To The Editor: Dr. Hobday (1) is to be commended for her candid description of her struggle to understand her narcissistic patient and to deal with the discomfort of his sexually provocative and demeaning communications. However, I would like to suggest a somewhat different interpretation of the patient’s departure from treatment than what was emphasized in the case report.
Although the discussants view “Mr. A” as a patient who did not comprehend the rules of the therapeutic situation, the facts as presented do not support this. The patient did not, after all, try to insist that his therapist see him outside the sessions or engage in sexual activity. His provocative and hostile writings were his attempt to express his thoughts and feelings, as his therapist had instructed, albeit within the limitations of his narcissistic defensive structure, and they demonstrate his acute awareness of the rules of therapy and his concern about the possible consequences of violating them.
The therapist’s own understandable anxiety interfered with her ability to respond from a secure empathic position, which would have entailed acknowledging the patient’s rage (and with time, shame) at finding himself sexually aroused by someone who had no intention of reciprocating. His perception of being manipulated by a stimulating but aloof object, rather than his sexual arousal itself, was the transference to be dealt with in therapy. The patient made several attempts to engage around his expectation of rejection, but the therapist let these attempts pass in favor of setting limits. What followed was an enactment in which Mr. A’s growing narcissistic rage and paranoia further alarmed the therapist, who then treated him as a dangerously out-of-control child, undermining his sense of self-worth and adult efficacy still more. After a few vain attempts to salve his self-esteem through blame, devaluation, and reaction formation, he terminated the therapy.
This case is a good example of how sexuality can obscure underlying deficits in self-efficacy and self-esteem and make it difficult for therapists to maintain an empathic holding environment in which to understand and repair these deficits.
1.Hobday G, Mellman L, Gabbard GO: Complex sexualized transferences when the patient is male and the therapist female. Am J Psychiatry 2008; 165:1525–1530
The author reports no competing interests.
This letter (doi: 10.1176/appi.ajp.2009.08121887) was accepted for publication in February 2009.