Countertransference Reactions to a Suicidal Patient

Physicians strive to prevent death and increase quality of life. Suicide goes against these teachings and to a psychiatrist is often thought to stem from mental illness. Suicide is prevented, often by restrictive means, whether it is hospitalization or physical restraints. When a patient wishes to choose death over life, it can invoke feelings of helplessness in the physician and call into question who is responsible for a person's life (1). Suicidal patients may elicit in a physician feelings of anxiety, pain, grief, and aggression, to name a few (2). Paradoxical combinations of hopefulness and distress with avoidance may occur when treating a suicidal patient (3).

In the treatment of suicidal patients, countertransference hate can be experienced. Countertransference can be broadly understood as past emotional reactions of the provider projected onto the present situation. Countertransference hate, as proposed by D.W. Winnicott, is a normal and understandable reaction of hate toward the patient's personality and behaviors (4). Countertransference hate, a mixture of aversion and malice, may be unconscious and further impedes the therapeutic alliance (5). The countertransference reactions may go unchecked and remain unconscious, interfering with patient care through the acting out of unresolved conflicts (6). D.W. Winnicott first described countertransference hate and cautioned physicians against ignoring the reaction. If countertransference hate is left unconscious, the therapy may adapt to the needs of the therapist, rather than the needs of the patient (4).

In treating patients with chronic suicidality, there has been a shift from psychotherapies that prioritize resolving unconscious conflicts in the therapist and patient to psychotherapy that focuses on helping the patient reduce dangerous and treatment-interfering behaviors. An example of this shift would be the dialectic-behavioral therapy approach. This approach focuses on group therapy to teach coping skills behaviorally in order to reduce suicidality and self-injury. It also utilizes individual work to simultaneously address goals (7). By focusing on a patient's behavior, the treatment benefit is ideally a reduction in dangerous behaviors.

In approaching a suicidal patient, treatment modalities may differ based upon patient presentation, as well as comfort and knowledge of the provider. The following case illustrates the issue of countertransference reactions with suicidal patients.

Case

“Mr. B,” a mixed-race man in his early 20s, was admitted to an inpatient psychiatric ward for suicidal thoughts. His psychiatric diagnosis remained unclear. The differential diagnosis included adjustment disorder with mixed disturbance of emotions and conduct, mild intellectual disability, and attention deficit hyperactivity disorder. He had been expressing intermittent suicidal thoughts throughout his hospitalization and was placed on correspondingly increased levels of supervision to ensure his safety.

As his resident physician, I went to speak with him one morning; he endorsed having suicidal thoughts and exploring ways to attempt suicide on the inpatient ward. When I asked him if he could keep himself safe on the ward, he began stating ideas of how to harm himself in the hospital. He repeatedly said that he just wanted to be dead and could not see any other solution to his current distress. He stopped speaking and refused to move when I asked him to walk to the nursing station to have someone stay with him. I asked for “line of sight” supervision and urged him to continue processing his emotions while I attended a meeting.

Soon after leaving for the meeting, I was called by nursing staff. The patient was actively trying to tie his bed sheet around his neck. Suddenly, there were swarms of staff piling into his room, as he writhed around grasping for anything he could reach. He continued grabbing for items to hold over his face. Four-point restraints were ordered and quickly applied. While he was restrained, he pleaded repeatedly, “Why won't you just let me die?” He received intramuscular medications for agitation, and I left the room as he dozed off. I felt rattled and uneasy, unable to push the pleading for death from my mind.

Discussion

My immediate decision to attend to my administrative duties, thus avoiding my patient, illustrates a level of countertransference hate. Perhaps it was the difficulty formulating a diagnosis, or perhaps I was turning the countertransference hate toward myself, leading to hopelessness (5). A question I struggled with was, “Who was I to decide that his life, or anyone's life, is worth living?” I felt helpless and uncomfortable. I felt like a fraud; I was supposed to be helping his suffering, but I was so confused by his repeated presentations, and did not feel like I had helped him make any improvement. I knew that depression was evident and clouding his ability to rationally discuss death. But, why couldn't I let him die? I had the patient restrained to prevent self-harm that could not be maintained less restrictively. But, could I relate and feel connected to his suffering?

My avoidance of this patient at his height of distress, through asking nursing staff to attend to him, is apparent. Although I initially had unconscious feelings of countertransference hate, it has been suggested that this countertransference can be managed through self-insight, self-integration, anxiety management, empathy, and improving skills in conceptualization (6). Other young physicians have experienced the need for relatedness, feeling that they had intervened completely, and being emotionally involved when treating suicidal patients (2). Five defenses have been described as preventing full countertransference awareness: repression of countertransference hate, countertransference hatred turned against the self, reaction formation, projection, distortion, and denial of reality for validation (5).

Without introspection into my reaction toward a suicidal patient, I may still be harboring unconscious countertransference hate, avoiding this patient, or unable to recognize the patient's withdrawal during crisis. Some level of consciousness was attained, helping to recognize the motivations behind behaviors exhibited by the patient.

Conclusions

The present case illustrated the importance of gaining awareness of countertransference reactions toward patients. When treating suicidal patients, physicians are sensitive to not only the patient's distress, but are also conscious of possible critiques or comments of their treatment and the fear of a bad outcome. With suicidal patients, physicians fear making mistakes, stress over uncertainties, and harbor concern for their reputation (2). Physicians are prone to confuse the limitation of professional ability to heal with a sense of personal worth because the nature of psychotherapy utilizes a physician's personality to heal (5). Although anxiety or hopelessness may occur, it remains essential to bring countertransference reactions to the consciousness. It is important to discuss experiences in order to elucidate the physician's defenses that could result in a patient acting out due to not feeling cared for, a physician losing empathy, or eventually severing a therapeutic relationship. In the above case, supervision and processing of the event brought countertransference reactions to consciousness. This allowed for the preservation of the therapeutic alliance and continued care.

Key Points/Clinical Pearls