Drs. Malmquist and Notman Reply

To the Editor: We appreciate Dr. Epstein’s calling our attention to some publications from the early 1990s, although they do not seem centered on the specific area we wrote about—namely, the need to clarify posttermination situations outside of the treatment context. The need to define “termination” is crucial. Dr. Epstein seems to belong to the group that believes that there really never is termination because of transference. In contrast, we argue that such a vague and undefined standard after termination of treatment gives rise to many difficulties for society in general and certainly for the judicial system. This holds not only for psychiatry but for the remainder of medicine as well. More specifically, even if transference continues (although we acknowledge that many psychiatrists and mental health professionals do not work within that framework), it does not mean that a person has lost his or her capacity to make decisions involving his or her future.

Dr. Epstein paints a picture of psychiatrists “grooming” their patients for a future liaison. While this situation undoubtedly happens in some cases, we see that as a situation in which treatment has not actually ended (Brown et al., 1992). However, we certainly expect that evidence about such grooming would be forthcoming in adjudication of a particular case, rather than attributing such a situation retrospectively to transference, in which the psychiatrist is said to have been harboring the idea during treatment.

Finally, we do not view arguments about the scientific validity of constructs, such as transference and countertransference, as “sophistry.” We prefer to view such arguments as essential if psychiatry is to progress beyond the level of making assertions and expecting our colleagues, and those in other fields, such as law or regulatory bodies, to give us any credibility. Only in this manner can we truly reduce the risk for medical error and promote a milieu of public confidence.

Dr. Gutheil rightfully points out how such reliance on a psychoanalytic concept became enshrined in the courts by way of plaintiffs’ attorneys needing some basis for their claim if they were to collect damages. It is a good insight into the contemporary scene. We can only wonder if there may not have been other ways to accomplish this end, although we stress a need to distinguish ongoing treatment situations from posttermination events.