Doctors Have Borders

This article was completed by Dr. Rudin shortly before his death.

Only yesterday he was a resident in my seminar on ethics for psychiatrists. Today he is charged with sexual misconduct with a woman patient. Did he remember our discussion of "boundaries"? Of the special problems for psychiatrists? That sexual involvement with a patient in treatment is illegal?

Yes, he says, but at the time he did not think any of that would ever apply to him.

He was a bright and serious resident known for his kindness and devotion to patients. In his practice, too, he phoned patients after hours, saw them at their convenience, not his; comforted them with word and touch.

Other physicians in his HMO treated some patients that way, but he treated all his patients that way.

His HMO assured him that if he managed medications effectively, promptly, and with courteous professionalism, he would never have to deal with "transference" or "counter-transference, " the complications that plague psychotherapy.

As a psychiatric resident, I arranged to sit with non-psychiatric physicians as they saw their "psychosomatic patients," generally patients with arthritis, chronic gastrointestinal disorders, and hypertension - syndromes "suspected" of having a large psychogenic component. The "real" doctors talked with their patients about symptoms and treatment responses; I asked about family or work situations.

If the primary doctor picked up on the patient's stories in response to my questions, the sessions grew friendlier and information flowed faster. On return visits, the complaints were milder and patient and doctor seemed to enjoy each other more.

Could "transference" be the sine qua non of rapport, of a "bedside manner"?

In my child and family psychiatry practice, nurses generally liked to meet and talk about their feelings toward their pediatric patients and the patients' families and the feelings the children and their parents seemed to have toward the nursing staff. Doctors generally felt they had no time for such "palaver."

In the community, too, non-physician health professionals, social workers and teachers generally valued the discovery and discussion of the feelings that seemed to flow between them and their clients and students and families as expediting their effectiveness.

Even doctors who "know" about "transference" and "counter-transference" generally do not believe that "happens" to them. All of us prefer to believe we are in conscious control of feelings that might divert us from our professional discipline.

However, "transference" is an unconscious shift of emotions from past authority figures, generally parents, to a person now in authority, the healer. "Counter-transference" is the healer's unconscious shift of such emotions to the patient. Both are involuntary and unplanned feelings that happen. The behavior, though, is under some voluntary control.

Rules that set boundaries between patient and doctor are intended to clarify the physician's voluntary behavior to avoid ethical and legal problems and to unclutter the treatment relationship. They do not regulate the feelings.

Patients are dependent on their doctor, no matter how long or short, how deep or superficial, the contact is. The doctor is the ultimate authority in matters of health and illness, of life and death; the patient has the pain, fear and suffering, but also has control over essential personal information and the choice to comply or rebel.

With dependence may come guarded submissiveness, and guarded rebelliousness. Physicians should take comfort from knowing that some of the passive obedience or passive or aggressive non-compliance of patients stems from the transference, not something the doctor did - other than the doctor's failure to recognize the transference and work with it to create a "therapeutic alliance" with the patient.

The healer, lest we forget, is also human and develops unconscious stereotypes of parents and other authority figures, the "counter-transference. With the healer as the parent, as the authority, the doctor may become an ultra-benevolent parent, a domineering autocrat, or a democratic "big brother," icily constricted with all or some patients or uncomfortably distant, even curt, with patients who "somehow" trigger an inexplicable dislike, remnants of a counter-transference.

We see what our colleagues do, but we rarely see what we do. We know what we want to be, but rarely what we are.

Each of us selects a pattern of friendly professionalism with which we are comfortable and which respect the rules about the patient-doctor boundary. Any deviation from what we generally do should be a signal of likely transference or counter-transference interference.

If we usually call a patient by surname and suddenly use the first name, we should go on amber alert.

If we schedule the same patient, or the same kind of patient, in the last appointment of the day, "to have more time," we should go on amber alert.

If we never have coffee with a patient in the office and we do with one, if we often have coffee with patients in the office and ask one to go out with us for coffee, or we extend that to lunch or dinner, we should be on blinking red.

If the rapport becomes seductive, whether initiated by the patient or the doctor, we should be on flashing red with sirens wailing.

Like any other physician, psychiatrists who dismiss the "transference" can get caught in the patient's magical attributions and encourage the patient's dependence, prolonging therapy beyond its optimal benefit.

The patient may want and expect the physician/psychiatrist to be omnipotent, either benevolently or malevolently.

That may end therapy prematurely, in a "flight into health," a flight from feared discoveries or feared feelings. Or a malpractice law suit or an illegal act.

The placebo effect is but one of the many health benefits of the "transference." Even a brief, superficial or fragmented relationship may catch the doctor and the patient in a transference web. Consider your most adoring patient; your most recalcitrant, non-compliant patient. Obste-tricians, surgeons - from cosmetic to orthopedic - join psychiatrists as high risk groups, but all doctors enjoy the benefits and risk the pitfalls.

Can we become friends with patients? Can we treat our friends? Yes, but cautiously, ready to lose either a friend or a patient. Between physician and patient the physician is the health authority and as such is dominant, the patient is a submissive sufferer and as such is submissive.

Between friends there is reciprocal parity. The different expectations endanger either the friendship or the treatment.

The same is true of treating one's spouse or marrying one's patient. A dominant-submissive relationship is not the strongest basis for a marriage. It can work, but it should sound an alarm.

Similarly, treating one's children or treating a patient as one's child should sound an alarm. The treatment relationship is not a parent-child relationship, whatever similarities exist.

Understanding "transference" and "countertransference" helps us deliberately follow or modify the boundary rules.