To the Editor: In their article on risk management principles for recovered memory cases in the November 1997 issue, Drs. Gutheil and Simon (1) conclude by advising that "if the patient persists with the intention to sue, the clinician should refer the patient to another therapist, if necessary, and terminate therapeutic work with that patient." Such a recommendation, unless used with caution, can create clinical or iatrogenic harms even as the therapist seeks specifically to avoid such harms.
First, it is important to keep in mind that clinicians often resort to recommendations to terminate treatment when feeling frightened, pressured by time, or otherwise constrained. Although the authors qualify their fundamental recommendation to terminate treatment and refer to another therapist, the danger remains that uncritical application of such a principle will encourage treating clinicians to shed responsibility in order to appear beyond reproach, while leaving the patient, family, and subsequent clinician with the risk for escalation of the patient's harmful behavior as a reaction to an experienced abandonment.
Just as we clinicians must not jump to conclusions about intersubjective reality, we must avoid threatening to conclude our work with our patients when they act disagreeably (2). We can set reasonable limits with the patient on the scope of our work by paying careful attention to maintaining our own neutrality between external and internal—objective and subjective—reality rather than run the risk of rationalizing a countertransferential wish to have the patient conform to our view of reality by threatening termination.
Second, as always, a therapeutic impasse is most likely to be resolved when the treating clinician takes responsibility for self-analysis of how countertransference issues may be impinging on the creation of a therapeutic alliance and its maintenance and re-creation as work proceeds (3). Often the background for childhood abuse is childhood neglect. A premature termination, while avoiding exploration of the former, may lead to a reenactment of the latter. When a therapeutic impasse is reached, a psychoanalytically informed consultation may be a useful tool for the treating clinician. The focus of such a consultation may be on the alliance and on how patient transference and clinician countertransference may be distorting the frame of the alliance.
Dr. Bursztajn is associate clinical professor in the department of psychiatry at Harvard Medical School in Boston.