着些许男性姿态，尽管显得有些笨拙但仍不失风韵。她笑起来很羞涩，好像有一个小姑娘被困在那个身体里。她当时的症状是，难以建立关系，性取向和间歇性解离。
Her psychiatric history included several hospitalizations in her early 20’s for suicide attempts and alcohol abuse. After being required to sign a contract not to commit suicide by her inpatient psychologist, she responded by burning down 2 buildings and being kicked out of the hospital. She did continue as an outpatient with a bearded social worker she was comfortable with. A gifted student and athlete, she finally finished her degree and moved to my city where she obtained a PhD. Her previous analyst, a woman, felt she had stabilized somewhat with multiple sessions weekly because she had object constancy problems. L initially was concerned about my capacity as a male to be helpful, but we did quickly connect. She has an excellent sense of humor and loves to banter about sports. I thought I could see glimpses of a positive brother transference emerging. I noticed a concreteness about her thinking in patches, a tendency to forget contents of sessions, and external events, that looked like dissociation. I made a conscious choice to be as interactive as possible, giving considerable here and now feed back as to my experience of her and what I was thinking. My thought was to deepen the engagement, counter the negative paternal projections, and present myself as much as possible as a real object in the hope of facilitating better object constancy.
她的史显示在她20来岁时多次因试图和酗酒入院治疗。当她的住院师要求其签署不自杀协议时，她纵火烧了两栋房子来作为回应，因此被赶出医院。她继续以门诊病人的身份与一个大胡子社工开展工作，她对这个社工很满意。她是一个很有天分的学生还擅长运动，她最后拿到了学位并移居到我所在的城市，并在这里获得了博士学位。她的前任分析师是一名女性，这名分析师认为她有客体恒常性的问题，觉得一周数次的咨询设置能使她有所稳定。起初L担心我是个男性而不能对她有所帮助，不过我们很快就连接上了。她很有幽默感还爱拿体育开涮。我想我能瞥到一些对于兄长的正性。我注意到她思维上的一些固化，容易遗忘治疗所谈的内容和一些外部事件，这看起来很像解离。我在层面决定让自己尽量活跃地与之互动， 并就我此时此地对她的感受和我所想到的内容向她反馈。我的想法是去加深彼此的连接，以对抗负性的父亲投射，并让自己显得尽可能是一个真实的客体，进而促进其更好的客体恒常感。
She described a most unusual childhood. Her parents, both college graduates, were dairy farmers in a rural area. L. was the 4th child with 2 elder brothers and a sister 2 ½ years older. The family dynamics centered around L’s sister, who was developmentally delayed. L experienced almost constant intrusion and absence of boundaries with her sister. She was mostly ignored, and not allowed to complain. The father was deeply attached to the sister with nothing positive towards him experienced by L. In all my years of seeing L, she could never retrieve a single positive feeling towards her dad. She always remembers herself as seeing the world only as an observer of others not a participant. She learned by observing and imitating others. She felt closer to the calves than her family in many ways, naming them and touching them daily(notice the parallel with Jane Goodall and her chimpanzees). She attended a one-room school-house till grade 7 having no playmates in her isolated rural neighborhood. Her memories of father are of a cold stern man with his gloved hand artificially inseminating restrained bleating cows, or callously shipping off her beloved calves for sale. The mother and sister stayed in the house, while L worked outside doing chores with her Dad and brothers, modeling herself after them. The mother was a needy and helpless person. L. took pleasure in caring for her mother but expected little in return. She convinced herself that she would eventually grow into a boy like her brothers and was devastated with the onset of menses. This also coincided with L’s changing schools, becoming lost in a group of strangers all of whom knew each other. A gifted athlete and student she organized herself around these activities. She developed some difficulty with absenteeism and drugs as a junior in High School leading to her first seeing a bearded counselor with marked improvement in her behavior. She described him as the first person to ever listen to her, She developed the idea that he could always see her, which was both gratifying and scary. Going away to university led to her first psychiatric admission when the chaos seemed just too much. I was to be another in the line of bearded therapist for her.
她向我讲述了一个非常不同寻常的童年。她的父母都念过大学，是乡下的牧场主。L在家排行第四，上面有两个哥哥和一个大她2岁半的姐姐。L的姐姐有发育迟缓问题，整个家庭的动力以她为中心展开。L的生活总是不断地被姐姐闯入而且和姐姐之间缺乏边界。她总是被忽视，并且不得对此有任何抱怨。父亲和姐姐的联系紧密，L感受不到任何与父亲有关的积极体验。在她的中她之于这个世界总是一个观察者而不是一个参与者。她从观察和模仿他人中学习。她觉得，她对小牛犊都比对家人在许多方面亲近得多，每天给它们起名字，并且抚摸它们（请注意，这恰好与Jane Goodall和她的黑猩猩之间的关系一样）。她在一个只有一间教室的乡村小学念书，直到7年级之前她在与世隔绝的乡下都没有玩伴。她记忆中的父亲是一个冷漠 严厉的男人，总带着手套在给咩咩叫的奶牛人工授精，或者冷酷地把她心爱的小牛运走卖掉。母亲和姐姐通常就待在屋里，L则学着父兄的样子跟着一起干活。母亲是一个高需求又无助的人。L乐于照顾母亲但很少期待回报。她说服自己终有一天她会长成像她哥哥那样的男孩子，但是例假的到来摧毁了这一幻想。这一点与L的转学也很一致， 她在一个别人都互相认识的陌生群体里感到迷失。起初她在活动中把自己塑造成一个有天赋的运动健将和好学生的形象。到了高中一年级她逃学和吸毒，为此她开始去见那个长胡子的咨询师，之后她的行为有了显著改善。在她的描述中，这是第一个倾听她的人，她以为他能一直见她，这既让她满意又让她害怕。上大学后她第一次被收治，因为当时的麻烦实在太大了。我成为了下一个与她工作的大胡子治疗师。
I decided to see L 4x’s weekly sitting up. I felt this would help with her clear problems with object constancy and attachment. I also decided to be more interactive with her, building on a bearded therapist, big-brother transference that seemed pre-formed. The biggest difficulty developed in the second year when she developed a violent negative transference rising at times to almost delusional quality, whenever she saw me with another pt. This paralleled the developing positive transference, as she started expressing rage directed towards me or any other patient who might be waiting to see me, or if I was literally one minute late. In this state, she would be delusional and paranoid. I was setting her up, deliberately making her think she was important only to take pleasure in her humiliation. She called these her “rants,” which initially lasted days and were associated with severe suicidal ideation.
我决定每周见L四次。我感觉这对她的客体恒常性和方面的问题会有帮助。我同时也决定多与她互动，以促进似乎是预先就已经形成的对大胡子治疗师和大哥哥的移情。我们之间最大的困难始于第二年，她从那时起发展出一种暴力的负性移情，而且几乎带有妄想的性质，只要她一看到我和其他病人在一起就会这样。与此平行的是她也发展了正性移情，比如他开始向我或其他可能等着见我的病人直接表达愤怒，或者当我迟到哪怕一分钟时也会抱怨。在这种情况下，她可能是处在妄想中或者是偏执的。我试着启发她，谨慎地让她认识到，她只能在体验到被羞辱时才能感到自己是重要的。这样的状况一开始会持续好几天，并且伴随着严重的自杀观念。她把这些表现叫做她的“咆哮”。
There was no looseness of thought process during these times, rather more like rigid delusional ideas. These could usually be dealt with by empathically talking her down in the following sessions, wondering with her about her amnesia for her good feelings towards me, how could I remember her last session and her history if I had truly forgotten her. She would insist that she knew I no longer had memory of her when I looked at the next patient. In these moments, I often felt a chilling sense of not being seen, becoming a thing in her mind while she raged at me. I tried a number of parameters. I shifted her to the last pt. of the day and scheduling a 5 minute buffer before her instead of my usual back to back schedule. Inevitably, a pt. might be in the restroom or talking on a cell phone outside the office and set off a rage, however they became less frequent, and over a long time less intense. The pt. experienced these as ego-dystonic and felt increasing frustration at the uncontrollable nature of them. I got a good bit of interpretive traction by connecting the intruders to the experience of her mentally disabled sister. The sister was 2 ½ years older, with the family focused exclusively on her needs. L described constantly being intruded upon by her sister. L’s clothes, mail, were all things the sister felt free to take with no limits being set. L’s considerable athletic and academic talents were never acknowledged. In contrast, she was always admonished to not make her sister feel badly by comparison, whenever she had success. The father was very involved with the sister who was very attached to him. Several parameters and the repeated interpretations as other patients’ intrusion into her space turned them into her sister were eventually helpful, but only after the explosion had begun to subside. Indeed many of my colleagues would see this as becoming intensive psychotherapy rather than analysis. My focus was on what was helpful and worked.
这些时候她并没有思维松散的表现，而是更像刻板的妄想观念。我面对这类情况通常的处理会是，在接下来的咨询中地与她交谈，和她一起探究她对我的好感觉的健忘，如果我真地忘了她，何以能够记得住她的上节治疗和她的过往呢。而她会坚持认为我在见下一个病人时就不再会记得她了。在这些时刻，我经常感到一阵不被看见的寒意，当她对我发火时，我在她头脑中成为了一个物品。 我尝试了很多办法。我把她放在当天工作的最后一个时段里，在上一个小节结束之后安排了一个5分钟的间隔。而我通常的做法是一个接一个的看病人。然而不可避免的是，总会有病人待在候诊室里，或者在办公室外面打电话，每当这个时候，都会激起她的愤怒。然而，这些愤怒爆发的频率在慢慢减少，很长一段时间以后，愤怒的强度也逐渐变低了。病人将这些体验为不和谐的，并且越来越为它们不可控的本质而感到沮丧。通过把入侵者和她对精神残疾的姐姐的体验联系起来，我得到了一个不错的解释。她姐姐比她大两岁半，全家人都只关注着姐姐的需要。L总是觉得被姐姐侵入。她姐姐总是会随意拿走她的衣服和信件，并且并不会被父母禁止那样做。L那相当令人瞩目的在田径和学业上的天赋从未被家人认可过。相反，她在获得成功时，却总是被告诫不要用自己的成就来使姐姐相形见绌。父亲对姐姐关爱有加，姐姐对父亲也十分依恋。我运用多种治疗手段，并且反复不断地把那些闯入到她的空间里的其他病人解释为她姐姐的替代者，这样的努力最终使她爆发出的愤怒逐渐减弱。确实，我的许多同事会把这个过程看做高密度的心理治疗，而不是精神分析。而我关注的重点是什么有益，什么起效。
Over time, she was increasingly successful at work and beginning to form a social network for the first time as she began playing an instrument in a local orchestra. She became a full professor, a licensed instrument rated pilot, and scuba instructor. Then while driving with a new friend M, they passed an attractive man in another car. L was astonished that her friend could describe his face in such detail when she had none. We had previously explored how differently our minds worked, in that I filed stories with faces and she did not. This time, she searched the internet, and discovered a trove of information about facial blindness. This information led her to take the Cambridge facial recognition test online scoring in the 40’s consistent with prosopagnosia. Suddenly our psychodynamic formulations had to be sharply altered to include this new information. I struggled to catch up with the new findings myself. In one session, I brought in a mirror from the waiting room. She was unable to see the mirror image as herself. “It’s like someone looking at me through a mirror,” she said. She experienced great discomfort in moving her arms and seeing them in the wrong place. This was amplified when I stood behind her so we were both visible. “I can’t see you and me at the same time. It’s too uncomfortable, if I concentrate hard, I can see us both but it’s too tiring to keep up very long. It’s like straining to focus on a difficult abstraction in math.
随着时间的推移，她在工作中越来越成功，而且由于她开始在一个当地的管弦乐队参与演奏，她第一次有了一个社交网络。她成为了一个正教授，获得了“靠仪表导航的飞行员”的执照，还是一个水肺潜水教练。在和一个新朋友M一起开车的途中，他们超过了旁边一辆车，那辆车上有一个很有魅力的男性。当她的朋友可以描述出那个男性脸上的许多细节时，她深感震惊。因为她自己对那些细节一点印象都没有。我们在此之前就已经知道，我俩头脑运行的方式是很不一样的。我用人脸来存档故事，而她却不这么做。这一次，她上网搜到了大量关于脸盲症的信息。这些信息让她参加了在线的剑桥脸部认知测试，只到了40分，这表示她有持续性的失认症。突然间，我们的心理动力性概念化必须被调整，因为我们需要把发展性面部失认症包含在内。我努力让自己跟上这个新的发现。在一个小节里，我从候诊室里拿来了一面镜子。她无法将镜子里的映像看做她自己。“这看上去就像有个人隔着镜子在看我一样。”她说。当她移动自己的胳膊，看到它们出现在一个错误的地方时，体会到极大的不适。当我站在她身后让她能同时看到我们俩时，这种感觉被放大了。她说：“我没办法让自己同时看着自己和你。这让人太不舒服了。如果我非常努力地集中注意力，我可以同时看到我们俩。但是那太累了，我没办法坚持很久。这就像专注于某个数学中很难的抽象概念时带来的紧张感。”
Let me describe some recent session material:
让我来讲一点最近几节咨询中呈现的材料：
She comes into the session sits down, and begins to tell me of her dinner with M. her new friend. She describes the evening by describing the sequence of events, the positioning of M’s hand bag, How she ordered straight vodka on the rocks, not being familiar with M’s drink selection. A description of the meal ensued interrupted only by my teasing her about ordering her filet well done. I threatened in jest to have her leave my office because beef should be at least pink. The ensuing banter reveals her real issue is with blood, which she associates with animal skin, dirt and feces like the renderings on the farm growing up. She assured me she was vigilant about overcooking and drying out good beef. We both reminisced about the bland diet of her childhood. Specifically she recalled the boiled beef tongue and white rice with the only seasoning available, being ketchup. “ I appreciate how my world has changed,” she says. I point out that while she has described in detail the sequence of events, there are no details about M’s facial expressions or how she looked etc. “ It’s the facial thing again,” she says, “it’s the sequence that holds it all together. I did notice an uneasy feeling when we left, a queasy unsettled feeling.” You had a pleasant evening with a friend you say, did you feel sad after the connection ended I ask? “I’m not sure I know what that feels like she says, like when you leave I feel anxious or angry so I know I act as if I miss you or at least the way other people do when they say they are missing someone.”
她来到治疗室，坐下来开始告诉我，她和一个新认识的朋友M一起吃晚餐的情形。她按照时间顺序讲述当晚发生的事情，讲M的手包摆放的位置，讲她如何在还不知道M的喜好的情况下点了一杯加冰的纯伏特加。她一直在说她的晚餐，直到被我打趣她点的牛排时才被打断。我开玩笑地威胁她，要她离开我的办公室，因为牛肉应该至少是粉红色的。接下来的打趣显示出，对她来说真正重要的事与血有关。她从这一点出发，联想到动物的皮肤、脏污的东西和粪便，它们都来自于农场。她向我保证，她在做菜的时候总是小心翼翼的，以免把好牛肉煮过了，让它们的口感变得很干涩。我们一起回忆了她童年时寡淡无味的饮食。她特别提到，在一段时间里只能吃到加了番茄酱的熟牛舌和白米饭。“我非常庆幸我的世界有了变化”，她说。我指出，当她事无巨细地描述一件接着一件的事情时，她并没有提到M的面部表情或者她看上去怎么样。“又是脸上的事！”她说，“是事情发生的顺序把它们联系在一起。我确实注意到当我们离开时，她有些心神不宁。那是一种令人反胃的，令人焦躁的感觉。”我问她说：你说，你和一个朋友度过了一个愉悦的夜晚。在你们的会面结束之后，你是否会觉得难过呢？她说：“我并不确定那是一种什么样的感觉。当你离开时，我觉得或者愤怒。所以，我知道我表现得好像我会思念你，或者至少，像其他人思念什么人时表现的那样。”
“There is something different now, that feeling I had with M. In the past I would have said it was sadness because you or someone else called it that. I would observe the behavior and use the words trying to be like everyone else and not so different. This is different, it’s hard to explain, it’s more coming from inside me. I can disagree with you now not because of logic but because it comes from a sensation in me. You’ve really created a problem here for us because you have given me language, I am aware of something coming from inside of me now that I am trying to describe with my own words. It’s complicated I know, but it is something I’ve never been able to do before.”
“现在，我对M的感觉变得有些不一样了。在过去，我会说，那是悲伤，因为你或者别的什么人那么叫它。我会观察这种行为，并且试着像其他人一样使用这些词语。这是不一样的，而且很难解释。它更多的来自于我的内在。我现在可以反对你，并不是源于逻辑，而是源于某些来自我内心的感觉。你在这里给我们制造了麻烦，因为你教会了我使用语言。我现在可以觉察到有些东西逐渐从我的内心浮现出来。我正在尝试用我自己的语言来描述它们。我知道这很复杂。但这是我之前无论如何都无法做到的事情。”
The next session begins, “last night I had a dream about you, but I don’t know if I can talk about it.” This is a great rarity and there is a hint of a blush. I figure there is something erotic about it, so using the light bantering style we have evolved over the years I say “Was it good for me too?” She laughs the tension gone, and says, ”Actually we kissed on the lips. I wouldn’t let it go any further even in my dreams. What was different was I felt a tenderness and vulnerability nothing like I’ve ever experienced with a man. Maybe I had glimpses of the wish with D(a colleague she briefly dated but he moved away), never with my father. It was a mutual thing like you’ve talked about, something I could never imagine.”. “Yes she says, something has changed, but now I’m afraid of how vulnerable I feel. I’m afraid a rant is coming!” she says. I say,“ I’ll tread lightly for a bit.”
下一个小节是这样开始的：“昨天晚上，我做了一个与你有关的梦。但我不知道我是不是可以说说它。”这在以前实在是难得一见的，而且她好像脸红了。我想，这个梦可能有一些性欲化的内容。所以，我用了在这些年里我们经常使用的打趣的方式对她说：“对我来说，那也是一件好事么？”她笑了，紧张的气氛一扫而光。“事实上，我们亲吻了对方的嘴唇。甚至在我的梦里，我都不允许这件事走得更远。不同的是，我感受到了一种当我和一个男人在一起时没有体验过的温柔和脆弱。或许我瞥见了一点点对D（一个她曾经短暂地约会过的同事，但是后来他搬走了）的期待，但绝不是对我父亲的。那就像是你曾经说过的某种成熟的东西，某种我无法想象的东西。”是的，正如她所说，有些事情已经改变了。“但是现在我担心的是，我自己感觉到十分的脆弱。我害怕紧接着的，会是咆哮！”她说。我说：“我会轻轻地向前走一小步。”
I am wrestling with how to understand how facial blindness affects the way she experiences herself as a self that is like or different from me. How does one feel attached in the full sense of the world without being able to put a face upon it. When I ask her she responds that it is all context. I say “I’ve teased you about whether you would miss me in the past around vacations and separations. You always say no but then act as if that were the case. I’ve never been clear if it was too shameful to admit or that you were unaware.”
我绞尽脑汁试图弄明白脸盲症如何影响她怎样把自己体验为自己，这或许与我的经验相同亦或不同。如果一个人不能为他对这个世界的整体感觉对应上一张脸时，他又如何对这个世界产生连接感呢？当我问她时，她说那只与环境有关。我说：“我曾开玩笑地问你在假期或者分离时是否想念过我。你总是说你没有，但之后总会表现得好像你其实是想念我的。我一直都不清楚，承认你在想念我对你来说会不会是一件令你感到十分羞耻的事情，或者，你仅仅是没有觉察到你在想我呢？”
She responds, “What I miss is the context, this place, the sound of your voice, the colors, the lighting. This is the you I miss, not a face. Your face fades in a day or so. That’s why context is so important. I expect certain people to be in certain contexts based on probability, I can remember their names that way, but not by a face. I say how hard it is for me to conceptualize that, for me faces are like a folder on a computer desktop, with all the narrative story and memories contained. ”
她回应说：“我怀念的是环境，是这个地方、你的嗓音、颜色和光线。这些是我想念的你，但不是你的脸。你的脸在一两天之后就会逐渐消失。这就是为什么环境那么重要。我期望某个人尽可能出现在某种特定的环境里。我可以通过这样的方式记住他们的名字，但不是他们的脸。对我来说，解释这些有些困难。脸对我来说，就像电脑桌面上的文件夹，里面存放着所有与之相关的故事和记忆。”
She brightens, “ I can see that, like a folder with a name for a group of things, I can visualize a folder on my Mac desktop like that. I can see that as a cognitive abstraction, but not at a feeling level.”
她的眼睛亮了起来：“我能看到我的记忆，就像一个装着很多东西的有名字的文件夹。我可以想象在自己的电脑桌面上有一个那样的文件夹。我可以把它看做是一个抽象的认知概念，但并不是某种感受。”
“When I was a junior in high school, I started smoking pot and missing a lot of classes. I was about to be suspended but I was referred to counseling instead. My Dad was president of the school board, probably because of his involvement with my sister. He never said anything to me, but I suspect I didn’t get suspended because they were afraid to, rather than anything he said or did. I don’t think he cared that much. I saw this social worker with a beard at the counseling center. He was the first man or person I felt was listening to me. I’m embarrassed to tell you this, it sounds crazy I know, but I started feeling like he was watching me all the time, like he had a periscope or something. I would drive by his house and think he could see me. ” I have fleeting concern these might have been ideas of reference, but instead I say “Perhaps it’s like when you look in the mirror and it feels like someone else.” She says, “Yeah being seen or listened to I can’t feel me and them at the same time. Like I have to look away here so one of us doesn’t disappear. It felt good and scary that he was always there. Anyway I decided if I was going to college I needed to buckle down. My grades had stayed pretty good but I didn’t miss any more class.” I say, “Since you can’t remember my face I must just be another beard in your life like him!” We both laugh.
“我一进高中就开始抽大麻，并且翘了很多课。我本来是要被勒令休学的，结果却被送到了咨询中心。或许是因为我爸爸想更多的关照我姐姐，所以他做了这所学校董事会的主席。我爸从来没对我说过什么，但是我怀疑我之所以没有被勒令休学是因为他们不敢这么做，倒无关乎我爸爸究竟说了什么或者做了什么。我并不觉得他有多关心这件事。我在咨询中心见到了这个留着大胡子的社工。我觉得他是第一个愿意听我说话的人。告诉你这些让我觉得好尴尬，听上去这很疯狂。但是我开始觉得，他似乎无时无刻不在注视着我，就好像他有个潜望镜或者别的什么东西一样。在我开车路过他家时我觉得他能看到我。”我当时觉得这都是些牵连观念，但我没那样说而是说“也许这就像当你照镜子的时候，镜子里的人看上去却像另外一个人似的。”她说：“是的。当我被人听到和看到的时候，我无法同时感受到自己和他们。就好像我必须看着别的什么地方，这样才能保证我或者对方中的一个不会消失。他总是在那里让我觉得很好，但是也很可怕。总之我决定如果我要去大学的话，我一定要全力以赴。我的成绩必须非常好，而且我决不再翘课了。”我说：“因为你记不得我的脸，那么对你来说我就得是另一个大胡子，就像他一样。”我们都笑了。
Another session: We are discussing the Sachs and Chuck Close podcast. www.radiolab.org/story/91967-strangers-in-the-mirror/). She says “Close is the artist describing working with small individual detail working up to the whole which makes a portrait even though he has facial blindness. That really spoke to me, I can remember the photograph of my mother I carry in my wallet even though I can’t remember her face. Same with my dad, I can remember the 2 dimensional representation in a photo but not the 3 dimensional face, which is never quite the same as you look at it.”
在另一个小节里，我们讨论了萨克斯和查克·克洛斯的播客。（www.radiolab.org/story/91967-strangers-in-the-mirror/）她说：“尽管艺术家克洛斯尽管患有脸盲，但他能把人物细微的局部细节拼凑起来组成一幅肖像。对此我也有体会。尽管我不记得妈妈的脸，但我能记得放在我钱包里的那张她的照片。对我爸也是一样的。我能记得照片里的二维图样，但不是三维的脸。这和当你真正看到他的时候是完全不一样的。”
A later session: She encounters a tardy previous pt. female, well dressed leaving my office. There is the usual explosive reaction. She sits in another chair, no eye contact. The familiar fixed litany follows, how she feels set up, can’t compete, she is always on time, why do they feel entitled to stay, obviously I prefer her. Feels I deliberately set her up, thought she could trust me then I do this!. I make sister interpretations. Eventually she takes chair feeling disgusted with herself. “I guess I still can’t control my feelings.” I explore whether she can recall any feelings of connection with me. Says she doesn’t give a flip, and can’t remember any. I wonder if same thing happened with dad, turning her rage against the part of herself that wants any connection. I prompt her with the recent kissing dream session. She describes a sensation like feeling a glass partition between herself, myself, and others. She can’t bear attachment because of this reaction. I say for me it’s like watching an Iraq war vet throwing self on floor every time a car backfires in street outside. I say I feel it is important to talk about this because this reaction is in part why she has no long-term relationships. I wonder if this wouldn’t happen with anyone that she cares deeply about who has other relationships. This seems more about envy of my having a perceived connection with, or attachment to, someone that she feels too defective to be able to experience herself. We both feel there is something unique about her rage reaction that has to do with her facial blindness more than just the developmental psychological trauma. It is as if there is something organic that we cannot yet discern with certainty. We both continue to struggle to understand this.
之后的一个小节： 在她前面的一个穿着考究的女性咨客较晚离开我的办公室，她们便偶然相遇了。于是就有了一个常见的爆炸性反应。她坐在另外一张椅子里，不看我的眼睛。紧接着是熟悉的固定的没完没了的抱怨，讲述她如何被整，无法竞争，她总是很准时，为什么其他人却觉得自己有权久呆？显然，我更喜欢那个病人。她觉得我是有意整她的。她觉得自己能够信任我，但我却做了这样的事！我做了一个与她姐姐有关的解释。最终，她对自己感到厌恶：“我猜我还是无法控制自己的感受。”我试图探索她是否能够回想起任何与我连接的感觉。她说她没有一点头绪，想不起来什么。我想知道，她和父亲之间是否发生了类似的事，使得她痛恨自己身上那个想与别人发生联系的部分。我提醒她那个谈论亲吻的梦的小节。她描述了一种感觉，好像有一堵玻璃墙隔在她、我和其他人之间。由于这些反应，她无法忍受依恋。我说，对我来说，就好像看着一个参加过伊拉克战争的老兵每次在街上遇到汽车逆火（会发出类似爆炸的声音——译者注）就会立刻趴下。我说，我觉得谈论这些是非常重要的，因为这正是她没有长期关系的其中一个原因。我想知道的是，这种情况是否不会发生在那些她深深地关心着的，同时也与其他人保持某种关系的人身上。她似乎在嫉妒那些与我有某种联系或者依恋关系的人，而她认为这些人都非常残缺并不能感受到他们自己。我们都觉得，在发展性心理之外，有一些与她暴怒反应相关的独特情况，或许也和她的脸盲症有关。好像有一些与身体器官相关的事情我们现在还不能确定地分辨出来。我们至今依然在努力弄明白这一点。
It is an ongoing challenge for me to try to understand someone whose mind operates in such a very different way. I feel the following observations are specific to L’s DP and not environmental. 1) L. can’t recognize her mirror image. She conceptualizes it as another person looking through the mirror at her. It is confusing to see moving her right arm is reflected on the left in the mirror. 2) She has almost no memories of looking in the mirror seeing herself as a whole just parts hair, arms even as a child. (3 She has great difficulty in maintaining eye contact with me. “I can’t see you and feel myself at the same time”. (4 She has always experienced herself as an observer. All she learned about people is by observation and imitation until her analysis. (5 Even in her dreams about the encounters with me and a previous patient, she is in my place looking at the other, no third party perspective. (6 As she says, context is everything. Her description of only being able to remember her mother’s photograph of her face does not include her ability to remember the activities, smells and the sound of her mother’s voice in her daily activities. She remembers people by context, color of hair, the way they walk, what they are wearing and where she sees them.
对我来说，尝试理解一个心智以某种与众不同的方式运转的人是一个持续的挑战。我觉得，以下这些观察可能与L的发展性面部失认症有关，而不是由环境引起的：1）L无法认出她自己在镜子里的映像。她把它理解为另一个通过镜子观察她的人。当自己移动右手臂，而镜子里的人相应的移动左手会让她感到十分困惑。2）她从未有过在照镜子时将她自己认作一个完整的人的记忆，她只能把自己认作头发、四肢这些部件的组合。即使在童年时也是如此。3）她很难与我保持眼神交流。“我没有办法做到一边看着你，一边感受我自己。”4）她总是觉得自己是一个观察者。在她进入分析以前，她对人的全部了解都来自于观察和模仿。5）即使在她的梦里，当她偶然撞上我和在她之前的病人时，她也是在我的位置上，看着另外一个人。在她的梦里并没有第三人称的视角。6）正如她所说，环境就是一切。她有说起过只能够记得照片上的妈妈的脸，但并没有提及她记得日常生活中她妈妈的活动、气味和嗓音的能力。她通过环境——头发的颜色，走路的样子，穿着打扮，以及她在哪里遇见了他们——来记住人。
I found the following parameters to be useful with this pt. It was important to be active and interactive. Frequently describing what is going on in my mind in the moment. Displaying curiosity about the differentness in the way our minds work. My pt. was fascinated by my description of people’s stories or narratives, I store away under faces. “ You mean faces for you are like file folders on a Mac desktop?” My relative openness to describing my experience in the moment forced her to confront her fantasies and preconceptions about men. This was interconnected with her own developing curiosity about her own emotions leading to the dramatic development of increased mentalization. “I now have a language for myself words not just feelings.” This has led to a more stable sense of self, even if evolving in a different context.
我发现以下因素对这个病人是有作用的。积极主动地与她互动是重要的。频繁地描述此时此刻我在想什么。对我们头脑运作方式的差异保持好奇心。我的病人对于我所讲述的储存在人脸之下的故事感到着迷。 “你的意思是，脸对你来说就像电脑桌面上的文件夹？”我比较开放地描述此时此刻自己的体验，迫使她面质自己对于人们的幻想和先入之见。这与她逐渐增强的对自己的好奇心相互联系在一起，并且推动着她的心智化能力有了激动人心的发展。“除了感觉以外，我拥有了用我自己的词语组成的语言。”这使得她呈现出更加稳定的自我意识，哪怕是在不同环境之中亦然。
L. has been able to use analysis successfully. From beginning as a severely disturbed young woman, she has achieved a lot. She is a successful professional, a full professor at a major university. She is an instrument rated pilot with her own plane and a scuba instructor. She plays a musical instrument in a prestigious local organization. She has developed an increasing circle of friends. Internally she has developed a remarkable capacity for mentalization and self-reflection. Her episodes of depression and suicidality have essentially disappeared. She is able to modulate and manage her emotional life in a dramatically better way. She has achieved a more stable self-representation and in her unique way, object constancy with me. In concluding I wish to encourage anyone working with patients exhibiting an apparent object instability, transient episodes of dissociation, together with social isolation and intimacy problems, to rule out unrecognized facial blindness or DP and adjust technique accordingly if present. I hope describing my experience may be useful to others.
L可以成功的使用分析。作为一个从一开始被严重困扰的女性，她取得了长足的进步。她是一个成功的专业人士，在一所重点大学里任正教授。她是一个有资格靠仪表导航的飞行员，拥有自己的私人飞机，也是一个水肺潜水教练。她在当地一个颇有声望的组织里演奏乐器。她发展出了一个还在不断扩大的朋友圈。在她的内在，她发展出了十分出色的心智化和自我反省的能力。她抑郁和自杀的发作大体上消失了。她能够以一种更好的，迅速的方式调整和管理她的情感生活。她获得了一个更加稳定的自我表象，以她自己的方式建立起了一个与我有关的客体恒常性。最后，我想建议那些与展现出明显的客体不稳定性，短暂的解离发作，伴随社交孤立和亲密问题的病人一起工作的同行，要排除未被确认的脸盲症或者发展性面部失认症。如果病人确实有这样的问题，那我们要调整我们的技术。我希望我的经验可以对其他人有所帮助。
Reference
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4 “A room full of strangers every day”: The psychosocial impact of developmental prosopagnosia on children and their familiesKirsten A. Dalrymple 1, , Kimberley Fletcher1, Sherryse Corrow, Roshan das Nair, Jason J.S. Barton, Albert Yonas, Brad DuchaineThe Journal of Psychosomatic Research ,August 2014 Volume 77, Issue 2, Pages 144–150
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6. Childhood Adversity Is Associated with Adult Theory of Mind and Social Affiliation, but Not Face ProcessingLaura Germine1,2,3,4*, Erin C. Dunn1,2,3, Katie A. McLaughlin5, Jordan W PLOS ONE | DOI:10.1371/journal.pone.0129612 June 12, 2015
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