Professional attitudes to requests for secondary facial reconstruction in patients who have attempted suicide

Two patients sustained multiple facial fractures after a suicide attempt. After a period of convalescence, both wished to undergo secondary reconstructive surgery to improve the cosmetic appearance and function. On the ward, patients induced strong emotional reactions in medical staff and nurses. It should be realised that in most cases suicide attempts are not fatal. It is essential that a psychiatrist is consulted who establishes a psychiatric diagnosis and has an active role in further treatment. What may interfere with the indications for operation is countertransference from the surgeon to the patient who consciously injured himself. Five types of countertransference hatred are distinguished and described; repression of countertransference, projection of countertransference, reaction formation, reversion, and distortion or denial of reality. Failure to recognise this mechanism will result in undertreatment of these patients. A good professional understanding between the consultation liaison psychiatrists and the surgeons may facilitate a positive outcome of consultations in this area.