Are you in love with your doctor?

It is not infrequent for us psychiatrists to have patients who develop transference or positive feelings towards us. This can also happen with non-psychiatrists (like priests, teachers, counselors).

What is transference? It is defined as "the set of expectations, beliefs, and emotional responses that a patient brings to the doctor-patient relationship." Transference does not necessarily reflect who a doctor is or how a doctor acts in reality. Rather, it reflects experiences a patient may have had with other important authority figures in his life.

This means that a patient’s attitude toward a doctor is likely to be a repetition of the attitude he or she had in the past towards persons of authority. This attitude may range from that of realistic basic trust (with the expectation that the doctor has the patient’s best interest in mind), to that of over-idealization and even erotic fantasy, to one of basic mistrust (with an expectation that the doctor will be probably abusive or contemptuous).

Recently, I referred one of my female patients to a male orthopedic surgeon. This young female patient now thinks she’s in love with him despite knowing he is already married.

When I was a resident trainee in Psychiatry at the Philippine General Hospital and was then pregnant with my second child, I almost panicked when, during a psychotherapy session, one of my male non-psychotic patients verbalized his erotic desire for me. I immediately requested my consultant psychiatrist to supervise me in handling this transference issue with my patient.

In many aspects, the role of psychiatrists is very different from that of physicians who are not psychiatrists. However, a lot of patients expect the same from a psychiatrist as they do from the other physicians. For example, when they expect a physician to take action, give advice, and prescribe a drug to cure an illness, they may very much expect the same interaction with a psychiatrist. Very often they get disappointed or even angry with a psychiatrist when their expectations are not met. "Hindi yata doktor yan," they grumble. "Walang nireseta. Kinausap lang ako."

Transference reactions more often occur during psychotherapy sessions of psychiatrists. There are many reasons why this happens. For instance, in the so-called intensive insight-oriented psychotherapy, the encouragement of transference feelings is an integral part of the treatment process. In some of the other types of therapy, the psychiatrist is usually supposed to be neutral. But the more neutral or less known a psychiatrist is, the more the transference fantasies are projected towards the doctor.

So what do we do when this happens? Once fantasies are stimulated and projected towards us, we help patients gain insight or understanding into how these fantasies and concerns affect all the important relationships in their lives.

Even if a doctor who is not a psychiatrist does not use or does not even need to understand transference attitudes in this intensive way, a good understanding of the power and manifestations of transference is necessary for optimal treatment results in any physician-patient relationship.

Many of you have seen that a doctor’s words and deeds seem to have a power far beyond the commonplace. This is perhaps because–owing to their dependence–patients give their doctors a unique authority. How the doctor behaves and interacts has a direct effect on the patient’s emotional and sometimes physical reactions. For example, a patient’s blood pressure may be high when taken by a doctor he dislikes but it may be normal when taken by another doctor whom the patient likes because of the doctor’s warm and understanding attitude.

If transference is the term for the feelings and attitudes of the patient for the physician, counter-transference refers to a doctor’s feelings and attitudes for the patient. Doctors are not gods; they are also human. So just as patients bring transference attitudes to the doctor-patient relationship, physicians themselves often have counter-transference reactions and attitudes towards their patients.

Counter-transference can be positive or negative. Negative counter-transference reactions will be disruptive to the doctor-patient relationship. Disproportionately positive counter-transference feelings of over-idealization or erotic reactions are, of course, also not good for the doctor-patient relationship.

Emotion breeds counter-emotion. If the doctor is hostile and tactless, the patient will be hostile too. If the doctor effectively handles a resentful patient by rising above such emotions, then the interpersonal relationship will shift from that of overt antagonism to one of increased acceptance.

Rising from such emotions involves being able to step back from the intense negative counter-transference feeling and being capable of exploring and understanding why the patient reacts in such a self-defeating manner. A doctor who reacts in a less angry and more empathic way towards a hostile patient is one who has gained insight that the patient’s antagonism is some kind of defensive or self-protective mechanism. This most likely is a reflection of transference reactions of fear of disrespect, abuse and disappointment.

Doctors with the strong unconscious need to be all-knowing and all-powerful may have problems with certain patients. They will have difficulty with patients who seem to repeatedly defeat attempts to help them. An example–patients with severe heart disease who continue to be chain smokers or heavy alcohol drinkers. Doctors will also run into trouble with patients who are perceived to be uncooperative, like those who keep on asking questions and refusing diagnostic tests and medications; with patients who demand a second opinion; with patients who fail to recover; with dying or chronically-ill patients; and with patients who use physical or bodily complaints to mask emotional problems. These patients are indeed difficult for any doctor to handle but if the doctor is able to have awareness of his own needs, capabilities and limitations, then difficult patients will eventually be deemed as less threatening.

Physicians are bound to like some patients more than others. But once a doctor feels a strong attraction for a patient and is tempted to act on this attraction, then this doctor needs to step back and assess the situation as objectively as possible. In non-psychiatric medical specialties wherein the doctor-patient relationship is not particularly intense, the prohibition against romantic involvement with the patient may not be that strong. However, in specialties like psychiatry, the ethical prohibitions are important.

So, dear readers, after reading this article and after gaining some understanding about transference and counter-transference issues, I certainly hope you won’t get too disappointed and learn to accept that there’s no real romance between you and your doctor.