To The Editor: We appreciate the opportunity to respond to the comments of Drs. Gordon and Silberman. Although Dr. Silberman’s remarks would apply in some clinical situations, in this case, Dr. Hobday was fully aware of Mr. A’s deficits in his self-structure, and the sexualization of the transference in no way obscured them, as suggested by Dr. Silberman. These deficits made it difficult for the patient to join in a collaborative search to understand the self-esteem issues inherent in the disruption of the therapy. Moreover, Dr. Silberman’s gender might possibly make him underestimate the importance of safety concerns when the therapist is a woman treating a male patient who is threatening. Psychotherapy cannot be conducted in an unsafe context, and thus safety issues must come first.
Dr. Gordon suggests that educating the patient about the nature of psychotherapy might have prevented his flight from treatment. Although we agree that such education can be helpful, it is naive to think that discussing erotic transference in advance will somehow mitigate its effect when it emerges in therapy. In addition, predicting the development of erotic transference may cause the patient to think that he or she is supposed to experience sexualized feelings, even though in reality many patients do not.
There is a long-standing pattern in psychotherapy case discussions of engaging in “Monday morning quarterbacking.” However, in this case, we feel that the first-hand evidence from clinical work with the patient suggests that the outcome would have been very difficult to prevent.
The authors’ disclosures accompany the original article.
This letter (doi: 10.1176/appi.ajp.2009.08121887r) was accepted for publication in February 2009.