Who's Afraid of Murderous Rage? When Euthanasia Colludes with Self-Destructiveness

The impact of intense countertransference affects in working with patients experiencing complex trauma can have a critical effect on decisions about euthanasia, especially when such decisions are made solely on the grounds of a psychiatric condition. These countertransference dynamics become particularly significant in the context of the rising number of euthanasia requests by psychiatric patients in the Netherlands. We contend that for a subgroup of patients with complex trauma, attachment trauma, and personality disorders, the label "treatment-resistant" may be applied prematurely and incorrectly. This may occur when highly complex transference-countertransference dynamics are not properly assessed, and tertiary treatment options like intensive short-term dynamic psychotherapy (ISTDP) are not considered, particularly in cases of chronic and severe childhood trauma leading to an unconscious reservoir of murderous rage that is directed at the self. A long-term therapeutic relationship can activate unconscious transferences, leading to the reenactment of previous attachment trauma. We propose that assessments for euthanasia must include a psychological analysis of the unconscious transference, enactment, and countertransference involved. This article presents a hypothetical case example to illustrate how a patient labeled as "treatment-resistant" can be supported through a psychodynamic formulation and proposes further pathways for clinical decision-making.