Any treatment relationship with regular meetings takes on echoes of the patient's early relationships: the past is used to predict the present. Expect it, including around prescribing, hold a strong frame, and treat feelings toward you as a sign of the patient's underlying thoughts and feelings, not as something real.
What it is
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.
“the brain trying to make sense of current experiences and relationships by seeing the... past relationships in the present. It's almost like there's information from the past is being used to predict information in the present, and it's limiting the input of new information”
24:33When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 Any treatment relationship where two people meet regularly will be strongly informed by early parent-child relationships and relationships with significant others.
“any relationship treatment relationship where you have two people who meet regularly it's going to take on echoes or going to be informed strongly by early parent-child relationships and relationships with significant others”
22:34When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 It can be positive, where enjoyable past relationships are projected onto you, or negative, where painful or unwanted feelings are.
“there's positive transferences where the relationships, they are projecting positive, enjoyable relationships of their past onto you. There's negative where painful or less desired emotions are projected onto you”
25:06When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 Some patients test you: they treat you the way they were treated, then watch whether you can react differently from the only ways they had as a child.
“The other kind of test is what they call passive into active transformation. They treat you the way they were treated, and then they watch you to see whether you have a way of reacting to that that is different from the only ways they had at hand when they were a kid”
1:30:59Nancy McWilliams on Psychoanalytic Diagnoses, Part 2: Depressive Personality, Histrionic Personality, OCPDNov 2024Guest episode
How we use it
Everyone has baggage, patients and clinicians alike. We bring it into the room and it alters what we perceive and how we act, so if we are not aware of it, we are in trouble.
“We all have baggage. Patients have baggage. Clinicians have baggage. We bring it into the room and it's going to alter how we perceive or notice or act clinically. And so if we're not aware of that, we're in trouble”
4:32Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026 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.
“if we maintain a strict and strong frame of treatment, if we refer to the shared project of treating the patient whenever necessary, and if we're sensitive to fluctuations in the treatment process”
23:26When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 Diagnosis matters here. Particular diagnoses carry real implications for understanding transference and countertransference, and if you are not thinking this way you may miss what is going on right before your eyes.
“particular diagnoses carry real implications in terms of understanding transference and countertransference. And this is where the psychoanalytic side of me comes out, where if you're not thinking in this sort of way, you may really miss what's going on right before your eyes”
35:09Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026Guest episode
In medication management
Transference and countertransference often play out around medicine. A prescriber who will not prescribe something can be seen as a withholding persecutor: someone who says they want to help but really wants to hurt.
“we often see transference and countertransference issues play out around medicine. Where the prescriber... if he doesn't or she doesn't agree to prescribe something as seen as a withholding persecutor, as someone who says he wants to help me, but really wants to hurt me”
28:45Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024Guest episode There is no clear literature on what to do about transference in the monthly medication management visit.
“there's not a clear literature that provides instructions on what to do in the monthly medication management visit”
27:09When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025
Talking to patients
When feelings toward you come up, say plainly that it is very common to develop feelings that might not make sense toward a treatment provider. That does not make them real, and it would interfere with treatment to take them as anything other than a sign of underlying thoughts and feelings.
“it's actually very common to develop feelings that might not make sense about your treatment provider, including myself, doesn't mean that it's real. And certainly it would interfere with your treatment if we take it as anything other than a sign of your underlying thoughts and feelings”
57:52The Treatment Frame in Action: Lessons from ‘I Fell in Love with My Psychiatrist’Sep 2025
It also comes up on
- Borderline personality disorderErotic transference alone gives no diagnostic information. In the borderline range it tends to appear rapidly, is often fear-driven, tests boundaries heavily and escalates quickly.
- Borderline personality disorderThe APA now says there is good evidence for transference-focused psychotherapy, mentalization-based therapy and good psychiatric management. More important than the specific model is that the patient is in a talk therapy they commit to.
- Erotic transferenceAn erotic transference on its own gives no diagnostic information about someone's psychological functioning.
- Personality organizationIn healthier patients, erotic transference shows up gradually and in disguised forms. The patient is a little ashamed and embarrassed and can look at it with curiosity and self-reflection.
- SupervisionWith sexual transference, unless you have a very clear idea of what you are doing, seek supervision.
- Treatment frameBorderline patients need more structured treatment: even transference-focused therapists call for a contract at the outset and careful attention to the frame, boundaries and ground rules.
- BoundariesMalpractice insurance may specifically exclude coverage for "mishandling the transference," a disguised way of saying having sex with patients.
- Malpractice and liabilityMalpractice insurance may specifically exclude coverage for "mishandling the transference," a disguised way of saying having sex with patients.
From these episodes
- Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026 · 1 point
- Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026 · 1 point
- The Treatment Frame in Action: Lessons from ‘I Fell in Love with My Psychiatrist’Sep 2025 · 1 point
- When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 · 5 points
- Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024 · 1 point
- Nancy McWilliams on Psychoanalytic Diagnoses, Part 2: Depressive Personality, Histrionic Personality, OCPDNov 2024 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.