The role of countertransference in assisted suicide deaths.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Drs. Mark Ruffalo (right) and Ronald Pies have written an hypothesis concerning the role of countertransference with relation to assisted suicide deaths that was published by the Psychiatric Times on June 21, 2024.

This article is based on a hypothesis, but I found it to have significant merit, especially in relation to the approval of euthanasia or assisted suicide for people with psychiatric issues.

Zoraya Ter Beek

The article begins by referring to the case of Zoraya Ter Beek (29) who recently died by euthanasia in the Netherlands, The authors write:

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.

Dr Ronald Pies

The authors then explain, with clinical terms, what they mean by countertransference or what is known as projective identification. They provide this example:

"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!”

They then explain how this may relate to euthanasia and assisted suicide:

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 authors provide more proof that their hypothesis is correct and they state that further research is necessary. The authors conclude:

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.

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.

Acknowledgments: They thanked Drs. Mark Komrad and Cindy Geppert for their helpful comments on countertransference that informed the preparation of this manuscript.