The scientific standing of psychoanalysis
的科学立场
作者：Mark
翻译：妃子笑
2018年2月
This paper summarises the core scientific claims of psychoanalysis and rebuts the prejudice that it is not ‘evidence-based’. I address the following questions. (A) How does the emotional mind work, in health and disease? (B) Therefore, what does psychoanalytic treatment aim to achieve? (C) How effective is it?
本文总结了精神分析的一些核心科学主张，驳斥了所谓的精神分析并非“循证”的偏见，作者主要阐述了如下的问题：A情感心智在健康和疾病领域是如何工作的？B精神分析的治疗目标是如何达成的呢？C精神分析有多么有效？
A. As regards the workings of the emotional mind, our three core claims are the following.
一、关于心智是如何工作的，主要有以下3个方面来论述：
(1) The human infant is not a blank slate;
1.1 人类并不是一块白板。
like all other species, we are born with innate needs. These needs (‘demands upon the mind to perform work’, as called them, his ‘id’) are felt and expressed as emotions. The basic emotions trigger instinctual behaviours, which are innate action plans that we perform in order to meet our needs (e.g. cry, search, freeze, flee, attack). Universal agreement about the number of innate needs in the human brain has not been achieved, but mainstream taxonomies (e.g. Panksepp, 1998) include the following.【1】
【1】Here I am focusing on emotional needs – which are felt as separation distress, rage, etc. – not bodily drives – which are felt as hunger, thirst, etc. – or sensory affects – which are felt as pain, disgust, etc. (See Panksepp, 1998.) The way in which I use the term ‘action plans’ in this article is synonymous with the use of the term ‘predictions’ in contemporary computational neuroscience.
这里主要聚焦在情感需求—比如分离痛苦、愤怒等等，而不是身体的需求—比如饥饿、口渴等，也不是感官的影响—比如疼痛、恶心等（见Panksepp，1998）我使用“行动方案”这个术语的方式和当代的计算机使用“预期”这个术语的方式是如出一辙的。
就像其他物种一样，我们生来是携带一些内在需求的。这些需求由情感来感知的，也是靠情感来表达的，（依靠头脑工作来满足需求，叫做本我的部分）。这些基本的情感激发了本能的一些行为，这些行为就是内在行动方案，我们依靠这些内在行为方案来满足我们的需要（比如说哭泣、寻找、僵直、逃跑、攻击）。现在关于人类大脑到底有多少内在需要并没有达成广泛的一致，但是主流的分类方法还是有的，（比如 Panksepp，1999），具体如下 1：
The (upper brain-stem and limbic) anatomy and chemistry of the basic emotions is well understood (see Panksepp, 1998 for a review).
关于上脑干和边缘系统的解剖学和主要情感化学物质的这些科学研究都已经很好的被解释了。（详见panksepp，1998年的研究）
The main task of mental development is to learn how to meet our needs in the world.
1.2 精神心智发展的主要任务就是学会如何在这个世界上满足我们的需求。
We do not learn for its own sake; we do so in order to establish optimal action plans to meet our needs in a given environment. (This is what Freud called ‘ego’ development.) This is necessary because innate action programmes have to be reconciled with actual experiences. Evolution predicts how we should behave in, say, dangerous situations, but it cannot predict all possible dangers (e.g. electrical sockets); each individual has to learn what to fear. This typically happens during critical periods in early childhood, when we are not best equipped to deal with the fact that innate action plans often conflict with one another (e.g. attachment v. rage, curiosity v. fear). We therefore need to learn compromises, and we must find indirect ways of meeting our needs. This often involves substituteformation (e.g. kicking the cat). Humans also have a large (cortico-thalamic) capacity for satisfying their needs in imaginary and symbolic ways. It is crucial to recognise that successful action programmes entail successful emotion regulation, and vice versa. This is because our needs are felt as emotions; thus, successful avoidance of attack reduces fear, successful reunion after separation reduces panic, etc., whereas unsuccessful attempts result in persistence of fear and panic, etc.
我们不仅仅为自身需要的原因去学习，我们这么做就可以建立起来最优化的行为方案来满足我们在给定环境中的需要（这就是弗洛伊德说的“”的发展）。这种发展是很有必要的，因为内在的行为模式一定要和实际经验相协调。进化能够预期我们应该如何行为，比如在危险的环境中如何行为，但是进化不能预料所有可能的危险（比如说电插座的危险），每一个个体必须学会害怕哪些东西。这种情况经常发生在童年早期的关键时期，在早期关键期我们还没有配备足够的能力来处理一个事实，就是有些内在的行动方案是和其他方案相矛盾冲突的，（比如说依恋和愤怒，好奇和害怕）。因此我们需要学会妥协，我们必须找到能够满足需要的那种间接的方式，这就经常涉及到替代形成（比如说踢猫理论）。人类也拥有一个巨大的能力（皮质丘脑的能力）用想象的和象征的方式来满足自己的需要。这种能力对于认识到成功的行为模式需要成功的情感调节至关重要，反之亦然。这是因为我们的需要都是以情感的方式来被感知的；因此成功避免被袭击的话就可以减少害怕，和依恋对象分离后重新团聚就可以减少恐慌等等。反之如果这些行为企图没能成功的话，就会导致害怕和恐惧持续下去。
Most of our action plans (i.e. ways of meeting our needs) are executed unconsciously.
1.3 我们大多数的行为方案（也就是满足我们需要的那些方式）都是的执行的。
Consciousness (‘working memory’) is an extremely limited resource, so there is enormous pressure to consolidate and automatise learned solutions to life’s problems (for a review see Bargh & Chartrand, 1999, who conclude that only 5% of our goal-directed actions are conscious). Innate action programmes are effected automatically from the outset, as are the programmes acquired in the first years of life, before the cortical (‘declarative’) memory systems mature. Multiple unconscious (‘non-declarative’) memory systems exist, such as ‘procedural’ and ‘emotional’ memory (which are mainly encoded at the level of the basal ganglia). These operate according to different rules. Not only successful action plans are automatised. With this simple observation, we can do away with the unfortunate distinction between the ‘cognitive’ and ‘dynamic’ unconscious. Sometimes a child has to make the best of a bad job in order to focus on the problems which it can solve. Such illegitimately or prematurely automatised action programmes are called ‘the repressed’. In order for automatised programmes to be revised and updated, they need to be ‘reconsolidated’ (Tronson & Taylor, 2007); that is, they need to enter consciousness again, in order for the long-term traces to become labile once more. This is difficult to achieve, not least because most procedural memories are ‘hard to learn and hard to forget’ and some emotional memories – which can be acquired through just a single exposure – appear to be indelible, but also because the essential mechanism of repression entails resistance to reconsolidation of automatised solutions to our insoluble problems. The theory of reconsolidation is very important for understanding the mechanism of psychoanalysis.
意识（“叫工作”）是一个非常有限的资源，要巩固和自动化学习应对生活问题的方案是面临巨大的。（Bargh和Chartand两位科学家1999年得出一个结论，我们人类以目标为导向的行为只有5%是意识层面的）。内在行为模式从一开始就是自动有效的，这是在生命的早年就获得的那些模式，在皮质记忆（“陈述性记忆”）系统成熟之前就有了。多种的无意识记忆（“非陈述性记忆”）系统是存在的，比如说“程序的”和“情感的”记忆（这些记忆主要是在基底神经的水平上来编码的）。这些记忆的运作取决于不同的规则。不仅仅是成功的行为方案是自动化的。我们简单观察一下，就可以弄清楚， “认知的”无意识和“动力学的”无意识之间是不同的。有时，一个孩子需要从不好的工作任务中获取最佳利益，就要聚焦在那些能被解决的问题上面，这种不合逻辑的或者说早熟的自动化的行为模式称为“压抑”。为了让自动化模式重新修订和更新，就需要一个重新整合的过程（Tronson和taylor，2007年），也就是说这些行为模式需要再一次进入意识层面，为了让那些长期记忆的痕迹变得更加松动。这一目标并不容易达到，不仅仅因为程序记忆“很难记住也很难忘记”，一些记忆只需要简单的暴露体验就可以呈现出来，看上去非常持久，而且也因为压抑的根本机制导致了阻抗，这些阻抗不利于重新整合和自动化那些难题的行动模式。重新整合对于理解精神分析的机制非常重要。
The clinical methods that psychoanalysts use flow from the above claims
二、精神分析师使用的临床办法起因于如下几个方面：
Psychological patients suffer mainly from feelings. The essential difference between psychoanalytic and psychopharmacological methods of treatment is that we believe feelings mean something. Specifically, feelings represent unsatisfied needs. (Thus, a patient suffering from panic is afraid of losing something, a patient suffering from rage is frustrated by something, etc.) This truism applies regardless of aetiological factors; even if one person is constitutionally more fearful, say, than the next, their fear is still meaningful. To be clear: emotional disorders entail unsuccessful attempts to satisfy needs.
2.1 病人主要是因为情感上遭受痛苦。精神分析疗法和精神药理学疗法之间的主要区别就是我们相信情感、感受意味着一些事情。特别是，情感代表着未能满足的需要。（因而，一个恐慌的病人是害怕失去某种东西，一个愤怒的病人被什么挫败了，等等）。不管病因学如何解释，这个常理是显而易见的，即使一个人本质上更加害怕了，那么也要说这种害怕是仍然是有意义的。澄清一下：情感障碍使得我们满足需要的那些企图没能成功。
The main purpose of psychological treatment, then, is to help patients learn better (more effective) ways of meeting their needs. This, in turn, leads to better emotion regulation. The psychopharmacological approach, by contrast, suppresses unwanted feelings. We do not believe that drugs which suppress feelings can cure emotional disorders. Drugs are symptomatic treatments. To cure an emotional disorder, the patient’s failure to meet their underlying need(s) must be addressed, since this is what is causing their symptoms. However, symptom relief is sometimes necessary before patients become amenable to psychological treatment, since most forms of psychotherapy require collaborative work between patient and therapist. It is also true that some types of psychopathology never become accessible to collaborative psychotherapy.
2.2精神分析治疗的主要目标是帮助病人们学习满足需要的更好的（更有效的）方式。从而，这就导致了更好的情绪调节。理学的方法正好相反，是要压抑那些不想要的感受。我们不认为压抑感受的那些药物能够治愈情感障碍。药物是针对症状的一种治疗方式。要治愈一种情感障碍，病人潜在的需要没有被满足这种情况是必须要言说的，因为这样才导致了他们的症状。当然有的时候在病人能够配合之前，症状的缓解是很有必要的，因为大多数心理治疗的形式都需要病人和治疗师合作进行。也有可能某些类型精神机能障碍永远也不能进行合作的心理治疗。
Psychoanalytical therapy differs from other forms of psychotherapy in that it aims to change deeply automatised action plans. This is necessary for the reasons outlined above. Psychoanalytic technique therefore focuses on the following.
2.3 精神分析疗法和其他心理治疗的方法有所不同。精神分析疗法的目标是致力于深入的改变自动化的行为方案，上文已经大体阐述了必须这么做的主要原因。因此，精神分析技术主要聚焦在以下几个方面：
Mental healthcare funders need to learn how learning works. For a more detailed account of the mechanism of psychoanalytic therapy, see Solms (2017).
精神健康中心的资助者们需要了解这种学习机制是怎么运作的。想了解精神分析疗法更加细致的机制是怎样的话，详见solms（2017）的研究成果。
Psychoanalytic therapy achieves good outcomes – at least as good as, and in some respects better than, other evidence-based treatments in psychiatry today.
三、精神分析疗法的效果至少和其他循证心理疗法一样有效，而且在有些方面更加有效。
Psychotherapy in general is a highly effective form of treatment.
3.1 一般来说心理治疗都是一种非常有效的治疗形式。
Meta-analyses of psychotherapy outcome studies typically reveal effect sizes of between 0.73 and 0.85. An effect size of 0.8 is considered large in psychiatric research, 0.5 is considered moderate, and 0.2 is considered small. To put the efficacy of psychotherapy into perspective, recent antidepressant medications achieve effect sizes of between 0.24 and 0.31 (Kirsch et al, 2008; Turner et al, 2008). The changes brought about by psychotherapy, no less than drug therapy, are of course visualisable with brain imaging.
对于心理治疗方法疗效的元分析研究显示：效应量在0.73到0.85之间（妃子笑个人补充效应量是指由于因素引起的差别，是衡量处理效应大小的指标。与显著性检验不同，这些指标不受样本容量影响。它表示不同处理下的总体均值之间差异的大小，可以在不同研究之间进行比较。一般用于针对某一研究领域内的元分析中，经常见于心理，教育，行为研究等。其主要统计思路是指主要变量引起的响应差别除以相应的标准误差，这一相对量对估算处理效应很重要。效应量太小，意味着处理即使达到了显著水平，也缺乏实用价值。）在的研究中效应量达到0.8就相当大了，中度的效应量为0.5，小的效应量为0.2。为了深入透彻地总结心理治疗方法的有效性，近期关于抗药物治疗的有效性研究中，效应量也才是0.24到0.31之间（Kirsch 及其他人 2008年；Turner 及其他人2008）。这样看由心理治疗带来的变化根本不低于药物治疗，当然这种变化也可以在脑显像中可视化的呈现出来。
Psychoanalytic psychotherapy is equally effective as other forms of evidence-based psychotherapy (e.g. cognitive–behavioural therapy (CBT)).
3.2 精神分析疗法和其他循证的心理疗法是一样有效的。（比如说认知行为疗法CBT）。
This is now unequivocally established (Steinert et al, 2017). Moreover, there is evidence to suggest that the effects of psychoanalytic therapy last longer – and even increase – after the end of the treatment. Shedler’s (2010) authoritative review of all randomised controlled trials to date reported effect sizes of between 0.78 and 1.46, even for diluted and truncated forms of psychoanalytic therapy. An especially methodologically rigorous meta-analysis (Abbass et al, 2006) yielded an overall effect of 0.97 for general symptom improvement with psychoanalytic therapy. The effect increased to 1.51 when the patients were assessed at follow-up. A more recent meta-analysis by Abbass et al (2014) yielded an overall effect size of 0.71, and the finding of maintained and increased effects at follow-up was reconfirmed. This was for short-term psychoanalytic treatment. According to the meta-analysis of de Maat et al (2009), which was less methodologically rigorous than the Abbass studies, longerterm psychoanalytic psychotherapy yields an effect size of 0.78 at termination and 0.94 at follow-up, and psychoanalysis proper achieves a mean effect of 0.87, and 1.18 at follow-up. This is the overall finding; the effect size for symptom improvement (as opposed to personality change) was 1.03 for long-term psychoanalytic therapy, and for psychoanalysis it was 1.38. Leuzinger- Bohleber et al (2018) will shortly report even greater effect sizes for psychoanalysis in depression. The consistent trend toward larger effect sizes at follow-up suggests that psychoanalytic therapy sets in motion processes of change that continue after therapy has ended (whereas the effects of other forms of psychotherapy, such as CBT, tend to decay).
这一点现在是众所公认、毋庸置疑的。（Steinert等人2017年）而且，有证据显示精神分析疗法的效果持续的时间更持久，甚至在治疗结束后还会持续增加有效性，2010年Shedler的权威评论报告了迄今为止所有的随机对照实验的效应量在0.78到1.46之间，甚至包含了那些简化、缩短的精神分析治疗。一项特别严格的方法学意义上的元分析研究（Abbass 等人，2006年）表明，精神分析治疗对大多数症状改善的总体效应量为0.97。当对病人进行追踪评估时效应量可以增加到1.51。一项更新的元分析由Abbass等人（2014）年做出，该研究表明，总体的效应量为0.71，并且再次确认了这个结论：追踪随访效应量发现效果持续巩固并且还会继续增加。这是短程精神分析治疗效果的研究。根据Maat等人（2009年）的元分析研究，Maat这个研究不如Abbass的研究那样严格和方法论，这个研究显示长程精神分析疗法的效应量在治疗结束后为0.78，追踪随访效应量话是0.94，并且正当的精神分析疗法的平均效应量为0.87、追踪随访效应量为1.18。主要的结论如下：长程精神分析疗法的症状改善（而不是指变化）的效应量为1.03，而精神分析的效应量为1.38。Leuzinger Bohleber等人（2018年）不久就会发布一个精神分析治疗的更高的效应量。追踪随访的效应量这种不断持续增长的趋势，意味着精神分析疗法的动力过程在治疗结束后还在持续发挥改变的作用。（对比其他心理治疗方法，比如说CBT的效应量是趋向减少的）
The therapeutic techniques that predict the best treatment outcomes, regardless of the form of psychotherapy, make good sense in relation to the psychodynamic mechanisms outlined above. These techniques include (Blagys & Hilsenroth, 2000):
3.3 忽略心理治疗的各种形式，预期会产生最好治疗效果的疗效型技术都与上文概括的心理动力学机制有很大关系，这些技术包括如下内容（Blagys和Hilsenroth ，2000年）：
It is highly instructive to note that these techniques lead to the best treatment outcomes regardless of the type of psychotherapy the clinician espouses. In other words, these same techniques (or at least a subset of them; see Hayes et al, 1996) predict optimal treatment outcomes in CBT too, even if the therapist believes they are doing something else.
非常有指导意义的是注意到这些技术可以产生最好的治疗效果，不管临床医生拥护哪种心理治疗流派，换句话说，同样的技术（或者至少是上述技术的子集，Hayes等人，1996年）也能够在CBT治疗中产生最优的疗效，即使治疗师以为他们在做别的事呢。
It is therefore perhaps not surprising that psychotherapists, irrespective of their stated orientation, tend to choose psychoanalytic psychotherapy for themselves! (Norcross, 2005)
3.4 因此，我们毫不惊讶的发现，也许心理治疗师，不管他们自己声称何种治疗方向，他们都倾向于为他们自己选择精神分析的心理治疗（Norcross，2005年）。
I am aware that the claims I have summarised here do not do justice to the full complexity and variety of views in psychoanalysis, both as a theory and a therapy. I am saying only that these are our core claims, which underpin all the details, including those upon which we are yet to reach agreement. These claims are eminently defensible in the light of current scientific evidence, and they make simple good sense.
本文总结的所有观点，没能公正全面的考虑到精神分析理论或者精神分析疗法涉及的所有复杂性和各种各样不同的观点，本文这些观点只是我们的核心观点，这些观点是所有细节的基础，包括那些尚未达成一致的细节。根据当今的科学证据来看这些核心观点是非常有说服力的，简洁而明了。
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