Even though there was no name attached to the message, I knew instantly who had sent the vague text that left my heart racing. This was the last communication I had with Mr R, a 36-year-old neuroscience researcher with no past psychiatric history.
It was just another busy morning filled with charts, scrips, and patients, when I noticed a line of text posted on the screen of my latest piece of mobile communications technology. It said, "I would not have come for therapy if it had been anyone else but you."
Even though there was no name attached to the message, I knew instantly who had sent the vague text that left my heart racing.
This was the last communication I had with Mr R, a 36-year-old neuroscience researcher with no past psychiatric history. Mr R had 3 children, a “beautiful” wife, and every material thing that most people want to have. He described himself as a fun-loving guy, coach of his kids’ sports teams, the life of the party at social events, and a successful young investigator. But his picture-perfect life had not come easily; he was raised by an alcoholic mother and abandoned by his father before he was 10 years old. He started working in high school and paid his own way through his university studies. He earned his doctorate and was invited into a prestigious lab to continue his work.
He presented for evaluation at the clinic after he found some incriminating e-mails between his wife and another man. Intensely anxious that his marriage was in danger, he decided to come for help. I diagnosed an adjustment disorder with anxious features. We agreed that he start with an antianxiety agent and expressive-supportive dynamic therapy. I had no idea what was in store for me in the 10 therapy sessions that lay ahead.
I set out to help relieve Mr R of his ailment by using the tools of my trade. First, I prescribed a safe and effective medication with minimal adverse effects. That was the easy part. Second, despite a disconcerting feeling of butterflies in my stomach, I harnessed my rational mind in the service of a course of psychotherapy designed to provide insight into the sources of his suffering. To my chagrin, I was faced with a complex question as I sat face-to-face with Mr R: What happens to the rational mind of the therapist when influenced by longings of the heart?
We know from experiences outside therapy that no one is immune to the feeling of intoxication that accompanies physical attraction. We fear it because it can allow reason to succumb to emotion. Although we may be embarrassed to admit it, we crave it because it provides a natural high. We struggle to have candid but necessary discussions on the subject at various stages in our physical and emotional development. Many of us remember the dreaded and infamous “birds and bees” discussion with our parents when we were growing up. Mixed emotions surface when forced to discuss something so personal with an authority-whether it be a parent when we are children or a supervisor when we are therapists-in-training. The seemingly forbidden ideas evoke shame and embarrassment.
Needless to say, when I experienced physical attraction in the context of psychotherapy, I was faced with understandably complex emotions. I called on all of my defenses. Suppression: “I’m attracted to this patient, but I’ll put it aside for now and write about it later in my journal.” Sublimation: “I’ll endure this uncomfortable experience and use the resulting nervous energy to clean my floors and train for a marathon.” Altruism: “I’ll write about this experience to help others who may be struggling with the same issue.”
Sitting in sessions with Mr R, I feared my sympathetic nervous system betrayed me. I awkwardly fidgeted and blushed. My choice of words sounded (only to me I hope) like I was asking Mr R out on a date: “We really need to meet at least once weekly to make progress in psychotherapy.” Furthermore, Mr R frequently asked me to disclose personal information. He would ask, for example, “Is it hard to do your job?” or “Do you have children?” Temptations to self-disclose lurked around every corner. He was also curious about my countertransference toward him: “I wonder what you tell your supervisors about me. I sense I’m different from your other patients.” (Sounds a bit narcissistic, no?)
It was time for me to discuss these issues with someone else. For me, as for many, those who make up my normal support system do not have much experience from which to draw on the subject of erotic countertransference. After considering all the options, talking with my individual psychotherapy supervisor seemed the best choice. But, while contemplating the sharing of this situation with a supervisor, predictable questions arose: “Will my supervisor recoil in horror?” “Will he immediately call my training director and drum me out of the program?” “Will he direct me to a pathology residency?” “Will my face turn crimson?” And finally, “Am I ready to reflect on this part of my psychological makeup?”
I took the case to my regular supervisor and expressed my tremendous discomfort. Still unable to outwardly acknowledge my feelings for Mr R, I focused on the patient’s behavior as the source of the “problem.” During an early session, Mr R announced, “I think you’re cute.” As I shared this part of the session with my supervisor, I waited expectantly for her to affirm my belief that he would be an impossible patient and to recommend termination. She did not. I asked, “How can I help him if he objectifies me? He is not taking me seriously as a professional. Look at the jam I’m in because of him.”
She reminded me that we had worked through a few prior instances of dealing with flirtation from patients in my medication management clinics. Those situations now seemed less distressing by comparison. We were unable to identify any objective evidence of inappropriate behavior on the part of Mr R, and finally my CBT-trained supervisor looked at me quizzically and said, “I think you need to take this one to Dr Gabbard. I have never seen a resident with this problem before.” “Never!?” I thought, “I’m the only one!?” I worried incessantly about what was wrong with me to feel so incapacitated, unable to feel in control of the therapy in this particular case. I kept thinking in circular fashion, “I should not have this problem. I must stop it. I can’t stop it. I should not have this problem”-and on and on.
Once I swallowed my pride and mustered the courage to follow the direction of my regular supervisor, I sought out Dr Gabbard. Under his patient and expert guidance, I was forced to look more closely at the transference relationship to understand my discomfort. It was with this supervision that a surprisingly discombobulating incident led to helpful introspection. Dr Gabbard raised several possibilities. Was I, like a previous therapist-patient of his, rebelling against social norms by desiring my patient? Was I unconsciously looking to fill an unmet personal need in this doctor-patient relationship? He also told me to “Remember this discussion we are having now in your next session with Mr R and you won’t feel as vulnerable.” And he repeatedly told me, “You’re feeling guilty for something you have not done and will not do.” I began to believe that I was in control of my behavior, despite my emotional reaction to Mr R.
At various points in Mr R’s therapy, I struggled with the issue of whether to continue his treatment. Would I be able to manage my own anxiety and actually help him? With support from my supervisor, I worked on understanding this part of myself, looking to conquer my fear lest it conquer me. Open and nonjudgmental communication about transference and countertransference helped to demystify my emotional response and distinguish fantasy from reality. It is fantasy that pursuing an inappropriate relationship with a patient would make him (or me) feel better. It is fantasy that those behaviors would be without consequence. It is reality that I have a duty to my profession, my family, and my community to behave appropriately. It is reality that balancing marriage, motherhood, and a profession is hard work. It is reality that as a psychiatrist, I am privileged to share private thoughts and feelings of others in a unique way. When he wrote his classic 1915 paper on transference love, Freud noted, the “analyst pursues a course for which there is no model in real life.”
Mr R reached his short-term goals in therapy, and we decided to stop treatment. In the last session with Mr R, I presented a summary of our work and a plan for the future. Following Dr Gabbard’s recommendation, I had a plan for how to end the session. I opened the door, said good-bye and offered a handshake as Mr R left the office. Dr Gabbard warned that feelings often intensify on termination of therapy. Mr R touched my arm and said, “I’ll see you later,” and walked to the clerk’s desk. I moved on to the next patient, hoping I would be able to put Mr R out of my mind. It was less than 24 hours later that Mr R sent me the text message that began this paper. With supervision, I deliberately chose not to respond to the text, which would have been an invitation to disaster. A different decision may have led to the first step down the slippery slope.
As therapists in training, our fears of condemnation and feelings of guilt may keep us from discussing important material with mentors and supervisors. But it is those very individuals, through experienced examination, who can help us protect our personal and professional lives, learn about ourselves, and offer successful therapy to patients. Without that examination, we may enact the very thing we fear.