Recognition and Management of the Overly Affectionate Patient Barry L. Hainer, MD Charleston, South Carolina Physicians should be aware that patients who offer excessive admiration, signs of affection, and flattery are exhibiting a form of seductive behavior. To understand and manage this behavior, the physician must recognize his or her susceptibil­ ity to the feelings of omnipotence it engenders. Setting realistic expectations, challenging these patients to be less dependent upon the physician, and recognizing the need for referral in certain situations is necessary in managing such patients. A mature physician strives toward developing self-reliance and independence in patients. Difficult patients have been defined as those stimulate a sense of self-importance in their who in some manner upset their physician.1 Ex­ physicians. Later these patients may exhaust their cessively affectionate and adoring patients are dif­ physician’s ability to cope with them. The early ficult without being upsetting. Characteristically sense of omnipotence is then replaced by feelings these patients offer physicians undue amounts of of weariness and aversion. praise, compliments, and gifts. Such behavior is seduction by flattery. Although this may be less Case Report threatening to a physician than other forms of se­ ductive behavior, seduction by flattery can de­ Mrs. W. is an 83-year-old white woman, di­ velop insidiously and be difficult to manage. Levin vorced since 1942 with two living children, currently has noted that “physicians are vulnerable in vary­ living by herself. I first encountered Mrs. W. dur­ ing degrees to different types of seduction. Some ing residency training and saw her from 1977 through may find erotic seduction not particularly trou­ 1979 on nine occasions for a variety of problems: blesome, but are hard put to cope with the patient osteoarthritis, mild depression, complaints of diz­ who plays upon their wish to be omnipotent, ziness, and treatment of a basal cell carcinoma of famous, admired or loveable.” 2 the nose, as well as for routine health mainte­ Overly affectionate patients are a subtype of a nance. Mrs. W.’s affection for me grew with each group that Groves has referred to as “ dependent visit. Gifts of food and compliments about my dingers.”3 Their need for explanation, affection, great fund of knowledge, my handsome appearance, medication, and other forms of attention exceed and my ward manner were increasingly offered. good medical care and often the tolerance of many As many elderly patients do, Mrs. W. sought physicians. Early interactions with such patients physical contact. She grasped my hand, embraced me, and kissed me on the cheek. As visits pro­ gressed, she even declared her love for me. These From the Department of Family Medicine, Medical Univer­ efforts at physical contact were either ambiva­ sity of South Carolina, Charleston, South Carolina. Re­ quests for reprints should be addressed to Dr. Barry L. lently supported or ineffectually resisted. Consulting Hainer, Department of Family Medicine, Medical University physicians often made remarks about her worship­ of South Carolina, 171 Ashley Avenue, Charleston, SC 29425. ful attitude toward me. As many of my needs were 0094-3509/82 !47-03$00.75 1982 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1: 47-49, 1982 47 THE OVERL Y AFFECTION A TE PA T/ENT being met by this relationship, I took such com­ Discussion ments by my colleagues good naturedly. In August 1978, a Pap smear taken during a Overly affectionate patients usually have an un­ routine health maintenance visit revealed moder­ conscious need for control or recognition.4 They ate cervical dysplasia. Gynecologic consultation attempt to control the patient-physician interac­ led to a cervical biopsy. Examination under anes­ tion by playing upon the physician’s wishes to be thesia revealed a stage IIB carcinoma of the ovary. admired. The susceptible physician often feels After uneventful recovery from surgery, Mrs. W. guilty when he or she is unable to meet such pa­ received 12 months of chemotherapy, which she tients’ needs or demands. Recognition of these tolerated well. The patient was convinced that I feelings and their origin may help the physician had “ saved her from cancer.” When Mrs. W. said appreciate the weakly disguised feelings of loneli­ her gynecologist was annoyed that she gave most ness, depression, or even hostility often found in of the credit for her recovery to me, I felt a mix­ these patients.5 When the needs of overly affec­ ture of chagrin, embarassment, and enjoyment. tionate patients go unmet or unrecognized, anger, Despite her poor vision and limited income, aggression, and rejection can quickly replace hero Mrs. W. continued to contact me after I entered worship, flattery, and affection.6 into private practice in another state. She wrote Physicians may label as difficult those patients frequent letters and made occasional long distance who fail to respond to therapeutic efforts. It is telephone calls to my home. According to Mrs. clear there are certain features of physicians that W., it was nothing short of an “ act of God” that I may contribute to these difficulties.7 A physician’s later returned to my residency program as a faculty encouragement of overly affectionate behavior member. At the request of Mrs. W. and her new may be as unconscious as a patient’s motivations physician, I again became her family physician. for exhibiting this type of behavior. All physicians A presentation of my relationship with Mrs. W., derive some satisfaction from patient encounters was the subject of a departmental Grand Rounds. because they meet to some degree the “need to be Through the preparation and presentation of this needed.” It is acceptable for a physician to wish conference, I gained new insights into my relation­ that patients develop confidence in him, but it is ship with Mrs. W. Further awareness resulted unacceptable for the physician to wish that pa­ from self-reflection, reading, and especially the tients see him as all-powerful. Curry reminds us, comments of my colleagues. “If one has omnipotent feelings he should reflect On subsequent visits I listened to Mrs. W. and upon the rapidity with which patients find other reassured her that I was as available to patients medical services when a physician leaves the who did not bring gifts as to those who did. She community or dies.”8 continued to bring gifts, but not so often. When It is true that physicians are most successful she telephoned me at home, I told her I would with patients who admire them. When a physician accept calls at home only if she felt her problem to receives an exaggerated compliment, there is be a true emergency. I explained that I needed probably no harm in accepting it with reserva­ private time, away from patient responsibility. Af­ tions, but it should not be swallowed whole. terward she rarely called except when lonely and Surely part of the credit belongs to someone else emotionally upset. and has been offered to the physician through dis­ I told Mrs. W. that I was not doing a very good placement.9 job if she felt she could not get along without me. I Patients often transfer some part of their own told her my goal was for her to be able to function past experience with powerful figures to their re­ well without having to depend on me. I think she lationships with their physicians. Transference is a believed me. I felt better about our relationship as two-way street. Both patient and physician bring a result of these changes. An office visit every six displaced feelings, passions, and attitudes from to eight weeks seemed sufficient to provide the former emotional attachments into their relation­ recognition and contact Mrs. W. needed during ships. The identification and exploration of these this lonely, frightening period of her life. I was transferred feelings has become the basis of many careful to reschedule visits independent of flatter­ forms of psychotherapy. In family medicine these ing praise or gift giving. phenomena are rarely explored formally, but 48 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982 THE OVERL Y AFFECTION A TE PA TIENT much frustration can be avoided when it is recog­ flattering remarks and may help to reduce rein­ nized that they are taking place. forcement of this behavior. Finally, if the physician’s feelings, whether positive or negative, are interfering with his ability to serve the patient optimally, it is time to consider consultation or referral to a trusted colleague. Recognition and Management Seduction by flattery must be recognized for what it is as it is occurring. The physician should be alert to feelings of omnipotence and a desire for self-importance. Acknowledging these feelings Conclusion will help the physician to understand why certain It is important for the family physician to rec­ patients are special for him or her and others are ognize and correctly manage the seductive behav­ not.10 This self-awareness will also help alert the ior of overly affectionate patients. An awareness physician to overly affectionate behavior and his that excessive flattery and guilt engendering be­ or her vulnerability to such behavior. havior are forms of seductive behavior is essential. When a physician leaves a patient encounter The physician needs to recognize a susceptibility and feels the patient has been let down, he should to feelings of omnipotence and a vulnerability to consider that he may be encountering overly af­ seduction by flattery. Clarification, challenge fectionate behavior in a seductive patient. This techniques, limit setting, and consultation can be physician should examine his guilt feelings to see if used in dealing with overly affectionate behavior.