Drs. Gabbard and Bennett Reply

To the Editor:

We thank Dr. Koblenzer for his interest in our work and for providing us an opportunity to respond to his concerns. He asserts that our treatment was not psychodynamic because we did not present evidence that the therapist’s interventions were guided by an understanding of the patient’s transference, which he argues is the defining characteristic of psychodynamic treatments. Here Dr. Koblenzer uses a familiar strategy to make his point: “It is so because I say it is so.” In fact, his view of the defining characteristic of psychodynamic treatment is rather idiosyncratic. One of us (G.O.G.) has written two best-selling textbooks on psychodynamic treatment (1, 2), and we have a dramatically different view from that of Dr. Koblenzer. In our view, there is no single defining characteristic of psychodynamic treatment. A psychodynamic approach to a patient is defined by a set of time-honored principles, including the unique value of subjective experience, the paramount importance of unconscious mental functioning, the principle of psychic determinism, a developmental perspective, and the understanding of transference, countertransference, and resistance.

Dr. Koblenzer informs us that we are confused about the concept of technical neutrality. In contemporary psychoanalytic discourse, neutrality has undergone radical redefinition. There is a broad consensus now that the therapist is a participant in the therapeutic process and is drawn into enacting a role in the patient’s internal object world in a transitory, disciplined, and partial way (3 – 6) . Pure technical neutrality is an ideal rather than a realistic position. The point that we made in the clinical case conference was that the patient’s provocative sexual behaviors made it virtually impossible for the therapist to maintain neutrality in this situation. Indeed, what our case presentation demonstrated is that the study of how the patient’s transference evoked specific countertransference response is a “royal road” to understanding the patient.

By necessity, case reports must focus on a fragment of the treatment. The kind of interpretive work that Dr. Flegenheimer suggests did indeed take place in the subsequent phases of the treatment with beneficial impact on the patient"s marital situation.