As a psychiatrist and psychoanalyst, I read the article by Drs. Gabbard and Bennett with mixed feelings. It is a fascinating, richly detailed, and convincing case report. Although Ms. A was significantly troubled, her history, symptoms, and the evolution of the treatment lent themselves to a psychodynamic understanding of her character and gave reason to hope that psychodynamic psychotherapy would be helpful to her. However, although the case was presented as a psychodynamic treatment, it did not appear to be one.
All psychodynamic treatments are based on an understanding of the patient’s transference (1). The degree to which interpretation of the transference is central and the degree to which technical neutrality and transference analysis are amended or supplemented by supportive and limit-setting measures are what define a treatment as psychoanalysis, psychoanalytic psychotherapy, or psychoanalytic supportive therapy. Ms A’s treatment did not seem to be guided by an understanding of the transference.
Once Dr. Bennett decided that technical neutrality was indicated in Ms. A’s treatment, it was necessary for her to begin to formulate a transference hypothesis, for without one, it was impossible to know what her interventions were likely to mean to Ms. A or what Ms. A’s responses were likely to mean. There was no clear evidence in the report that either Dr. Bennett’s initial “neutral” attitude of acceptance and nonjudgment or her subsequent posture of maternal support was guided by an appreciation of Ms. A’s likely transference. It seems clear from the case report that neither posture actually was experienced by the patient as neutral and that the authors repeatedly appeared to equate or confuse the concept of technical neutrality with the attitude of acceptance and nonjudgment.
There are signs that a truly neutral posture might have been indicated for Ms. A. She appeared to respond dramatically to Dr. Bennett’s neutral observations, which I construe to be technically neutral, about the realities of her traumatic past: she became less detached and was able to bring up her worries about her body and femininity. This is evidence that Ms. A was capable of working in an exploratory mode. By engaging Ms. A’s observing ego in a neutral way, Dr. Bennett might have been able to help her explore her unconscious motives for behaving as she did, thereby helping her to be more independent and to take better care of herself instead of continuing to depend on her mother or surrogates, such as Dr. Bennett. Without that exploration, a return of her self-destructive impulses seems possible when she becomes dissatisfied with Dr. Bennett or at termination.
In an era when all psychotherapies must show their scientific bona fides, I think it is incumbent on authors who espouse psychodynamic theories, which have a smaller empiric foundation than some others, to be as clear and consistent as possible in their presentations of psychodynamic concepts.
Kernberg OF: Psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy. Int J Psycho-analysis 1999; 80:1075–1091