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Kioko and Requena propose a primary therapeutic focus on assisting patients in finding a meaning in their suffering and life itself.1 They also propose that euthanasia is incompatible with psychotherapeutic care, referring to psychiatrist Frankl's example of self-endured suffering once one's attitude towards suffering has been modified and the meaning of life itself has been found, despite being confronted with the most extreme manifestations of dehumanisation.2 The rationale of his coping mechanism is that hurtful situations in themselves might indeed be beyond one's control, but that attitudes toward these situations – and, as a consequence, suffering experiences – can be mastered. There are many religious and philosophical tendencies supporting this point of view, in contrast to the many counterpoints. One can find many different stances in many more areas of expertise which express opposing – though inconclusive – positions. To the best of our knowledge, there is no evidence that the abovementioned meaning-of-life approach can be effective to alleviate unbearable suffering or prevent/revoke psychiatric patients from requesting euthanasia.

The authors evoke anecdotal evidence of great deeds done by (responding to) suffering. In this vein, many artists have created unique art, perhaps because of that suffering, perhaps not. Contrarily, there are also many examples of artists who committed suicide. Such anecdotes confirm the subjective nature of suffering, determined by a patient's environment, context, current and future perspectives, physical and mental capacity, and personality.3

Concerning the role of psychotherapists, their aim to alleviate human suffering indeed stretches back to antiquity. Nevertheless, a deeper understanding of suffering and ways to alleviate it remain elusive. Physicians denying that there are limits to treatment and holding an absolute stance on life protection, not fully fathoming patients' total suffering that leads to suicidal ideations, attempts or euthanasia requests, paradoxically might steer the therapeutic relationship to a standstill as patients might feel unheard, misunderstood and strengthened in their conviction of being unworthy and, as a consequence, in their death wish.4

In acknowledging unbearable suffering and the limits of medical treatment to alleviate suffering in an adequate way, the psychotherapeutic key focus on protection of life only seems to be undermined. However, the scarce available evidence from Belgian clinical euthanasia practice shows that following a two-track approach, with a focus on psychotherapeutic treatment while also acknowledging euthanasia as a plausible emergency break, paradoxically might offer psychiatric patients sufficient peace of mind to continue their lives and give further or alternative treatment options a fair chance for success.5 Hence, more research into the nature of suffering and meaning of a death request is needed in order to develop highly needed clinical interventions that might both relieve patients of their death wish and enforce new or alternative life perspectives. We hope our qualitative study can contribute to paving the way for further research endeavours that are tolerant and respectful to patients' subjective notions of unbearable suffering and death wish, as well as directly addressing their cry for extended life aid and thus assisting the patient to continue living, without polarising these into irreconcilable opposites.

1Verhofstadt, M, Thienpont, L, Peters, G-JY. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry 2017; 211: 238–45.
2Frankl, VE. Man's Search for Meaning. Beacon Press, 1997.
3Delbeke, E. Legal Aspects of Care at the End of Life. Intersentia, 2012.
4Vandenberghe, J. De “goede dood” in de Vlaamse psychiatrie. Tijdschr Psychiatr 2011; 53: 551–3.
5Thienpont, L, Verhofstadt, M, Van Loon, T, Distelmans, W, Audenaert, K, De Deyn, PP. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5: e007454.