To The Editor: In his otherwise excellent recent editorial on the use of transference in dynamic psychotherapy, Glen O. Gabbard, M.D., states that clinicians practicing mentalization-based treatment of borderline personality disorder “specifically eschew transference interpretation” (1, p. 1668). We would like to correct this misunderstanding. We specifically recommend working “in the transference” and have attempted to specify the structure and content of effective commentary on the transference as well as appropriate timing.
The misunderstanding is likely to boil down to one of definition. As Dr. Gabbard usefully points out, many different interventions come under the guise of transference interpretation. Some facilitate the creation of alternative perspectives within an interpersonal context fraught with emotion. In our view, such interventions are essential to the effective treatment of individuals whose capacity for mentalization is fragile. Others present complex descriptions of the patient’s mental state and behavior that are beyond her or his ability to process at moments of high arousal. These run the risk of undermining rather than generating a capacity to contemplate feelings and thoughts (2). To delineate this key technical distinction, we have been careful to define what we mean by working on the transference (3, 4). In essence, we eschew the “expert stance” potentially implied by reinterpreting the patient’s behavior to provide insight within a model of mind alternative to that which the patient (at least initially) holds. Instead, we recommend exploring transference phenomena in a spirit of inquisitive curiosity. Patient and therapist jointly specify and elaborate the aspect of the patient’s feelings that suggest transference. They then consider alternative perspectives, with the therapist carefully monitoring the patients’ and her or his own reactions to the consideration of these ideas.
We talk about “mentalizing the transference”’ to distinguish this process from transference interpretation viewed as a technique to provide insight. “Mentalizing the transference” is shorthand for encouraging patients to think about their current relationship (the therapist-patient relationship), to focus their attention on another mind (the mind of the therapist, which ideally has the patient’s mind in mind, this being the therapeutic component), and to contrast their own perception of themselves with other people’s perceptions of them (the therapist or members of a therapeutic group). Our aim is not to provide the patient with an explanation (insight) that they might be able to use to control their behavior pattern, but far more simply to facilitate the recovery of mentalization, which we see as the overarching aim of psychotherapy with patients with immature object relationships.
1.Gabbard G: When is transference work useful in dynamic psychotherapy (editorial)? Am J Psychiatry 2006; 163:1667–1669
2.Fonagy P, Bateman A: Progress in the treatment of borderline personality disorder. Br J Psychiatry 2006; 188:1–3
3.Bateman A, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment. Oxford, Oxford University Press, 2004
4.Bateman A, Fonagy P: Mentalization Based Treatment: Practical Guide. Oxford, Oxford University Press, 2006