Key moments, in order
These feelings are par for the course in any long-term treatment, and especially long-term psychiatric treatment.
After a bad outcome it is a natural instinct to distance ourselves from the problem by declaring it a huge mistake.
Some boundaries are essential for every practitioner and cannot be changed, such as protecting confidentiality.
The fewer hard and fast rules you have about boundaries and frame, the more dangerous things are. Even if nothing bad ever happens, you are making it harder on yourself.
Stick with "Doctor." It is not about ego: it sets up a role in which you are in charge of the treatment and there for the patient's good. Keeping the rule also gives you a little bonus test of patients' personalities.
Boundaries protect the patient and the clinician from anxiety and give patients predictable parameters for how to interact with the clinician.
A crossing is anything that risks harm to the treatment process, the patient or you; a violation definitively harms them. Crossings can further the work when they are processed appropriately. Violations are never acceptable: a sexual relationship with a patient is never acceptable under any context.
When a patient wants more closeness, such as using your first name, hold the line: "This is still a medical relationship. The reason we are meeting is for your good. I'm not just here to be friends. I'm your doctor too."
Asking about self-harm should be standard in every encounter. Say you ask every patient, every visit, and make sure that is true, so no one feels singled out.
Be wary of discussing your own professional work and achievements when it is not pertinent to the treatment.
Any treatment relationship where two people meet regularly will be strongly informed by early parent-child relationships and relationships with significant others.
Keep a strict and strong frame, refer back to the shared project of treating the patient when needed, and stay sensitive to shifts in the treatment process.
Think of it as the brain making sense of current relationships by seeing past relationships in the present: information from the past is used to predict the present, which limits the input of new information.
It can be positive, where enjoyable past relationships are projected onto you, or negative, where painful or unwanted feelings are.
There is no clear literature on what to do about transference in the monthly medication management visit.
When there are no clear rules, keep strict boundaries and frame, and refer back to the frame and the alliance whenever anything seems amiss.
An erotic transference on its own gives no diagnostic information about someone's psychological functioning.
In healthier patients it shows up gradually and in disguised forms. They are a bit ashamed or embarrassed and can look at it with curiosity and self-reflection.
In the borderline range it can appear rapidly, is often fear-driven, tests boundaries hard and escalates quickly.
Exploring sexual fantasies is not part of medication management. Doing something markedly different with one patient than with the others is a red flag.
Reading how an analyst in thrice-weekly psychoanalysis responded to sexual transference does not mean you should make a half-baked attempt to recreate it in your own setting.
Unless you have a very clear idea of what you are doing, seek supervision.
Malpractice insurance may specifically exclude coverage for "mishandling the transference," a disguised way of saying having sex with patients.
When a patient declares feelings: I'm not feeling those feelings. What I feel is care for your well-being as a patient, and that is my job as long as we work together.
When a patient declares romantic feelings, do not reciprocate: "I'm not feeling those feelings. What I feel is care for your well-being as a patient. That's my job here." Ending treatment does not change it: a psychiatrist can never have a romantic relationship with a patient, and we do not keep friendships with patients after termination either.
If a patient cannot agree with you about what is real, refer back repeatedly to the frame and the plan. If it gets to that point in plain medication management, you are in hot water: call risk management.
Acknowledge what is going on without encouraging enactment: recognize the feelings, but do not collude, reciprocate or reinforce the fantasy.
If you cannot move forward without it getting in the way, say that the best thing for them is to find a new doctor.
When something alarming comes up unexpectedly, you are less likely to jump in and say something based on your own misinterpretations.
The patient's physical safety comes first, so if there is a possible medical emergency, stop the session and send them to the emergency room. You cannot continue psychotherapy if the patient is dead.
It is not the psychiatrist's role to practice every form of medicine, and therapists should not do a medical assessment to decide whether to continue. If unsure, do not pretend and do not do a half-baked emergency visit.
Even if the patient refuses to go to the emergency room, still stop the session and recommend care. Tell them to call 911 or go to the hospital if they worsen, and see them at the next appointment.
Courts and society love to hold clinicians accountable, even for things outside their control. That is why we recommend following some pretty strict rules and boundaries.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.