A Patient Flirts in Therapy

When a patient starts to flirt with me, I think, "here we go."

I know it is flirting when the person who is persistently depressed starts to laugh more in sessions and may slip in a dirty joke or two. I can tell the person is flirting when they casually use my first name rather than calling me Dr. Chan. But mainly, I know it is flirting by the energy the patient is bringing. There is a charge, and a direction to that charge. I know I am the target, I am the only other person in the room.

I also know I am being flirted with because of the reaction within myself I have been trained to pick up on and then to analyze. I feel more choked up and I am more aware of my heart beat. I feel seen and I feel good. I will notice myself laughing and smiling more. Unconsciously I will play with my hair and there is an untick in my positivity that lasts for the rest of the day.

I also know I am being flirted with because an alarm bell rings. BOUNDARY CROSSING ALERT is what it is saying. DO NOT GIVE THIS PATIENT EXTRA TIME, DO NOT TREAT THIS PATIENT ANY DIFFERENTLY THAN YOUR OTHER PATIENTS. So I also go into a mode of hypervigilance. And it is not without reason. Therapists and psychiatrists are repeatedly been found with their pants down (quite literally) and sexual transgressions are a common reason of disciplinary action. On one occasion, I found myself having the urge to buy a coffee before seeing a particularly flirty patient. I imagined how sipping on a coffee while we were talking would just feel so relaxed and it made me smile. I found myself anticipating a kind of pleasure which my hypervigilance picked up and I immediately left the lineup at the coffee shop and returned to the office empty handed, but full of embarrassment. What a close call, I remembered thinking. I almost unconsciously fulfilled my fantasy of having a coffee date with this patient when I never drink coffee in any of my other appointments.

And so it is the task of the therapist to receive the flirting and to be curious what it might be telling me about the patient in the moment. It is the responsibility of the therapist to not act on it. Because when a patient flirts with me, it is NOT me, Sarah Chan the flawed and complete human being that the patient is feeling attraction for, but the therapist who they see for 1 hour every 2-4 weeks and whoever that person represents to them. The very interesting thing about the therapeutic relationship is that the patient both knows and does not know the therapist at the same time.

As a therapist, when a patient is flirting with me, I am literally writing the words, "HE IS FLIRTING" on a blackboard in my mind. I then take a step back and listen. I admit it can be hard, because my body naturally reacts to being an object of desire. I have to keep my thoughts clinical while my face goes flush, there is a pounding in my ears and my throat goes dry. Sometimes a patient flirting will tell me that he is having a good day, because flirting if anything, is an act of optimism. Sometimes it tells me that the patient needs to humanize me, that perhaps she is intimidated by the one-sidedness of the patient-therapist relationship. Other times it is a leveling of the field, rather than being the one always under the gaze and scrutiny of the therapist, the patient would like to trade places. At times it is a testing of the rules, by flirting the patient is telling me he is wanting to be playful, wanting a bit of fun.

So flirting is neither bad or good, but a very predictable and common experience in therapy. If a therapist is unaware or poorly trained, boundary crossings into unprofessionalism happen. This is why ongoing supervision and therapy for the therapist is so important. Therapists themselves need to feel comfortable with and aware of their own sexuality and attitudes in personal, intimate relationships. Therapists need to know their own feelings and needs and be monitoring them so that they can remain neutral and completely focused on being helpful to the patient, no matter the reaction the patient brings out in the therapist.

In fact, this is how I approach all feelings and sensations that come up in sessions: 1) a feeling emerges, 2) I sense and label the feeling, 3) I understand why I am having the feeling , 4) I understand what my having this feeling tells me about the patient 5) I formulate what to say so that this feeling is helpful to the patient in some way. 6) All the while abiding by the cardinal rule: Do not act out on the feeling.

This may sound confusing or difficult. Being a good therapist is both of these things a lot of the time. But we are used to dealing with a vast array of human experiences from celebrating what is sweet in life to processing what is bitter. Flirting is one of those feelings that brings in some spice.