Диссоциативные состояния в сравнении с психопатиями

Как было отмечено в главе 7, некоторые антисоциальные лю­ди имеют Диссоциативные защиты. Различение социопатов с дис­социативными чертами и диссоциативных людей с социопатиче-ской частью личности — умопомрачительно трудная задача. В основном потому, что ко времени, когда возникает данный воп-

рос, от него зависит много правовых последствий. Индивид, об­виняемый в серьезном преступлении, делает большую ставку на то, чтобы убедить судью или присяжных во "множественности". Реже персекуторная часть собственного "Я" пытается наказать лич­ность-хозяина, оценивая собственное "Я" антисоциально. Будет благоразумно подозревать психопатию, когда кто-то имеет серьез­ные причины симулировать. Некоторые недавние книги в жанре "настоящих преступлений" (Weissberg, 1992) исследуют сложно­сти, связанные с психологическими хитросплетениями, которые возникают в тех случаях, когда подозреваемый выдает себя за мно­жественную личность. Если мы действительно выступаем за достоверную дифференцировку сущностно диссоциативных и сущностно психопатичес­ких людей (даже если существует значительная вторичная выгода для пациента в представлении тем или иным образом), последствия для системы правосудия могут быть очень важны. Поскольку дис-социативные личности (за исключением наиболее полифрагменти-рованных) имеют хороший прогноз, должна быть заметная польза в плане предотвращения дальнейших преступлений от проведения интенсивной психотерапии с теми преступниками, у которых об­наружено нарушение в виде множественной личности. Клиници­сты могут излечивать диссоциацию более быстро, чем они моди­фицируют антисоциальные паттерны. В условиях ограниченных средств люди, работающие в тюрьмах или в исправительной сис­теме, могли бы сконцентрировать свои усилия на этих более чув­ствительных к их помощи клиентах.

Заключение

В настоящей главе я обсудила историю понятия диссоциации и ее интигующего характерологического варианта, нарушения в виде множественной личности. В объяснении индивидуального развития диссоциации как ядерного процесса я отметила консти-туциональный талант к самогипнозу, часто сосуществующий с высоким интеллектом, креативностью и социофилией. Эти фак­торы могут предрасполагать индивида к ответу на травму диссоци­ативными защитами, невидимыми для окружающих. Обсуждалась BASK-модель диссоциации Брауна в качестве альтернативы концеп­ции защит Фрейда. Объектные отношения диссоциативных людей

объяснялись как укорененные в травматическом абъюзе в детстве, не облегченном помощью в эмоциональной переработке такой раны. Собственное "Я" индивида с диссоциативной идентичнос­ тью обрисовано не только как фрагментированное, но также как пропитанное парализующими страхами и самообвинительными когнитивными структурами. Подчеркнута сила трансферных и контртрансферных реакций с диссоциативньши пациентами. Особенно то обстоятельство, что они провоцируют фантазии о спасении, а также сверхвовлеченность терапевта. Лечебные рекомендации при данном диагонозе делают упор на интернализации чувства базальной безопасности и коопе­ рации в терапевтических взаимоотношениях. Они включают обес­ печение воспоминаний и эмоционального постижения диссоции- рованного опыта; последовательную поддержку всех частей лично­ сти; установку на то, чтобы быть "реальным" и теплым, строго придерживаясь профессиональных границ; анализирование патоген­ ных верований; использование гипноза в качестве дополнения; уважение потребности клиента в достаточном количестве времени для допущения отреагирования и интеграции. Диссоциативная динамика отдифференцирована от шизофренических и биполярных психозов, пограничных состояний, истерической и психопатичес­ кой личностной организаций.

Дополнительная литература

Путнам (Putnam, 1989) и Росс (Ross, 1989) написали прекрас­ные фундаментальные тексты по диагностике и лечению диссоци-ативных состояний. Психоаналитически ориентированному чита­телю не надо отказываться от Росса из-за его несколько странного отношения к анализу. Его экспертное исследование огромно. Наиболее краткой статьей по множественной личности и диссоци­ации из всех, что я знаю, является обзор Клафта (Kluft'a, 1991). Глава о множественной личности в антологии Клафта и Фаина (Kluft & Fine, 1993) очень хороша и постоянно читается.

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