This summer, a child psychiatrist colleague told me that he had been thinking a lot about love lately. We got talking about how having love toward our patients feels like an essential ingredient to our work. We agreed that we always seem to find our way to feelings of love toward the people we work with, and that this seems like an essential part of the healing process. We also agreed that bringing the self-love we strive for to our clinical work was an important aspect of our ability to help others. We wondered to what extent our colleagues would agree with this; it isn’t something either of us have heard many clinicians talk about. So we sent out an anonymous survey to 150 doctors, nurse practitioners, and mental health professionals — over half of them on Martha’s Vineyard. We received 60 responses from 16 nonpsychiatrist M.D.s or nurse practitioners, 15 psychiatrists, and 29 other mental health professionals.
Everyone said that love had at least some role in their clinical work, although we speculate that some among those who chose not to respond to the survey might feel differently. But of the respondents, 76 percent thought that love in their work was very important or essential. Ninety-five percent said that the love that they brought to clinical interactions was somewhat important to essential to their patients’ healing, and 90 percent felt that it was somewhat important to essential to their own professional well-being. In addition, 97 percent felt that their own self-love was either somewhat important or essential to their patient’s healing.
The bottom line is that almost all of us feel that that love, however we define it, plays a central role in our work. Yet we don’t seem to feel comfortable acknowledging it. When the study’s respondents were asked about talking about their love for their patients, only 53 percent said that they would feel comfortable talking about it with a trusted colleague, 44 percent would be comfortable talking about it in professional circles, and 33 percent would be comfortable talking about it with their patients themselves.
We sent the survey to Dr. Nancy Donovan, director of geriatric psychiatry at Brigham and Women’s Hospital, whose research has demonstrated that loneliness and social isolation are important risk factors for dementia. She wrote us that she believes love “is the secret sauce in helping our patients.” I called her to ask what she meant, and she helped clarify a definition of love in the healing process. She referenced the Corinthians quote about hope, faith, and love — that “the greatest of these is love.” Her understanding is that the original text was referring to the love of humanity. “In clinical medicine, we bring that to the person in front of us. It is our purpose to care for and love our patients. There is nothing more important than that; feeling deep concern for someone and doing something about it, all in the interest of loving our fellow man, is medicine at its best.” She went on to tell me that there are times when she has mixed feelings for some of her patients. “But something inside of me always wakes up when I see a patient and am aware of what a privilege it is to be connected to them. In that sense the boundaries between us are permeable. In those moments, I feel that there’s a common space between us.” In large studies of aging and in her own research, she told me, “it is becoming increasingly clear that close relationships, relationships that make one feel loved and cared for, have a protective effect against cognitive decline. Feeling love is powerful medicine.”
Another colleague wrote back that he felt that we needed to define “love.” The word love, of course, is understood in many different ways. We chose not to offer a definition for it, and assumed the our respondents would use their own. That being said, we like Bell Hooks’ definition of love as “a combination of care, knowledge, responsibility, respect, trust, and commitment.”
I recently met a vacationing urologist. I asked him whether love for his patients played any role in his work. He told me that it did not. “People come to me for my technical skills. When they have a tumor on their kidney and need me to remove it, love has nothing to do with it.” I read him the Bell Hooks definition of love. He paused, then said, “Well, I suppose that by that definition, I love all of my patients.” As we talked on, he told me that when he acknowledged loving his patients, he felt good. He hoped that the next time he was feeling emotionally challenged by a difficult case, he would remember that he was driven by love. “It will really help me,” he said. Just before we moved on to other subjects, he told me that though he had coverage that day, he had called twice to check on patients. He concluded that if he told himself he was calling only because it was the medical/legal right thing to do, it would put him at higher risk for burnout than if he acknowledged to himself that he was motivated by love. Loving his patients evoked warm and healing feelings in him.
Given Hooks’ definition, it is easy to understand why all of our respondents thought there was some role for love in their work. But why do most of us feel at least somewhat uncomfortable talking about it? Perhaps it is because we are taught in school to keep a professional distance in order to maintain “objectivity.” Or maybe it is because there is something frightening about the intimacy of what Dr. Donovan means when she says she feels common space with her patients — that there are permeable boundaries between them. Perhaps it is because the word love can have a romantic or sexual connotation. Crossing romantic and sexual boundaries with our patients is unacceptable. Perhaps discussing our love for our patients in itself would feel like a boundary crossing, but that seems readily remedied if we are clear that love is not necessarily romantic or sexual, and is neither of those things in the context of professional practice. (Of course healthcare professionals are humans, and may experience feelings of attraction to a patient, but it is their job not to act on these feelings. Perhaps a better understanding of clinical love, which stems from a love of humanity, and more open acknowledgment of its role in healing, might actually help reduce boundary transgressions.)
Many of the people with whom I work have been terribly traumatized by people who supposedly loved them; for such people, love is associated with danger. Clearly, there are times when talking about love with patients would be inadvisable. Yet it is often a critical part of healing to learn to distinguish between supposed love that was actually exploitative and damaging, and love that is Hook’s combination of “care, knowledge, responsibility, respect, trust, and commitment,” and to learn to stand up against the former while knowing that one is deserving of the latter.
I am sure that my patients often intuit my feelings for them, and that is enough. The father of psychotherapy, Sigmund Freud, believed that the therapist should be a blank screen. Freud wrote that the analyst “should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.” But what if a patient asks, Do you love me? I have been trained to avoid such questions with responses like, What would it mean to you if I answered that I did or did not love you? There is certainly a value in exploring that question, but after more than three decades of practicing psychiatry, I have come to believe that there is also often a value in responding to direct questions (depending on the question, who is asking it, and at what point in the treatment) with direct — and honest — answers. Having been through a five-year, four-day-per-week traditional psychoanalysis that taught me a great deal about myself, I have nevertheless come to believe not only that being a blank screen is rarely possible, but also that it can leave patients isolated with the deep-seated feelings of loneliness and helplessness that are vestiges of painful childhoods. Even though we might not talk about it much, healthcare practitioners appear to intuitively know that the blank screen ignores the human connection and love that is so central to healing. Love has a connotation of tenderness, an element of devotion, and perhaps something that is stereotypically gendered as feminine that our culture has communicated professionals are not supposed to feel. And yet most of us, perhaps covertly, believe that it is the “secret sauce.”
Renowned prison psychiatrist, philosopher, and part-time Vineyarder Dr. Jim Gilligan writes, “An operational definition of love would be: the emotion that motivates us to enhance the lives and welfare of those we love.” As it was for 75 percent of the colleagues who responded to the survey, that emotion is also very important or essential to our own professional well-being. While the purpose of the clinical interaction is to help heal our patients, it appears that most of us believe we are better at helping others when we are experiencing love. Experiencing love is an enormous gift to the healer as well as to the patient, and it may be a necessity for practitioners if they are to be protected from burnout.
In a recently submitted book chapter for “The Routledge Handbook of the Philosophy and Practice of Punishment,” Dr. Gilligan writes, “Transcending shame and guilt requires developing the capacity to love both self and others … When people love, they do not need moral commandments in order to treat those they love well. They spontaneously and automatically want to do so … the problem with morality is that it inhibits love. Shame, and shame-driven ethics, inhibit love toward others.” Perhaps that is why the most enlightened healthcare gurus promote nonjudgmental and supportive inquiry when errors are made. And perhaps the reason why there is increasing burnout among healthcare professionals is that there is a drive for shorter visits, more focused on the computer and billing codes than on the human connection and love between healer and patient.
I was discussing this with my 25-year-old daughter, who aspires to be a psychologist. She thought that it is more acceptable to express and talk about love in her generation. She speculated that in a world in which there is so much cruel, authoritarian, and hateful behavior, there is a natural backlash in which it is increasingly imperative to experience and express love. She suggested that this is why I am writing this column at this particular time in history. Whatever the reason, as it was for the visiting urologist, I find that thinking about and acknowledging love is a powerful, healing salve for the soul.
Dr. Charles Silberstein is a psychiatrist at Martha’s Vineyard Hospital and Island Counseling Center, where he is the medical director. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.