Transference in the Age of #MeToo: What Counts as Harassment From a Patient?

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A 1999 survey conducted in the United Kingdom found that of 100 male and female psychiatric trainees, 86% reported sexual harassment, with most offenses having been perpetrated by patients.
A 1999 survey conducted in the United Kingdom found that of 100 male and female psychiatric trainees, 86% reported sexual harassment, with most offenses having been perpetrated by patients.

#MeToo is a hashtag coined by actress Alyssa Milano as a rallying cry to draw attention to sexual assault and harassment, initially in the movie industry and workplace.1 During the first 24 hours after the hashtag initiated, it was posted 12 million times on Facebook and has increasingly taken root since then.2

The medical world is not immune to issues of sexual harassment, typically of women but also of men.3 And although much of the focus has been on the harassment of physicians by other medical professionals (eg, superiors), there have also been accounts of physicians who experience harassment at the hands of patients and who are not prepared for how to handle that type of encounter.4

Part of the Job?

Psychiatrists have historically been vulnerable to several aspects of sexual harassment. A 1999 survey conducted in the United Kingdom found that of 100 male and female psychiatric trainees, 86% reported sexual harassment taking the form of deliberate physical contact, excessive proximity (eg, leaning over or cornering), letters, telephone calls, and being exposed to sexual material, with most offenses having been perpetrated by patients.5 Although the majority of sexual harassment seems to take place in hospital settings, such as the emergency department, female physicians have also reported it from patients in their offices as well.6

One reason psychiatrists are unclear how to respond to patients' advances is that they do not always regard them as "sexual harassment," the study authors note. In particular, diagnoses of confused states, mania, or schizophrenia made subjects less likely to consider unwanted sexual behavior to be "sexual harassment." Nevertheless, the authors emphasize that the psychological impact on victims "should be acknowledged even when the behaviour of the perpetrator can be explained by diagnosis."5

Sexual harassment involves not only touch but also sexually seductive statements. And although people in other professions or other areas of medicine might see these types of statements as inappropriate, hearing them without judging or labeling is part and parcel of being a psychiatrist.

"The mandate of psychotherapy is for the patient to talk about what is on his/her mind and to provide a safe environment for the expression of concerns that may not be appropriate or acceptable in other relationships," according to Dinah Miller, MD, Assistant Professor of Psychiatry, Johns Hopkins School of Medicine, Baltimore, Maryland.

"There are times, however, patients may talk about topics that make the therapist uncomfortable," she told Psychiatry Advisor.

This includes not only discussion of sexual fantasies or experiences but also erotic transference that the patient might feel toward the therapist -- a central component of therapy that applies to female psychiatrists treating male patients as well as male psychiatrists treating female patients.

Transference can be defined as "unconscious feelings that are transposed onto another significant individual."7 Sexualized transference is "any transference in which the patient's fantasies about the analyst contain elements that are primarily reverential, romantic, intimate, sensual, or sexual," whereas erotic transference is "an intense, vivid, irrational erotic preoccupation with the therapist characterized by overt, seemingly egosyntonic demands for love and sexual fulfillment."7 The patient is "unable to focus on developing appropriate insights and attends the sessions for the opportunity to be close to the therapist, with the hope that the therapist will reciprocate love."7

Often, a person's discomfort can be internal "radar," an internal clue that something is off with another person's comments. But personal discomfort is not always a signal for a therapist.

"Psychotherapists get used to being uncomfortable. Patients may talk about their own misbehavior; for example, if a patient talks about taking advantage of another person, or of exacting revenge, or of having committed a crime," said Dr Miller, who also has a private practice in Baltimore. "Or patients may talk in therapy about political views that the therapist finds difficult to hear." 

She continued, "In the case of sexual material, the therapist needs to figure out if the patient is bringing the topic up because it's troubling him or her, or if he's bringing up sexual topics for the purpose of evoking a response in the therapist; in which case, it makes sense to explore this as part of the therapy."

Does this mean that the patient gets carte blanche to make advances or seductive comments to the therapist?

Dr Miller clarified that if a patient is "overtly aggressive, threatening, or inappropriate in a way that can't be explained by a psychotic state, a therapist can't work with a patient when safety is a concern in the session."

How to Differentiate

Psychiatrists should be aware of the origins of their own discomfort and whether it arises from countertransference, according to David Goldenberg, MD, Assistant Professor of Clinical Psychiatry at Weill Cornell Medical College and Director of the Psychodynamic Psychotherapy Program at New York Psychiatric Society and Institute in New York City.

"You have to distinguish between your own countertransference reaction, as opposed to a patient's obvious provocation," he told Psychiatry Advisor.

One of the most important aspects of "the delineation between erotic transference and exploitation" is the importance of being well trained and continuing to hone therapeutic skills, he continued.

Another is to be aware of "anything that deviates from standard practice."

For example, "be alert to patients who dress seductively, attempt to give you gifts, contact you on social media or outside the appointment time, ask frequent questions about your sex life, or refuse to talk about subjects other than sex," he suggested.

He advised psychiatrists to be cognizant of their own countertransference. "Are you not charging or undercharging your patient? Are you accepting too much contact outside of the therapeutic frame? Are you colluding by avoiding uncomfortable subjects or bringing up sexual subjects when not warranted?"

The more self-aware a practitioner is, the more attuned he or she will be to the nature of a patient's advances and whether to interpret them as grist for the therapeutic mill or as a sign of more insidious harassment.

Protecting Yourself Against Patients' Claims of Sexual Harassment

Therapy is an intimate experience and often involves discussion of intimate subjects. "I ask everyone about their sexual history and sex life, which I think is essential even if you are prescribing medication, and certainly if you are doing therapy," Dr Goldenberg said.

The therapeutic setting and nature of the questions may make patients uncomfortable and may elicit the patient's concern that the therapist is making advances to them.

If a patient is uncomfortable with sexually related questions, the clinician should explain why he or she is asking these questions and also proceed slowly with the questioning process.

"If you are exploring a patient's sexual or masturbation fantasies, for example, you have to be alert to the person's level of stimulation and overstimulation, and if they are experiencing you as seductive or coming on to them," Dr Goldenberg recommended.

"If a patient is uncomfortable with sexually related questions, the clinician should seek to explore and understand the discomfort and, necessarily, be able to explain why he or she is asking these questions," he continued. "The clinician may need to proceed slowly with the questioning process."

However, it is important not to avoid necessary questions about sex out of concern that the patient might misinterpret them, he added.

Navigating the Terrain

Both experts offered tips for protecting against being either the victim or the accused perpetrator of sexual harassment.

Get supervision. Consult a supervisor or peer if you are concerned that a patient may be harassing you or that a patient may be misinterpreting the therapeutic process, Dr Goldenberg advised.

Documentation is essential. Careful notes on the treatment plan and any concerns you have can be protective in either scenario.

Suggest that your patient seek a second opinion. Second opinions are routine in most areas of medicine, but "we as psychiatrists don't consider it often enough." If a patient is concerned about sexual discussion, especially if the patient continues to misunderstand the reason for particular line of questioning or feels it is not helping to resolve the issues that brought him or her into therapy, "a second opinion is always a reasonable option," Dr Goldenberg said.

Have a safety plan. For example, avoid seeing patients whose behaviors or remarks concern you when you are alone in the building, and have your cell phone turned on, albeit on silent, in case you need to call for help.

New Avenues of Exploration

#MeToo has opened up new vistas of reflection and introspection, both on the part of practitioners and on the part of patients, Dr Goldenberg noted.

"I have noticed that many of my patients are examining their own experiences, both as 'victims,' in which they allowed harassment or abuse to happen and sacrificed their own agency, and as aggressors who may have exploited or harassed others," he said.

Continuing to examine these issues can pave the way for growth on the part of both the patient and the therapist.

References

  1. Zacharek S, Dockterman E, Edwards HS. Time person of the year 2017: meet the silence breakers. Time. December 18, 2017. http://time.com/time-person-of-the-year-2017-silence-breakers/. Accessed May 20, 2018.
  2. CBS. More than 12M "Me Too" Facebook posts, comments, reactions in 24 hours. https://www.cbsnews.com/news/metoo-more-than-12-million-facebook-posts-comments-reactions-24-hours/. Accessed May 19, 2018.
  3. Jagsi R. Sexual harassment in medicine — #metoo. N Engl J Med. 2018;378(3):209-211.
  4. DeFilippis EM. Putting the "she" in doctor. JAMA Intern Med. 2018;178(3):323-324.
  5. Morgan JF, Porter S. Sexual harassment of psychiatric trainees: experiences and attitudesPostgrad Med J. 1999;75:410-413.
  6. Phillips SP, Schneider MS. Sexual harassment of female doctors by patients.N Engl J Med. 1993;329(26):1936-1939.
  7. Ladson D, Welton R. Recognizing and managing erotic and eroticized transferences. Gillig PM, ed. Psychiatry (Edgmont). 2007;4(4):47-50.
  8. Freud S. Observations on transference-love : further recommendations on the technique of psycho-analysis III. J Psychother Practice Res.1993;2(2):171-180.
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