Countertransference in Physician-Assisted Suicide: A Hypothesis

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COMMENTARY

“Above all, I must not play at God.” – from Louis Lasagna’s 1964 version of the Hippocratic Oath, the most commonly used version in medical schools today

A 29-year-old woman named Zoraya ter Beek was recently euthanized in the Netherlands. Ter Beek, who was diagnosed with borderline personality disorder,¹ among other things, had a history of chronic suicidality and self-injurious behavior. When she realized that her relationship with her new partner was not going to save her from her suffering, she sought physician-assisted suicide (PAS), which has been legal in the Netherlands since 2001.

The ter Beek case raises important questions around PAS of psychiatric patients, including, in our view, the role of the physician’s countertransference in the PAS situation. While much has been written about countertransference in psychotherapy and psychiatric treatment more generally, relatively little attention has been paid to its relevance to PAS. Here, we briefly offer some preliminary ideas on countertransference in PAS, including in particular the role of projective identification—a particularly perilous countertransference reaction.

What Is Projective Identification?

Freud initially defined countertransference quite narrowly as the analyst’s transference to the patient, that is, feelings belonging to the analyst’s past that were displaced onto the patient in the same way that the patient displaced feelings from their past onto the analyst. Later adaptations to the concept of countertransference construed it more broadly, such that all feelings related to the patient experienced by the therapist are counted as countertransference. This shift led to great interest in the notion of projective identification, introduced by Klein,² in which the analyst comes to identify with the patient’s projection.

In projective identification—a hallmark defense in borderline disorders—the patient unconsciously induces the object to assume the role of what has been projected, in the actual interaction between the patient and the recipient. For instance, a patient may project their own hostility onto the therapist who then begins to treat the patient in a hostile manner, unconsciously replaying an earlier theme in the patient’s life. As Gabbard explains, “These changes [in the therapist] are effected largely through powerfully coercive interpersonal pressure exerted by the patient.”³

In the words of Laing, in projective identification “the one person does not use the other merely as a hook to hang projections on. He or she strives to find in the other, or to induce the other to become, the very embodiment of projection” [emphasis added].⁴

The following vignette from hospital practice may help elucidate the concept of projective identification:

A patient insists to inpatient staff, day after day, “You all hate me and want to kick me off the unit!” The more staff denies this (“No, no—we want to help you!”), the more insistent the patient becomes, repeating the same charge over and over. Soon enough—after about a week or so—many staff members do wind up feeling hatred towards the patient and advocate kicking her off the unit. The patient, entirely blind to what has occurred, proclaims, “I knew it! I told you so!”

Projective Identification and PAS

How does all of this relate to PAS? We believe that there is a risk—indeed, a real danger—that in at least some cases of PAS, projective identification plays a central role in the physician’s evaluation and decision-making. In considering the issue of PAS, we must ask ourselves what happens in between the patient’s request to die and the physician’s granting of such a request. In our view, much of this process occurs outside of the awareness of both patient and doctor. That is, it is motivated by unconscious mental forces.

For example: Why would patients who could easily take their own lives by various means want to involve physicians in that process? Leaving aside those who may be physically infirm and unable to do so, we hypothesize that the rest may derive some psychological gratification by involving a caregiver or authority in their suicide.

With respect to the physician, we hypothesize that in at least some cases of PAS—especially those complicated by the patient’s personality pathology or traits—the physician unconsciously identifies with the patient’s hostility and self-destructiveness and subsequently assumes the role of aggressor. That is, the physician is unconsciously induced by the patient to play out the patient’s projected aggression and self-destruction. If the physician does not come to understand this phenomenon, the result may be the termination of the patient’s life.

The psychodynamics of projective identification are complex, and there is disagreement among psychoanalysts as to the specific dynamic mechanisms involved. One hypothesis, advanced by Kernberg,⁵ is that the patient is motivated primarily by a need for control. In projective identification, victim and victimizer are reversed, and the patient can be relieved from internal conflict by placing it in and behaviorally inducing it in the other.

Certainly, projective identification is only one countertransferential reaction relevant to PAS, but we believe it is an important and understudied one. Other countertransference issues include feelings of guilt or helplessness over the patient’s medical situation; exhaustion; and frustration, anger, or even hatred towards the patient. As Gabbard notes, “Decisions made by medical professionals, including psychiatrists, can never be entirely free of what we would broadly call countertransference issues.”⁶

Regarding feelings of helplessness, in particular, Stef Groenewoud, a health ethicist at the Theological University of Kampen in the Netherlands, says, “I’m seeing euthanasia as some sort of acceptable option brought to the table by physicians, by psychiatrists, when previously it was the ultimate last resort. … I see the phenomenon especially in people with psychiatric diseases, and especially young people with psychiatric disorders, where the healthcare professional seems to give up on them more easily than before” [emphasis added].¹ Undoubtedly, the psychodynamic mechanisms at play in PAS are complex, powerful, and all-too-often unrecognized.

Need for Further Study

The physician’s countertransference to the patient—and, in particular, the defense mechanism of projective identification—remain somewhat elusive and poorly understood concepts, even among experienced psychotherapists. Physicians involved in the evaluation of PAS patients may be even less knowledgeable of these complicated psychodynamic processes. We already have data showing that some physicians involved in PAS may find the experience emotionally disturbing.⁷ Given the moral, legal, and clinical significance of PAS, we believe there is a need for research on the experience of countertransference in the PAS situation.

One such method of investigation could be a survey of PAS-facilitating physicians to shed light on their countertransference reactions, eg, a question that asks, “To the best of your recollection, do you recall feelings of anger, hostility, or helplessness in the weeks or days leading up to your prescribing the lethal drugs for your patient?” Other questions could aim at uncovering the patient’s potential borderline dynamics.

In sum, we believe that any comprehensive understanding of the PAS situation must include an examination of the powerful psychodynamics at play between patient and doctor, including the experience of countertransference and projective identification. We ignore these things at our own—and our patients’—peril.

Acknowledgments: We would like to thank Drs. Mark Komrad and Cindy Geppert for their helpful comments on countertransference that informed the preparation of this manuscript.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. Dr Pies is a professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York; a clinical professor of psychiatry emeritus at Tufts University School of Medicine in Boston, Massachusetts; and editor in chief emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.

References

1. Tudela J, Aznar P. A young Dutch woman with autism will receive euthanasia due to depression. Bioethics Observatory—Institute of Life Sciences. April 18, 2024. Accessed June 20, 2024. https://bioethicsobservatory.org/2024/04/a-young-dutch-woman-with-autism-will-receive-euthanasia-due-to-depression/46248/

2. Klein M. Notes on some schizoid mechanisms. J Psychother Pract Res. 1996;5(2):160-179.

3. Gabbard GO. An overview of countertransference with borderline patients. J Psychother Pract Res. 1993;2(1):7-18.

4. Laing RD. Self and Others. Penguin; 1969.

5. Kernberg OF, Selzer MA, Koenigsberg HW, et al. Psychodynamic Psychotherapy of Borderline Patients. Basic Books; 1989.

6. Gabbard GO, ed. Countertransference Issues in Psychiatric Treatment. American Psychiatric Publishing; 1999.

7. Pies RW. How does assisting with suicide affect physicians? The Conversation. January 7, 2018. Accessed June 20, 2024. https://theconversation.com/how-does-assisting-with-suicide-affect-physicians-87570