To the Editor: In their Treatment in Psychiatry article, published in the May 2009 issue of the Journal, Glen O. Gabbard, M.D. and Mardi J. Horowitz, M.D. (1) offered a finely delineated psychotherapeutic approach in the treatment of borderline personality disorder. I wish to suggest an alternative perspective on listening to the patient and thereby on understanding of transference and the nature of therapeutic action. I refer to a position not limited to patients of a specific diagnostic category, but rather to a central shift in outlook on how we listen and its impact on clinical work.
It is my view (e.g., reference 2) that therapeutic action occurs more profoundly when the therapist—rather than attempting, however subtly, to dissuade the patient from his or her own felt experience (as to correct “misinterpretations”)—seeks instead to locate the patient’s vantage point and its inherent legitimacy. A statement such as “the therapist is not verbally abusing her” (1, p. 520) when the patient feels that he is would then require the qualifier “from his vantage point” (i.e., the therapist’s vantage point), with her vantage point (i.e., the patient’s vantage point) yet to be found. The transference, then, is understood as a perceptual experience to illuminate, not a distortion or projection to alter. This perspective does not preclude the therapist’s addressing concerns regarding what seems to be dangerous or worrisome behavior, but that is a determination different from one attempting to negate or “correct” what is felt or perceived. It is striking how outer behaviors and symptoms may abate—ideations about the therapist’s mal intent or lack of care genuinely ease—when the inner world is recognized.
In the hypothetically drawn example, “Ms. A” spoke of her embarrassment. She had shouted at the clerk, who would not accept her credit card, then noticed people staring at her. Had the clerk not been “rude and curt,” she would not have shouted. These were the feelings she described coming into the hour. The therapist did not speak of them, asking instead about the store’s credit card policy. The patient then became furious, feeling that he was suggesting she had overreacted. “What difference does it make? [H]e still should have been courteous!” (p. 517) she exclaimed. Were the therapist to reconsider her perspective, heeding her rage and increasing sense of injury, rather than suggest that she is “making herself miserable,” he might regard how uncaring his response felt to her in failing to acknowledge her difficult experience. In saying “the same thing that happened in the store is happening with me” (p. 517) to highlight a parallel in her seemingly maladaptive response, he might note the parallel between his response and that of the clerk’s, both as critics. This is not to echo the patient’s words as a feel-good measure, but a moment of recognition.
Feeling her perspective to be given credence, its inherent legitimacy located, the patient’s own capacity for reflection may be enhanced. Memories may be awakened, recent or long-term, of analogous experience, shedding light on defenses arising in response or anticipation, indeed of what had perhaps been, until then, outside conscious awareness. In this way, I believe—recognition, articulated by another and one’s self—therapeutic action in a dynamic psychotherapy takes hold.
Gabbard GO, Horowitz MJ: Insight, transference interpretation, and therapeutic change in dynamic psychotherapy of borderline personality disorder. Am J Psychiatry 2009; 166:517–521
Schwaber EA: The struggle to listen: continuing reflections, lingering paradoxes, and some thoughts on recovery of memory, in Contemporary Psychoanalysis in America: Leading Analysts Present Their Work. Edited by Cooper AM. Washington, DC, American Psychiatric Publishing, 2006
The author reports no competing interests.
This letter (doi: 10.1176/appi.ajp.2009.09050737) was accepted for publication in June 2009.