One day in the course of treating a young woman with schizophrenia, the patient—whom I’ll call “Laura”—asked me if I would like to take her out on a date. For a good half-minute, I was stunned. I had to think carefully about my answer, as I struggled with my conflicting emotions.
Now, psychiatrists and other psychotherapists don’t date their patients—period. To do so would be to exploit the vulnerability of those who are seeking treatment for difficult and debilitating conditions.
Even years after the patient’s psychotherapy has concluded, this is a boundary that must not be crossed. So goes the gospel of psychiatric ethics, according to nearly all authorities in the field.
When a patient in psychoanalytically-oriented therapy begins to develop “romantic” feelings toward the therapist, it’s the therapist’s job to help the patient understand these feelings, rather than act on them. And so, the therapist may interpret the patient’s amorous overtures as arising from the “transference”—that powerful, unconscious process by which feelings and attitudes toward someone in our past are “transferred” to a person in the present. For example, a young female patient might express “love” for her older, male therapist because she is unconsciously transferring feelings she once had toward her father.
But patients with psychotic disorders like schizophrenia are almost never treated with psychoanalytic techniques. Though there are a few dissenting voices in the field, most psychiatrists believe that deep, interpretive probing of the unconscious tends to unhinge the already fragile psyche of persons with schizophrenia.
Instead, the therapist tries to be a “real” person for the patient—someone who stays in the here and now; empathizes with the psychotic person’s fears; and helps the patient navigate the rocks and rapids of psychosis. While we always bear in mind the role of transference, deep interpretations of the patient’s unconscious fears and impulses are rarely made when working with psychotic patients.
So, if the patient with schizophrenia asks, “Are you going to dump me as your patient?” the therapist isn’t likely to link that fear with, say, the patient’s ne’er do well, abandoning father. Instead, the therapist might say something like, “I bet it’s very scary to think that I would just up and leave you like that. I know that when people I cared about suddenly left me in the lurch, I felt pretty scared. But I want you to know that I’m going to work with you until we both decide it’s time to stop treatment.”
All this theory is well and good. But when Laura said, “Dr. Pies, would you like to go out with me?” I felt anxious and flummoxed. Had I been asked at the time, I might have acknowledged feeling a little flattered and rather intrigued by my patient’s overture.
It would have been harder for me to acknowledge that I also felt a mixture of excitement and guilt. Sometimes, the therapist’s unconscious reaction to the patient—called “counter-transference”—has roots in the therapist’s own past relationships with important figures. But, to tweak an old saying associated with Freud, sometimes physical attraction is just physical attraction.
After all, this was over 30 years ago, and I was young and single, just starting my private practice. Laura was a smart, attractive woman in her late twenties, who—when not terrified by her threatening “voices”—could be charming and vivacious. In these respects, Laura didn’t fit the stereotype of the person with schizophrenia, an illness that often leads to a “flattening” of emotion or “inappropriate affect.” (Textbooks may give the example of the patient’s smiling while talking about a loved one’s death.) Laura was more emotionally alive and interpersonally connected than this, and, at times, I wondered if she suffered from a mood disorder with psychotic features.
And yet, as a young girl, Laura had always felt “different” from her peers. She saw herself as alienated and damaged, and her low self-esteem dogged her well into her adult years. With the help of medication and supportive psychotherapy, the hostile voices were brought under reasonably good control. Even better, as our work together proceeded, Laura grew increasingly confident and self-possessed.
Over the course of treatment, I noticed that she had begun to see herself in an increasingly positive light. So when she popped the question—“Dr. Pies, would you like to go out with me?”—I felt instinctively that this was a healthy sign. The last thing I wanted to do was reply in a way that would undermine Laura’s hard-won self-esteem. At the same time, I needed to convey that her “invitation” was out of the question. But for a very long 30 seconds, I struggled to find the right words.
When I was a resident, I had a very wise supervisor—a full professor in the department—who used to spend much of our supervisory sessions carefully trimming his nails. At first, I mistook this for inattentiveness, but I soon learned that he was listening carefully to everything I said. One day, I confessed to him that I was at a loss in working with a severely disturbed patient who had been admitted to our inpatient unit. I didn’t know whether to use a behavioral approach, supportive psychotherapy, medication, or what.
He smiled, put down his nail file, and said, “You know, I’ve been in psychiatry for 40 years, but sometimes I just fly by the seat of my pants.” That was probably the most helpful and liberating thing anyone had said to me during my residency. It meant that even experienced psychiatrists sometimes didn’t know exactly how to navigate in the sometimes turbulent skies of psychotherapy.
I decided to answer Laura while “flying by the seat of my pants.”
“You know, Laura,” I said slowly, “it would be real honor to go out with you. I bet we’d both have a nice time. Thank you so much for asking me. But I really can’t date you—it’s just not something that a therapist and a patient can do.”
A long silence followed, and I feared the worst. Would my patient start crying, or storm out of the session in a huff? Instead, Laura smiled, even as a trace of melancholy flickered in her eyes. “I guess I kinda knew that, Dr. Pies,” she said, shrugging, “but I thought I’d give it a try.”
In the days following that crucial session, I was glad I had replied to Laura’s overture in the way I did. The dating issue never came up for us again, and Laura eventually moved to another city. She managed to land a responsible office job, and when I heard from her by letter a year or so later, she was doing well. I was happy for Laura, but surprised by a vague sadness that seemed to shadow me for several days. I think it was the unavoidable sorrow that springs from a possibility forever foreclosed, even as a responsibility was fulfilled.
Acknowledgments: Thanks to Dr. Peter Kramer and Dr. Glen Gabbard for their helpful comments on earlier drafts of this piece.
Photo courtesy of Nono Fara on flickr