How is relating shaped by unconscious communications?

It is now widely accepted, across neuroscience, cognitive science and psychoanalysis, that most mental activity operates unconsciously. ‘Transference’ and ‘countertransference’ are the terms used to describe how these unconscious processes emerge in the clinical relationship, through the subtle communication of unspoken feelings, anxieties and conflicts.

All relationships are shaped by early experience, and these patterns inevitably appear in the clinical encounter. Patients bring unconscious expectations of care, as well as strong and often primitive emotional responses to illness, vulnerability and death.

Clinicians, in turn, respond through the lens of their own histories. A patient who has experienced ruptures in early attachment may find this pattern re-evoked in contact with services, whereas one who expects nurture and care may evoke protective or rescuing responses.

A simple illustration of countertransference is the caregiver who feels frustration or anger in response to a baby’s distress, yet is able to recognise these emotions as belonging to the baby and contain them, holding and thinking about the feelings rather than reacting to them. Clinicians face a similar task to notice such emotions rather than act them out unconsciously.

At the individual level, a patient may project feelings of hopelessness, impotence, rage and shame, together with the fear that nothing can relieve the situation, onto the clinician. What appears to be the physician’s own despair or frustration can, in fact, be the patient’s state of mind, communicated through projection and projective identification, unconscious processes where intolerable feelings are evacuated into another person and experienced as their own. If unrecognised, this can distort clinical decision-making, for example, leaving the doctor suddenly convinced that no treatment will be effective.

At the group level, ambivalence may be split between members of a team or family, one person carries rage and hopelessness, while others embody optimism and warmth, together enacting the patient’s internal conflict.

At the organisational level, whole populations can transmit distress to institutions. For example, repeated self-harm on a ward may unconsciously drive staff to adopt rigid, defensive practices, thereby enacting patients’ dread of being controlled.

At the societal level, groups may communicate their suffering collectively. The visible distress of those living with severe mental illness, frailty or disability can evoke an unconscious dread of dependence and loss, expressed through stigma, coercion or idealised narratives of recovery. Such dynamics risk reinforcing unconscious ableism, casting frail or disabled lives as somehow diminished in worth.

Unconscious forces in assisted dying

Unconscious forces inevitably shape the practice of assisted dying. A Dutch survey found that in a quarter of requests for assisted dying, clinicians recognised that transference and countertransference directly influenced their decisions. ^{Reference Hicks1} These end-of-life projections, where patients’ despair, urgency or fear are taken up by clinicians can evoke disturbing countertransference feelings, ranging from rejection or indifference to an urgent pressure to end suffering and a sense that the situation is intolerable. ^{Reference Briggs, Lindner, Goldblatt, Kapusta and Teising2}

One striking example concerns the impact of the physician’s presence on completion rates. In Belgium, the Netherlands and Canada, where euthanasia is physician-administered, completion rates reach 98 to 100 per cent, compared with 60 to 80 per cent in self-administered regimes such as Switzerland or some US states. There has been little reflection on what this discrepancy might mean. What role is the physician drawn into? Why is the process more likely to falter when patients self-administer compared with when a physician administers the lethal medication? It seems that the physician’s presence at the moment of death may reduce hesitation. If so, we need to understand what may be being unconsciously enacted in this relationship.

Strikingly, fewer than 100 clinicians oversee more than a third of all Canadian cases, with one individual alone responsible for over one thousand assisted deaths. Limited consideration has been given to the complex, resource-intensive and emotionally demanding psychological toll on this small group, or to how unconscious dynamics may be shaping their practice. ³

Some insight can be found in the memoir of Dr Stefanie Green, ^{Reference Downie and Green4} a leading provider of Medical Assistance in Dying (MAiD) in Canada, in which she describes the nature of these projections. Patients press urgency upon her, seeking immediate relief and positioning her as the one who must not delay. Families often look to her for certainty, casting her as the calm authority who can resolve their own ambivalence. At the bedside she is idealised as redeemer and midwife, ‘delivering’ people out of suffering, while at the same time being asked to contain dread, guilt and fear of abandonment.

Green, too, idealises her role with little apparent conflict, repeatedly framing assisted dying in the language of intimacy and reward. At the bedside, she highlights the validation and gratitude she receives. This account suggests unconscious enactments in which projections are transformed into idealisation, creating a pull towards roles of certainty, denial or deliverance in managing the end of life. This comforting narrative may also reflect the doctor’s unconscious needs, a personal valency for the work shaped by experiences of loss and helplessness.

Normalisation may represent a countertransference response. Projections that initially evoke anxiety are managed by making the act routine, even rewarding. Green describes just such a shift, moving from the anxiety of her early cases to increasing ease. This normalisation is captured in another physician’s remark: ‘It’s becoming quite easy, you know, to do euthanasia.’ ^{Reference Gerson, Koksvik, Richards, Materstvedt and Clark5}

These dynamics are understandable as a defence in the face of suffering at the end of life. Idealisation and normalisation can ease deep distress and mourning, but when they harden into a national narrative that casts MAiD as the archetype of a ‘good death’, the risk is distortion. The lack of reflection on these unconscious dynamics may itself be a key driver of MAiD’s remarkable and troubling expansion in Canada, where cases have risen from around 1000 in 2016 to more than 15 000 in 2023 (4.1% of all deaths; 7.4% in Ontario). Lyon and colleagues ^{Reference Lyon, Lemmens and Kim6} argue that this growth is fuelled less by broad public demand than by a small activist minority of providers, such as Green, who have reshaped the public narrative. What remains unclear is the balance of forces driving this rapid expansion.

In The Many Faces of MAiD, ^{Reference Clark and Cram7} deaths are described as ‘profound journeys’, ‘beautiful’ or ‘filled with love and laughter’. While some of these accounts may indeed describe profoundly moving deaths, their ubiquity suggests something more: a national narrative that risks denying the full range of emotions necessary for grieving, and that, at times in Canada, may resemble a collective delusional bubble of idealisation. ^{Reference Calabro8}

At the organisational level, unconscious dynamics are evident in the ways organisations do or do not provide MAiD, and in the speed with which requests move through the system. In Track 1 cases, where death is reasonably foreseeable and no mandatory waiting period applies, provision can occur almost immediately. More than one-third (36.7%) take place within 10 days of the request, and over half within 30 days. ³ Such rapid timelines leave little space for reflection or mourning.

At the societal level, unconscious forces shape cultural narratives of life, death, ageing and disability. Public opinion reveals collective splitting: around 70% support assisted death when it is called ‘euthanasia’, rising to 80 to 85% when reframed as ‘Medical Assistance in Dying’. This shift reflects both the unconscious sanitising effect of language and the reassuring appeal of medical involvement. National ableism and economic considerations add another layer. Government estimates of 86.9 million dollars in annual savings create unconscious political incentives that, once established, are difficult to reverse. ^{Reference Mishara and Weisstub9}

In conclusion, unconscious emotional forces shape all relationships, including those within clinical encounters, and are especially powerful at the end of life. Legal frameworks provide safeguards of autonomy, consent and oversight, yet unconscious dynamics continue to influence how requests for assisted dying are heard, validated or resisted. When unacknowledged, these forces can distort judegment, turning painful complexity into certainty, or psychic pain into an unquestioned call for death. The rapid rise in jurisdictions legalising assisted dying, and the sharp increase in deaths worldwide, may themselves reflect these forces at work, reshaping how societies understand suffering and death. They act on a collective anxiety that helplessness and suffering are intolerable, and that dying must therefore be managed and controlled.

Safeguards must extend beyond legal structures to include active recognition of unconscious dynamics and awareness of the psychological toll of this work on clinicians. These forces should be regarded not only as a threat but as an inevitable and potentially valuable source of information, emotional responses that, when recognised and contained, can become resources for understanding rather than unexamined drivers of action.

Assisted dying is not only a clinical act but also a symbolic one, carrying deep cultural meaning about medicine’s role at the boundary between life and death. Protective measures should include careful attention to patients’ psychological states, their experiences of grief, loss, mourning and ambivalence, and to the layers of unconscious pressure that accompany such decisions. This need not involve formal psychiatric assessment in every case, but it should form an integral part of all clinical encounters concerned with these final decision-making processes. Clinicians should receive specialist training to recognise and work with these dynamics at the end of life. Systems of oversight should monitor uptake closely, recognising that rising numbers may reflect not only legal change but also deeper cultural and psychological shifts in how suffering and death are understood. Reflective practice must be embedded through regular multidisciplinary supervision, allowing clinicians to process their own emotional responses and to avoid unconscious collusion that might otherwise distort judgement.

This paper has not argued for or against assisted dying. It has emphasised the need to confront the unconscious realities that shape its practice. To ignore these forces carries profound risks for both individuals and society. To face them is essential if assisted dying is to be undertaken with ethical integrity and clinically responsible decision-making. Attending to these unconscious dynamics is part of ensuring that medical practice remains grounded in its most fundamental obligation, in line with the Hippocratic oath, to do no harm.