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작성자  simonshin 작성일  2019.01.15 06:53 조회수 215 추천 0
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 신현근 박사 강의안: 정신분석적 치료 행위에 관한 스트레이치의 이론  
 

과목전이와 저항

주제: The Nature of the Therapeutic Action of Psycho-Analysis (James Strachey)

지도 교수신현근 박사

교재:

Esman, A. H. (Ed.) (1990). Essential papers on transference. New York and London: New York University Press.

 

 

1.   요약: 스트레이치가 가진 가설의 4가지 요점

1.1.  정신분석적 치료의 최종 목표는 발달의 유아적 단계에 묶여 있는 신경증 환자의 모든 심리 조직이 정상적인 성인 단계를 향하여 계속 발전할 수 있게 하는 것이다.

1.2.  주요한 효과적인 변화는 환자의 초자아를 본질적인 질적 수정으로 이루어지며, 여기서부터 다른 변화들이 대부분 자동적으로 따라온다.

1.3.  환자가 가진 초자아의 수정은 교정적 해석(mutative interpretations) 수단이 채택하는 일련의 수많은 작은 단계를 통하여 이루어 지며, 변화 지향 해석은 분석가가 가진 환자의 이드 충동들의 대상과 보조적 초자아 지위 덕분에 분석가에 의하여 이루어진다.

1.4.  교정적 해석이 정신분석의 치료적 행동의 궁극적인 작용 원리라는 사실이 암시, 안심시키기, 해제 반응 등 다른 많은 절차들을 어떤 특정한 환자의 치료 요소들 애서 제외시키는 것을 의미하는 것이 아니다.

2.   해석(Interpretation)

2.1.  분석가들은 해석에 대하여 다양한 정서를 가진다.

2.1.1.   Analysts are inclined to feel interpretation as something extremely powerful where good or ill.

2.2.  교정적 해석에 대한 정의

2.2.1.   I shall proceed without more ado to define as clearly as I can one particular sort of interpretation, which seems to me to be actually the ultimate instrument of psycho-analytic therapy and to which for convenience I shall give the name of mutative interpretation.

2.3.  교정적 해석의 간략한 묘사

2.3.1.   I shall first of all give a schematized outline of what I understand by a mutative interpretation, leaving the details to be filled in afterwards; and, with a view to clarity of exposition, I shall take as an instance the interpretation of a hostile impulse.

2.3.2.   By virtue of his power (his strictly limited power) as auxiliary super-ego, the analyst gives permission for a certain small quantity of the patients id-energy (in our instance, in the form of an aggressive impulse) to become conscious.

2.3.3.   Since the analyst is also, from the nature of things, the object of the patients id-impulses, the quantity of these impulses which is now released into consciousness will become consciously directed towards the analyst.

2.3.4.   This is the critical point. If all goes well, the patients ego will become aware of the contrast between the aggressive character of his feelings and the real nature of the analyst, who does not behave like the patients good or bad archaic objects.

2.3.4.1.      The patient will become aware of a distinction between his archaic phantasy object and the real external object.

2.3.5.   The interpretation has now become a mutative one, since it has produced a breach the neurotic vicious circle.

2.3.5.1.      For the patient, having become aware of the lack of aggressiveness in the real external object, will be able to diminish his own aggressiveness; the new object which he introjects will be less aggressive, and consequently the aggressiveness of is super-ego will also be diminished.

2.3.5.2.      As a further corollary to these events, and simultaneously with them, the patient will obtain access to the infantile material which is being re-experienced by him in his relation to the analyst.

2.4.  교정적 해석의 2 단계

2.4.1.   Such is the general scheme of the mutative interpretation. You will notice that in my account the process appears to fall into two phases. I am anxious not to pre-judge the question of whether these two phases are in temporal sequence or whether they may not really be two simultaneous aspects of a single event.

2.4.2.   But for descriptive purposes it is easier to deal with them as though they were successive. First, then, there is the phase in which the patient becomes conscious of a particular quantity of id-energy as being directed towards the analyst; and secondly there is the phase in which the patient becomes aware that this id-energy is directed towards an archaic phantasy object and not towards a real one.

3.   해석의 1단계

3.1.  The first phase of a mutative interpretation—that in which a portion of the patients id-relation to the analyst is made conscious in virtue of the latters position as auxiliary super-ego—is complex.

3.2.  In the classical model of an interpretation, the patient will first be made aware of a state of tension in his ego, will next be made aware that there is a repressive factor at work (that his super-ego is threatening him with punishment), and will only then be made aware of the id-impulse which has stirred up the protests of his super-ego and so given rise to the anxiety in his ego.

3.3.  In actual practice, the analyst finds himself working from all three sides at once, or in irregular succession. At one moment a small portion of the patients super-ego may be revealed to him in all its savagery, at another the shrinking defencelessness of his ego, at yet another his attention may be directed to the attempts which he is making at restitution—at compensating for his hostility; on some occasions a fraction of id-energy may even be directly encouraged to break its way through the last remains of an already weakened resistance.

3.4.  There is, however, one characteristic which all of these various operations have in common; they are essentially upon a small scale. For the mutative interpretation is inevitably governed by the principle of minimal doses.

3.4.1. It is, I think, a commonly agreed clinical fact that alterations in a patient under analysis appear almost always to be extremely gradual: we are inclined to suspect sudden and large changes as an indication that suggestive rather than psycho-analytic processes are at work.

3.4.2. The gradual nature of the changes brought about in psycho-analysis will be explained if, as I am suggesting, those changes are the result of the summation of an immense number of minute steps, each of which corresponds to a mutative interpretation.

3.4.3. And the smallness of each step is in turn imposed by the very nature of the analytic situation. For each interpretation involves the release of a certain quantity of id-energy, and, as we shall see in a moment, if the quantity released is too large, the highly unstable state of equilibrium which enables the analyst to function as the patients auxiliary superego is bound to be upset.

3.4.4. The whole analytic situation will thus be imperiled, since it is only in virtue of the analysts acting as auxiliary super-ego that these releases of id-energy can occur at all.

3.5.  Let us examine in greater detail the effects which follow from the analyst attempting to bring too great a quantity of id-energy into the patients consciousness all at once.

3.5.1.     On the one hand, nothing whatever may happen, or on the other hand there may be an unmanageable result; but in neither event will a mutative interpretation have been effected.

3.5.2.     In the former case (in which there is apparently no effect) the analysts power as auxiliary super-ego will not have been strong enough for the job he has set himself. But this again may be for two very different reasons.

3.5.2.1.          It may be that the id-impulses he was trying to bring out were not in fact sufficiently urgent at the moment: for, after all, the emergence of an id-impulse depends on two factors—not only on the permission of the super-ego, but also on the urgency (the degree of cathexis) of the id-impulse itself.

3.5.2.2.          This, then, may be one cause of an apparently negative response to an interpretation, and evidently a fairly harmless one.

3.5.2.3.          But the same apparent result may also be due to something else; in spite of the id-impulse being really urgent, the strength of the patients own repressive forces (the degree of repression) may have been too great to allow his ego to listen to the persuasive voice of the auxiliary super-ego.

3.5.2.4.          Now here we have a situation dynamically identical with the next one we have to consider, though economically different.

3.5.3.     This next situation is one in which the patient accepts the interpretation, that is, allows the id-impulse into his consciousness, but is immediately overwhelmed with anxiety.

3.5.3.1.          This may shew itself in a number of ways: for instance, the patient may produce a manifest anxiety-attack, or he may exhibit signs of real anger with the analyst with complete lack of insight, or he may break off the analysis. In any of these cases the analytic situation will, for the moment at least, have broken down.

3.5.3.2.          The patient will be behaving just as the hypnotic subject behaves when, having been ordered by the hypnotist to perform an action too much at variance with his own conscience, he breaks off the hypnotic relation and wakes up from his trance.

3.5.3.3.          This state of things, which is manifest where the patient responds to an interpretation with an actual outbreak of anxiety or one of its equivalents, may be latent where the patient shows no response.

3.5.3.4.          And this latter case may be the more awkward of the two, since it is masked, and it may sometimes, I think, be the effect of a greater overdose of interpretation than where manifest anxiety arises (though obviously other factors will be of determining importance here and in particular the nature of the patients neurosis).

3.5.3.5.          I have ascribed this threatened collapse of the analytic situation to an overdose of interpretation: but it might be more accurate in some ways to ascribe it to an insufficient dose. For what has happened is that the second phase of the interpretative process has not occurred: the phase in which the patient becomes aware that his impulse is directed towards an archaic phantasy object and not towards a real one.

4.     해석의 2단계

4.1.  In the second phase of a complete interpretation, therefore, a crucial part is played by the patients sense of reality: for the successful outcome of that phase depends upon his ability, at the critical moment of the emergence into consciousness of the released quantity of id-energy, to distinguish between his phantasy object and the real analyst.

4.1.1.     The problem here is closely related to one that I have already discussed, namely that of the extreme liability of the analysts position as auxiliary super-ego. The analytic situation is all the time threatening to degenerate into a real situation. But this actually means the opposite of what it appears to.

4.1.2.     It means that the patient is all the time on the brink of turning the real external object (the analyst) into the archaic one; that is to say, he is on the brink of projecting his primitive introjected imagos on to him. In so far as the patient actually does this, the analyst becomes like anyone else that he meets in real life—a phantasy object.

4.1.3.     The analyst then ceases to possess the peculiar advantages derived from the analytic situation; he will be introjected like all other phantasy objects into the patients super-ego and will no longer be able to function in the peculiar ways which are essential to the effecting of a mutative interpretation.

4.2.  In this difficulty the patients sense of reality is an essential but a very feeble ally; indeed, an improvement in it is one of the things that we hope the analysis will bring about. It is important, therefore, not to submit it to any unnecessary strain; and that is the fundamental reason why the analyst must avoid any real behaviour that is likely to confirm the patients view of him as a bad or a good phantasy object.

4.3.  This is perhaps more obvious as regards the bad object. If, for instance, the analyst were to shew that he was really shocked or frightened by one of the patients id-impulses, the patient would immediately treat him in that respect as a dangerous object and introject him into his archaic severe super-ego.

4.4.  Thereafter, on the one hand, there would be a diminution in the analysts power to function as an auxiliary super-ego and to allow the patients ego to become conscious of his id-impulses—that is to say, in his power to bring about the first phase of a mutative interpretation; and, on the other hand, he would, as a real object, become sensibly less distinguishable from the patients bad phantasy object and to that extent the carrying through of the second phase of a mutative interpretation would also be made more difficult.

4.5.  Or again, there is another case. Supposing the analyst behaves in an opposite way and actively urges the patient to give free rein to his id-impulses.

4.5.1.     There is then a possibility of the patient confusing the analyst with the imago of a treacherous parent who first encourages him to seek gratification, and then suddenly turns and punishes him. In such a case, the patients ego may look for defence by itself suddenly turning upon the analyst as though he were his own id, and treating him with all the severity of which his super-ego is capable.

4.5.2.     Here again, the analyst is running a risk of losing his privileged position. But it may be equally unwise for the analyst to act really in such a way as to encourage the patient to project his good introjected object on to him.

4.5.3.     For the patient will then tend to regard him as a good object in an archaic sense and will incorporate him with his archaic good imagos and will use him as a protection against his bad ones.

4.5.4.     In that way, his infantile positive impulses as well as his negative ones may escape analysis, for there may no longer be a possibility for his ego to make a comparison between the phantasy external object and the real one.

4.6.  It will perhaps be argued that, with the best will in the world, the analyst, however careful he may be, will be unable to prevent the patient from projecting these various

4.6.1.     This is of course indisputable, and indeed, the whole effectiveness of analysis depends upon its being so. The lesson of these difficulties is merely to remind us that the patients sense of reality has the narrowest limits. It is a paradoxical fact that the best way of ensuring that his ego shall be able to distinguish between phantasy and reality is to withhold reality from him as much as possible.

4.6.2.     But it is true. His ego is so weak—so much at the mercy of his id and super-ego—that he can only cope with reality if it is administered in minimal doses.

4.6.3.     And these doses are in fact what the analyst gives him, in the form of interpretations.

5.     해석과 안심시키기(Interpretation and Reassurance)

5.1.  It seems to me possible that an approach to the twin practical problems of interpretation and reassurance may be facilitated by this distinction between the two phases of interpretation. Both procedures may, it would appear, be useful or even essential in certain circumstances and inadvisable or even dangerous in others. In the case of interpetation, the first of our hypothetical phases may be said to liberate anxiety, and the second to resolve it.

5.1.1.     Where a quantity of anxiety is already present or on the point of breaking out, an interpretation, owing to the efficacy of its second phase, may enable the patient to recognize the unreality of his terrifying phantasy object and so to reduce his own hostility and consequently his anxiety.

5.1.2.     On the other hand, to induce the ego to allow a quantity of id-energy into consciousness is obviously to court an outbreak of anxiety in a personality with a harsh super-ego. And this is precisely what the analyst does in the first phase of an interpretation.

5.2.  As regards reassurance, I can only allude briefly here to some of the problems it raises.

5.2.1.     I believe, incidentally, that the term needs to be defined almost as urgently as interpretation, and that it covers a number of different mechanisms. But in the present connection reassurance may be regarded as behaviour on the part of the analyst calculated to make the patient regard him as a good phantasy object rather than as a real one. I have already given some reasons for doubting the expediency of this, though it seems to be generally felt that the procedure may sometimes be of great value, especially in psychotic cases.

5.2.2.     It might, moreover, be supposed at first sight that the adoption of such an attitude by the analyst might actually directly favour the prospect of making a mutative interpretation.

5.2.3.     But I believe that it will be seen on reflection that this is not in fact the case: for precisely in so far as the patient regards the analyst as his phantasy object, the second phase of the interpretation does not occur—since it is of the essence of that phase that in it the patient should make a distinction between his phantasy object and the real one.

5.2.4.     It is true that his anxiety may be reduced; but this result will not have been achieved by a method that involves a permanent qualitative change in his super-ego. Thus, whatever tactical importance reassurance may possess, it cannot, I think, claim to be regarded as an ultimate operative factor in psycho-analytic therapy.

5.3.  It must here be noticed that certain other sorts of behaviour on the part of the analyst may be dynamically equivalent to the giving of a mutative interpretation, or to one or other of the two phases of that process.

5.3.1.     For instance, an active injunction of the kind contemplated by Ferenczi may amount to an example of the first phase of an interpretation; the analyst is making use of his peculiar position in order to induce the patient to become conscious in a particularly vigorous fashion of certain of his id-impulses.

5.3.2.     One of the objections to this form of procedure may be expressed by saying that the analyst has very little control over the dosage of the id-energy that is thus released, and very little guarantee that the second phase of the interpretation will follow.

5.3.3.     He may therefore be unwittingly precipitating one of those critical situations which are always liable to arise in the case of an incomplete interpretation.

5.3.4.     Incidentally, the same dynamic pattern may arise when the analyst requires the patient to produce a forced phantasy or even (especially at an early stage in an analysis) when the analyst asks the patient a question; here again, the analyst is in effect giving a blindfold interpretation, which it may prove impossible to carry beyond its first phase.

5.3.5.     On the other hand, situations are fairly constantly arising in the course of an analysis in which the patient becomes conscious of small quantities of id-energy without any direct provocation on the part of the analyst. An anxiety situation might then develop, if it were not that the analyst, by his behaviour or, one might say, absence of behaviour, enables the patient to mobilize his sense of reality and make the necessary distinction between an archaic object and a real one.

5.3.6.     What the analyst is doing here is equivalent to bringing about the second phase of an interpretation, and the whole episode may amount to the making of a mutative interpretation. It is difficult to estimate what proportion of the therapeutic changes which occur during analysis may not be due to implicit mutative interpretations of this kind. Incidentally, this type of situation seems sometimes to be regarded, incorrectly as I think, as an example of reassurance.

6.     교정적 해석의 즉각성(“Immediacy” of Mutative Interpretation)

6.1.  But it is now time to turn to two other characteristics which appear to be essential properties of every mutative interpretation.

6.2.  There is in the first place one already touched upon in considering the apparent or real absence of effect which sometimes follows upon the giving of an interpretation.

6.3.  A mutative interpretation can only be applied to an id-impulse which is actually in a state of cathexis. This seems self-evident; for the dynamic changes in the patients mind implied by a mutative interpretation can only be brought about by the operation of a charge of energy originating in the patient himself: the function of the analyst is merely to ensure that the energy shall flow along one channel rather than along another.

6.4.  It follows from this that the purely informative dictionary type of interpretation will be non-mutative, however useful it may be as a prelude to mutative interpretations. And this leads to a number of practical inferences. Every mutative interpretation must be emotionally immediate; the patient must experience it as something actual.

6.5.  This requirement, that the interpretation must be immediate, may be expressed in another way by saying that interpretations must always be directed to the point of urgency.

6.6.  At any given moment some particular id-impulse will be in activity; this is the impulse that is susceptible of mutative interpretation at that time, and no other one. It is, no doubt, neither possible nor desirable to be giving mutative interpretations all the time; but, as Melanie Klein has pointed out, it is a most precious quality in an analyst to be able at any moment to pick out the point of urgency.

7.     심층 해석(‘Deep’ Interpretations)

7.1.  But the fact that every mutative interpretation must deal with an urgent impulse takes us back once more to the commonly felt fear of the explosive possibilities of interpretation, and particularly of what is vaguely referred to as deep interpretation.

7.2.  The ambiguity of the term, however, need not bother us. It describes, no doubt, the interpretation of material which is either genetically early and historically distant from the patients actual experience or which is under an especially heavy weight of repression—material, in any case, which is in the normal course of things exceedingly inaccessible to his ego and remote from it.

7.3.  There seems reason to believe, moreover, that the anxiety which is liable to be aroused by the approach of such material to consciousness may be of peculiar severity.The question whether it is safe to interpret such material will, as usual, mainly depend upon whether the second phase of the interpretation can be carried through.

7.4.  In the ordinary run of case the material which is urgent during the earlier stages of the analysis is not deep. We have to deal at first only with more or less far-going displacements of the deep impulses, and the deep material itself is only reached later and by degrees, so that no sudden appearance of unmanageable quantities of anxiety is to be anticipated.

7.5.  In exceptional cases, however, owing to some peculiarity in the structure of the neurosis, deep impulses may be urgent at a very early stage of the analysis. We are then faced by a dilemma. If we give an interpretation of this deep material, the amount of anxiety produced in the patient may be so great that his sense of reality may not be sufficient to permit of the second phase being accomplished, and the whole analysis may be jeopardised.

7.5.1.     But it must not be thought that, in such critical cases as we are now considering, the difficulty can necessarily be avoided simply by not giving any interpretation or by giving more superficial interpretations of non-urgent material or by attempting reassurances.

7.5.2.     It seems probable, in fact, that these alternative procedures may do little or nothing to obviate the trouble; on the contrary, they may even exacerbate the tension created by the urgency of the deep impulses which are the actual cause of the threatening anxiety.

7.5.3.     Thus the anxiety may break out in spite of these palliative efforts and, if so, it will be doing so under the most unfavourable conditions, that is to say, outside the mitigating influences afforded by the mechanism of interpretation. It is possible, therefore, that, of the two alternative procedures which are open to the analyst faced by such a difficulty, the interpretation of the urgent id-impulses, deep though they may be, will actually be the safer.

8.     교정적 해석의 구체성’(Specificity of Mutative Interpretations)

8.1.  A mutative interpretation must be specific: that is to say, detailed and concrete. This is, in practice, a matter of degree. When the analyst embarks upon a given theme, his interpretations cannot always avoid being vague and general to begin with; but it will be necessary eventually to work out and interpret all the details of the patients phantasy

8.2.  In proportion as this is done the interpretations will be mutative, and much of the necessity for apparent repetitions of interpretations already made is really to be explained by the need for filling in the details. I think it possible that some of the delays which despairing analysts attribute to the patients id-resistance could be traced to this source.

8.3.  It seems as though vagueness in interpretation gives the defensive forces of the patients ego the opportunity, for which they are always on the lookout, baffling the analysts attempt at coaxing an urgent id-impulse into consciousness.

8.4.  A similarly blunting effect can be produced by certain forms of reassurance, such as the tacking on to an interpretation of an ethnological parallel or of a theoretical explanation: a procedure which may at the last moment turn a mutative interpretation into a non-mutative one.

8.5.  The apparent effect may be highly gratifying to the analyst; but later experience may show that nothing of permanent use has been achieved or even that the patient has been given an opportunity for increasing the strength of his defences.

8.6.   Here we have evidently reached a topic discussed not long ago by Edward Glover in one of the very few papers in the whole literature which seriously attacks the problem of interpretation.

9.     해제 반응(Abreaction)

9.1.  I have already remarked that many patients derive direct libidinal gratification from interpretation as such; and I think that some of the striking signs of abreaction which occasionally follow an interpretation ought not necessarily to be accepted by the analyst as evidence of anything more than that the interpretation has gone home in a libidinal sense.

9.2.  The whole problem, however, of the relation of abreaction to psycho-analysis is a disputed one. Its therapeutic results seem, up to a point, undeniable. It was from them, indeed, that analysis was born; and even to-day there are psycho-therapists who rely on it almost exclusively. During the War, in particular, its effectiveness was widely confirmed in cases of shell-shock. It has also been argued often enough that it plays a leading part in bringing about the results of psycho-analysis.

9.3.  Rank and Ferenczi, for instance, declared that in spite of all advances in our knowledge abreaction remained the essential agent in analytic therapy. More recently, Reik has supported a somewhat similar view in maintaining that the element of surprise is the most important part of analytic technique.

9.4.  A much less extreme attitude is taken by Nunberg in the chapter upon therapeutics in his text-book of psycho-analysis. But he, too, regards abreaction as one of the component factors in analysis, and in two ways.

9.4.1.     In the first place, he mentions the improvement brought about by abreaction in the usual sense of the word, which he plausibly attributes to a relief of endo-psychic tension due to a discharge of accumulated affect.

9.4.2.     And in the second place, he points to a similar relief of tension upon a small scale arising from the actual process of becoming conscious of something hitherto unconscious, basing himself upon a statement of Freuds that the act of becoming conscious involves a discharge of energy.

9.5.  On the other hand, Radó appears to regard abreaction as opposed in its function to analysis. He asserts that the therapeutic effect of catharsis is to be attributed to the fact that (together with other forms of non-analytic psycho-therapy) it offers the patient an artificial neurosis in exchange for his original one, and that the phenomena observable when abreaction occurs are akin to those of an hysterical attack.

9.6.  A consideration of the views of these various authorities suggests that what we describe as abreaction may cover two different processes: one a discharge of affect and the other a libidinal gratification.

9.6.1.     If so, the first of these might be regarded (like various other procedures) as an occasional adjunct to analysis, sometimes, no doubt, a useful one, and possibly even as an inevitable accompaniment of mutative interpretations; whereas the second process might be viewed with more suspicion, as an event likely to impede analysis—especially if its true nature were unrecognised.

9.6.2.     But with either form there would seem good reason to believe that the effects of abreaction are permanent only in cases in which the predominant etiological factor is an external event: that is to say, that it does not in itself bring about any radical qualitative alteration in the patients mind. Whatever part it may play in analysis is thus unlikely to be of anything more than an ancillary nature.

10.   교정적 해석과 분석가

10.1.                Although the giving of mutative interpretations may thus only occupy a small portion of psycho-analytic treatment, it will, upon my hypothesis, be the most important part from the point of view of deeply influencing the patients mind.

10.2.                It may be of interest to consider in conclusion how a moment which is of such importance to the patient affects the analyst himself.

10.2.1.  Mrs. Klein has suggested to me that there must be some quite special internal difficulty to be overcome by the analyst in giving interpretations.

10.2.2.  And this, I am sure, applies particularly to the giving of mutative interpretations. This is shown in their avoidance by psycho-therapists of non-analytic schools; but many psycho-analysts will be aware of traces of the same tendency in themselves. It may be rationalized into the difficulty of deciding whether or not the particular moment has come for making an interpretation.

10.2.3.  But behind this there is sometimes a lurking difficulty in the actual giving of the interpretation, for there seems to be a constant  temptation for the analyst to do something else instead.

10.2.4.  He may ask questions, or he may give reassurances or advice or discourses upon theory, or he may give interpretations—but interpretations that are not mutative, extra-transference interpretations, interpretations that are non-immediate, or ambiguous, or inexact—or he may give two or more alternative interpretations simultaneously, or he may give interpretations and at the same time show his own scepticism about them.

10.3.                All of this strongly suggests that the giving of a mutative interpretation is a crucial act for the analyst as well as for the patient, and that he is exposing himself to some great danger in doing so.

And this in turn will become intelligible when we reflect that at the moment of interpretation the analyst is in fact deliberately evoking a quantity of the patients id-energy while it is alive and actual and unambiguous and aimed directly at himself. Such a moment must above all others put to the test his relations with his own unconscious impulses.
 
 
 
 
 
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