Countertransference Reactions to a Suicidal Patient

“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.

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.

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.

The author thanks the patient for the opportunity for self-evaluation, as well as the staff at the Tripler Army Psychiatry Department for support and encouragement.