āLeave the door open for the unknown, the door into the dark. Thatās where the most important things come from.ā
Rebecca Solnit (2006)
Early in our work, Jacob gave me two of Rebecca Solnitās memoirs, Hope in the Dark (2016) and A Field Guide to Getting Lost (2006). He said both books captured in different ways a portraiture of his life ā one that was filled with tragic love, endless uncertainty, intolerable exuberance, and a driving search for transformation. He said her essays inspired him to connect pieces of his story to hers and helped him manage the cauldrons of his despair. Ironically, I have loved and followed Solnitās work for years and shared Jacobās enthusiasm for how she has been able to so eloquently narrate the juxtaposition of lifeās agonies with its existential counterparts. Her artistic rawness has provided us a shared language from which weāve been able to speak and mutually unfold the hidden complexities of our minds. (Aron, 1996). Even more, Jacob saw her as an author with whom he could identify and whose intellect was equal to his own. Her writings have given him inspiration for creating his own epithaph ā one that he wants stored for future use.
Jacob is preoccupied with suicide. He thinks about it when he wakes up, before he goes to bed, after having sex, or taking a walk in the park. He thinks about it when heās feeling triumphant and when heās lost in melancholy. I canāt let go of my worry that one day Iāll show up to our session and he wonāt be there. Even during periods of lighter moods Iām aware that his suicidal hauntings shadow our work. His chronic wish to die is both terrifying and absorbing and yet offers him sanctuary from all that he canāt control. His suicidal ruminations are frequent and rambling ā despair (his and mine) headlines many of our sessions. Especially now that heās getting older, suicide feels remarkably pragmatic, and if that were not reason enough to kill himself, the calamities of our current pandemic and national distress make him doubt even more his essentialness to himself and to others. The passage of time and his inevitable mortality feels more like an ill-fated solution to his despair rather than it being an alternative to suicide (Winnicott, 1969). As his sense of potentiality diminishes, I can find his attitudes about suicide hard to argue with. While I donāt often identify with the temptation to end his life, I occasionally share Jacobās sense of futility and the quandary he feels between letting go and giving up. I am aware that our intersecting traumas including my own history of loss has made me both a well-intentioned and a well-suited partner to work with. Except when Iām not.
The fears and functions of suicidality
How do we do analytic work with someone who appears to be more interested in dying than living, whose present and future seem to hinge on the possibility of suicide? How do we stay clinically thoughtful in a treatment when, at any moment, there might not be one? What do we do when we are told there is no light at the end of the tunnel and that the option of killing oneself is what enables our patient to go on being? How do we keep our eyes wide open to the pulls of contagion (Goldberg, 1985) and not get contaminated by our patientās defeat? Are there ways to understand suicidality other than through the lens of destruction and despair?
Chronic suicidal thinking and its dialectic tensions can lock an analytic couple into an impossible dynamic, especially if there is something in the analystās history that makes her particularly susceptible to this type of retraumatization. Dread and fear can colonize (Silverman, 2015) her associative and listening capacities and confine the interpersonal field to long stretches of impasse. Anticipating that a patient might suicide is what analytic nightmares are made of, not because a patient is unlikeable or is hard to engage with but because the power of suicidality can interfere with the analystās pledge to ādo no harm.ā Hospitalization and medication can mitigate the intensity of patientsā impulses but do not necessarily change their thought process. Overwhelming anxiety and the fear of being left by suicide (Allphin, 2018) may cause the analyst to interpret in ways that offer her comfort but are dysregulating to the patient. It is not uncommon for an analyst to lose her footing and doubt her competence when her interpretive efforts get rejected or are perceived as another nail in the patientās coffin. Repeated exposure to a patientās self-harm and suicidal threats can disarm the analystās skill set and cause her to wrestle with the limits of her therapeutic abilities, which can further undermine the effectiveness of her interventions. While some patients will do anything to free themselves (and their analysts) from the destructiveness of suicidal thinking, others ā like Jacob ā find their suicidality compelling, alluring, and reassuring.
This chapter examines aspects of a patientās suicidality, its communicative function, and the impact it has on the intersubjective field, especially, at moments when the patientās experience of loss and grief resonates with the analystās. My work with Jacob shows how his idiosyncratic attachment to suicide paradoxically lends him a feeling of omnipotence while keeping him tethered to relational patterns that are disempowering and repetitive. Jacobās ambivalence about whether he wants to be alive plays a central role in how we connect and organize our experience. His chronic uncertainty brings us not only to the edge of disaster but also to the cutting edge of change.
Iāve worked with suicidal patients before but none like Jacob. With him, I find myself bombarded by a confusing mix of memory and metaphor. Our conversations are evocative but lack in cohesion. Disjointed affect and incongruent thoughts suggest the presence of enormous trauma, but the crowding in his head makes its access nearly impossible. He worries that his suffering will spiral him into a āKing Learā type of madness and that his life, a collision of unmet longing and need, will reflect more tragedy than triumph. Jacobās sense of failure and shame renders him feeling both impotent and insignificant often causing our lines of communication to become congested. Yet, I also resonate with these emotional states, which make me a worthy advocate ā if not sometimes an overzealous and misguided one.
Just when I think weāve moved into a more hopeful exchange of ideas and continuity, Jacobās suicidal fantasies intrude. I canāt always trace their source nor predict their timing. Even though his suicidal thinking is repetitive, I am nevertheless continually surprised by its recurrence and tenacity. The possibility of suicide seems to offer Jacob more solace than I ever will be able to. Jacobās suicidality sustains him in ways that are profoundly meaningful and yet seem to undo the very thing heās striving for ā a more integrated and tangible life.
When Jacob first came to see me, I wasnāt aware of much of this. We certainly did not start out talking about suicide, although I knew he had periodically suffered from severe depression. In the beginning, we discussed his past treatments, their successes and failures and how much more he still wanted to develop as a human being. He had achieved a great deal, travelled extensively and had built a life many of us would envy or feel proud of. Initially his presentation was engaging, affable, and intellectually stimulating, and I admired his drive for self-improvement. He was willing to psychologically meander his way through the analytic fog of not knowing, and I felt hopeful about the scope of our work and of our ability to develop a fruitful alliance. Our early beginnings were replete with a sense of possibility and intellectual challenge. He admired my empathic range and my depth of attunement, and I loved showing him those qualities. I even had the audacity and/or hubris to think I could facilitate change for him in ways his previous analysts had not. I remembered enjoying our analytic repartee but was aware of a growing, albeit subtle, dis-ease within me. I thought of Sullivanās reported quote (Levenson, 1982) āGod save me from a therapy that goes well and God keep me from a clever therapistā (pp. 4ā5). I braced myself for what lay ahead.
Increasingly, I observed just how much Jacob diminished his accomplishments and felt they paled in comparison to what he was really looking for ā a loving and rooted connectedness with another. He spoke about the discontinuity and sense of alienation he experienced both at work and with his family, and his loneliness began to occupy more space in him and between us. I started to feel estranged from him much in the same way he felt from the world and that the couch that had once cushioned him from the difficulties of our work now only added to them.
During our second year of treatment his impatience began to escalate and his frustrations with me and with the pace of our work grew. His restlessness felt aggressive and distancing. He spoke in a flat, monotone voice and the sullenness he described as a child seemed to have returned with a vengeance. I increasingly found myself eyeing the clock during our sessions and was troubled by recurring waves of indifference (his and mine). My initial excitement was being replaced by an arduous and insidious wish for our sessions to be over, if only to remember there was life and hope outside of this treatment! Of course, there were times when our conversations turned towards less urgent matters and we even shared a laugh or two. But Jacobās suicidal thoughts, rife with states of despair, isolation, and ambivalence, sat between us like a menacing force field. Anxiety and dread interfered with my ability to think, and neither of us could crawl out from inside of each otherās minds. The more vigilant I became, the more he seemed to get pleasure from my discomfort. I never knew how close to the edge he really was ā nor was I convinced he wanted me to know. I tried evading his aggression by reminding myself of my own and by explaining away what was occurring between us as simply transference. Still, I had the urge to run from my responsibilities, but half the time I wasnāt even sure what they were: Refer him to another type of therapy, suggest medication, hospitalization? I knew heād experience these suggestions as deeply offensive, so I worked to soften my approach. I cringed at my mean thoughts and said to myself, āYou canāt possibly pay me enough for thisā as I fixated on how much to raise his fee. The empathy I once prided myself on seemed to assume an inauthenticity, and behind its curtain appeared more anger than concern (Shubin, 2018) I was caught in an unnamed dynamic that seemed to be collapsing the space between us, and our obsessional reverie about his potential suicide was both riveting and repellent (Guntrip, 1996). Jacob never shared a plan about how he wanted to die, but the threat of his ruminations gradually paralyzed my interest and froze my analytic curiosity. I worried for the self I feared I was becoming with him (Davies, 2004) and resented him for making me feel so mentally shackled. His fluctuating moods and recurring melancholia dimmed our hope and curtailed our sense of possibility. Given that the potential to suicide was always on Jacobās horizon, there was little room for me and/or for us to suspend our awareness. We couldnāt find a way to pause and momentarily dwell in Rehmās notion (Rehm, 2018) of āremembering to forget.ā Jacobās suicidality kept us from going on being (Winnicott, 1960), and yet it seemed our only reason to be.
Making meaning out of misery
I return to the question that opened this chapter: how might we free ourselves from the frightening grip of suicidal thinking? Might suicidality be a way to relationally shake things up and bring new awareness to the less available parts of the mind? Jacobās obsessive suicidal thoughts reflected his desire to end years of pain and torment and represented his less conscious search for repair and reconciliation. At the same time, those thoughts kept him safe from his hunger for and fear of intimate connection. His suicidal imagination conceived of plots that not only condemned his existence but provided him with purpose and definition, the resurrection of and reunion with the missing other. We sometimes thought of Jacobās suicidal fantasies as veiled vignettes scripted by his unconscious in an effort to bring new life and meaning to archaic and stagnant formulations. He saw them as reversals of past misfortunes. Or are all these musings merely an attempt to keep me enlivened and engaged in the face of a potentially profound loss?
Death was introduced to Jacob very early in his life. His mother endured a long-term post-partum depression and eventually died from complications of an āaccidentalā overdose. His father, an unwell man himself, never fully recovered, and despite remarrying a few years later remained in a state of prolonged mourning. Jacobās care was left to either a host of nannies or to parents whose sonās needs often took a back seat to their own. This discontinuity and absence strained his relationship to the outer world and galvanized a retreat into his own. When he was in grade school, Jacob was told by both parents that the woman he always knew to be his mother wasnāt in fact his biological mother and that his ārealā mother had died when he was a toddler. Already considered a ādifficult, recalcitrant child,ā Jacob became even more angry and rejecting of his parents. Despite their good intentions, he felt betrayed by their ruse and couldnāt forgive them their lie or their secrecy. His already precar...
