(The male gender for the doctor and female for the patient has been chosen only for convenience and simplicity. No misandry or misogyny is intended.None of the characters are based on real people. Any resemblance is a coincidence.)

Masoom, a 26 year old divorcee, college teacher of philosophy consulted Dr. Tejas, a psychiatrist for depression. Masoom has just come out of a 6 month long love marriage. Her husband had financially and sexually abused her. Dr. Tejas listened to her with empathy, probed gently and helped her to understand what happened. He offered her an antidepressant to which she agreed.

Over the next few follow-ups, she started feeling better. Dr. Tejas helped her make sense of the turmoil she was going through and suggested ways to integrate the experience and grow deeper. She would WhatsApp him about any doubts of any side effects and he would allay her fears. Masoom improved dramatically and Dr. Tejas was pleased with himself with his own expertise. Lately, the sessions consisted of a fair amount of pleasant talk. Masoom began sending him inspirational forwards on WhatsApp and they would often discuss the wisdom in these forwards during the consultations. Masoom would occasionally send him humorous material to which Dr. Tejas would respond with laughing emoticons. Once, in a while he also received jokes of an adult nature. Dr. Tejas would feel a sense of discomfort at getting such jokes from a female patient. However, he did not discourage them nor did he apply his mind to this behaviour. Masoom, also, got a wrist watch for him but Dr. Tejas refused saying that he was adequately compensated by the fees she paid. He was pleased at her gesture but did not dwell on it.

One night, he got up to visit the washroom. He checked his WhatsApp as he prepared to go back to sleep. Masoom had written, “I think I am falling in love with you“. At first, it did not register. A moment later, Dr. Tejas was wide awake.

Dr. Tejas was flabbergasted. He did not know how to respond.

He met his mentor Prof. George in the morning after a sleepless night. Prof. George was the Head of Department at the institution where he had studied. Prof. George let him ventilate his anxieties, his confusion. As he ventilated, Dr. Tejas’s bewilderment decreased and they were able to discuss the issue with Dr. Tejas in a more settled frame of mind. Now and then, Dr. Tejas would go into a spasm of anxiety and catastrophising but Prof. George would gently lead him back to rationality.

Prof. George explained there were three aspects to go into – the patient, the potential medicolegal concerns and Dr. Tejas himself.

Transference is a phenomenon which can occur in any relationship, not just a doctor-patient relationship.
Transference occurs when we project significant people from the past onto people in the present, and then expect them to behave in that way which is inappropriate to the current situation. For example, you meet someone at a social gathering who reminds you of a disliked uncle and you feel guarded towards him and expect him to behave like your sour uncle. All this could happen outside your conscious awareness.

Here, the patient was in a vulnerable frame of mind. She felt grateful to Dr. Tejas who to her contrasted completely with her seemingly brute of an ex-husband.

Many a patient finds they are being listened to for the first time without any judgement. Privileged communication is revealed. The doctor empathises with them. He helps relieves their distress. He steers them towards well being. He can seem to some patients almost like a magical figure, an omnipotent person and an occasional patient may see him as the Mr. Right, which they never had.

It is not surprising that the patient imagines she is in love with him and theirs union will be one of eternal bliss. This defence mechanism is known as idealisation where the person views the object of love through rosy glasses. No human frailty on part of the idealised is acknowledged or well, they just seem cute.

The patient is in love with an illusion, the fantasy that has been built up from the limited time spent in the clinical context with the doctor.

Idealisation is often followed rapidly by devaluation as the relationship continues. Here, the person is now seen as ‘all black’ as against the ‘all white’ previously. The patient is shattered, feels cheated and deceived by someone to whom she had bared her heart to.

Doctors have little training in such delicate matters and almost, no forewarning as they start practice.  Dr. Tejas, himself as a psychiatry resident, found that under a super busy workload of severely ill patients requiring rapid relief with biological therapies, counselling input often got the short drift.

Mistaking idealisation for love can, of course, happen between any two human beings. The outcome can be ill fated.

Dr. Tejas recognised what had happened during the therapeutic process. He had read about it in theory but now was experiencing it for the first time in his practice.

Then, Prof. George proceeded to analyse the medicolegal angle.

Dr. Tejas was insistent that Masoom was a genuine case with no fraudulent, ulterior motives and unlikely to litigate but Prof. George gently chided him that there was no harm in checking. A broken heart can find cause, real or imagined for umbrage. Like anger at fate, shock and guilt at the sudden death of a near one can displace as rage at the treating doctor. The unconscious can work in mysterious ways.

Beginning with the basics, he asked Dr. Tejas if he has been regularly paying for his medical indemnity and if it was of an adequate cover for today’s times. Dr. Tejas had been maintaining a copy of his detailed clinical notes. He did check her ankle once at her request for what seemed a mild sprain and had prescribed an analgesic ointment. He rebuked himself for not having a female chaperone present. He resolved from now on to always have a female chaperone and also, a female relative, if possible, if he did any physical examination of a female patient. He wondered if it would be paranoid behaviour to make the chaperones sign on his notes as well besides documenting their names. But he was quickly resigning to being safe than sorry after all that he was reading in the papers.

An ugly outcome scenario would be the patient litigating and going to the press. Here, the doctor is on an unequal footing. The patient can speak without restriction to the press whereas the doctor cannot give his version due to his duty of confidentiality to the patient. Regarding the litigation, Dr. Tejas seemed likely to be acquitted. He would just have to grit his teeth and bear the toll of the arduous litigation process.

The worst case scenario would be Masoom becoming suicidal. But Dr. Tejas said that even during the worst of her depression, she had been quite level headed and strong. She had never entertained suicide as an option which went against her religion which Dr. Tejas had mentioned in his notes during the first consultation.

The most important and ethical issue for Prof. George, which he straightforwardly brought up was whether had Dr. Tejas led her on. Consciously or unconsciously.

Dr. Tejas took some minutes to introspect on this. He had spent more time with her than he would have with other patients. He would look forward to her visits but the visits fell short of seeming like a date which his books had informed him often happens during such transference and counter transference. On his side, at least. But he noted wryly that these consultations were not as routine as his other consultations. He had especially enjoyed listening to her even as she chatted about issues irrelevant to her illness. He had lapped up the admiration and gratitude when she gushed about how lucky she was to have found such a nice doctor. He did not put it in perspective that he did what any doctor does and he was only a facilitator in her journey to better health. He winced now as he regretted their interaction on WhatsApp. But he was clear in his mind that he had not sent back anything except laughing emoticons. He was so glad he had not responded to the adult jokes. As he recollected her journey from the anguished person who first visited him to the gushing girl who sent him adult jokes, he realised that he had not been alert and missed to pick up the signs.

Experience is the best teacher, Prof. George simply said, as he waited for Dr. Tejas to emerge from his self admonishment.

Prof. George also asked Dr. Tejas to think about his companionship needs and whether he was trying to meet them inappropriately through his patients without realising it. Dr. Tejas got the point and now he knew enough to raise his antenna instead of being flattered when a patient seemed too happy with him.  About his companionship needs, this was something he had to delve into at length.

Counter transference is the response that is elicited in the doctor by the patient’s unconscious transference communications. Prof. George was convinced that there was no significant counter transference on Dr. Tejas’s part. He had been oblivious to the developing idealisation but did not actively foster it.

Finally, they pondered on how to manage the situation. The whole sequence of events was unfortunate. Masoom had fallen in love with the illusion she had built of Dr. Tejas. This had to be stopped and corrected before the situation spirals. She will have to be counselled. She will go through a period of mourning for the loss of her fantasy. Her depression can relapse and this will have to be managed. Prof. George observed that it might be worth considering for the patient from now on to be seeing a female psychiatrist until her issues are resolved but then often the patient see it as a slight. And that is the last thing she needed.

As he left, Dr. Tejas noted that the veteran Prof. George kept a family photograph in his consulting room displayed prominently.

Accordingly, Dr. Tejas met the referring GP, Dr. (Mrs.) Kale, a senior and respected figure who knew Masoom’s family well. (He was glad there was a GP involved). He had earlier told his receptionist to phone Masoom to meet him in the evening during his clinic timings. He had cancelled his other appointments for the day making sure that time will not be a constraint.

Masoom’s face fell when she saw the Dr. (Mrs.) Kale sitting next to Dr. Tejas. Dr. (Mrs.) Kale kindly reassured that she had known her since Masoom was a toddler and she was there to help her. Both she and Dr. Tejas had her best interests at heart.

It went better than expected. Masoom did not fell into any violent display of emotions. She seemed to understand what they both explained had happened in the therapeutic relationship. It sank in slowly but with sensitive, calm and repeated explanations it did. She cried softly for a brief while. More out of sadness at the vagaries of life than rage at feeling betrayed.

Dr. Tejas apologised for the way the whole thing had gone. He admitted that his behaviour blurred the boundaries between the relationship of a professional and a friend. These sent out unintentional wrong signals which he again apologised for. He should have anticipated that such behaviour could have been misconstrued by someone in her susceptible condition. He emphasised that he respected her as a person. He was glad that she saw see things in perspective now that they had explained how the mind can play tricks and distort the perception of reality to suit itself.

He explained delicately that it would not be in her best interest for him to continue seeing her as her doctor. Dr. Tejas admitted that neither did he have the training nor experience to guide her out of the idealisation psychodynamics. Dr. (Mrs.) Kale offered to refer her to another psychiatrist, this time of a psychodynamic orientation which would be more suited to Masoom’s condition, as and when she felt ready. Dr. Tejas would, of course, pass on all the required information to the treating psychiatrist if Masoom was ok with it. Meanwhile, it would be wise for them not to have any contact. Dr. Tejas had already blocked their WhatsApp contact. He wished her well for the future as he expressed regret for the unfortunate ways things had worked out. Eventually with the right help, this episode can help her unravel and resolve some unconscious issues. He hoped they part with mutual respect.

Dr. (Mrs.) Kale reinforced that she was happy to have Masoom under her wing until she began to see another psychiatrist. Masoom was obviously crestfallen but she seemed to have taken it well. Maybe, she had been prepared having realised that the WhatsApp channel of contact had been blocked and when the receptionist called her for the meeting. Both the doctors had been delicate in their approach making sure that she felt no sense of shame or humiliation.

Dr. (Mrs.) Kale would make sure to check on her regularly over the next few weeks. Though Masoom seemed composed now, more extent of disturbance could emerge as days went by.

The meeting lasted for an hour and a half. After Masoom left, they both documented the session.

Dr. Tejas reported to Prof. George the next day as to how the consultation went. Prof. George felt that there were many variables and nobody could predict the future. However, one can take a bit of solace in the hope that the whole episode could work as a corrective emotional experience for the patient that all men are not exploitative like her ex-husband. Some people at least can be counted to only do what is in her best interest.

That night, Dr. Tejas fell into a state of reverie. Policemen, politicians were not even seen as being in the helping profession. Doctors had always been held to more exacting standards by society.

He was in no delusion about the grief Masoom may go through. He blamed himself though the behaviour had been unwitting on his side. Unwitting or not, he was the one with the supposed expertise. Physician, first do no harm, he chastised himself. He then caught himself and reminded that he always advocated and practised compassion with his patients. He had to be compassionate with himself now without letting the lessons go. The art of medicine could be as complex as life itself. One can never stop learning. It was a privilege to be in a helping profession and he intended to live upto it.

He thanked his stars for the resilience Masoom had shown. He sent a silent prayer for her well being. He soon turned over to sleep. Tomorrow was another day.

The above is a relatively clean scenario. It is not ambitious in scope or the range of complications that can arise when a patient falls in ‘love’ with the doctor. One can call it a Hum Apke Hain Kaun setting where an incident happens and everybody behaves more or less ideally. Reality would indeed be much more trickier.

The illustration above is just an attempt to remind doctors of these particular psychodynamics with a patient creeping in unawares as they go about their daily work helping people get healthier.

Else, the repercussions can be disastrous for the doctor and disastrous for the patient.