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Countertransference Hate and the Suicidal Patient

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Psychoanalyst Dan Buie describes hateful reactions that are common when working with suicidal patients and how to manage these intense emotions

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Published On: 01/10/2022

Duration:  9 minutes, 16 seconds

Chris Aiken, MD, has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.


Have you ever felt helpless when working with a suicidal patient, or had a sense of dread when you saw their name on your calendar? Today, psychoanalyst Dan Buie, MD, guides us through these thorny emotions.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor and coauthor of the new textbook Prescribing Psychotropics. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

In 1974, Dan Buie and Terry Maltsberger published a paper in the Archives of General Psychiatry: Countertransference Hate in the Treatment of Suicidal Patients. It’s unlike any you’ll see today in that journal – which changed its name in 2013 to JAMA Psychiatry. But Buie’s paper has wisdom in it that is just as necessary today as it was in 1974. Psychoanalysis may have given way to other treatments, but suicidal patients are still with us, and the intense reactions they evoke are a struggle for psychopharmacologists and psychotherapists alike.

Today we’re going to get into that paper, but first a preview of our CME quiz:

How can countertransference hate be used productively in psychodynamic therapy?

A. It alerts you of potential problems in the therapist-patient match

B. By “acting the opposite” the therapist can offer the patient extra support

C. It reminds the therapist that the patient’s problems are separate from theirs

D. It can be used by therapists to help the patient understand how they elicit intense, negative reactions in others

Now, back to Countertransference Hate in the Treatment of Suicidal Patients. The idea in this paper is that patients who make frequent suicide attempts can generate intense countertransference reactions – particularly when they have borderline or other personality disorders. We want to run and avoid them, or we want to attack and retaliate. Dr. Buie calls these aversive and sadistic countertransferences.

For therapists, it’s the sadistic reactions that are more disturbing than the aversive ones, but for patients it is often the opposite. Sadistic reactions might include fantasies of harming, suing, locking up or ceremoniously firing the patient. Sounds far fetched? A few years ago Courtney Love’s psychiatrist sued her for breach of contract. Well, acting out on these fantasies like that is fortunately rare, but for most of us the ideas cross our minds when patients get under our skins or drive us crazy. And it may come out in milder ways, like trying to control the patient with excessive contracts, involuntarily committing them when it is not clearly necessary, arguing or confronting them a bit more than is called for in session, or just assigning lots and lots of homework. 

Therapists don’t like to think of themselves as sadists, but in Dr. Buie’s view it is the aversive countertransference that is more dangerous. This is when we forget to return the patient’s calls, daydream during therapy sessions, or refer them to someone else who has more expertise in their disorder. The problem is that aversion leads to neglect; neglect triggers abandonment; and abandonment can lead to more suicide attempts in these patients. It reminds me of a similar finding in child development – that childhood neglect usually leads to worse psychological outcomes than child abuse. 

So what do you do about countertransference hate? Dr. Buie’s prescription is awareness, to acknowledge the intense feelings, bear them, and see them in perspective. Otherwise, they may come out in ways that you can’t control, like becoming overly controlling or detached from the patient, or watching the clock during session, impatiently waiting for it to end. Some therapists who are uncomfortable with these feelings may react by acting out the opposite, becoming overly anxious about the patient’s safety or going out of their way to rescue the patient, stepping over the usual boundaries by offering extra time in sessions or intervening directly in the patient’s life.

All of that can be avoided by noticing, tolerating, and accepting these curious reactions. There is no reason to feel guilty about them. We all have negative feelings towards a patient from time to time. With self-restraint, and a kind and steady focus on the patient’s growth, countertransference hate can come and go without destroying the therapy. And, when the time is right, you might help the patient see how their behavior evokes attacking or rejecting responses in others. 

Dr. Buie was a patient student of these countertransference reactions throughout his 6-decade of work as a psychoanalyst. He recently retired from clinical work, and our board member Marcia Zuckerman, MD, sat down with him for an extended interview on working with people who have severe personality problems. It’s in our January issue, and it’s worth a read. His wisdom has not faded, but seems to have grown more potent through the years, as if distilled into a concentrated form. The interview stirred up a lot of memories and emotions in me. You don’t have to be a psychoanalyst to find relevance in this stuff; these so-called “difficult patients” are not easy to forget. 

And now for the word of the day…. Neurotic Personality Organization

In the psychoanalytic view, there are three levels of personality organization: Neurotic, Borderline, and Psychotic. The neurotic is the healthiest, and arguably every healthy person has some level of neurosis or inner conflict. The psychotic level is the most disorganized and maladaptive of the three; this is not exactly the same as psychosis in the DSM. People with psychotic personality organization may have overt hallucinations and delusions or they might just have a very fragmented sense of self. 

The borderline level is – as the name implies – between the two, just below neurotic and right above psychotic, and often vacillating between these extremes. These patients often look neurotic in the first interview, but then decompensate into disorganized behavior and primitive defenses in an unstructured therapy like psychoanalysis. 

Otto Kernberg surveyed this landscape in the 1960’s, and suggests these three questions to tell them apart:

  1. Does the patient have intact reality testing?
  2. Do they have a consistent sense of self and others? Can they see themselves as others see them? Do they understand their own role in relationships and the boundaries between them and others?
  3. And finally, do they use mature defense mechanisms like suppression, humor, and sublimation, or more primitive, maladaptive ones like denial, splitting, and dissociation?

Dan H. Buie, MD, is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute. Next week, we’ll hear from him once again on how a psychotherapist can adjust their approach to these three levels of personality organization.

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