If You Kill Yourself, Don’t Make a Mess: Paradoxical Intention with a Suicidal Client

If You Kill Yourself, Don’t Make a Mess: Paradoxical Intention with a Suicidal Client

by Dan Williams
In this raw but compelling clinical vignette, therapist Dan Williams uses paradoxical intention in an all-out effort to save his client from committing suicide.

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"Maybe I was happy for like a day or two”

Marcus once told me he has no memory of what it feels like to not suffer. You’re exaggerating, I told him. He insisted he wasn’t. You are, I fought back. Everyone has such a memory, at least one. Marcus concedes little.

“Well, maybe I was happy for like a day or two.”

“That’s it?”

I’m visiting Marcus in a psychiatric stabilization unit. My task this morning is straightforward but not easy: confirm that he won’t harm himself when he leaves this place, and that he’ll take his medication. “You mean, not think about it?” he blubbers, in response to my direct question whether he’ll kill himself once he’s released. “I think about it all the time.” Coughs. “It don’t mean I will. And it don’t mean I won’t. So that’s that.”

Marcus is rotund and bald, with a noticeable stoop when he stands and a limp when he walks, as if he were an octogenarian trudging through the day under the invincible weight of his age. But he’s not yet even forty.

I walk over to the large window and open the blinds. “Is this okay?” I ask.

So thorough is Marcus’s lethargy that it would take supreme effort to imagine him at any point in his life gamboling joyously while soaking in the sunshine. The way he slouches, the way he mumbles and mutters, the way the sagging flesh on his face seems to collect around his neck, the way his drooping eyes make him look like a human bloodhound, the way he wears his bedraggled clothing, draped tent-like over his fatness—all of it, from his unlaced Converse sneakers to the labor of his breathing, speaks to the torments inflicted upon him as a child and the torments he inflicts upon himself ever since because that past is no mere residue of memory but instead exists within the corpuscles playing bumper cars in his veins. Marcus’s past is vastly alive inside him.

“Knock yourself out,” Marcus says. “I like it dark but it’s fine.”

I can see it more clearly now, with the sunlight drenching the room. The discolored bandage on his neck, the one that covers the stitched-up gash. It is puffy and loose. Like a cloud stained by urine. I ask if I can see the wound.

“For what?”

“For fun,” I say, winking.

Marcus tugs gently on the urine-cloud bandage. All the while he is mute, tongue sliding through soft lips, not unlike a narcotized snake. His tai-chi pull reveals the inch-long railroad track a little off-center on his pink, fleshy neck, the entire slow-motion divulgence giving the unveiling the feel that something ceremonial—no, something intimate—is happening.

The Real Nature of Suffering

Intimacy is what good talk therapists hope to achieve through this special encounter—which is why I strongly hold the view that talk therapy is a kind of artistry, for all art stems from an encounter between the artist and the subject, wherein the two become entwined in an intimate collaboration. What I mean by intimacy in this context is that a special kind of healing can occur when facades fade away, when neither person sees the other as potentially useful, which is to say the other is not a means to an end, the other is not expected to perform a function in one’s own advantage-seeking scheme, where the other is not to be used in some way (subtle or otherwise) to get some wanted outcome.

So talk therapy is something entirely different from having a rap session. An hour of heartfelt exchange without a handheld computer vitiating the experience—that right there makes it sadly unique. We might think of lovers sharing an intimate moment, but when there is the subtle (or not-so-subtle) underlying quest to keep the other close because the other serves the useful function of bringing about an inner experience that we have become attached to (meaning, we love the other’s presence because of the ability that the other has in bringing about a certain feeling within us), the intimacy is tainted thereby. Healing intimacy, I mean to suggest, and the face-to-face encounter that gives rise to it, is untainted. And it is this sort of intimacy that creates opportunities for the therapist to connect with the real nature of suffering.

The real nature of suffering—what is that? Well, I’m looking at it as I look at Marcus’s sagging face, with his eyes barely visible and his lips now sucked into his mouth. I hear it in his mumbling, the gravel, scratchy vocalizations that evoke a sense of futility about life.
No matter what Marcus says, the way he says it conveys his attitude that the whole enterprise of living is fruitless and cruel.
No matter what Marcus says, the way he says it conveys his attitude that the whole enterprise of living is fruitless and cruel. To Marcus’s way of thinking, life consists of events that happen to you; events are rarely neutral and they surely are not participatory; events by and large inflict suffering and there isn’t much to be done to exert control over them. All that is to be done is to take cover.

The existentialist philosopher Martin Heidegger and Doors singer Jim Morrison speak of our being “thrown into” the world, which is to say we have had no say (unless you believe in karmic reincarnation) in what our fundamental life circumstances will be. Will we be born in an affluent country or a war-ravaged one? Will our parents be wealthy or will they be drug addicts? Will they be skilled in the art of parenting or will they mutilate the child’s soul through mental torments or physical deprivations? A pile of shit or a basket of rose petals, or something in between—you don’t get to choose which you get thrown into. I’m sure Marcus has never read a word of Heidegger and I doubt he has ever grasped Morrison’s reference to “thrown-ness” when he sings, “into this world we’re thrown.” But Marcus understands thrown-ness in a way that few do. His understanding is purely experiential, and thus utterly non-conceptual. And that is why it is pointless to talk with him right now about choice and responsibility and meaning—all core concepts in my therapeutic repertoire, but useless at this moment.

His is an attitude of hopelessness, a recalcitrant, immutable belief that his emotional pain is permanent. But there is much more to it, as I see it through my own existentialist lens. Depression might be a clinical description of how Marcus experiences his life, but to restrict ourselves to that misses the deeper truth. Being depressed is, for him, a strategy, in the same way that the fox’s “sour grapes” in Aesop’s fable is a strategy, an emotion experienced to deflect something more painful. Depression is his cover. He has learned to use it—learned helplessness, one might say—to announce to the world that he is not responsible for his choices, that he cannot be blamed or held to account for his many self-sabotaging acts. In effect, helplessness and dysphoria serve as protection against the rigors of transcending his life circumstances. Depression protects him from any demands that he relate to his own life as a process of creation and the living of it as a kind of artistic endeavor.

"I'm Surprised You Used a Knife"

“Does it still hurt?” I ask.

Marcus taps on the wound with two fingers, as if to test it. “Nah,” he says. “Not if I don’t turn my head.”

“I’m surprised you used a knife,” I say.

Marcus had told me early on, repeating it often, that he envisioned himself going into the woods and shooting himself in the head. A fantasy perhaps, some aesthetic end to his particular decrepit story, as if a gun-blast obliterating the cranium in a quiet forest is the quintessential response to an ugly and alienated existence. A worthy denouement to a life of unmentionable sorrow that, though silent to the rest of us, now screams inside his head. A knife? No, I’m sure of it—he’s never mentioned that that would be a suitable instrument to effectuate his escape from the tribulations of his life. And bleed himself out on his mother’s kitchen floor like a slaughtered pig? Not the Marcus I had come to know. He had told me a gun-blast to the head in a secluded area of the woods, a spot he had already designated in his death-welcoming mind, would not leave a mess for others, as if his remains would be shoveled and disposed of with no more ceremonial fuss than the discarding of road kill.

He’s a complete mess inside and yet he has this concern for the mess he might leave when his inner mess becomes too intolerable.

Marcus and I have talked of suicide and death from day one. “Day one,” and many days thereafter, was in his a squalid single-room occupancy hotel. Existential therapy in a paint-peeling, cigarette-smelling room with a mattress on the floor, a small knee-high table abutting it—so much easier to roll cigarettes that way—and an always-on large flat-screen television five feet away. “I think about it all the time, every day, it’s how my life is.” Usually in the morning: such thoughts to be considered before he heaves himself off of the mattress to endure more inconsequential suffering. Not one session ends without him mentioning suicide.

I always make it a point to demonstrate that I’m unafraid of the subject. We’ve even laughed together over how naïve so many are to think that our so-called “survival instinct,” our presumed “will to live,” ineluctably trumps our desire for self-destruction. Self-destruction, alongside myriad habits of self-numbing, is so omnipresent in our world that it seems absurd to think that we humans actually do treasure the gift of living.

If we treasure life, really treasure it rather than just give lip-service to it, then why so much squandering of it?

“What does anyone know about living?” Marcus had said to me once. He wasn’t really asking me a question. He was declaring his own wisdom, his own hard-earned wisdom, the only kind of wisdom that’s worth a damn.

I think it is useful to look upon the urge to kill yourself as arising from a “self” that wants to manage the pain (which includes vanquishing it entirely).
His remark reminded me of the scene in the Vietnam movie Platoon where Sgt. Barnes, the dark character competing for the soul of the Charlie Sheen character says to a group of young soldiers who are smoking pot: “Death? What y’all know about death?” Sgt. Barnes, with his scar-chiseled face and pain-knowing eyes, has undoubtedly peered into some abyss and thus has little patience for the young soldiers who seek escape and avert their eyes from the abyss through petty distractions. I don’t recall how I answered Marcus. But I do remember being impressed by the fact that he understood so well the interdependence of life and death, that to understand life one has to understand death. Not that Marcus spoke from a place of understanding death—far from it. He never spoke with any particularity about how contemplating death might bear on the artistry of living.

“I became an altar boy when I was 12,” he continued. “Did that for a few years. Father Lewis didn’t know nothin’ about living. I’ve seen psychs, therapists, energy doctors, fuckin’ you name it, and none of’em knows a goddamned thing about living.”

Not much to argue with there. I told Marcus that hardly anyone knows anything meaningful about how to live. How pathetic we are, I told him, the vast majority of us in the land of plenty, in the art of living. How can we know? After all, we lack a vocabulary for it. In this money-making, status-seeking, distraction-obsessed culture, we’ve lost the capacity to talk about it; we’ve lost the tools to even think about it in any serious way. Marcus lit a cigarette, offered me one, and as I waved him off I realized I had lapsed into preacher mode. I’ve been prone to do that.

I always refrain from talking Marcus out of suicide. He has commented on that fact a few times, usually to express gratitude for not doing what other health-care providers do—tell him that it would be best to forge ahead (best for whom?), that things will get better (how the fuck do you know things will get better?), that killing himself would only leave a legacy of pain (oh, I get it, I should suffer through life out of obligation). I never take that approach, for two reasons.

First, I think it is useful to look upon the urge to kill yourself as arising from a “self” that wants to manage the pain (which includes vanquishing it entirely). That managerial “self” must exist against another “self” that generates and experiences the pain. There is thus a polarity within the suicidal human organism: the managerial “self” who can’t stand the pain polarized against the pain-experiencing “self” who just won’t stay sequestered in some psychic locker tucked away among all the other toys in the attic. To preach at the managerial “self” about the folly of suicide, to guilt-trip the managerial “self” or appeal to that “self’s” sense of obligation, only leads to an intensified desire to commit suicide because it ignores completely the interplay of the polarities within the human organism. The polarity itself needs to be addressed.

Second, I don’t believe in the notion that living is an obligation and I don’t think it is truly therapeutic to signal such a notion to others, including those in despair. It’s an implicit mental model that generates ripples of more pain and suffering. I’m not one to promote to a desperately suffering person the brightly lit news of how wonderfully magical life can be, if only you just hang on. I do the opposite: I go towards the darkness, the pain, even the madness itself; I climb down into the pit of despair and sit with the person and ask questions like What’s holding you back now? What’s held you back in the past? Why haven’t you’ve given up already? Usually that sort of questioning arouses a spirited discussion, led by the client (a crucial fact), about what makes living worthwhile. It can often take a while to get there, but I have found that it almost always happens.

"If I Had a Gun"

I ask him again to tell me about his choice of killing implement, this time with a forward-leaning posture and a hand-slicing gesture, using my body in the way I used to do in my former life as a courtroom lawyer cross-examining witnesses. “I would have used a gun,” Marcus explains. Silence, for two beats, and then he adds, “If I had a gun.” He taps the wound again. “All I had at the moment was a knife. So I. . . .” He falters in his speech, as he often does.

“So you used it,” I say to complete Marcus’s sentence. He nods. “Small wound,” I add. “Scary, but small.” He shrugs. He tells me he doesn’t want to talk about it anymore and I tell him sure, no problem.

Do It Day

A week passes and I visit Marcus again, this time to prepare him for discharge. But first I have to make a judgment—can Marcus leave this place?

“Look, Marcus, you keep talking about killing yourself and sometimes you do stuff like—hell, you know, you cut your throat, for Christ’s sake.”

Marcus interrupts me. “Yeah, and I wouldn’t be here right now if I had a gun around. I woulda killed myself a long time ago. I woulda killed myself a lot of times.”

“Yeah,” I say, holding back a laugh. I guess I’m not too successful because Marcus asks me, with a stupefied look, what’s so funny? And I tell him nothing and he insists that he wants to know so I tell him it’s just the shit you say, Marcus, and he asks me what shit? and I tell him you just say funny shit sometimes and the fact that you don’t know that it’s funny just makes it funnier. Marcus shrugs and he smiles wanly. That’s my cue to push forward and quit the banter.

“Anyway,” I say in a low register, “I get that you always think about it. But let’s talk about doing this whole thing right.” Marcus perks up. His lips separate and form an oval. “First off, let’s set a date. No messing around. Let’s write it in your calendar.” Marcus has a paper calendar taped on the wall near his bed. We go back and forth about a suitable day to “do it” and Marcus keeps saying this is ridiculous, it’s fucking ridiculous and I keep countering no it isn’t, we need to do this right, and then he says stop messing around, Dan, and I tell him I’m very serious right now. It’s early April and we discuss Memorial Day as “Do It Day.” Marcus keeps repeating this is ridiculous, fucking ridiculous, and then—

Paradoxical Intention

Paradoxical intention is what Victor Frankl called it in his book, Man’s Search for Meaning. The fundamental idea is that of going towards, rather than away from, the peril, the darkness, the pain. Resistance and evasion prolong and intensify suffering; healing is predicated on overcoming. Still, ushering a client towards the distress is frightening, which is probably why Frankl’s paradoxical intention is most often restricted to treating garden-variety phobias. I don’t use Frankl’s technique in any formalistic way. I use it more by happenstance because it accords well with my Zen training, which in turn harmonizes with my therapeutic orientation towards existentialism. That probably explains why I am not frightened to use it with Marcus. My time in a Zen monastery was replete with exercises in paradoxical intentionality, largely invoked to lighten the practitioner’s attachment to “self.”

He relents.

“What difference does it make?” he says, clearly exhausted by the rapid banter. “Let’s make it Memorial Day then.”

I ponder that date, staring at the calendar. It’s a free calendar with a Walgreens logo and a photo of two youthful faces, white male and black female, bearing happy smiles, the cliché image of human joy and social progress. “No, not then,” I say.

“Why not?” Marcus asks.

“You should have one more summer before you call it quits. It’d be stupid to waste a summer, get what I’m saying?”
“You should have one more summer before you call it quits. It’d be stupid to waste a summer, get what I’m saying?”

“No, I don’t.” He starts to rise off the bed. “C’mon, let’s get me signed outta here. That’s that, huh?”

“Summer! Dontcha want one more summer?”

Marcus considers my expression. I feel exuberant, like I’m proposing something wild and fun, maybe even sinister. “Yeah, you’re right,” he says gamely.

“That’s the spirit. Live it up and then do it on Labor Day.” I reach over and pull the calendar off of the wall. I find September and I write “The End” in the little box for Labor Day. Marcus is looking at me with electric eyes. “But here’s the deal, Marcus. I’m serious about this, so listen to me.” I pause, wait for the emotional gravity of the moment to hit. “You can’t back out of this. If you are feeling then what you are feeling now and like you’ve felt in the past, then you have to make Labor Day the last day of your life.”

He nods but I can tell he’s puzzled and yet interested in this therapist-led madness. I tell him we are going to designate a place for The End but that we’re not going to do that now because it’s worth thinking hard about since it’ll be a really important event and we need to treat it as such. I insist that he promise me that he will not harm himself in any way before Labor Day.

“Understand, Marcus? You need to promise me that.” I get him to promise. “But there’s one more thing, Marcus.” I say this solemnly.

“What’s that?”

“This is crucial. This is the key to the whole deal.”

“Fucking what?” Marcus is no longer slouching. He stopped slouching several minutes ago but I’m noticing it now.

“You only get to do it—it’s only The End—if you live it up this summer. You have to go to the beach, like, every day. You have to ask women out and not give a rats-ass if they say no. You have to . . . you know . . .”

“Get laid?”

“If that makes you happy. And I want you to go to the library and go on the Internet and make a reservation for a campsite in August.”
“I love camping,” he says.

“I know, Marcus. You’ve told me that before. That’s why I’m telling you now—I’m telling you, you hear?—to reserve a campsite.”

“Willya come out? To the campsite, I mean.”

“Sure,” I say hastily. I grab his knees, squeeze them together. “Listen to me, man. You have to live it up this summer and then you can do it on Labor Day. You must do it on Labor Day.” I let go of his knees and lean back in my chair. “Unless, of course, you aren’t depressed anymore like you are now.” Marcus picks up the calendar from the floor where I dropped it. He studies it. “Deal?” I say.

“Deal,” he says.

We shake on it. Then I leave the room and return with a legal pad. Marcus asks me what I’m writing and I tell him I’m writing an “Odysseus agreement.”

“What’s that?”

“It’s a thing you sign. It’s your signed promise not to harm yourself, and if you do feel like you’ll harm yourself, you’re promising here that you won’t, that instead you’ll call nine-one-one or somehow, someway, get yourself to the hospital.”
“What’d you call it?” he asks

“An Odysseus agreement is what it’s called.”

“A what?”

“Hey, Marcus, what does it matter? Let me write this and you sign it. Okay?”

“Yeah, okay. So that’s that. But what’s with the name?”

“Marcus, lemme write this,” I protest. “Sooner we do this, sooner we get you signed outta here. That’s what you want, right?”

“Yeah, but what’s this Odys thing? Never heard of that word.”

O—dyss—e—us,” I say, as I put the pad and pen on the floor. I explain to Marcus, because he really wants to know, a bit about the Homeric poem, The Odyssey—about the gore and blood-thirsty violence, about vengeance and honor, and I tell him that back then, in ancient Greece, they valued things differently than we do nowadays. Heroism, courage, unflinching acceptance of death. “Back then, to be respected and to have self-respect, you had to have conquered your fear of death.”

“Sounds like The Gladiator,” Marcus says, referring to the Russell Crowe movie.

“Yeah,” I say, “the Greeks influenced the Romans.”

“So why is this thing you’re writing called what it’s called?”

Odysseus, the hero in Homer’s classic, requested to be tied down to the ship’s mast because he couldn’t trust his ability to withstand the call of the Sirens. I explain the whole scene to Marcus and he gets it.

“Oh. So, signing this piece of paper, that’s like you tying me down to a pole on the ship.”

“Exactly.”

He laughs. Not a chuckle, but a real laugh. “Go on, then. Write it and I’ll sign it. That’s that.”

Postscript

Marcus is still alive. He discovered that “living it up” isn’t as easy as one might think. Working with Marcus reminds me how difficult being easy-going actually is. Giving oneself permission to live life with ease, free from attachments to our dramas, is something that requires patience and practice. Permission-giving has been the therapeutic project preoccupying me and Marcus, once the Labor Day moment passed, with Marcus telling me, “I’m game to keep going.” Physical challenges continue to get him down—structural damage to one knee, a bad back—but he has become more resilient, largely because he takes fewer things personally. The sessions following those described in the essay—sessions where he was encouraged to “live it up” before following through on his determination to “end it all”—led him to a realization that treating life as an obligation only intensifies suffering. Our slogan these days: Nothing matters, but everything is honored.
 



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Dan Williams Dan Williams is a psychotherapist and performance consultant practicing in the Boston area. He is also a writer. Aside from writing many essays and scholarly articles, he is the author of one book, Executing Justice: An Inside Account of the Case of Mumia Abu Jamal, and is nearing completion of another, The Storm and The Whisper. Before becoming a psychotherapist, Dan was a courtroom lawyer, specializing in capital punishment, and then a law professor, teaching at Northeastern and Harvard University. He is an ardent Zen practitioner.

CE credits: 1

Learning Objectives:

  • Illustrate Viktor Frankl's theory of paradoxical intention
  • Understand how Williams' seeming light-hearted approach is paradoxically therapeutic
  • Describe some common characteristics of chronically suicidal clients