Corrine Johnson dissertation by ICSW

Institute for Clinical Social Work

Remains of the Dead: One Therapist’s Experience of Patient Suicide

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Corrine Johnson

Chicago, Illinois October 30, 2020

Abstract

The purpose of this autoethnography was to study one therapist’s experience of patient suicide, develop psychodynamic-oriented conceptualizations, and deepen clinical understandings of the therapist as a subject of patient suicide. This study postulated that the therapist’s experience of suicide warranted psychodynamic inquiry, and clinical concern, due to a gap in psychodynamic literature and clinical theory that insufficiently, and mistakenly, concretized patient suicide as a physical event, creating shame, and a professional stigma, about patient suicide that silenced the therapist and encouraged her to hide this traumatic loss. Through autoethnographic research, the study discovered, in the year following her patient’s death, the therapist continued an object relationship with her dead patient: one that existed, or she created, in an altered relational, object field; and she continued to relate metaphysically, psychically, internally with her dead patient. It was concluded that the therapist lived on, as a partobject, in this dead object field, unable to reckon with her patient’s traumatic decision to abandon treatment and her with it. To articulate the therapist’s experience of what remained unformulated, split off, and rejected in the aftermath of patient suicide, the study recognized itself as a wish for the therapist to keep her dead patient alive. In part, this autoethnographic study found that to offer an honest, true recognition of her patient as a subject of his life demanded this intersubjective recognition of her subjectivity too. It intended to salvage, resurrect, or identify what remained of the dead patient, in a dream by the therapist to become usable in another object realm. iii

For Jack and Hazel—whose beating hearts fill mine

"Sadness doesn't grow, only the space it takes up" ~Marieke Lucas Rijneveld, The Discomfort of Evening

Acknowledgments

I am grateful to the many who truly have been essential to this work. Jennifer Tolleson, my chairperson, offered a steadfast commitment to and unwavering stewardship of this study. Her fortitude guided me fiercely and compassionately through the complexities of my research and her conviction about my methodology was invaluable. She provided a constancy I leaned on and a resilience I learned from. Joan Servatius offered a willingness to be found where, when, and how I needed her; she generously entered the clinical vulnerabilities of the study, to foster the integration of formulating my thoughts and being with my experience. Woody Faigen brought his vast knowledge of Freud, the unconscious, and of me to bear, offering his keen clinical insight, his unique ability to find the marrow in my working-through, and his reminders to trust the process. My readers, Paula Ammerman and Gabe Ruiz, brought the depth of their clinical experience and psychodynamic scholarship, helping me find my voice through sharing their own. John Ridings, IRB chairperson, provided unequivocal and institutional advocacy for my research. My cohort generated a force of insight, curiosity, and kindness, to nurture my thinking, not-knowing, and being heard. CJ

Table of Contents

Page Abstract…………….………………………………………………………………….... ii Acknowledgements….…………………………………………………………………..vi Chapter I. Introduction……………………………………………………………………...1 General Statement of Purpose Significance of the Study Statement of the Problem and Objectives of the Study Hypothesis and Research Questions to Explore Theoretical and Operational Definitions of Major Concepts II. Literature Review………………………………………………………………20 Introduction Foundational Psychoanalytic Theories on Death, Suicide, and Object Loss Conceptualizing Multiple Subjectivities and Death as the Analytic Third Conceptualizations of the Therapist as a Subject in Her Dead Object World Countertransference Realities and Fantasies: The Subjective Experience of a Dead Patient Conceptualizations of Suicide: Intrapsychic Event, Social Construct, Therapeutic Failure

vii

Table of Contents—Continued

Chapter

Page Autoethnographic Literature: The “I” as a Source of Truth and Reality The Role of Social Constructivist and Hermeneutic Literature to Defining Knowledge Conclusion

III. Methodology……………………………………………………………………44 Introduction Rationale for Qualitative Research Design Rationale for Autoethnographic Methodology Research Sample Research Process Data Collection Plan for Data Analysis Ethical Considerations Issues of Trustworthiness Limitations and Delimitations The Role and Background of the Researcher IV. Findings………………………………………………………………………….64 Some Context The Unexpected: From Missing to Dead The Dead, the Mourners, and the Murderers viii

Table of Contents—Continued

Chapter

Page A Preoccupation Forms The Seduction of Death Suspended Madness Liminal State What My Patients Know Guilt, Paranoia, and Dread The Steadiness of Loss

V. Discussion…………………….…………………………………………………98 Themes of the Experience Categories of Meaning to Emerge from the Themes Limitations of the Study Clinical Implications Research Implications Conclusion

References…………………………..….…………………………………………..129

Chapter I

Introduction

General Statement of the Purpose The purpose of this autoethnographic study (Ellis, Jones & Adams, 2015) was to describe one therapist’s experience of patient suicide and to explore and develop psychodynamic-oriented, clinical understandings of the therapist as a subject of patient suicide. In this research, the autoethnographic study of the therapist as a subject was defined as the therapist’s subjective, intrapsychic experience of patient suicide. The hope of this study was to recognize the therapist’s clinical experiences as an expansive, as an historically one-dimensional, one-person psychodynamic field. It has been observed that theoretical and clinical material on patient suicide has reductively concretized suicide in the treatment relationship as a singular, intrapsychic, individual event ignoring patient suicide as an object-relationship experience for the therapist. Also, this study attempted to speak to the undeniable stigmatization and against the understandable silencing (Tillman, 2016) of the therapist’s experience of patient suicide. Self-referentially, the study has recognized the ongoing psychodynamic treatment relationship that continued after death and acknowledged the significance of the patient and his suicide, by examining this experience of him, through the therapist’s subjective

process. She has been identified as the remaining subject of the murdered pair. Ideally, the study has expanded the collapsed space of suicide by widening the scope of interest and inquiry. So, the research has aimed to transform a positivist search into what happened into a constructivist authoring of and reckoning with a different experience: physical suicide, metaphysical death, and intersubjective life.

Significance of the Study

Continued reification of patient suicide as a traumatic loss for the therapist to bury and hide from has foreclosed the potential for post-traumatic growth and psychodynamic discovery. To ignore the clinical experience for the therapist, as she returns to her work, carrying the incontrovertible reality of suicide that lives with and inside her, has created what Lacan described as a "blind alley": one in which the therapist works, not as she did, not as who she was, and no longer with, nor completely without, her patient. So, this study has argued that her experience of suicide, never more important than the patient’s death, and her clinical work, ongoing with her dead patient and other patients, too, has warranted psychodynamic curiosity and clinical and personal concern. While her patient was alive, she, like her patient, was both subject and object of their work and of her patient; after his suicide, she became an object of his death but a remaining, changed subject of their relationship. The study has indicated that she found herself—completely lost; killed as his therapist but among the living and altered profoundly, in the clinical, relational field.

Having rendered the therapist a complex subject from inside her subjective experience allowed for an experience-near construction of the clinical, personal, psychic findings of patient suicide. Creating an autoethnographic study that gave primacy to her subjective experience aimed to deconstruct the taboos and prohibitions that sanctioned and ensured therapeutic silence. Anchoring this study has been a belief that the privacy of the consulting room, the sanctity of confidentiality to the treatment relationship and the unspeakable anguish endemic to suicide needed not foreclose or suffocate learning from this trauma. The study has identified itself with a tenet of clinical work: essential to developing knowledge, deepening understanding, and seeking therapeutic growth has remained the sharing of one’s work. In fealty to Freudian principles, advising that the search for self-knowledge serve as a central goal of the psychodynamic process, the study has conceptualized not only the patient, but the therapist, also, as subjects of inquiry. Through this specific, personal accounting of my experience, I have worked to quiet stigma about patient suicide and open up sharing about the most traumatic patient death possible for clinicians. Winnicott (1974) theorized that what patients fear most is the event that has already happened; they know, all too well, how they have suffered and dread the terror, returning as a ghost. Perhaps, likewise, this research signifies a solipsistic enactment, a defense against the unbearable pain of what has already happened and a dread of falling apart because of it.

Statement of the Problem and Objectives of the Study

Psychodynamic theory since Freud (1917) has conceptualized suicide as an intrapsychic patient event. Freud’s (1917) most seminal writing on suicide has focused

on: the individual’s biological instinct toward and fear of death; the strength or disintegration of the patient’s ego functioning; or, the internalization of and identification with a murderous, bad object. Becker (1973) argued that Freud’s key psychoanalytic theories on development were errantly interpreted relating to the individual’s conflicts to understand his unconscious and his soul. With this emphasis on the importance of making the unconscious conscious and on conflict resolution, Becker (1973) highlighted a vulnerability in psychoanalytic theory. According to Becker (1973), there has been a myopic focus on growth and an avoidance of reckoning with what he considers the essential reality of being human: death. Consequently, the therapist has learned to train her attention on the patient’s internal object world and its intrapsychic workings to understand suicide and, also to avoid the reality she works to deny, the possibility of patient suicide. Contemporary clinical training and education on the potentiality of suicide in the treatment relationship has been narrow in scope and reductive in conceptualizations. For example, poured into the foundation of clinical social work education about patient suicide has been the idea that it can be prevented. In fact, most social work programs include a curriculum of suicide assessment that portrays the patient’s intent to kill himself as an internal state of mind that the clinician can access and identify through a multiplequestion screening process. Perhaps this is best exemplified by the fact that every social work graduate or practicing clinician has memorized the following sequential suicide assessment: does the patient express suicidal ideation, offer or reveal a detailed suicide plan or intention, and/or describe the means to kill himself? Patients have become trained

in this too. When they are asked to share a deep despair, before any query, they add: I know you have to ask me do I have a plan or do I have the means to do it? Well, I don’t. Framing the work with a patient who is at risk of suicide in this way—as a state of mind that the therapist can discover through interview tools centered on risk assessment, crisis intervention, or emergency room admittance—naively and falsely has suggested to the clinician and the patient that suicide is an act the therapist can anticipate, interrupt, and then stop. In addition, the fact that many therapists’ voicemail messages include the directive to call 911 or go to the nearest emergency room in case of a clinical emergency speaks to this falsely constructed narrative. Once deconstructed, this directive appears as a defense against liability; an assumed liability the therapist guards against because of the initial problematic presumption of responsibility. A closed system has developed, one rendering the therapist a mythical creature: a person who can prevent suicide. Of course, there is inherent value in and need for clinicians to ask patients about suicidal ideation, suicidal intentions, or suicidal plans. Therapists want their patients to live. But there are profound consequences and psychodynamic implications for the therapist in the aftermath of patient suicide—amplifying the horror of the event—if the entirety of her professional training has indoctrinated her, falsely armored her, and grandiosely cloaked her with the notion that she has the power or ability to stop a patient from ending his life. It is difficult to imagine what it would mean for the social work profession if psychodynamic case studies and clinical training recognized the reality of suicide in the consultation room and death as part of the treatment relationship. Becker (1973) believes the therapist clings to her "denial of death" because to do otherwise would drive her into

madness. In addition, cultural norms collude with professional and educational conceptualizations of suicide. Because suicide has been long-recognized as a trauma of catastrophic proportion and, in that vein, unacceptable and unaccepted, systemic defenses against vulnerability to this trauma and feeling powerless in the face of it have been created. For example, there is suicide prevention week, suicide hotlines, and of late there have been shared suicide stories by people who attempted but did not "succeed" (or should it be fail) at ending their life. While there exists undeniably merit and worth to encourage and support connection and community about suicide for parents, partners, and children what has lurked wordlessly is the premise that it can be perceived and understood. This study has attempted to move patient suicide from its orphaned status and split off state through its identification and integration of the other subject in the room: the therapist. Suicide, culturally and in psychodynamic literature, has proven reductively conceived as a closed system tethered to a single experience of the patient and his object world. Becker (1973) has argued that the depth of death is too unknowable to incite further exploration. He has claimed that to alter one’s orientation to the clinical space of suicide would mean to transform it from a closed system of death. Instead, this study has imagined it as an expanded, elastic clinical therapeutic space, one that recognizes intersubjective enactments in the relational field. Literature on the topic of the therapist’s experience of patient suicide has proved organized in the following general categories: (a) articles about the experiences or "occupational hazards" of patient suicide published in medical journals geared towards psychiatrists, psychologists, and medical residents or interns; (b) articles in

psychoanalytic journals focused on the treatment of and difficulties of treating suicidal patients; (c) educational articles for "novice" social workers and therapists-in-training to support "working through" the experience of a patient suicide; (d) phenomenological studies of the psychotherapist’s experience of patient suicidality or suicide based on interviews with clinicians; (e) articles offering a clinician’s psychoanalytic formulations on the internal object world or intrapsychic dynamics of the suicidal patient. In addition, as noted, Freud (1917) theorized suicide as an intrapsychic, objectrelating experience for the patient, in "Mourning and Melancholia." Becker (1973) in Denial of Death, has explored the failure in psychoanalytic theory to address the reality of death; he has stated that psychoanalysis narrowly and mistakenly grapples only with a "symbolic" self, denying the existence of a physical "animal" self that must accept the fact of his own death. Autoethnographic literature on patient suicide has appeared non-existent. There has been autoethnographic literature focused on the experience of unexpected death, that generally has illuminated the subject’s experience of traumatic loss. This literature has included: an author’s experience of the sudden death of her spouse, in Didion’s (2005) The Year of Magical Thinking; a writer’s experience of the suicide of his good friend and colleague, Sylvia Plath, in Alvarez’s (1971) Savage God; a mother’s experience of the suicide of her son, in her letter to him, When Reasons End (Li, 2019); or, in the case of When Breathe Becomes Air, a physician, chronicles his own death from cancer (Kalanithi, 2016). Though not autoethnographic in its methodology, there appears some literature that has studied the therapist’s clinical experience of patient suicide. Alexander’s (1977)

article, "A psychotherapist’s reaction to his patient’s death," presents a case study of a patient who kills himself, focusing primarily on the therapist’s treatment approach, including his countertransference responses, and on the psychodynamics of the clinical work before, during, and after the patient’s suicide. Another study, Tillman’s (2006) "When a patient commits suicide: an empirical study of psychoanalytic clinicians," presents phenomenological research focused on the experiences of 12 therapists whose patients killed themselves during or shortly after treatment. Tillman (2006) identifies multiple "common themes," emerging around loss and trauma, unifying the experience of patient suicide amongst these clinicians, that include issues of "professional identity" and "grief" (p. 159). Lastly, Symington (2002) describes "clinical engagement" as one of life’s "perils" and suicide as the "prototype" of self-destructive activity, illustrative of "the very soul of madness" (p. 212). The work of the therapist, he has argued, is to recognize her participation in the madness as she works to contain and "absorb" the patient’s hatred (Symington, 2002, p. 213). In this act of participation, the clinician activates her "unity of being," with him, to move the mad, suicidal patient toward "sanity" (Symington, 2002, p. 213). Neither current psychoanalytic literature nor autoethnographic literature, however, has offered an autoethnographic study of the therapist’s experience of a patient suicide. First person accounts of sudden loss, traumatic death, and the loss of a loved one to suicide have emerged from the field of literature, not from the clinical field of research. Studies of patient suicide in psychoanalytical literature primarily have focused their lens inside the patient, not on the subjective world of the therapist.

In general, the therapist in current clinical literature has not been considered a subject of patient suicide. Her invisibility has reduced her into an object of patient suicide. Her absence has given way to wondering: is she hiding, ashamed, or afraid? Her silence has allowed for assumptions: she is grieving, devastated, full of regret, gripped by selfrecrimination, and remorse, feeling helpless and vulnerable. Indeed, the presence of a suicide eclipses the meaning and significance of all other experience. This study has suggested such an eclipse has foreclosed, not the opportunity, but the importance of registering her clinical experience with the social work community. Therefore, autoethnographic research, arguably, has offered essential means to understand her subjective experience and develop and deepen a clinical body of experiential knowledge of patient suicide. Ellis (2015) has claimed that the subjective experience autoethnographic research documents fosters the creation and discovery of the truth(s) of all experience. Given that truth is a social construction, Ellis (2015) has maintained that autoethnographic research functions to legitimize the formulation of knowledge through personal narrative, storytelling, and the subjective interpretation of experience. Denzin (2014) has stated that autoethnographic research concerns itself with "the metaphysics of presence," which means that "real concrete subjects live their lives with meaning," and "these meanings have a presence," in the lives of its subjects" (p. 2). In this way, he has argued, "experience lived and otherwise, is discursively constructed. It is not a foundational category" (Denzin, 2014, p. 2). So, it is important that this autoethnographic study of the therapist as a subject has an engagement in discourse with other subjects and creates a discourse where none currently exists. Rendering her

experience, a focus of study has ended a silence, called others to share their experiences, and expanded the negative space created by suicidal death.

Hypothesis and Research Questions to Explore

Clinical social work education, training and literature, has historically rendered the therapist as an object of patient suicide, casting the clinician as someone who can assess, prevent, and treat the suicidal patient, denies the reality of the therapist’s vulnerability to patient suicide. Furthermore, identifying the therapist as an interventionist blocks a deeper exploration of her clinical vulnerabilities and denies acknowledgement of her personal limitations or needs. An autoethnographic study of the clinician as a subject of patient suicide hypothesizes a poverty of knowledge on this experience and that to explore this experience could be meaningful to the field of social work. It is suspected that the rendering of patient suicide as a singular, terminal event forecloses a psychodynamic exploration of the intersubjective field of experience. Furthermore, it is hypothesized that the therapist is multi-determined: she is murdered as his therapist when he kills himself; she remains alive as a clinician and in an objectrelationship with his suicide and with him as a dead patient. It is suspected that she communicates the dynamics of this physical death as a psychodynamic death and that she experiences: concordant and corollary countertransference fears (Racker, 1968) to other suicidal patients and to suicides in other patients’ lives; unconscious communication about her identification, internalization, denial or avoidance of the suicidal patient that installs him as a dead-object, oscillating in her treatment space and inside her treatment relationships; professional norms that stigmatize her symbolization of the experience and

cultural institutions and systems organize around death religiously, medically, or on familial grounds. It is believed that the therapist lives in a dead field, yet her clinical field, requires growth and assumes life continues. Finally, it has been hypothesized that knowledge about and understanding of suicide remains fixed as an event, singular in nature, and a physical experience but that psychodynamic theory and clinical practice have become well-positioned to break apart the monolithic, positivist nature of this experience. It further has been hypothesized that contemporary, cultural, and clinical norms about suicide prevent exploration of the experience beyond its physical reality, myopically dictating that therapists disavow their psychodynamic experience of the suicide for a narcissistic investment in grandiosity. Death, as a fantasy, Becker (1973) has claimed, though welcomed into the consulting room, as a reality, has been shunned, co-opted by the medical community as a medical disease, and denied by psychoanalytic theory.

Theoretical and Operational Definitions of Major Concepts

One key definition explored in this study has included psychoanalytic conceptualizations and theorizing about patient suicide. Suicide, as defined by Freud (1917) and Green (cited in Kohon, 1999) seems understood not only as an object experience, but a negation or an absence of object-relating. Freud (1917) believed the ego can "kill itself," rendering suicide an internal object experience. Green (cited in Kohon, 1999); however, conceptualized suicide not as an act of aggression or hatred turned against the ego but a withdrawal of object-investment, rendering the patient’s

suicide an "unintrojectable object," a "dead" object, forever relegating the subject’s objects "not wholly within, and not quite without" (p. 154). Importantly, the theorization of suicide as an object-relating experience has provided a recognition of the existence of a subject. Thus, the concept of intersubjectivity—of multiple subjective experiences in a relational field—has conceived of the therapist’s subjective experience of her objects and of being an object, too. It has been theorized that the intersubjective relationship formed while the patient was alive created an analytic third that remains, and whose "traces" remain, as an "experience of being:" and in this instance, of being the subject of the patient’s suicide (Ogden, 2004). Arguably, identifying the therapist as a subject has challenged reductive, binary, and singular identifications of subject-object in the object-relating pair to multiplydetermined identifications that include subject-subject. In other words, to conceptualize the therapist as a subject has first asked: what makes a subject? Admittedly, the therapist has always been the subject of her experience, even now of the patient, dead; however, she has also become the object of his suicide. Green (2002) has argued that: "‘intersubjective’ does not mean either ‘interpersonal’ or ‘interactive.’ It refers to the relation between two subjects, which requires one to define what a subject is (Green, 2002). As Freud (1917) stated and Bollas (1987) re-interpreted, where the object goes a subject must be. To this point, Green (cited in Kohon, 1999) has argued that the "essential function," of the subject is to "create objects" (p. 35). Thus, one aspect of conceptualizing the therapist as a subject has included an identification not only of her experiences of suicide as an absence and a negation, but her creation of objects in this lack or gap: therefore, concepts, in addition to the analytic

third, of a potential space and negation, have proven important to define theoretically. For example, Balint (1958) has described the presence of a subject "on his own," where there is "not external object present [as] the area of creation" (p. 337). What characterizes the work of being a subject, in this "area," according to Balint (1958), is that the subject must "produce something out of himself; this something to be produced may be an object but is not necessarily so" (p. 337). Hence, the operational questions that have been essential to this study included: what creates a subject, what is the role of objects in the work of becoming a subject, and what emerges in the space between subject-subject and subject-object.

Assumptions.

One of the key assumptions of this study has been that a gap exists in understanding patient suicide as an intersubjective clinical experience and in recognizing the therapist, not as a surviving witness, but a murdered partner. This assumption has insisted that there is another experience—that of the therapist’s—significant to understand and register. To this point, Gergen (1998) has stated that "In a materialist culture, natural science claims are trusted more than others; we can be certain of atoms and neurons, as it goes, but we are less certain of unconscious process and the world of spirit is scarcely in the running" (p. 48). Another key, corollary assumption of this study has problematized the therapist’s silenced and un-symbolized experience of patient suicide and has viewed the subordination of her subjectivity as a professionally and culturally sanctioned death, endemic to the trauma. Inside and surrounding this multi-dimensional trauma of patient

suicide, it has been assumed that collusive forces mobilize to singularize the therapist’s subjective experience into concrete conceptualizations: professional idolatry of therapists as suicide-preventers or suicide-assessors; false and facile medicalizations of the event of patient-suicide; misplaced identifications or misunderstandings of patient suicide as a death like any other to mourn; and limited to non-existent clinical case material or consultation on the therapist as a participant, both subject and object of the patient’s suicide. Instead, this study has assumed that suicidal-death in the treatment relationship can be experienced and investigated as a dynamic, and changed, intersubjective field and that core psychoanalytic principles and theories on transference, countertransference, projective identification, and unconscious communication can be at work with a dead patient, not only a physically alive patient. It has been accepted that the therapist subjectively experiences object-relating with multiple imagined, created, or absent objects. The researcher also assumed that to suggest a metaphysical or transcendental encounter with suicidal death strains the conventions of traditional psychoanalytic inquiry, thereby necessitating an inclusion of other, multi-disciplinary applications of literature and philosophy to expand the clinical exploration. One final assumption has included this recognition: any attempt to render meaning from the experience of patient suicide represents, to some extent, what Becker (1973) has named a denial of the "oblivion" of death; in fact, Becker (1973) has suggested that to find a "larger meaning" and to "pursue the psychoanalytic movement," in any form, represents an effort to "reflect power back" onto the therapist-self and to deny the helplessness one faces with the reality of death (p. 116). In other words, perhaps the only

authentic and honest acknowledgment of the experience of patient suicide would have been an empty, wordless page: this study has accepted that truth in search of other true experiences. In sum, this study has considered the following questions, as essential to the field of social work: (a) How does the therapist symbolize, verbalize, and render visible her experience of patient suicide outside the professional norms of griever, consoler, or guilty participant and witness in the context of confidentiality?; (b) What are the other institutional and cultural binds that the therapist encounters in the face of patient suicide that contribute to silencing her?; (c) How do cultural and professional norms in response to suicide collapse the clinical space, further isolating the therapist in her experience?; (d) How does the therapist’s story authenticate patient suicide, not simply as a physical death, but as intersubjective-field of object relations with the dead patient and with the suicide as an object, also?; (e) How does the therapist’s experience of patient suicide affect her clinical practice in the subsequent year and change her experience of and working with the reality of death in the clinical space?; (f) What are the implications for the clinical field of social work through this exploration of the therapist as a subject of patient suicide?

Epistemological foundation.

The epistemological foundation for this research has been located within a social constructivist paradigm, largely because of its conceptualization of truth and reality. According to Gergen (1998), within the social constructivist framework, the concept of truth and the idea of "truth-telling" have been best explored and understood through our

interactions with others, framing these truths as co-constructed, multi-dimensional, continuous, and generative. This constructivist conceptualization of what creates a true or real experience has countered a positivist framing of truth, which has envisioned reality as a fact or facts found, buried, or discovered. Also, the constructivist valuing of narrative truth, in which experience renders truth from the telling of it, has rejected the concept of historical truth, in which the researcher has set herself to discover what "really happened" (Spence, 1982, p. 32). Instead, in a social constructivist view, subjects create meaning and truth emerges from the subjective interactions with other subjects and objects. Contextualized by a postmodern lens, the social constructivist paradigm has envisioned the researcher as an "activist" who has rendered "multiple framings of reality" from her experiences and relationships (Gergen, 1998, p. 12). Autoethnographic research, having found its home in a social constructivist view of life experience, has grounded the study of the therapist’s subjective experience in assumptions about the multiplicity of truth in the realm of social experience. According to Ellis (2015) the autoethnographer engages herself in the social-relational field with "critical reflexivity" viewing reality as multiple, co-determined, and engaging singular realities with doubt, curiosity, and discussion. In addition, the autoethnographer has assumed that "social life is messy, uncertain and emotional" (Ellis, 2015, p. 9). In sum, Ellis, Jones and Adams (2015) have asserted that: "If our desire is to research social life, then we must embrace a research method that, to the best of its/our ability, acknowledges and accommodates mess and chaos, uncertainty and emotion" (p. 9).

In fact, a social constructivist epistemology argues that challenging conventions has been essential. Gergen (1998) has pointed out that the acceptance of "truth" without challenge has been part what fosters oppression, hatred, and murder and that constructions and conventions survive when there is a "social utility" protecting these conventions from being questioned (pp. 10-11). Suicide, a tragic event forever shrouded in mystery and the unknown, too often has bound the therapist to this endless, dead loop of inquiry: (a) What happened?; (b) How did it happen?; (c) Why didn’t I know?; (d) Could I have done more? The conventional clinical conceptualization of suicide as an event, whose inquiry turns inward towards the patient while he was alive, has functioned to protect the therapist from inquiry into her lifework in the context of this death. If she continued simply to tell herself: I did all that I could, then what remains lost has been an experience unexplored.

Foregrounding.

Interest in this topic has been forged from recent clinical experience: a patient killed himself. When he murdered himself, his life ended, and he simultaneously and permanently altered mine. Undeniably, there can be no greater loss than death. The suicide of a patient, the occurrence of it—for all time—overshadows any other experience in the therapist’s life. In truth, there only exists the death by suicide. Yet, from this reality, has emerged other real, important experiences. There has been a sense of being lost, dead, and killed-off—as if in a perpetual liminal state, psychologically both awake and asleep, and there has remained, quite oddly, a constant, object-interaction with him as a dead patient and with his suicide as an object, too.

What has seemed available to me as his therapist has felt insufficient yet, to identify and explore this lack, has appeared grandiosely, self-involved. In this gap; however, there has been license to focus on the ethical implications and legal consequences; to derive a sense of purpose in offering comfort to the family; to participate, in the community of mourners at his funeral; or, herein, to study the experience from inside it, in hopes that the absence fills with something or with something more than the nothing-of-him. The medical community, the religious community, the norms of the social workers community, none of the other identified arenas, have captured my experience of him, either alive with me or my experience of myself, dead with him. The state of non-being as his therapist, the experience of relating by non-relating with him, and object-relating with his suicide has presented an unarticulated subjective experience—of being a subject of his suicide and of being without him as a co-subject. My assumptions have included a belief or perhaps a need to believe that an autoethnographic exploration of this experience has yielded experiences represented by more than absence. Ogden (2004) has stated that the "partial collapse of the unconscious dialectical movement of individual subjectivity and intersubjectivity" leads to "the creation of a subjugating analytic third" (p. 193). This "subjugating analytic third becomes a vehicle through which thoughts may be thought, feelings may be felt, sensations may be experienced;" however, for growth to occur, the "individual subjectivity" must become an experience of "intersubjectivity" allowing for "oneness and twoness" (p. 190), not only a separateness.

When there is this "failure of recognition of each by the other," Ogden (2004) has argued that the subject experiences a "dead unity" and the self as a "static, non-selfreflective being" (p. 193). And, in describing the analyst’s response to a patient, whose emptiness marks a dead-object introject and an absent, object-identification, Green (1986) has stated, "I greatly fear that the rule of silence, in these cases, only perpetuates the transference of blank mourning for the mother" (p. 155). Having experienced this fear as a therapist, one whose transference became fixed on a dead patient and his suicide, I have identified a need for representation in language and in symbolization in order to transform "negative identification" (Green, 1986, p. 155) into a different, not necessarily good, but other, object-experience.

Chapter II

Literature Review

Introduction

A review of the literature on the therapist’s experience of patient suicide has exposed a fault line, indicating a discontinuity of psychodynamic discourse and clinical inquiry into a subjective account of the psychodynamic experience of patient suicide. Existing theoretical literature and clinical material has focused on the intrapsychic and interpersonal dynamics of death, including the absence of object-life; what has not been found in the literature includes attention to the aftermath and, to what remains, for the therapist whose patient commits suicide. Part of the work to understand this experience began with the body of knowledge that potentially or partially speaks to aspects or elements of the therapist’s subjective experience. In identifying and defining these essential aspects of the therapist’s experience, what has emerged are the following conceptual categories: (a) theories on responses to death, suicide, mourning, and object loss; (b) theorizing about intersubjectivity, subject-subject relating and the analytic third; (c) the theoretical conceptualization of the therapist as a subject of the dead patient and his suicide; (d) countertransference experiences with a dead patient; (e) conceptualizations of the subjective experience of suicide as a psychic, relational, multi-dimensional object field; (f) psychoanalytic and social-historical

conceptualizations of suicide as a singular event, a therapeutic failure, or a social construct; (g) methodological literature on autoethnography and the work of the "I"; (h) and finally, grounding theories of social constructivism and hermeneutics as legitimate, invaluable means for generating understanding, meaning, and truth. As the literature review has aimed to explore the therapist as a subject of suicide, it has served to identify gaps in historical and contemporary psychoanalytic conceptualizations of patient suicide as well. Also, the review has striven to identify an absence of literature that recognizes patient suicide as a continuous object-relating experience. The intended audience of this literature review has been the psychodynamic community of theorists and clinicians. Foremost, was a hope that those therapists, who experience the suicide of a patient, do not relocate themselves, however silently, invisibly, or indeterminately, to wandering around the graveyard of their own killing fields, psychically not-dead but also not-quite-alive.

Foundational Psychoanalytic Theories on Death, Suicide, and Object Loss

Beginning with Freud, psychoanalytic theorists have attempted to understand how the subject lives with the reality of death and to imagine the intrapsychic experience of suicide. To conceptualize and study the therapist, as a subject of patient suicide, has required a recognition of the theoretical surroundings created by psychoanalytic literature that has, understandably, shaped and informed her experience of death, suicide and object loss.

Death and mourning conceptualized as intrapsychic and intersubjective: Freud.

The foundational psychoanalytic theorizing about suicide and object loss in Freud’s (1917) "Mourning and Melancholia." Freud (1917) has set the theoretical groundwork on which psychoanalytic understanding of suicide became conceptualized as an intrapsychic, object experience and simultaneously laid the framework for future theorists to conceptualize the experience of the subject relating in an intersubjective object-field. Describing his conceptualization of suicide as an intrapsychic experience, Freud (1917) explained what renders melancholia, the refusal to mourn object loss, so "dangerous" (p. 252). According to Freud (1917) ". . . the ego can kill itself only if . . . it can treat itself as an object—if it is able to direct against itself the hostility which relates to an object and which represents the ego’s original reaction to objects in the external world" (p. 252). Therefore, for both "being most intensely in love" and suicide, "the ego is overwhelmed by the object, though in totally different ways" (Freud, 1917, p. 252). With characteristic prescience, Freud (1917) outlined the framework for an intersubjective experience of death: he explained that as one subject’s ego turns against itself in suicide, there exists another subject, the mourner, who faces a choice of either "withdrawal of the libido from this object" or an "identification of the ego with the abandoned object" (p. 249). In this construction, Freud (1917) suggested the experience of the therapist-subject, abandoned by the dead patient-object, faces the threat of her own psychic death, her potential identification with the dead patient preternaturally engendered her intrapsychic death as the therapist. Furthermore, in the Ego and the Id, as Freud (1923) conceptualized death as an egoexperience, he expanded the template for psychoanalytic understanding of death from an

intrapsychic to an intersubjective object-relating experience, opening a theoretical door to explore the therapist’s experience of patient death. Freud (1923) stated: "We know that the fear of death makes its appearance under two conditions . . . namely, as a reaction to an external danger and as an internal process, for instance in melancholia" (p. 61). In this recognition of response to death as both an internal and external object-experience, Freud (1923) circumscribed a theoretical frame for the subjective experience of suicide as an intersubjective relationship and the suicide as a subjective object.

Mourning and suicide conceptualized as a violent internal object world: Klein.

Furthering Freud’s (1917, 1923) work to understand suicide and death, in Love, Hate, and Reparation, Klein (1964) theorized that suicide results from an introjection of "harsh" object-figures and "harsh" feelings about those objects creating an "internal warfare" and a "vindictive conscience" (p. 114). The internal object experience of this hatred in "relation to ourselves," Klein (1964) believed, can "lead to suicide" (p. 114) and that these internal object projections can "become a source of danger in human relationships" (Klein, 1964, p. 60). Thus, Klein (1964) aptly characterized the powerful reality that one’s capacity for hatred and destruction cements the eternal possibility of suicide, either by the patient mobilizing his "internal warfare" into a murderous hatred against one’s self or projecting the violent hatred onto the therapist. In response to this violent projection, when introjected by the therapist, she could experience a hateful murderous introject (Klein, 1964). In addition, Klein (1940) conceptualized the work of de-idealization which disturbs the work of "normal mourning" and imagines the therapist’s experience, as a mourner of

patient suicide, to be full of potential for her to experience a violent, persecutory internal object world. Klein (1964) has argued that "The greatest danger for the mourner comes from the turning of his hatred against the lost loved person himself" (p. 136). In theorizing about the internal object experience of the mourner, as the therapist might be conceptualized in this study, Klein (1940) offered this insight: "When hatred of the lost loved object in its various manifestations gets the upper hand in the mourner, this not only turns the loved lost person into a persecutor, but shakes the mourner’s belief in his good inner objects as well" (p. 136). In this way, Klein (1964) has forecast the therapist’s vulnerability to persecutory, suicidal introjects that cause good object death.

Death as an ineffable experience to construct, conceptualize or accept.

Also, the psychoanalytic literature has acknowledged a paradigmatic, enigmatic, or recursive challenge. Not only does understanding the subject’s experience of death prove conceptually complex but, recognizing this ever-present reality of death, has been difficult too. For example, Freud (1930) himself admitted an initial resistance to the notion that man struggles with his instincts for destruction, having stated "how long it took" for him to acknowledge the death instinct. In Civilization and Its Discontents, Freud (1930) claimed that the "meaning of the evolution of civilization" is "the struggle between Eros and Death" (p. 111). In fact, "this struggle," according to Freud (1930), "is what all life essentially consists of, and the evolution of civilization may therefore be simply described as the struggle for life of the human species" (p. 111). But the therapist in the consulting room with her patient might not consciously recognize Freud’s conceptualization of the challenge that death poses to civilization; instead, she might

falsely imagine his theorizing as only relevant to the world at large, or to groups in a culture, and mistakenly not incorporate his thinking to the therapeutic dyad. In an avoidant stance or an act of complicit denial, the therapist herself might easily avoid, deny, or wish for death to remain outside her office door (Hoffman, 2000). In Denial of Death, Becker (1973) elucidated what he describes as a core paradox man faces: "the truth that he is an inner symbolic self, which signifies a certain freedom, and that he is bound by a finite body, which limits that freedom" (Becker, 1973, p. 75). According to Becker (1973), the more one has sought in Freudian psychology to know the self, the more one has faced this "irony of man’s condition" and, has argued that this "deepest need is to be free of the anxiety of death and annihilation; but it is life itself which awakens it, and so we must shrink from being fully alive" (p. 66). In this paradigmatic way, Becker (1973) believed Freud perpetrated "a fiction of death" through a conceptualization of death as an instinct, not a reality (p. 99). Therefore, as a result, according to Becker (1973), this resistance to the reality of death, and the terror of living with that reality, has coursed through psychoanalytic theory undeterred since Freud. Perhaps, in this study, as I have attempted to understand my experience of the suicide of my patient, there has been a seductive pull and a psychoanalytic collusion to locate my dead patient and his suicide as outside of my relationship with him, rendering his suicide an event that occurred outside of my presence and; therefore, falsely constructed as outside the realm of my experience.

Conceptualizing Multiple Subjectivities and Death as the Analytic Third

Psychoanalytic literature on the theory of intersubjectivity and the analytic third has made possible a conceptualization of the therapist as a subject (and object) of the patient and, simultaneously, a subject of the suicide.

The dynamics of subject-subject relating: Benjamin on intersubjectivity.

In defining an intersubjective psychoanalytic model, Benjamin (1990) has identified "two categories of experience as the intrapsychic and the intersubjective dimensions" (Benjamin, 1990, p. 185). What differentiates an intrapsychic dimension of experience from an intersubjective dimension of experience, according to Benjamin (1990), has stemmed from the capacity for mutual recognition between two subjects. This capacity, Benjamin (1990) has argued, exists not in a fixed state but rather a state of "constant tension between recognizing the other and asserting the self" (p. 191). Through the act of "negating and obliterating" the object, Benjamin (1990) has believed the subject discovers if the other exists outside the self "in her own right," or only as an "intrapsychic" object to use in fantasy, not reality (p. 192). This concept holds potential relevance to this research topic if, as might be imagined, the intersubjective space has collapsed with a patient suicide. The therapist can no longer experience mutual recognition yet, she remained the subject of the patient’s suicide, and of the patient, as different objects. Speaking to the significance of mutuality to the analytic dyad, Benjamin (1990) has claimed that a relationship remains fixed in a "complementary structure," of "giver and taker, doer and done to, powerful and

powerless," and that, if there is no opportunity to "dissolve omnipotence," then "power is transferred back and forth in an endless cycle" (p. 194). Thus Benjamin’s (1990) theorizing on intersubjectivity has had the potential to characterize the aftermath of patient suicide as something other than a singular physical death, as the therapist faces her own powerlessness. Her (false) sense of omnipotence has been not so much dissolved as frozen in the experience, left to wonder what more could have been done and, simultaneously, to recognize that nothing more is possible has left her forever hanging between the realities of two different dimensions, her collapsed subject-self and a dead object world.

The functions and work of being a subject: Green.

In addition to the literature that has enabled the conceptualization of the therapist’s experience of patient suicide as an intersubjective object-experience, this study has led to literature that also has theorized the multiple-subject arena of what creates a subject. According to Green (2002), ". . . ‘intersubjective’ does not mean either ‘interpersonal’ or ‘interactive,’ it refers to the relation between two subjects, which requires one to define what a subject is. More often than not, this definition is neglected or hidden" (Green, 2002, p. 69). To develop this conceptualization, Green (cited in Kohon, 1999) has suggested: "What I have proposed is the concept of what I have called the ‘objectalising function.’ What I mean is that one of the main aims of psychic function is to create objects. Not only to relate to objects but to create them" (p. 35). Theoretically, therefore, it is through this "objectalising" process, that the therapist might create an object of the suicide, one

that co-exists with the dead patient object and one with whom the therapist forms an identification (Green cited in Kohon, 1999). In this way, the literature has suggested the possibility that the subject-therapist relates to the suicide by installing it as an object, that she forms an identification with, in her own dead-state of patient loss.

Changes in subjectivity and death’s creation of a third: Ogden.

Additional literature relevant to the study has explored the limits or elasticity of intersubjective/subject-subject, relating in the context of patient suicide, for instance, can the therapist remain a subject, one who interacts with the dead patient, even when her dyadic subject is no longer alive? Winnicott’s notion that there is no infant without a mother has provided one response to this question. Also, Ogden (1994) has stated: "I believe that, in an analytic context, there is no such thing as an analysand apart from the relationship with the analyst, and no such thing as an analyst apart from the relationship with the analysand" (p. 4). In fact, according to Ogden (2004) "Human beings have a need as deep as hunger and thirst to establish intersubjective constructions (including projective identifications) in order to find an exit from unending, futile wanderings in their own internal object world" (p. 193). In this context, according to Ogden (1994), "The intersubjective and individually subjective each create, negate and preserve the other" (p. 5). In this way, the theory of intersubjectivity has fostered an acceptance of the therapist as a subject and made room for understanding a paradox inherent to her experience; her patient’s suicide includes a change in her subjectivity concurrent with a destruction of her as a subject, her

subjective experience of her patient as a dead object co-creates her eternal preservation as a negation of being a subject. Importantly, the literature that has spoken to this experience of negation in the intersubjective field has conceptualized the creation of an analytic third, even when subject-subject relating collapses. According to Ogden (2004), "If there is a failure of recognition by each other, ‘the middle term [the dialectical tension] collapses,’ into ‘a dead unity’ of static, non-self, reflective being" (p. 192). And, he has stated what results: ". . . there is a partial collapse of the unconscious dialectical movement of individual subjectivity and intersubjectivity, resulting in the creation of a subjugating analytic third (within which the individual subjectivities of the participants are to a large degree subsumed)" (Ogden, 2004, p. 193). This conceptualization has highlighted the collapse between subject that the suicide—as a third—has created.

Conceptualizations of Therapist as a Subject in Her Dead Object World

The recognition of the therapist as a subject worthy of exploration does not appear frequently in psychoanalytic literature. In fact, literature and poetry have more often acknowledged the voices of subjects who grapple with their experience of death.

Hughes on the subjective experience of suicide.

In the Birthday Letters, Hughes (1998) has written about his experience of his wife, Sylvia Plath’s suicide, giving image to an intersubjective experience of that death: "You are ten years dead. It is only a story. / Your story. My story" (p. 9). In his only

personal exploration of both his life with her and his loss of her, Hughes (1998) has depicted her suicide as an analytic third of their marriage: "Was Death, too, part of our luggage?" (p. 111). And, interestingly enough, he has identified an ongoing subjective relationship with a dead-object, through his active psychic object-relating with her now dead. In "Life After Death," Hughes (1998) offers: "What I can tell you that you do not know / Of the life after death?" (p. 182).

Didion and the subjective experience of death.

Also, Didion’s (2007) Year of Magical Thinking has provided a window into the subject’s experience of death. Written in the year following her husband’s unexpected death, Didion (2007) has explored her "magical thinking," that she might have been able to prevent his death, and has described her modes of suspending reality to forestall grieving her loss. Unable to move his shoes from beside his reading chair, she poignantly characterizes the fantasy, one imaginably endemic to the experience of patient suicide, that he is not gone.

The therapist as a self and a death survivor.

Accounts of the therapist as subject of death have been found in psychoanalytic literature, such as Chasen’s (1996) "Death of a psychoanalyst’s child." Chasen (1996) chronicled her experience as a therapist following the death of her 12-year-old son. In an autoethnographic account of aspects of her experience, including, "First Day Back at Work," "How Patients Found Out," "To Tell or Not to Tell," and, "My Suicidal Wish,"

Chasen (1996) has described the importance of "being productive" at work, of her connection with her patients being essential to her mourning, and the ongoing, unbearable pain of her loss that she does not hide nor initiate sharing with her patients; instead, she has described, with each patient, tending to her clinical work, with a sometimes spoken, sometimes more hidden subjective self.

Green on the subjective experience of absence and negation.

Constructing an identification or recognition of the therapist as a subject, in the face of patient suicide, has been axiomatically necessary in order to study the efforts to understand the subject’s experience of loss. The primary literature that speaks to the subject’s identification with negation, and of the presence of constant absence, has been "The Dead Mother" (Green, 1986). In "the Dead Mother" Green (1986), has detailed an intrapsychic process by which "the object has been encapsulated and its trace has been lost . . . transforming a positive identification into negative identification, i.e. identification with the hole" (p. 155). In this process, Green has conceptualized a mirror to the therapist’s experience of object-relating to the suicide as a present absence. Green (1986) has depicted the object-relating with an absent object that speaks to the subject who relates with the patient and the suicide: his suicide and his object function, as a dead patient, keeps her at psychic work, in a constellation of dead objects, and rooted in her own concordant deadness. "This is to say that when the analyst succeeds in touching an important element of the nuclear complex of the dead mother, for a brief instant, the subject feels himself to be empty, blank, as though he were deprived of a stop-gap object, and a guard against madness" (Green, 1986, p. 162).

Dead object usage and the self as an object: Winnicott and Bollas.

In addition, Winnicott’s (1969) theorizing on object-relating and object usage has provided a foundation to consider aspects of the therapist’s experience of patient suicide as a failure in object usage, as in the failure of the therapist to be of any further use to the patient. Suicide destroys the therapist as a usable object, abandoning her to a state of object-relating with her dead objects: the dead patient and the suicide. She has been confronted with her capacity to survive this destruction and if she does, she wonders: whose object is she or she is an object at all? Bollas (1983) has stated that: "Each of us is perpetually engaged in a complex relationship to the self as an object" (p. 8). He has argued, "Patients create environments. Each environment is idiomatic and therefore unique." (Bollas, 1983, p. 4). In this way, Bollas (1983) has suggested the therapist might relate to herself, as an object, one abandoned by the dead patient, rendering the therapist, a self whose objects include the dead patient and herself as a surviving object. Object survival, however, has begged further definition. Surviving implies remaining alive and ignores the psychic or functional death. To define an object as surviving contrasts with the reality that the therapist has been murdered as the therapeutic object with the patient’s suicide. This would seem a form of total annihilation on the part of the patient, not only of himself, but of her as an object: a death of their dyad. Winnicott (1969) has provided this conceptualization, delimiting the notions of destruction and survival: ". . . after ‘subject relates to object’ comes ‘subject destroys object’ . . . and then may come ‘object survives destruction by the subject’. But there may or may not be survival" (Winnicott, 1969, p. 713); ". . . The word ‘destruction’ is needed, not because of

the baby’s impulse to destroy, but because of the object’s liability not to survive." (Winnicott, 1969, pp. 714-715). Indeed, the subject’s survival of her object death may not be best or most accurately described by the fact that she has remained alive.

Countertransference Realities and Fantasies: The Subjective Experiences of a Dead Patient.

One central aspect of the therapist’s experience as a subject included her countertransference to her patient. Notably, her countertransference experiences and expressions remained alive in the intersubjective and object relational field even after her patient committed suicide. As these fantasies and realities have emerged, the literature has indicated that further examination of this psychic content has been warranted. The importance of understanding transference-countertransference as part of the analytic situation has been widely established (Racker, 1968). And, there has been no reason to believe that countertransference experience dies with the patient; in fact, exploration of countertransference material with a dead patient has seemed essential in deepening the understanding of the therapist’s experience of suicide. Racker (1968) has argued there are psychically dangerous consequences for the therapist who does not make herself aware of her countertransference material: Every transference situation provokes a countertransference situation, which arises out of the analyst’s identification of himself with the analysand’s (internal) objects . . . These countertransference reactions are governed by the laws of the general and individual unconscious. . . . It is of great importance that the analyst be conscious of

the law, for awareness of it is fundamental to avoid ‘drowning’ in the countertransference. (p. 137) Identification of what has constituted countertransference responses to a dead patient potentially included: the therapist’s fantasies, unconscious communications, and conscious struggles with realities related to her patient (dead and alive). In sum, her countertransference, as imagined by Bollas (1983), has been best characterized by her experience of his suicide, not her knowledge of his suicide: The most ordinary countertransference state is a not knowing yet an experiencing one. I know that I am in the process of experience something, but I do not as yet know what it is, and I may have to sustain this not knowing for a long time. (p. 4) Furthermore, Bollas (1983) has argued for an awareness and openness to experiencing countertransference material as part of the therapist’s location of who she is as a therapist and as a person: I find that to discover where I am, what I am, who I am, how I am meant to function, and in what psychodevelopmental time of the patient I live in, these features of the countertransference take months and years to see. (p. 5)

Conceptualizations of Suicide: Intrapsychic Event, Social Construct, Therapeutic Failure

What has dominated the literature appears a rendering of patient suicide as an internal, individual experience or a dyadic response to object-relating with the therapist. Suicide, in the literature, has been most widely examined from outside the patient’s internal object world, through projections, fantasy, or the literature, has addressed the

internal world of the patient dying by suicide. What happened and why, understandably, have been questions the literature historically has attempted to address.

Suicide, an intrapsychic experience not a singular, physical event.

For example, Asch (1980) has understood the suicidal patient to be an individual who fantasizes about his object relationships, including his relationship with "Death." Therefore, Asch (1980) has indicated that an examination of the patient’s internal conflicts and fantasies has been necessary to deepen understanding of the suicidal patient. Because Asch (1980) has focused his inquiry on the patient’s projections and identifications, his lack of interest in the therapist’s experience of projections and identifications has illustrated the myopic scope of literature trained on the internal object world of the patient. Other literature has offered its recognition of the therapist’s identification as an object. For example, Bell (2000) has focused on the internal, intrapsychic dynamic of suicide as a phenomenon, conceptualizing the therapist as an object of the suicide. All suicides, Bell claims, can be viewed as an "attack upon an object," specifically a "hated" object, and, simultaneously, an attack "upon the self" (p. 24). Bell’s theorizing has mirrored the conceptualizations of suicide by Freud (1917); in addition, Bell (2000) has argued that the patient who commits suicide is not only killing the self but is attempting to "murder" the bad object introjects with whom he has now identified: it is an object, he can no longer tolerate. The therapist, in this dynamic, according to Bell (2000), often holds the split off part of the patient, the part of the self that wishes to live.

Suicide as a social, cultural, and historical construction.

Counter to psychoanalytic reifications of suicide as an individualized, singular event, in Savage Gods, Alvarez (1971) has provided an expansive inquiry into the social, cultural, historical constructions, as well as his personal understandings of suicide. In addition, Alvarez (1971) has positioned himself inside the experience of suicide, as a subject, noting his multi-dimensional experience of one, who both attempted suicide and whose friend, Sylvia Plath, died by suicide. Alvarez’s (1971) pluralistic journey into the historical, cultural, analytic, and personal interpretations of suicide, not as a positivist phenomenon, has suggested that suicide be examined as a social construction reflecting more about culture than the individual. In his chapter on the historical context of suicide, Alvarez (1971) has traced its origins to: its beginnings as a moral failure; its celebration in the violent Roman empire; its transformation into a scientific sociological event; its status as an event to hide, as once suicide was considered to reflect on the ills of society. In addition, Alvarez (1971) has pointed to the dearth of attention in psychoanalytic literature with highlighted "fallacies," rendering suicide either a romantic gesture, a scientific phenomenon to study, or, ultimately, a shameful secret. Most importantly, Alvarez (1971) has suspected that the ego of the psychoanalyst ensures or silences any discourse on the topic. In his assessment of psychoanalytic silence overall, he believes an implicit belief announces itself: what else can be made of the analyst whose patient kills himself except that she has failed? (Alvarez, 1971). In fact, according to Alvarez (1971), "the analyst can only deal with suicidal threats and attempts: the successful suicide is, in every sense, beyond him" (p. 98). "As a result,"

Alvarez (1971) has claimed, "suicide has been dealt with largely on the side, in its relationship to topics which provide the analysts with more precise and verifiable clinical material" (p. 98). Given the dearth of psychoanalytic literature, providing "verifiable clinical material," this field of inquiry has been expanded by entering the realm of the clinician’s subjective experience through autoethnography.

Therapeutic failure and narcissistic injury: Clinical silence on suicide.

Quite possibly the literature, most similar to the research topic, has been found in Tillman’s (2006) interviews of psychotherapists: "When a patient commits suicide: an empirical study of psychoanalytic clinicians." In the study, Tillman (2006) has interviewed twelve psychotherapists/psychoanalysts who had experienced a patient commit suicide either while or soon after being in treatment. Using a phenomenological interview, Tillman (2006) has posed the following research question to her subjects: "I am conducting a study about the effect of patient suicide on clinicians; I am interested in how this event has affected you. Would you tell me, in as much detail as possible, about your experience?" (p. 162) After analyzing her data, Tillman’s (2006) findings centered on "eight themes" that she grouped into three main categories: "traumatic loss and grief," "interpersonal relationships," and "professional identity concerns." Of interest and relevance to this study, Tillman (2006) found a "silence in the professional community" that created and "served as a resistance" to the ability for therapists to process their experiences more deeply (p. 162).

Autoethnographic Literature: The "I" as a Source of Truth and Reality

The literature on autoethnography (Ellis, Jones, & Adams, 2015; Denzin, 2014) as a research methodology has proved essential to legitimizing the subjective experience of the therapist and the "I" as a primary source of truth as a meaning-maker, a truth-seeker, and a constructive force of knowledge and experience. Not only has the literature rendered subjective experience primary but it also has characterized the work to explore marginalized voices as necessary.

Subjective experience as a means for creating knowledge.

For example, Ellis, Jones and Adams (2015) have provided a rigorous argument for autoethnography as an essential form of scientific research that legitimizes the subjective experience as a form of creating meaning and gaining knowledge. Their work in autoethnographic research has affirmed the role of the "I" as a means to engage with reality, thus underscoring that the work to inquire into the subjective experience of the therapist generates knowledge (Ellis, Jones, and Adams, 2015). Key points have included their recognition that: all knowledge is based in subjective interpretation; no research is truly objective; truth is a social construction; subjective experience is essential to creating and discovering the truth(s) of any experience; biases prevail that marginalize storytelling or narrative, rendering autoethnography vulnerable, as a form of research (Ellis, Jones, and Adams, 2015).

The primacy of the self and the personal: Essential to discourse and inquiry.

In addition, Denzin (2014) has argued that autoethnographic research not only counters the concretization of truth and knowledge, but in so doing creates a dialogue between self and "the world" with the aim of change and action. Experientially grounded, these texts speak alongside the voices of science, privileging the personal over the institutional. So, conceived, this form of textuality challenges empirical science’s hegemonic control over qualitative inquiry. Refusing the identity of empirical science, the experiential text becomes a form of social criticism that no longer seeks validation in scientific discourse." (Denzin, 2014, p. 83) Thus, this notion of self-experience as a catalyst for dialogic engagement has underscored the aim of this study to fill the void in psychoanalytic literature.

Truth is constructed from the personal.

Wall (2008), too, has made the argument for the acceptability and legitimization of autoethnography as a form of research. Highlighting the postmodernist tradition out of which auto-ethnography has emerged, Wall (2008) has stated that the "truth" of a personal experience signifies a "representation" of life, self, and culture that warrants a relevance and a primacy superordinate over other forms of knowing, knowledge, and rendering meaning. In addition, Wall (2008) has argued against rendering objectivity a research or epistemological ideal, claiming scientific valorization of objectivity has become a screen behind which experience, reality, and self are hidden remotely and out

of reach for participation, response, integration, or interaction. True research, according to Wall (2008) must be dynamic and collaborative. An important component to this research question has included the ethics of the discussion of patient suicide, including the idea that any other experience outside the patient’s death warrants interest or clinical attention. Wall (2008) has stated that the ethics of auto-ethnography raise issues similar to those that face any researcher, asking the autoethnographer to consider: how does this work represent or not speak for the vulnerable. Furthermore, Wall (2008) has framed it as an ethical demand and expectation to respect all forms "knowledge," be it personal, experiential, or observed.

The Role of Social Constructivist and Hermeneutic Literature to Defining Knowledge

The literature on hermeneutics and social construction has provided this autoethnographic study an important epistemological foundation for the research to affirm subjective experience as a legitimate form of understanding and to symbolize and interpret what has rendered that experience significant and real.

The hermeneutic circle and the pluralism of truth.

The centrality of hermeneutics has made defining what constitutes this perspective of creating understanding important. Of this epistemological framework, Gadamer (1965) has offered: "We recall the hermeneutical rule that we must understand the whole in terms of the detail and the detail in terms of the whole;" "The movement of

understanding is constantly from the whole to the part and back to the whole" (p. 291). Thus, inside this circle, the autoethnographic study of the therapist’s experience— including how she interprets all or any aspects of her experience—hermeneutically can generate a body of knowledge. As Ricoeur (2012) has noted: "The result is that what is relevant for the analyst are not observable facts or reactions to variables in the environment, but rather the meaning that a subject attach to these phenomena. I will risk trying to sum this up by saying that what is psychoanalytically relevant is what a subject makes of his or her fantasies" (p. 58). Furthermore, interpreting the research findings from inside the hermeneutic circle, importantly has accepted and recognized the multiplicity and plurality in all concepts of reality and the truth. In Truth and Method, Gadamer (1965) has stated: We accept the fact that the subject presents different aspects of itself at different times or from different standpoints. We accept the fact that these aspects do not simply cancel one another out as research proceeds but are like mutually exclusive conditions that exist by themselves and combine only in us." (p. 284)

Truth as a social construction.

In addition, conceptualizations of social construction as a form of generating knowledge and signifying reality, have provided another core foundation to interpreting and validating this study of the therapist’s experience. Social constructivist theories that have endorsed centralizing the individual’s experience as primary to generating what is true or real. Gergen (1998) has argued, "Because there is no account of the real that is not influenced by mental process, there is no ‘god’s eye view’ enabling us to adjudicate

competing accounts, thus no truth, objectivity, or progress that can transcend the individual standpoint" (p. 45). Also, social constructivist thinking has countered the concretization and valorization of truth as "objective" and, therefore, has proved essential to cementing the validity of this study. As Hoffman (2009) has argued, My thesis here is that the privileged status that this movement accords systematic research and neuroscience as compared with in-depth case studies and strictly psychological accounts of the psychoanalytic process is unwarranted epistemologically and potentially damaging both to the development of our understanding of the analytic process itself and to the quality of our clinical work. (p. 1044)

Conclusion

In sum, the literature review has aimed to recognize the foundational theories and conceptualizations that speak to the therapist’s experience of patient suicide by illuminating psychoanalytic theories on: death, mourning and loss; the conceptualizations of multiple subjectivities with death as an analytic third; conceptual renderings of the therapist as a subject and an object of her patient’s subjectivity; theories on countertransference experiences and expressions of self and (dead) other; theories on suicide as an event, a social construct, and a silenced, stigmatized therapeutic experience; methodological conceptualizations rendering autoethnography and the "I" as primary to

generating knowledge; and, foundational theories on social constructivism and the hermeneutic circle exploring the meaning of truth and its pluralistic constructions. It is hoped that in the analysis of existing literature and the recognition of gaps that emerge in the literature that a place for this research study to take root in the body of knowledge about the subjective experience of patient suicide has made itself known.

Chapter III

Methodology Introduction The purpose of this autoethnographic study (Ellis, Jones, & Adams, 2015) has been to describe one therapist’s lived experience of a patient suicide in the year following the patient’s death: the experience described has been mine. Through the utilization of an autoethnographic study design, the narrative of a subjective experience has offered, according to Ellis, Jones and Adams (2015), a means to illuminate and explore "a social experience that we cannot observe directly" and that "cannot be recreated in an experiment or laboratory" (p. 32). In addition, it has been through sharing experience-near encounters, that autoethnographic researchers, according to Ellis, Jones and Adams (2015), "intentionally use personal experience to created nuanced, complex, and comprehensive accounts of . . . experiences, norms, and practices" and that the autoethnographic study "is uniquely poised to "facilitate an understanding and often a critique of . . . life" (p. 33). Towards this aim, this autoethnography has utilized personal, subjective, and countertransference experience as data that has been examined through a psychoanalytic interpretative framework.

Thus, through the documentation and development of an autoethnographic narrative, I have worked to expand and deepen a historically invisible, silenced, and perhaps, taboo topic: the life of the therapist, as a person and a professional—in sum, as a subject—in the aftermath of patient suicide. This autobiographical journey has rendered what the psychodynamic field has traditionally concretized as an intrapsychic event into an intersubjective, object-relating experience. Also, in this autoethnographic narrative I have attempted to critique multiple cultural norms and institutions that locate the therapist’s experience of patient suicide reductively into a legal, moral, ethical, or spiritual issue or that explores patient suicide with a singular lens or views suicide as by-product of the work between two separate individuals, the patient and the therapist. As Denzin (2014) has noted: People are arbitrators of their own presence in the world, and they should have the last word on this problem. Our texts must always return to and reflect the words persons speak as they attempt to give meaning and shape to the lives they lead. (p. 4) This study, therefore, has served as my effort, not to make meaning of a patient’s suicide, but to find and deepen understandings of the therapist’s experience of patient suicide through the use of my own narrative. Towards that aim, this study has focused on my experience of patient suicide as an intersubjective, multi-dimensional, object-relating experience. In a deconstruction of patient suicide, as a singular, one-person physical event, this autoethnographic study has explored the therapist as a self, whose object relating to the patient and to the suicide as an object, has altered her fields of clinical and personal experience irrevocably.

As has been stated by Wall (2008), "Autobiographical writing is part of a new writing imagination that is based on movement, complexity, knowing and not knowing, and being and not being exposed" (p. 41). Given the silence surrounding patient suicide, the horror, the devastation, and the sorrow, consideration of the therapist’s experience has likely evoked a sense of irrelevance in the face of the larger issue: death. But therapists must live with this experience throughout their professional lives and the absence of literation, of clinical accounts, of discourse on this experience has been maddening. As Robert Littman has noted: "The important scientific problem is this: is the taboo of suicide so intense that even psychoanalysts are reluctant to expose their case materials and personal experiences in this area?" (cited in Alvarez, 1971, p. 97).

Rationale for Qualitative Research Design

According to Creswell (2013), "We use qualitative research when we want to empower individuals to share their stories, hear their voices" and "because we need a complex, detailed understanding" of these stories and voices (p. 48). In addition, Creswell (2013) has stated, "We conduct qualitative research when we want to write in a literary, flexible style that conveys stories . . . without the restrictions of formal academic structures and writing (p. 48). Positioned epistemologically in a qualitative paradigm of research, the autoethnographic study has actively countered reified concepts of research as objective, experience-distant, or impersonal through its legitimization of the personal narrative as a source of meaningful data. As Wall (2008) has noted, the autoethnographer stands opposed to the bifurcation of data in research as labeled either as "hard evidence" or "soft impressions" (p. 45). To the point, she has added, "It seems that unless data about

personal experience are collected and somehow transformed by another researcher they fail to qualify as legitimate" (Wall, 2008, p. 45). Instead, autoethnographic qualitative research, most uniquely, has given primacy to personal story and has valued the centrality of first-person voice to the story, by its focus on and interest in the individual’s subjective, personal narrative, autoethnography has located the researcher’s subjectivity meaningful and significant to social discourse and professional development. As noted by Wall (2008), "Autoethnography offers a way of giving voice to personal experience to advance sociological understanding" (p. 39). Indeed, it has been hoped, that the qualitative research presented in this autoethnography will act as a generative force to develop and grow the field of clinical experience of the therapist’s experience of patient suicide and perhaps, also, to tend to her isolation in this trauma. Because the qualitative work of an autoethnographic narrative has recognized and authorized the "many ways of knowing and inquiring," the autoethnographer has challenged positivist constructions of truth, reality, and knowledge by arguing that "individuals do not exist apart from their social context, and for this reason personal experience can be the foundation for further sociological understanding" (Wall, 2008, pp. 39, 49). In this epistemological vein, the qualitative study in the form of an autoethnographic narrative, has honored the therapist as the subject of study, and a subject in her own right of patient suicide, not as a means of diminishing the event of patient suicide; but rather, and importantly, as a meaningful or honest route to expand and deepen our discourse on the clinical field of perception, experience and growth, in the face of devastating loss and

death. As noted by Denzin (2014), "The use and value of the autoethnographic method lies in its user’s ability to capture, probe, and render understandable problematic experience" (p. 36). And, while suicide completely collapses the capacity of the therapist to "understand," it has been in the autoethnographic account of the experience that attention to the trauma of this collapse could be heard.

Rationale for Autoethnographic Methodology

Because of its ability to give voice to the "inside" of the therapists’ experience of patient-suicide, autoethnography has cracked open the field for an historically invisible, muted experience. This has been one of the chief functions of autoethnography: "autoethnographic work must always be interventionist, seeking to give notice to those who may otherwise not be allowed to tell their story or who are denied a voice to speak" (Denzin, 2014, p. 6). To bring this experience into the therapeutic field, has untethered my experience from potentially restrictive theoretical constructs that traditionally would have conceptualized any exploration of my experience as personal, a form of selfdisclosure, or a sort of countertransference material. According to Gerson (1996), "The analyst’s feelings and reactions to patients are no longer regarded as manifestations of the analyst’s pathology or as unresolved residues . . . Rather our reactions are essential and necessary aspects of who we are: reacting personally is all we can do" (p. xvi). There has another compelling rationale for creating this autoethnographic study as a means to counter the valorization of science in the clinical field. This autoethnographic study has presented subjective experience as a source of truth and knowledge at a time in the psychoanalytic field, when the individual’s experience lays most vulnerable to

concretization, subjugation, and capitulation to other discourses and disciplines. Other fields that summarize human experience with the ideas of neuroscience, evidence-based practice, or a medical-model have threatened the status of personal narrative in clinical work. What has made this possible, Hoffman (2009) has argued, has been a desperation to feel secure coupled with an inability to accept complexity. To this point, Hoffman (2009) has stated: I believe we are at a critical juncture in the history of our discipline. Perhaps it is an ongoing struggle in human history generally, and for all of us as individuals, to sustain our tolerance of, even appetite for, complexity, ambiguity, and uncertain moral commitment in the face of a competing constant pull that we all feel to gain control, to master, to know, to feel safe and secure." (p. 1064)

Research Sample

In an overview of research sample strategies, Bloomberg and Volpe (2016) have noted that "some qualitative researchers object to the use of the word sample in qualitative research, preferring terms such as research participant or selected participants" (p. 150). In autoethnographic research, the sample has been a participant and the researcher has been the sample. In this study, researcher as the sample and as the subject, perhaps, has been most comparable to the "intensity" sample that Bloomberg and Volpe (2016) have described, in that the researcher’s experience in autoethnography “manifests the phenomenon" (Appendix F). Denzin (2014) has identified the historically complex task of rendering the I of the autoethnographic narrative as the subject or the sample: "Experience lived and otherwise

is discursively constructed. It is not a foundational category. There is no empirically stable I giving a true account of experience" (p. 2). So, Denzin (2014) has argued that the acceptance of the I as the subject in autoethnography, must arrive from the linguistic significance of the personal pronoun in a social context: "When as a writer, and a speaker, this person appropriates this pronoun (I, you, he, she, me) he or she brings the full weight of his or her personal biography to bear . . . It becomes a historical claim, a writing and speaking event" (p. 10). Ellis (2015); however, has stated the subject, as the sample, has affirmed the circular significance in creating "sense making loops" by examining events from the "inside-out" (p. 47). One question that these terms have raised is whether to consider not only the therapist as the subject-sample, but to address the issue of the patient, his suicide, and the patienttherapist dyad (post-suicide) as part of or derivatives of the sample. In other words, should the researcher have identified the patient as a participant in the research or would it have been more accurate to have identified his suicide, and the patient death, as part of the sample. Autoethnographic research, in this way, has conceptualized a research sample as multi-dimensional and as a non-autonomous entity and thereby paralleled my experience of patient death.

Research Process

In an overview of "Doing Autoethnography," Ellis, Jones, & Adams (2015) have stated that the first step in the research process, for the autoethnographer, starts with a "personal experience that we want to understand more fully, deeply, and meaningfully" that moves towards creating or finding a "storyline" within that experience and, then,

focuses on "an opening or ‘gap’ in the story where you can address a topic or experience that is missing, not well understood, or not told thoroughly or correctly" (p. 47-49). In this autoethnographic study of my experience of patient suicide, the research began with the story, not of the patient’s suicide, but of my discovery of the suicide. As his therapist, the "gap" that my story has attempted to fill has been located in all moments after this one, the unknowable, unbearable experience as his therapist of his death. Noting the absence of research on suicide, Alvarez (1971) has stated, "suicide has been dealt with largely on the side, in its relationship to topics which provide the analysts with more precise and verifiable clinical material" (p. 98). In other words, my autoethnographic process has not intended to illuminate the causes of patient suicide but, instead, worked to fill the void of story by describing my experience. "The suicide," Alvarez (1971) aptly has noted, "creates his own society" (p. 92). In this autoethnography study, I have found (and lost) myself in the wake of this experience, one that has been confusingly, clinical, professional, personal, and at times, metaphysical. In an effort to operationalize the process of writing autoethnographically, Ellis, Jones and Adams (2015) have advised me, as the researcher, to consider and answer the following questions: Who are you?; What are you doing and why?; How did you choose your occasion?; How long will you stay in the ‘field’?: What will you do with the ‘results’ of your project?; How will your work benefit or put your participants at risk?; What efforts will you take to protect confidentiality? (p. 51) In large part, the first of the three questions have been answered by the research purpose and questions, ones that have located my experience of the patient’s suicide as

the subject of the study. The plan for staying "in the field;" however, has not been easily delineated, as my field of experience became alternately marked and decimated by the aftermath of the patient’s suicide. In order to force a delineation of this field of inquiry, I have conducted the data collection for one year following my patient’s death. Also, Ellis, Jones, and Adams (2015) have highlighted the importance of a process that protects the participants from exposure. These instructions have served as a reminder and a guideline that the research process has protected the patient’s confidential treatment records, experience, and any demographic information that would have rendered the patient or his suicide recognizable to others.

Data Collection

The data of this autoethnographic study has been my journal that has recorded my experience of my patient’s suicide. Ellis, Jones and Adams (2015) have noted that, "because autoethnography is the study of culture through the lens of the self, separating the content of the text from the form of its representation is not desirable or possible" (p. 83). Therefore, the data of the autoethnographic experience has included my subjective experience of my patient’s suicide but also has included my subjective encounters with my colleagues, my patients, my family, and with my own internal object world, including fantasies and dreams. Wall (2008) has described her autoethnographic data that relied exclusively on "memories" of her "lived experience," sharing the challenge of her committee’s demand to justify her experience as data as it was seen as less reliable simply because her data was her experience. She noted the irony that if another researcher had interviewed her,

then analyzed and presented his findings based on her memories and her lived experience, that her account of her experience would be considered "more legitimate" (Wall, 2008). On this bias, in the process of data collection, she has argued: "The privilege given to observations and ‘factual’ descriptions are based on realist ideology" (Wall, 2008, p. 45). Bloomberg and Volpe (2016) have stated that in general "it is important that the study’s findings are informed by the data rather than the researcher’s own preconceptions" (p. 153). One of the key premises of an autoethnographic study, however, relates to its rendering the researcher’s perceptions as the data. Furthermore, the essential "sequential" steps Bloomberg and Volpe (2016) have instructed the researcher to identify have not readily or easily applied to autoethnography: for example, the use of the journal, as a form of collected data, is not easily "field-tested" as an "instrument" (p. 153). Instead, the autoethnographic study to a large extent has declared "if an author thinks something existed and believes in its existence, its effects are real" (Denzin, 2014, p. 15). The data for this study, as noted, has included my journal as a written record of my experience in the year following my patient’s suicide. For one year, I documented my experience of my patient’s suicide, dividing the written journal entries into monthly documents. Each month of written material documenting my experience has included a weekly entry, so there is a minimum of forty-eight entries of written data. As I wrote each week, with the supervision of my committee chair, I explicitly chose not to censor the recording of my experience. I considered any material related or relevant to my experience worthy of documentation.

Some of the data that I collected included notes about: my experience with the psychiatrist who notified me of my patient’s suicide; my contact with family members, two of whom asked to meet with me; my attendance at the funeral service; my consultation about death and suicide with my consultant; my own therapy sessions; and, my consultation with an attorney about my fears of litigation and legal culpability. I recorded this material as it occurred and considered this data as field notes on one aspect of the experience: the concrete, ritualistic, professional, and familial responses to the suicide. So, the data, because of its effort to record experience close in time to its occurrence, has reflected a chronological unfolding of my response to the suicide, moving from an emphasis on the external events in the first months, towards an internal and intrapsychic recording as the year progressed. In addition, the data included my thoughts, feelings, and actions in relation to: my awareness of my absolute silence with colleagues on the experience; my near-total refusal to tell family and friends about my patient’s suicide; my fantasies and projections to include constant imagined sightings of him, occasional experiences of following or shadowing people who resembled him, and seeing ongoing visual representations of him both alive and dead; my efforts to seek consultation, retroactively, about my experience of the days leading up to and following his suicide; my transference and countertransference responses to other patients, marked by an increase in material about never-mentioned family members who committed suicide or suicidal ideations. In addition, I recorded my responses to the experience in the form of image-fragments, dream-fragments, and poems. Also, I recorded changes in my consumption of/interaction with other cultural materials, specifically literature, art, television, and film as I noted that

I organized these choices around a common theme: representations of experiences with suicide. Because my journal recorded experiences that were multiply determined, an accounting for my experiences that are personal, professional, and institutional could not readily be organized into differentiated fields. In other words, my experiences of the suicide were not categorically separable. All of my experiences contained aspects of another realm of experience and, in all experiences as the therapist, I was the subject relating to another subject, another object, an analytic third, or to myself as an object (Bollas, 1982). If I were to concretize the content, the data recorded in the journal might have been conceptualized as physical-external events, interpersonal/intersubjective experiences, intrapsychic processes, and metaphysical encounters. But, because the data was recorded in a chronological order, every journal entry identified and established its relationship to the day I learned that my client killed himself, while I simultaneously recorded my ongoing, contiguous experience of his suicide. Recorded experiences; however, were not necessarily related to one another in a linear context. For example, recorded data on one day might have evoked other past experiences, those prior to his suicide. Because my ongoing intrapsychic experience of his suicide has defied being bound by convention, the data collection process was imposed itself by the one, unavoidable organizing construction: time.

Plan for Data Analysis

The analysis of the data required looking for emerging themes, recurring categories of themes, and identifying any aspect of psychoanalytic practice and literature as it

interacted with the data. Creswell (2013) has described the data analysis process of ethnography as: "Analyzing data through description of the culture-sharing group and themes about the group" (p. 105). Although he has made no reference to autoethnography, the concept of analyzing the "culture" that surrounds suicide in general and the psychoanalytic literature on suicide makes sense. But primarily, the "culture" has been my experience of suicide as the focus of analysis. The coding of the data included clustering or categorizing emerging themes from my experience. Creswell (2013) has stated that "in vivo codes" derive from "the exact words used by participants," (p. 185). Using in vivo coding has meant that the data was organized not by "counting," but organized according to "emergent," categories from my experience of patient suicide," (Creswell, 2013, p. 185). Bloomberg and Volpe (2016) have noted that the data analysis ideally leads to a conceptual framework, one in which key concepts either emerge or become clear. Tolleson (1996) has suggested that the researcher develop "categories of meaning," and that these categories should be examined both within each "case" and "across" subject experiences (p. 93-94). An application of her data analysis framework has indicated that I consider each month of my experience as a "case" to study for emergent themes within that experience. This process of developing "categories of meaning" (Tolleson, 1996, p. 93) has included my work to consider the data of my experience as multiply determined but psychodynamic-defined, so that my subjective experience of the dead patient and my object-relating to his suicide can be analyzed across time and in multiple contexts of experience (e.g. professional and personal).

In considering the data collected through the weekly journaling process, the categories that emerged have centered on: my subjective experience of patient suicide or my experience as a subject of my patient’s suicide, (to include my intrapsychic experience, my transference and countertransference data and my conscious and unconsciously communicated material); how the intersubjective space collapsed and I was killed, as my patient’s therapist, leaving a gap in our subject-subject relating; my object-relating to the dead-patient and his suicide as an object; and the cultural intersections of legal, religious, familial, and ethical spheres of experience.

Ethical Considerations

There have been uniquely challenging ethical issues I addressed with this autoethnographic study of my experience of patient suicide. First, and obviously, there has been the confidentiality of the patient to protect and concurrently, my liability as a therapist in the face of that ethical commitment. Therefore, the autoethnographic data has not revealed, in fact it has disguised, confidential information or reference to confidential clinical material that would render client material identifiable. Protecting the confidentiality of the relationship, has meant that, as Ellis, Jones and Adams (2015) have claimed, the autoethnographer must attend to "procedural ethics," "situational ethics," and relational ethics," in their studies, (p. 60). In addition, I needed to guard against what Ellis, Jones and Adams (2015) have noted as Conquergood’s identification of one of many ethical concerns to "plague" ethnographers: "Curator’s Exhibitionism" (p. 13). This occurs when the autoethnographer seeks to "sensationalize" and to "astonish rather than understand others" (Ellis, Jones &

Adams, 2015, p. 13). Because of the norms guarding against therapists sharing their experiences, I carefully monitored my data collection and analysis for themes that pointed towards rendering the suicide, or my experience of it, a sensational event or making a fetish of the trauma. Denzin (2014) has argued that the code of ethics for autoethnographers rests on confirming that the autoethnographic study responds affirmatively to the following "injunctions," that it "nurture critical consciousness;" use historical restagings to subvert and critique official ideology;" "heal" and "empower;" and "present a pedagogy of hope" (pp. 81-82). An ethical consideration for this study has been to guard against any suggestion one might render hope from a suicide but, according to Denzin’s (2014) ideals, the autoethnographic study of this experience itself has stemmed from the hope that a critical discourse on the experience could foster growth and expand the clinical field of learning. As such, Denzin (2014) has stated that the code of ethics followed by an autoethnographer should base itself on "a communitarian dialogical ethic of care and responsibility" (p. 80). In other words, to balance this autoethnographic study of my experience alongside protecting the privacy of that experience, I considered my story as an ethical collaborator, one in an ongoing "dialogue" with its field of clinical study and with the field of affected and traumatized others, thereby one primarily defined by a sense of responsibility to those most shattered by his death.

Issues of Trustworthiness

As noted by Bloomberg and Volpe (2016) as the researcher, I needed to "clarify to the reader how you have accounted for trustworthiness regarding" the study. In the autoethnographic study, Denzin (2014) has noted that the "various standards of truth or the verisimilitude . . . have been proposed" (p. 13); however, for the most part, "the sincere autobiographer is assumed to be willing to tell the subjective truths about his or her life" (p. 13). In addition, Bloomberg and Volpe (2016) have stated: "Lincoln and Guba (1985) originally made the argument for the importance of trustworthiness . . . as a means for reassuring the reader that a study was of significance or value" (162). Therefore, one of the challenges of this autoethnographic study included my ability to render the experience meaningful, not on its own terms but as important on ethical and moral terms; because someone killed himself, it has remained undeniably true that his death and his life matter, in all fields of being and experience, including the clinical one. Credibility. The issue of credibility in the autoethnographic study cannot be based on "whether the participants’ perceptions match up with the researcher’s portrayal of them" (Bloomberg & Volpe, 2016, p. 162). Instead, as the researcher, my credibility in part has been based on my ability to create a discourse within the psychoanalytic community about my experience of patient suicide. It has been difficult to imagine "member checks" or "peer reviews" as advised by Bloomberg and Volpe (2016) in this autoethnographic study; however, I needed to address the challenges of not having multiple sources of data and the absence of an ability to triangulate data as I have not and cannot use my clinical notes, I cannot and have not utilized my consultation notes, and I cannot describe my

clinical encounters with the patient in order to maintain my credibility as an ethical, professional researcher. There has been an assumption, as the researcher, that I have made: the autoethnographic study of my experience earned a degree of credibility because of its unlikeliness and because of the stigma of exploring the experience through personal narrative. In other words, there has been an assumption that my vulnerability and honesty as elicited by the topic rendered me a modicum of credibility. Dependability. It has seemed possible that as the researcher I could adequately offer and ensure my dependability, in part because I was able to fully "track the processes and procedures used to collect and interpret the data," and to offer the data and the journal "for review by other researchers" (Bloomberg & Volpe, 2012, p. 162). Denzin (2014) has noted that "the dividing line between fact and fiction thus becomes blurred in the autobiographical text" (p. 15) and, though this autoethnographic study addressed the experience with a chronological context, the emphasis on my subjectivity acknowledged that a personal narrative creates a story, in all instances, of one person’s experience. Confirmability. Ellis, Jones, and Adams (2015) have argued: "Confessional tales focus on the researcher, use first-person narration, and demonstrate the ways researchers are limited and vulnerable" (p. 84). As the researcher, therefore, I simultaneously privileged my subjective experience and admitted the limits of my understanding or the reach of my lens. Ellis, Jones and Adams (2015) have stated that "When we do autoethnography we look inward—into our identities, thoughts feelings and experiences—and outward—into our identities, relationships, communities, and cultures" (p 46). This dialectic of writing inside and experience while exploring outside the

experience has lent my autoethnographic study its place not in confirming reality but in constructing and deconstructing the realities of my experience. Transferability. Bloomberg and Volpe (2016) have stated that "transferability is not whether the study includes a representative sample" but "rather, it is about how well the study has made it possible for readers to decide whether similar processes will be at work in their own settings" (p. 162). Therefore, the "richness of the descriptions" and the "amount of detailed information," (Bloomberg & Volpe, 2016, p. 162) ideally have augmented the transferability of the study. In this autoethnographic study, I did not intend to advise readers on how to deal with a patient suicide, nor did I intend to offer a detailed account of the patient’s suicide. Instead, I have offered my experience, including that of feeling silenced, isolated, and therapeutically dead, as a story that hopefully has opened up inquiry into this field of experience, filled in gaps of unspoken about clinical experiences, and altered the capacity to engage in discourse on the experience in the psychoanalytic community.

Limitations and Delimitations

There have been two chief limitations to this autoethnographic study. First, the necessity to protect confidentiality has limited the scope of my ability, as the researcher, to share aspects of my experience that would have revealed protected information, however well-disguised it would have been. Secondly and primarily, the study has been limited, like all studies, by my own blind spots, as a subject. Bloomberg and Volpe (2016) have asked: "Do these problems with errors, methods, trustworthiness, etc., eventually matter and if so, to what extent?" (p. 165). The extent to

which an autobiographical account of a patient’s suicide could feel narrow in scope or limited in its ability to address the significance of the issue has depended on if the readers’ expectations centered on how to be informed rather than how to understand my experience. The delimitations of the study have required that as the researcher I detail my reasoning for choosing an autobiographical account of my patient’s suicide rather than another type of study; for example, a study that analyzes a survey of therapists who have had patients kill themselves or interviews with therapists about this experience (Tillman, 2006). In addition, the delimitations of the study have included a description of my intent and sense that an autoethnographic study offers a route into meaningful inquiry and deepening understanding of the experience. Although some of the exclusionary decisions have been likely obvious to the readers, as in the issue of confidentiality, the choice to rely on the journal, to highlight the subjective experience of my work as a therapist, has been based on my belief that traveling deeply inside my experience has provided the most meaningful route to deepening the field.

The Role and Background of the Researcher

As an autoethnographic researcher I centered the study in my experience of the patient suicide, I became both the subject of the study and the lens through which the readers encountered my experience. My background has been essential to describe and identify so that the reader can locate my story in a context, professionally, culturally, psychodynamically, historically, and discursively. The role of the researcher in providing my subjective, or "insider" account of my patient’s suicide has not been glamorous, nor

would I dare render myself a victim of tragedy. My role has been to remain honest, clear, and subjectively-true, having accounted for my experience in as detailed a method as my commitment to ethical research will permit. As Wall (2008) has described the work of the autoethnographer: "I want to speak a language that my audience can understand so that what I am saying can be heard" (p 48). Ellis, Jones and Adams (2015) have added, "Autoethnography is a method that affords an insider’s perspective on the practices, meanings, and interpretations of cultural phenomenon/experiences" (p. 31). This has been my role as the researcher; therefore, to bring the readers inside my experience of the aftermath in the year following patient suicide. But Schroeder (2017) has argued that "As well as being reflexive and critical, autoethnographies need to move us to action. Autoethnographies are unabashedly tied to social justice aims, and many authors hope, by their research to change themselves and their cultures" (p. 323). It has been my hope that an autoethnography study of my experience as a therapist in the wake of a patient’s suicide has created clinical awareness and movement in the field of social work.

Chapter IV

Findings

Some Context The year following my patient’s suicide has been landscaped with loss. His unexpected death made and kept its threats for most of immediate life to continue as insignificant, unbearable, and at times, unreal. His decision to end his life ushered in an immediate urge to silence myself, hide our relationship, and to bury him physically and psychically. In fact, to do so initially felt respectful, thoughtful and, perhaps, even realistic but after his suicide, he did not disappear. Quite the opposite. After his death, he engulfed each day. He lived on, in my internal and external object world, as an absent, dead person and, quite confusingly and aggressively, as a live and missing object. The unending absence caused by his suicide became inextricable and unknowable from his unforgettable presence in death, who he was alive in our work together failed to differentiate itself from who he became dead, actually strangled alive by suicide. He became both multiple and binary in being, always both dead-and-alive, murdered-and-mourned, gone but not missing. Never one without the other.

Each day I carried a weight of responsibility and sorrow. Inside the depths of missing him ran continuous fantasies of both my own suicide and discovering him alive. Since, I have recognized these as fantasies of merger and reunion, a going-on being-together. This objectrelationship with him proved enduring, since his suicidal death and as a dead patient, he became a third being, both absent from life and present in death in our halfdead, half-alive object pair. My attempts here to find the words for this experience and to tell the story of the aftermath of his suicide, should not be mistaken as an attempt to find meaning in his suicide. Truly, it was his life that was meaningful. But, that story was never mine to tell and, perhaps this story, while as much ours as mine, only could be told without him. It has been a wish, like those buried in a dream, that, in the telling, I might find a new ending, one that included him still alive. So instead, what I hope to find, in these remains, has best resembled the work to be one among the living, the work that makes survivors of us all.

The Unexpected: From Missing to Dead

I found out about T’s suicide in a phone call while home on a Saturday morning. The psychiatrist T had seen recently, Dr. A, called and told me that T was dead. I know I shouted at him, What? Then, I began to cry. While I tried to breathe, Dr. A, slowly and quietly, told me his story, the one that would shape but also differ from my own. He told me that, at their session, T had reported that he was doing pretty well and was planning to see me later that week. In fact, T and I had an appointment for the next day. One that he did not show up for, call to cancel, or respond to my call to him: his first and, ultimately,

only no-show. The beginning of his unexpected disappearance that became his unexpected, and unaccepted, death. As Dr. A talked, I furiously fast-forwarded and fast-rewound, through my images of the past few days, weeks. It was crowded, these words and images raced in a chaotic scramble, loud and overwhelming in my mind. Dr. A’s words ran through me and alongside my fast-replaying and fast-rewinding images of T. His voice was co-occurring in a strange double-loop, blurring T, blurring Dr. A, blurring me into them and their words, and T’s face without pause. This remembering, repeatedly replaying, and trying to work those days through as if I was missing a piece, as if I could find that missing piece, as if finding that missing piece would make T not-dead did not cease. It was an endless loop, one I would circle, or it would circle me (and still does) tighter and tighter until I felt dizzy and out of breath. All the while, I knew the missing piece was him. It felt like a narrative in search of a different end, a narrative of a story that ended with his suicide, and yet, no matter how often I ran through it in my mind, it never ended without missing the centerpiece of him. Still on the phone with Dr. A, I felt him shifting from informing me to consoling me or, maybe it would be truer to say that I became aware of myself asking him for information then instead asking him for help. Though a stranger, he tenderly asked me if I had ever experienced a patient suicide. I told him no. He then asked if I had someone, I could call for support after we hung up. I said yes. And, he offered to call me the next day to check in on me. He generously made a patient of me in those moments, as if I was someone struck by a ravaging disease not of my own making (though I would doubt that soon enough). It

was an act I never found a way to thank him for, something I still regret. He then carefully encouraged me, in recognition of this trauma or in his prescience of what would barrel towards me soon enough, that it was not my fault and that I could not have anticipated T’s violent act. It has felt strange to pinpoint the trauma of T’s suicide to this call, or this moment, because, as Dr. A described to me, he had died a few days earlier. But, this gap, between the day T died and the day I found out, became its own kind of empty pool, one that I would find myself staring into because nothing concrete could fill it. Instead, I heard a constant echo and, part of it or all of it, was the absence of T and along with his absence the unending, unanswerable wondering: Did I suspect that he might have killed himself but deny it? Why did I tell myself he would call me later? Why didn’t I do more to find out why he wasn’t there? Why didn’t I find him? Why didn’t he find me? On the day that I had considered the day he didn’t show, that became the day he died, a friend of his texted me: He has sent some messages that worry me. Please ask him to call me when he arrives. I called her about his absence and left her a message that she never returned. I had met her once and wasn’t sure she would call me back. So, I told myself to wait. I told myself someone would call me back (who was this someone I imagined?). I told myself that he always got in contact with me, eventually. But, Thursday, he was missing. Friday, he stayed missing. Saturday, he was no longer missing, he was dead. It would not be until the following week, when T’s brother

contacted me, requesting to meet, that I would learn that the day T and I were to have met, he had hung himself from a basement beam, with a rope. Once Dr. A and I got off the phone, I was alone. I was alone with T dead and with his suicide. I was unable to move, think, or feel. If I had to describe the vast emptiness, the endless silence, the total nothingness, it would not be even an empty hole, because a hole is still a shape of something. What is the word for a total absence of being? Death, I suppose. And, how could I give voice to the total absence of T dead from suicide, a silent scream perhaps? I know now that I was frozen deep inside the paralyzing net of death, caught, and I was remaining. This, of course, would have been the land of trauma swallowing me whole. In replaying the story of what happened during those days when I told myself he was missing, not dead, I began to see this is the story I told myself, not the story that happened. The story I share now must include the story of what I told myself then. The story of not knowing now includes my doubt of myself and my wondering if I wouldn’t let myself imagine it then, which is very different than not knowing. The minute I knew he was dead I began to hunt through the hours I had imagined him missing for clues or signs. In this fruitless search, finding nothing, I conjured different actions that might have led to a different outcome (These conjurings have become too endless to mention now). In picking through the hours before I knew, there has been much I cannot find besides my not-knowing. But, I have found other things, I found my need to deny the possibility of his death and I found my wish to avoid imagining his death. What I found and held closest was this single fantasy: had I known his suicide was possible, I might have saved

him from it. It has unsettled me that when he went missing it seems I went missing too, either in search of him or hiding from his absence. Because this is a truth of this story: each hour since his suicide has become demarcated by the hour of knowing, the hours between him missing and him dead, the hours of an alterable change between not knowing and knowing. Since his suicide, this circling of the hole opened up between knowing he was missing and not-knowing he was dead has never ended: what always surfaces is my wish to return to the moment before he hung himself and find him: of course, so I could stop him. It beat inside me: Why didn’t you call me? Why didn’t you call? You. Call. Me.

The Dead, the Mourners, and the Murderers

His death immediately obliterated all else. He invaded each day; he was everywhere and nowhere. His absence and the way he was absent created a fault line I continuously feared traversing, like an electric fence. Confusingly, I felt frozen and paralyzed by his absence, yet haunted and terrified by his suicide. The stillness and silence of my grief cemented itself to the unrelenting, disturbance of his suicide. I discovered that I wanted to speak to no one about his death, but desperately longed for contact with his family members. Though he was with me without interruption, an alive ghost, I dreaded anyone in the community—his or mine—finding out that he had been my patient. This twinning absence of him and the presence of his suicide fractured my sense of self and time in two. There was only before he died and after. Once I began to selectively share T’s death, first with my therapist, then with my consultant, the search for a narrative—tracing through the last few days and weeks, an endless loop—collapsed

inside me. Later, when I would begin to share with others, understandably, the first question asked was: What happened? My own questions never changed: What didn’t happen? What did I miss? His suicide created this cavernous, dark well and in the spate of missing hours, days, moments I scoured for him. I had lost him but told myself that I lost track of him, surely this must be true. His suicide meant that I had lost time but some part of me wondered if not knowing was the same as losing. Ogden (2003) has claimed that death "fragments" structure. T’s suicide felt as if it fragmented, stalled, and forbid the discovery of a true story, unless I were to accept that this was the truth of our story: he killed himself, he died, he left me, and others, behind. In the immediate weeks following his suicide, I felt frozen and suspended, in a space in time before his death happened: in this place where I dwelled, I could change course, find him, make a different decision and find him still alive. It did not feel like denial: instead it felt like a dream. Yet, these imagined moments of changing course were constantly out of reach—a dream I was having in waking-life. And, like one of those falling dreams, it startled me: instead of startling me awake, though, it brought me closer to him in my fantasy. In these dream-moments I could hear what I said to him, that he would be returned to me in a session and, then, everything, every decision he made would be altered. And he would be alive. Soon, I began to hear from the living. His brother and a former partner contact me: two people central to T’s life, now drowning in his death. I decide to meet with each of them. In fact, I am relieved to hear from them, having still no idea how he died and longing for details. My greediness to know more makes me feel guilty. I have no idea

who I am to them; I now have no idea who I was to him. I wonder: Am I still his therapist? His former therapist? Can I be a mourner with them? In meeting with them, I learn details about his suicide. With every detail, he hangs between us, silently swinging. I am shaken with the fear of the guilty, terrified one of them will blame me, in the way that I blame myself. Instead, each asks for my support in the terror of this loss, the unbearable grief of his suicide. I am relieved to have a purpose. In consoling them, I find the most temporary of shelters, too. I find myself telling them: It is not your fault. It is not your fault. It is not your fault. He is the only one who had the power to change this outcome. But secretly, after they leave, I scold myself: if anyone could have done something different it was me. It was impossible to let each of them go. I longed to sit with his brother who resembled him, to hold T’s partner who cried. I could see how he abandoned each of us differently. I hungered to be less alone and to keep him close, in the ways they each embodied him. His brother told me that about finding his journals; I did not say, he wrote so much to me in his last few months alive or I kept none of his emails, save the last one, and, how I mourn this, too; in that he is honest; and, worst of all, he is hopeful. Two days before he killed himself, I could see and feel it, his sense of a life ahead of him. It was unbearable to encounter his hope, left there, discarded on the page. In their wake, I find myself left with details of what I cannot un-see: the scene of his death. Still: Why didn’t you call me? Why? I decide to attend the funeral. Once there, I hide myself in the back, scanning the room for familiar faces: unlike other funerals, it is frightening to find some. I am afraid of being seen. Charged. I feel like a criminal who might be called to the stand. Two women

next to me begin to talk and I freeze: I am terrified about hearing the therapist mentioned and blamed. Please do not blame me. I am then ashamed of my selfish fear. I see T’s children, their faces overcast, overcome with grief. I long to touch them, so real now from inside T and now outside in their real selves. Someone asks me how I knew T and I shake. Please don’t blame me. Instead I say: We were good friends. His friends and family share stories and I learn more about him, like that he loved modern art. How did I not know this? His father can barely stand under the weight of this loss; His mother cannot lift her head to acknowledge mourners filling the pews: I imagine it would make it too real. More friends, family speak. One friend mentions the loss of T not hearing how he is loved, if only he could. Then, as sudden as his death, it is over. I leave the way I came, alone. I go back to work, shaken. I tell no one, save my therapist. I bury myself along with him. I do not stop shaking inside. I begin to see him each morning on my run. He is hanging from the trees out on the landfill, swinging in the dark. I walk into my office and see him in the chair where he waited for me. I see him on the couch, I hear him sitting and saying, I like the middle. He appears at the grocery store where I once ran into him and he smiled, a welcome surprise. I do not feel safe inside myself, something is ticking, whirring and I am constantly on the verge of tears. I google how to deal with patient suicide. I read about legal implications, culpabilities and consequences; the issue of confidentiality and whether it survives in death; and I read about grief. I begin to wish that I believed in God. As I read, I experience an echo of sorts: I engaged in this parallel process, similar to his now-final months, when he scoured the internet for stories of redemption, recovery,

and resilience. He would send me inspirational TED talks and video clips of men who had changed themselves; in his search of faith, kernels of hope, model lives to inspire his own. I once countered this, which I regret, telling him, “You will not find an understanding of yourself on the Internet.” He would be glad for my delayed recognition: now I am looking to understand him on the Internet, too. That fall, I barricade myself and I disappear into the story of us. It becomes the story of his absence and the story of our dyad minus him. I do not mourn him because he lives on, a ghost who haunts each day. Each remembering takes me, slavishly, back to him. I return to exchanges to see them (I tell myself) more honestly and through the reality of his ghost. In this way, he haunts the present and the past: but his absence is my future, the future of an endless absence of him. I begin to fill my consultation time with him: consulting on a dead patient to what end is unclear. All I know is that I cannot stop running through it, his suicide, or him. Backand-forth, I run through it—the suicide, him, and me—and then freeze in it or sometimes drown in it. I tell my consultant that I feel like the character in the film Memento where, as an amnesic, injured, post-traumatic state, the main character studies a slow-developing Polaroid, trying to find his way back to the moment that got him to where he is now. I can remember watching it and wondering: Why is he searching? Maybe he should just accept that he doesn’t know or what his life has become, who he is now. But it is both that are impossible, of course: the not-understanding of what happened and the notknowing of who he is. The acceptance of neither, each day defeats him and once undone, he feels incomplete. I know now what this tells me: looking for someone will only confirm he has gone.

I see my therapist who accepts me as I am. Some sessions only crying, some sessions completely numb, every session always going over and over the days and the hours, looking and searching for someone my therapist knows will not be found. She lovingly and without hesitation goes on this manhunt with me and I feel less alone. It is a beingalive and staying-alive place she gifts me, unendingly. She allows herself to interrupt me when the self-blame becomes brutal. Her stamina for empathy will, as it always does, astound me. Later I will wonder what this asked of her, if she feared I might lose myself, along with him, in loss. My friend calls to tell me about the death of his father’s second wife: she killed herself. He is shaken by the chaos she has created in this act and how she has shattered those left behind, most of all her two young sons. Their lives are ruined now forever, he says. I agree. I want to, but do not tell him this: that there are no rituals for mourning a suicide, no solace, no getting over the death because there is never a way to get through or beyond the suicide, to mourn the loss of person without the shadow of the suicide. The suicide makes T’s time and place of death a crime scene. In this suicide is a murder and a death. Isn’t that why the symbols and rituals of grieving and loss feel so hollow, so ineffectual? It explains the urgency to detect the moment of the crime, to identify the weapon, to describe the scene and to search, so fruitlessly, for signs of premeditation. His suicide makes mourners or murderers of us all. Isn’t that why I feel so guilty, as if I, too, committed a crime: mine, one of omission? In fact, I become unsure about which one I am, a mourner or a murderer. In this pull of duality, I find the urge to bifurcate my experience into poles of being, as if I might tidy-up this violent mess. I consider myself someone who was helping him; but I didn’t. I

believed I was the one person he told everything to; but I wasn’t. He hung himself and is dead; how dare I explore my own pain as if something in me has died, too. The loss of him is not mine but never not-mine, either. He is everywhere; he is nowhere. I am somewhere in-between.

A Preoccupation Forms

In the fall, I stop holding my breath. But the moment that I attempt to put the loss of him into words, he evaporates. He becomes wordless. He turns into an invisible loss. The privacy of our work brings the risk that he could disappear. So, I begin to carry him with me. There is dead-him, by suicide, and not-alive him, in memoriam. I tell myself this is not a refusal to mourn: I convince myself this is a recognition of a different relationship with him. In my journal, I begin to address him directly. I find there is so much to tell him. I begin to feel a little crazy. In the hours outside of work, he stays with me. I keep him close. Attending high school conferences for my daughter, I turn a corner and suddenly he is there. I stop and stare at him. Thudding inside me: There you are. You scared me. But the man’s face turns towards me: it is not him. It occurs to me that this is more than looking for him; this is a belief that he exists, somewhere in hiding, and that I might find him. It does not strike me as a wish. Instead, it presses on me as possible, an alternative to being gone. Fridays are no longer Fridays but the day we would have had a second session. The weekends are no longer simply a weekend but another weekend without him. I associate to his difficult weekends, made into my own. I wonder about the projections of the dead, how he lives on in me this way. I read a novel that begins with a woman agreeing to take

care of a dog, shortly after the suicide of her friend. She finds herself imagining what her friend would have said to her about this decision. She observes that everything about her friend, his whole self, has become conditional. Like her, I begin to interact with T, living his conditional life. He would have been interested in the Kavanaugh hearings; he would have wanted to talk about the new season of his favorite TV show and disappointed another favorite was cancelled; he would have been excited about a new season of his favorite sport. Oddly enough, I begin to watch and think of these TV shows as his shows. I memorize them as if he and I are going to talk about them later. I think about themes he would have been drawn to discuss. I begin to discuss them with him, anyway, running both parts of the imagined conversation in my mind. It becomes unsettling, that I must watch without him and, that I refuse to be alone, creating a discussion with him anyway. Both aspects of this disturb me. I start to feel that this inside-world with him is more important than the outside-world without him. This becomes another secret, like his suicide, I must keep. One night, his television hero attempts suicide but fails. (Why is a suicide that doesn’t kill the person called a failed attempt?) I envy the rescuer. I covet his window of opportunity, however slender. My jealousy of this fictitious savior bleeds into the fiction of being a savior. I see the moment before T died. I imagine he called me, and I rushed to him, because I know where he is. I find him and I save him. He lives. Instead, I whisper to him at night: I tried to save you. I tried. I failed. His suicide consumes me. I begin to actively search out films to watch and books to read that involve suicide or an unbearable death. I read William Styron’s memoir

Darkness Visible. Styron achingly describes the depth of his depression, his hopelessness: he fantasizes about suicide, contemplating it every day and all day. He comes through it, finally, and glad he didn’t succeed. (Isn’t the success coming through it alive?) No word sits right with me. Nothing sits right with me. I read Ted Hughes’ poems about his wife, Sylvia Plath. I re-read the ones about her grave, her blood, the children she orphaned. I become maniacal about reading and rereading his poems that attempt to capture the stone-dead silence and weight of her suicide. Its endlessness. I watch The Hours, a movie suddenly revealed to me as entirely about suicide and suicidal ideation. Later, I tell my consultant: How did I ever imagine it was about women stymied by not having a voice? Everything I see, I see through suicide eyes. I watch Blue. Juliet Binoche loses her husband and her child in a car accident: she attempts suicide when she learns they are dead, but she survives, forced to live without them. She creates an entirely new life,; she tells no one about her losses. I envy her motion. I envy her becoming someone unknown to others, detaching herself from the loss by becoming a stranger to herself. She lives half a life, furiously protecting her isolation and deprivation; but I envy her certainty, or her discipline, about separating from the loss of her family. There are no photos, no stories shared, only a shimmering, blue glass mobile from her daughter’s room scattering blue light everywhere she goes. Instead, I dwell in a world centered around his suicide and his death. It feels as if I draw comfort from being close to others’ losses, that it matches my sense of loss. I feel ashamed by a fear of fetish about death and his suicide, as if I am a vampire drawing

death-blood to keep myself alive wherever I go. I admit to my consultant that all I see is death. I feel unhinged, loose, and unmoored inside myself. She worries, ever-gently and ever-kindly if I have begun to circle a drain; she is so quietly tender with me, entreating that we must find a way to pull me back from it somehow Soon, I see him again. Honestly, I almost run into him leaving a coffee shop near my office, which is strange, I find myself noting, because he had stopped going to coffee shops, preferring the freedom of a bookstore instead. It isn’t the experience of feeling I have seen him that feels strange or these facts about him becoming more artifact than fiction: it is only, completely, disappointing. Nonetheless, for one minute it is him. His face, his coloring, his stature. For one minute, it was true: he was alive. And I felt alive, too. In this way, my fantasy, my ever-present wish, preoccupies me: that it was not really him who died, that he did not do it; he is walking among us, hidden and silent but still alive. I begin to wonder about the moment when he decided to murder himself: what did he wish for, if anything at all? There are these gaps, in the morning, before light, during the day between appointments, walking from office to store, in which I look for him, or maybe I look to be close to him. In these in-between times, I can no longer tell if I’m trying to keep him or trying not to lose him; and, I am a little frightened, that I am no longer sure if I know the difference between the two.

The Seduction of Death

Some days I consider myself in mourning. The mourners include those now forced to live without him. I tell myself I am one among many and I find myself ranking us. It’s as

if I believe in a hierarchy of grief and grievers: the most important mourners are his parents, his children, his sibling, even his former partner. I fall or place myself outside that circle; surely, I am complicit, one of the murderers, tainting my rightful place among those who mourn. I begin to wonder who was the saddest of us all, but I know the answer: he was. One night I dream of T and he tells me: It isn’t so awful to be dead. When I wake, I long to go back to sleep and tell him: Yes, it is. It is awful that you are dead. You have no idea. I decide to tell another consultant about T’s suicide: he knows me well and asks with his quiet, grave, and genuine concern about my sense of responsibility, my sense of culpability. I tell him I believe it was my job to keep T alive. (Isn’t that why most therapists enter the field? To save people?) At the very least, I expected T to stay in treatment with me. Even more, I realize I expected him to want to live: and, I turned that expectation, maybe for my protection, into a fact. I begin to feel that when he murdered himself, he murdered us, killing our work together. I create a most unusual alliance with him: it makes murderers of us both. The viscous logic of my grief goes something like this: he killed himself, I did not stop him from killing himself, so I share, along with him, responsibility for his death. A shadow-third emerges in our relationship (and he and I do continue to have a relationship). This third is the person who murdered him, the part of him that murdered himself. I did not know this part of him, I wonder if he hid it from me or if there is a part of me, too, that I did not know, a part that does not imagine death as real or possible. This third in our relationship is the one who has killed; it was part him and part me. Some days I feel as if I might suffocate. What did I miss?

Who was the person that planned to kill himself, the person who did it, was he there all along? His death creates an open grave beside every person I know. I can see it, waiting for us, waiting for me. Unexpectedly, I drift into moments of wanting to be gone with him. Driving down the expressway one day, I imagine swerving into the oncoming traffic. Another day after work, I imagine walking to the top floor of the parking garage and looking down: What if I fell over? What if I jumped? I find myself unsure of these wonderings: are they to feel close to him? A way to imagine being with him in that moment when I must have been so far away? I silence the mantra I have heard a thousand times over after a death, one meant to comfort me: There was nothing more you could do. I reject comfort and feel rage, believing there is no place to grieve, no place for my sense of betrayal. In anger, I begin to imagine joining him in death. I am unsure if I am afraid that he will disappear or afraid that I will. I begin to suspect that in some ways I already have. I have moments of believing that suicide could be a form of survival. Is this what he felt? I feel abandoned, soon sad more often than angry. Some days I imagine him killing me, then himself. In the underside of abandonment there lay this seduction. If I died with him, I would not be left behind.

Suspended

Then one day there is snow, but not just any snow: snow he won’t see. So, days become marked by the continued absence of him. He is elsewhere really, everywhere, hanging. Hanging. I imagine him hanging between the floor and the ceiling; hanging for some seconds between being dead and alive; hanging between surrender and action,

between submission and domination. I begin to see him as a master of death while I am helpless, hanging between being here and somewhere else, having become a halfmeasure of myself. Even the words for him, for his death become a half-measure, a halflife, half true, only half of the story that once included me. Historically the hanged man has been a criminal. Those who watched viewed the hanging as justified. But this confuses me. I cannot stop seeing him hanging, but I wish to punish myself, not him. I recall playing the game hangman as a child (did the violence of this game go unnoticed?) with my brother: filling in the empty spaces, making meaning of empty space after empty space, we raced to find each letter to make the word, the world, whole. I am looking for the letters to collect that will make things whole; no that is not true. I am looking for him. I am looking for him as a way of finding the missing parts of me. I worry that T has become more alive to me dead. I cannot recall having thought of him this often when he was alive. Maybe that is part of the problem. In this, I feel the powerful undertow of guilt, the pull to see my every act and my every lack of action as a cause. He has transformed himself into someone unforgettable. Although, this is not so different from who he was to me alive. I just know now it will never change. I find myself pleading with him, maybe myself: I should have found a way to show you, you mattered. There is a shift. The distinction between what I imagine and what I know to be real blurs. And I feel sort blurry to myself. It is not that T feels like a dream, but the experience of being with him, in memory or conversation or fantasy, begins to feel like entering a dream, or some kind of a dream state. I am not sure if I am hiding from the

reality of his being dead or the fear of not knowing how to live with his death. Some days I remember him and I am not sure if what I remember is real. And then I wonder: does it matter? If he is dead and I am alive, does it matter what is real?

Madness

I start to wonder if I am going mad. My consultant asks me if I had known how attached I was to T. I pause and wonder but also do not hesitate: Yes. This must have been a blind spot: I imagined T was as attached to me as I was to him. This becomes an endless argument with me and with T. If he was as attached to me as I was to him, he would not have ended his life. It makes me dizzy, this thinking. But I hate to imagine his suicide as an act of honesty; honest, because he could no longer stand being alive. So, instead I imagine that the moment before he killed himself, he had gone mad. And now I have caught it. I begin to imagine I am in a session with T. I re-imagine sessions that we had, but this time I make a different interpretation, or I make a comment that I had not made: there is always this spinning, twin-ship. What did I do? What did I not do? I am either breaking apart or trying to hold on: to him, to myself, to what was, to what will never be. During this time, I am home alone. Even from a distance, my children anchor my life, their lives permanently connected to mine. I try to hold onto that permanence and that permanent goodness of them; I hold on tightly. I continue to work. My clients give me a weight of being. I am here. That winter it drums through me: things are not the same. I am not the same. Things will never be the same. I will never be the same. My clients

begin to talk more about death. One tells a story about a phone call from his mother that saved him from being drafted for Vietnam. He tells me, in that phone call, that she saved his life. Again, the envy, the jealous rage, it never quiets: Why didn’t you call me? One client breaks down, telling me the death of her brother broke her family apart. She sobs. I breathe loss in and out with her. Another client shares his own experiences with death at work. He tells me about the importance of remembering the life of the person before he died; the responsibility he carries to honor that life. Another client shares a poem she has written about her dead spouse. In it, she stares at an absence; I long to stand with her, alongside her, and to stare at mine. Each of them giving me a gift in their grieving; if only they knew how I cherished these gifts and them. I accept a new client, one who lived in a third world country as a child. Death was everywhere, he tells me. Now, as a young adult, he experiences a paralyzing phobia of death. He scans his life for its potential. Part of me wants to grab his hands, to tell him, I live in fear of another death, too. He wants help with his death phobia; I wonder if he has arrived to help me live with mine. I start to believe that each client brings an offering: passage through an underworld to make less alone, together tending to the wounds of the surviving that never heal. I worry about not listening to their fears in my preoccupation and about not hearing their sadness when mine is so deafening (Is this what happened before—I wonder? Did I not hear his pain?). But my consultant suggests that I am more open and more available to these communications about death from the living. T sits in almost every session, watching, and waiting: I become furious that he has opened this window to death. I cannot close it, this window now forever cracked open. I

become an islander of his death. Part of what I cannot grab hold of is this: perhaps, his decision, my consultant suggests, had nothing to do with me at all. I bury myself in work. I begin to tell everyone I am buried at work. I find myself over-using this word: buried. I am buried in the holidays. Buried in stress. I feel buried by another tremendous loss, the death of my marriage. My children begin to worry that I am working too much. Gently, they ask about my hours, obviously haven spoken to each other privately, co-conspirators in love and concern. A friend tells me that perhaps I am working to avoid my life. Another friend is angry with me: I am told that I seem to have more time for my clients than other people in my life. But outside the office, I remain alone with T. I become afraid to be alone, afraid to be without a patient, a patient other than T. Then, without notice, the year must end without him. The last day of December is one of those days where it seems a bad dream has not ended. For parts of the day, I believe I will wake and meet T at the office for his appointment. I think of a client who once told me that the world felt like a dangerous place. I know her world a little better now; it has become my world, too. I mark the end of the year with the same, singular marker: it is the year that T died. I have no idea how to begin a new year in which he is not alive. And I am not certain that I want to: it is a future without him that I attempt to postpone, unsure how to remain alive. Unexpectedly, this uncertainty brings close another tenuous first, making a crowd of loss. It is the first Christmas after my divorce: I replay how my children, no longer little, began to hang the stockings: one, two, three. Then, from the bottom of the box, my exhusband’s stocking stared up at us. It could not be hung nor discarded: neither seemed

right or true. Here, too, the permanence of absence. Suddenly, there were too many parts, too many people, missing. My son turned to me and said, It’s ok, Mom. We are still a family. I hugged him for this gift of perseverance, one made of love. The child, Wordsworth has said, is father to the man.

Liminal State

Nothing outside of me stops. The year begins without him: I cannot shake this constant modifier, his suicidal death, always coupling or shadowing the events contained in a day. I wake on the first new day of the year, realizing it will be an entire year without him. I feel a pull not to leave the past year because that year included him. He is not in the past, however; I can still see his face and hear his voice. I struggle to put these two worlds together: one haunts the other, the ghost story of T and me. It feels, as if together, we form a pair of Nothings. Between his death and my life, I find myself in a kind of silence with him: I want to tell him, here we are, in a you-and-me absence of being. I think about the dreamer who wakes from the dream but for a moment, in a liminal state, cannot distinguish between the dream and the waking from the dream. I find myself suspended here, the in-between place, in the moment when the dreamer could slip back into either state, dreaming or being awake. I start to feel that things are slippery inside me. Because he is sometimes dead and sometimes alive in my dreams, I begin to feel uncertain if his death is part of a dream, a dream that does not end or, if I am refusing to wake from life, insisting on going back to the dream. The waking begins to feel like entering a nightmare; and, when I am able to

go back to sleep, I find not a dream about his death but a dream of his life, his life ongoing. I start remembering the night terrors of my childhood, waking myself up screaming and then the relief, such relief, when I would come out of the terror, fully awake. Somehow, now I live in a reversal of this: the terror lurks in being awake. With my consultant, I can think of nothing else but T. I tell her I do not know about consultation about a dead patient, but I know this is what I am asking of her. She accepts this, something I can find no words to thank her for, but I know that because she does, I can have the hour to unfreeze and breathe. I admit to her that I recently stood outside the window at Target, pleading with the man at the checkout line to look up and be T. I stood there begging him, please be you, wishing I could wake up to discover that this has all has been a nightmare. She accepts this quite generously; thereby helping me accept it. When I drive home, I imagine drifting into oncoming traffic and having an accident, surely a crash would stop this endless loss. My final semester as a doctoral student begins: we discuss clinical impasses in class. There will be an opportunity to present cases of clinical impasse for group consultation. I wonder about seeking consultation on the experience, not the event, of impasse with T’s suicide but I dread speaking of him. I dread this private dark world I live in with him being invaded, crowded by questions: the "what happened" spotlight; the "how did he die" search lights inquiring. I dread making a narrative of his suicide but, most of all, I dread the end of that narrative: his death. I begin to wonder if I am living in an invisible hollow: one T created. I imagine myself moving in, installing myself amidst the clutter of non-realities. Is the first one I

hide in—his act of suicide? I move through days with a sense of static. If any one of my patients were made aware of T’s suicide, they would suspect my competence. So would my colleagues. Most certainly, I doubt myself now. I find T’s children unbearable to imagine. I fantasize about holding them silently and tightly. But I would hate me if I were them. Blame and hate me. My consultant suggests that one of the many losses I am grieving is this stark reality: I was not the primary object, the most important person to T, but I had believed that I was. I was on the outside, never inside, a position I had not known was mine until he killed himself. As soon as she says this, I know it to be true. One night, I dream about a patient who had ended and not returned to treatment. In the dream, he tells me that he was afraid to go deeper inside himself, scared to share himself more. For an instant, inside the dream, this patient was also T: he was alive! Then, still inside the dream, I remember T is not alive (Is this something I tell myself because it is different than dead?). I become confused and frightened: is the patient who has disappeared also dead? Suddenly, I am inside the dream in a dream, terrified there are now two deaths. Later that week, the missing patient contacts me to schedule an appointment. I feel a rush of an odd homecoming, one in half-measure. Every missing person, who either returns a phone call or shows up for their next appointment, suffers this bizarre avalanche in my response: relief about their arrival and about not being dead. For class, I read Ogden. He said, truth is not a discovery, but a creation. To discover true experience is to create something new. I plug in his thinking, as I do all matter and material now, to my experience of T’s death: this interminable liminal state of neither dead nor alive, of neither hidden nor visible is true. So, the creation? I know what is

newly created: the experience of the absence of you. Everywhere I go, T, you are missing. I hear Yeats: the center does not hold. Even the structure of my memory fragments and collapses as I circle T-dead and T-alive or T in-between dead and alive. I recall a bomb threat at a nearby university. T came in the next day: he had been on the campus (Why? And why didn’t I ask you this?). He described the organized, institutional response and being crowded into a small, windowless area. He told me, he realized, that if a bomb was tossed near the group, that he would not hesitate to throw himself on the bomb (Is this what you did in the end?). He shared this discovery about himself: there was a sense of goodness, inside him, that he seemed relieved to find. This was a truth he discovered, or created, about himself during what we then called the bomb-hoax (another discovery). But he discovered this during the bomb-scare; so, it keeps slipping away from me, this idea of a discovered-truth created during a discovered-hoax. That was two months before T hung himself. Since then, these ideas have begun to get mixed up in my mind and in time, in an endless, incoherent loop. I find myself imagining that the bomb he discovered was a truth he left with me. His description of a suicidal act was not a hoax: it was a deadly bomb he created that never stops its explosion. Every image shifting its place: all memories have begun drifting. Then it is six months since his death. When I get up, I usually wonder, then fear, that I will feel like crying. It seems I have placed a grief thermometer next to my bed: I dread a febrile state, one of sorrow, tears, maybe it is longing. I see T between this moment of

stillness and activity: I see him in the space between reality and fantasy. He is there: at both and neither place at once. I search out any material that might fill in the holes inside that I feel. I read "Standing in the Spaces;" of course, of course, T is standing in all my spaces. I wonder about looking for him in other spaces where he might live: for example, my clinical notes. So far, I have refused to do this. The thought terrifies me. What if I find something I missed? I know well enough this means: what if I confirm that it is my fault; what if I find something written that he told me that I won’t allow myself to remember now? I refuse to look at what he wrote to me, also. I cannot bear to see the traces of him being alive: feeling, hoping, thinking, planning to live. I know he was planning to live. Until he wasn’t. This is the space where I stand: between his choosing to live and choosing (did he choose this? I will never know) to die. Once he said to me, every person deserves a chance at redemption. And I said to him, Even you. I wait patiently, no, stubbornly, for the space to fill.

What My Patients Know

I begin to suspect that my patient B knows I am in mourning. Since T died, he has begun to bring in recordings of piano pieces he is working on, pieces he has played all of his life and that he finds himself playing more deeply right now. It is a mystery that, at turns, delights and surprises him. One day I listen to a recording of him playing a Chopin piece and begin to cry. It seems to be the most beautiful piece of music I have heard. Inside the music, I hear B asking me to stay in the world of the living: it is a seduction to life. Perhaps he has sensed me one foot in and one foot out of this world.

Another patient tells me that, on some days, he feels like his life doesn’t matter much. I feel terrorized by fear, imaging his death and even more frightened because I cannot find the right words. It becomes one of the many days that I do not know how to find the right words to say to clients. It feels as if even my words, have I failed to keep alive. Always, at the start of the day, there is a moment, just for an instant, that this isn’t true, but then, inescapably, it is. What follows, is a collapse of the entire day before it has even really begun. Maybe I can no longer go on with it; maybe I can no longer do this work. I think of my former colleague C, whose child died. One day, I ran into her at an elevator bank. She looked at me, ghostly and glassy-eyed, and said, I could no longer do the work. I could see her grief, a shroud she never escaped. Another patient, one whose brother died of a drug overdose almost ten years ago, tells me: How do I go on, not fearing the worst could happen but knowing that it can? Because it already did? I follow her, on some sort of path, inside me inside her, and try to stay beside her. I experience her longing and her sorrow: both bottomless. Her neverending loneliness being in the world without him. She has realized that her family has never really talked about what happened. She believes he killed himself; she was the one who found him. She begins to slowly take me, take us, through the days before he died, then the day he died, then the scene of his death. She blames herself. She cannot forgive herself for letting him down. She tells me no one grieved together: no one admitted that it was a suicide. It is in this isolation, the dead-end tunnel of grieving a suicide, that together we find her alone and tend to her loss. I recall McCullers, that the Heart Is a Lonely Hunter. I find this aloneness in myself, too. Somewhere in this loneliest of lonelyhearts clubs, we meet.

One day a patient, a fellow therapist who works with adolescents, asks me if I think she would be responsible if one of her clients committed suicide. This does not strike me as strange: it feels like she is searching for something just out of her reach, something she knows is there, inside me. I feel a grasp at holding on. But I feel it turned around: I wonder if she is trying to hold onto me, to help me hold onto myself, or to help me hold onto her. I look at her and wonder if she is asking me to absolve her—she has experienced her own traumas at work—or if she is helping me to absolve myself. Perhaps this is the unspoken mutuality born of trauma and grief. She tells me that she believes a therapist can do all the right things and still not stop her client. I long to whisper, thank you. A client brings in a list: 13 reasons not to kill himself. A month ago, my daughter mentioned a TV show, whose title associates its name to Stevens’ "Thirteen Ways of Looking at a Blackbird." The night she mentioned it to me, I wrote down thirteen reasons that I thought T killed himself. I was one of them. I tell my client that one of his thirteen reasons not to die must be that I would be devastated. That I would never get over it. I don’t stop to think about this, the clinical value, or our therapeutic engagement: none of it matters. I decide not to doubt this: nothing matters when suicide enters the room, a vulture waiting for us. So, I repeat it to him: I would never get over your killing yourself. Never. He writes me down as a reason. Again, if only, it comes to me, if only I had a been a reason for T. Later that night at home, I wonder if I failed to communicate this to T, if what keeps us alive is our primacy for one another. Maybe this is what his suicide does: it reduces every experience to choosing to be alive or choosing to be dead. Some days I wonder if

the patient is in treatment with me or I am in treatment with my patients. This notknowing feels dangerous. I decide to move my office. I tell my officemate that we need to move our suite because of all the noise the new coffee shop brings (this is true) and because it has central air (also true). I buy a new couch, telling myself it is because the old one is cheap (true) and no longer firm (also true). Only, I know a deeper truth: I can no longer be in the place where he is missing. I cannot stand to see where he isn’t sitting. I cannot keep walking into the waiting area and not see him in the chair where he always sat. I cannot keep finding him missing. (I cannot stop reminding myself, taunting myself: I thought you were feeling better.) Everywhere I turn, he is not. He never stops filling a space that I need to empty. So, I move. I begin a book by Eggers that a client recommends. My client who lives with death: fifteen years ago, her spouse died, leaving her alone with a young child. I am trying to learn from her about how to live with death. She describes the part of her she came to know: the one who pushed herself into the work of living. Always, when she feels her spouse’s absence, she feels the pain of missing him: in these moments, it returns to her completely, the grief of her loss. His absence, and missing him, never fades; she just decides to keep going. I wonder what I can learn from her: her honesty and sorrow never dormant, never hidden. I become more open with clients about death. One client, active in his addiction, continues to passively kill himself. A year ago, I might have been curious with him about his self-destructive behavior. Now I tell him he needs to make a choice: does he want to live? T’s death has bifurcated, maybe reduced, my sense of all experiences being about

life or death. I read Becker who believes we are trying to stay alive, trying not to die, avoiding death, denying death, or psychically locating ourselves somewhere along this spectrum, but we are never not in relationship to the reality of death, he says, even in our denial of it. If I could ask him, I would: Did you want to die or no longer live? The gap between these two questions, becomes a cavern I never fill. In this gap, I obsess over language. I learn that suicide comes from the Latin word, suicidium, meaning the act of taking one’s life. I read an article by a physician who questions the use of "commit" with suicide. He argues that we do not use the term "commit" with having a heart attack and likens suicide to a deadly disease. These ideas do and do not ring true. I see-saw from one pointless question to another: Did you want to die or was it too hard to live? Did you commit suicide? I surprise myself with anger and a rageful accusation, you never committed to anything. You murdered yourself. If only you knew how much you took with you. Two clients, I learn, begin a journal around the time that I begin mine. Then I see a longer line of journals: first was his, then I began mine, a journal of him. I wonder if I am finishing the one he started, the one where he looked for himself, desperately, and in fear. I begin to wonder if he is the only subject: maybe it is my journal of death. His suicide and the part of me that disappeared with him.

Guilt, Paranoia, and Dread

Nine months after his death, I stop waking up to his absence and stop going to bed on his suicide. I think about my two pregnancies, wondering if this is the third one that I

never had: the gestation of two lives and the gestation of one death and its sickly, deathly twin, suicide. Still he continues to visit me in my office and on my runs. Always running, he and I. Once I asked him about this, what would it take for you to stop running? All that runs through my mind is suicide. Again, I watch the Hours. Virginia Woolf, asked by her husband why someone in her novel must die, tells him: Someone has to die so that the rest of us appreciate life. How wrong she is about this. Suicide does not usher in an appreciation of life. Instead, the survivors, are left to grieve a loss we can never understand. I am puzzled that I begin to imagine myself as one of a collective, the survivors of suicide. But I am not that: I am not surviving. I wonder if all those left behind believe, I was not enough for you to live. I wonder about the "we" I create. I imagine it is a fantasy, like many others these days, conjured to make me feel less alone. I read Alvarez, who writes about Plath, their friendship, and his own contemplation of killing himself. He believes suicide is a way of making sure one is not forgotten. So, the dialogue with T continues (everything brings my questions back to him): Is this what you did? You made sure I would never forget you? Still some days I cannot get out of bed. There is a lead blanket over me. I whisper, I would not have forgotten you. Never. I begin to feel paranoid, a suspicion of myself that I cannot evade. I hunt around in self-accusation for clues of being an accomplice to a murder, consumed with the wonderings about what I missed. This morphs into a projector playing moments over and over, looking for missed signals and unread signs. I won’t accept that maybe there was nothing there. It is impossible to un-convince me of this: that the absence of his life means that signs of death and wanting to die were present. It is a strange, imperfect math

that does not work on both sides of the equation. It would mean that because I am alive, I have no signs of wanting to be dead—and I know this is not true. Later, when a former consultant tells me, generously and warmly, that she would like to help me survive this, I imagine it is this torturous circle she hopes to help me interrupt. The truth of the experience becomes this: I will never stop thinking there is something I could have done differently, something that would have led to a different outcome. I will never accept his suicide. Would Freud say that I am refusing to mourn the lost object or the loss of the love object? I do not expect myself to move on or accept the loss. I know he is responsible. But I will never not feel a tremendous sense of responsibility. In fact, I believe it is important that I do feel responsible. I have fantasies of acceptance, but it is actually a fantasy of freedom from guilt. It is a fantasy of forgiveness that escapes me. How do the living forgive the dead is usually the question: I wonder if I can forgive myself for not keeping him alive? Some days I carry his suicide as if it were my own. As if it were my future suicide that waits for me, belonging to me. What scares me is the way it comforts me to have something that belonged to him and to make it mine. I continue to hide in work. I say yes to every new client and work more than I could possibly imagine. I wonder if I am working with the living to avoid the dead who never leave me. I wonder what I have to prove: if I need to prove to myself that I am wanted, if I need to compensate for the injury and rejection. At the end of every session, I dread the separation and I fear the client may not return. I doubt my ability to be accepted, wanted, returned to: the fear is endless. The desperation feels unwieldy. I return to the fantasy about one of his children contacting me for therapy: it is a fantasy of connection and closeness. It is closely followed by a shiver of fear: I might be hated or maybe simply feel

just as helpless as they are in this loss. But what I would give to hold one of them; it is a longing for the parts of him that remain.

The Steadiness of Loss

My daughter readies herself for college and begins to transform the rooms of our home. The little girl disappears; a college student takes her place. Childhood toys, stuffed animals, sister dolls are tucked away, all companions from another lifetime placed on a shelf. Everywhere there is loss. At times, I fear how bound I am to his death or that I cling to the absence of him to avoid a sense of being nothing. Maybe it is rejection that ultimately, selfishly, I feel. I fear the sadness that does not end and the missing him that does not quiet. Some days, when I imagine him hanging, I wish I could lie underneath him and stop living, simply not to feel the loss. I know this is what his death does to me, what suicide maybe does all on its own. When I am not imagining dying, I continue imagining a response that would have changed his decision. I trade one fantasy for another: the wish to not be alone threads them together. When the anniversary of his death nears, I realize what I have known all along: there is no comfort and never will be. Nor should there be. I no longer think of his suicide as a choice to die but as a decision to stop living. It is a decision I do not survive or nor one I accept. Each day I simply get up and make a different one for myself. I keep choosing to live, in part, because I do not end my life. There remains a deadness where he was and yet he stays alive with me on most days. It is an argument I stop trying to resolve. I accept the wish not to be without him alongside the impossibility of this wish. I will always be without him; his death will never leave me.

Always and never: the relics of our relationship and the traces of what will never be. The loss endures and I with it.

Chapter V

Discussion In studying the experience of my patient’s suicide for the year following his death, my aim has been to give voice to the unspeakable; to give image to the unimaginable; and to make known, an unknowable subject: the therapist, whose commitment to confidentiality historically secreted her experience and permanently buried it with her client. In this discussion of my experience, or rather of the data of my experience, I located me, the therapist, as the subject of inquiry, ideally not solipsistically. Also, I have worked to avoid globally or reductively characterizing this autoethnography as either an essentialist or an existentialist exploration of suicide as an event and to avoid a debate about realism and nominalism evoked by the experience of death. In fact, in analyzing the dimensions of this experience, what has been revealed largely is this: a wish to be less alone with an unending, devastating loss. As Winnicott (1969) has theorized, what has emerged here is my own fantasy about usability as an object in the clinical field. In this, there is a wish to not die as his therapist but to become, instead, a different object. Perhaps, this would be best described as an autoethnography of a suicidal loss, death and disappearance in a metaphysical object world. However, I have suspected another truth, one noted in the experience of absence and disappearance, that it is a joy to be hidden but a disaster not to be found (Winnicott, 1964).

Without question in this discussion the exploration of my experience has represented an urgency to close the gap, the one created between life and death, reality and fantasy, truth and lies, mourning and murder, subject and object, self and other, and therapist and patient. To discuss the findings with a recognition of this gap has meant to impregnate an absence that doesn’t fill, to encounter a void that doesn’t close, and to recount my endless oscillation from the feeling presence to holding absence of my patient.

Themes of the Experience

In an analysis of my experience, multiple themes emerged differentiating psychodynamic dimensions of the suicidal loss of my patient. These themes revealed less a polarization of my experience—from life to death—and articulated more about my grappling with, falling into, and trying to fill the space between these two poles of existence. One major theme of my experience illustrated an ongoing psychodynamic relationship and relational experience in a part-dead, part-alive patient-therapist, subjectobject world. My experience, in this way, has been conceptualized as a found-andcreated dimension or an othered area of existence conveying the plurality, rather than the singularity, of his suicide as an object-relating experience not an intrapsychic or physical event. Other discourse-organizing themes of meaning that have predominated the narrative come from the ways his suicidal death ushered in a complex, often confused state of being with him and his suicide. In this, a triadic (patient-therapist-suicide) object matrix existed in its own dynamic state of being in immortal grief. Also, his suicide murdered him and created murderers, poles of being and relating that ultimately and unavoidably

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included us both. Because he killed himself while in a treatment relationship with me as his therapist, I could not stand outside our intersubjective field as a neutral, passive subject. It felt that in killing himself, he killed me as his therapist; and, in correlation, when I died as his therapist, I assumed culpability for his death and internalized an identity or identification of being a suspect of a crime. The part-dead and part-alive object pair we formed included killings and killers. The initial relational and experiential field of believing he was missing and not knowing he was dead created a gap that framed all subsequent object experiences: in this gap, there emerged an absence of his presence, an emptiness of knowledge about him, an oddly impermanent loss of his being, and a sense of isolation in and fidelity to our dyad. In this space, I created, discovered, and found myself drawn into other ways of relating to him, some fantastical, some mad, some desperate, all sorrowful. Another category of meaning centered on my experience of being in suspension, or more accurately, how I experienced our relationship in a state of being suspended and in a purgatory-like, treatment liminality. In forestalling an acceptance of him as finitely dead, I related to him in a transitional place, neither experiencing him fully outside or inside the consulting room, we existed in a static, immutable, relational world: one characterized as in between reality and fantasy, part together and part separate, both hiding (him) and seeking (me). This subjective experience of our treatment relationship felt born of, or located in, an alternate reality, one where I transitorily and psychically oscillated between an internal and external world, not dead but afraid to live, in the rejected state of an abandoned object and the abandoned state of relating to a dead, rejecting object. I kept myself stuck

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and in transit between both worlds—asleep, with fantasies of death, and awake, with the dreaded reality of remaining alone. A final, but not penultimate, theme of meaning to develop, identify, and recognize important functions of others, who served as caregiving custodians of the living with death/not dying, and acted as unconscious facilitators of an infidelity. These others intervened to break my slavish devotion to my monogamous relationship with my dead patient, one filled with guilt, paranoia, and unbearable sadness. These significant others included consultants, patients, my family members and my therapist all of whom in their own fields of experience generated and shared invaluable rituals and rhythms of being and made the kindest, most sustaining of offerings: they stayed with me.

Categories of Meaning to Emerge from the Themes

Suicide, the unwelcome third: Compromises with the tyranny of suicidal loss.

Following my patient’s suicide, I continued an object relationship with him and created one with his suicide. These object relationships formed an unhappy, threesome: I never related to him without his suicide shadowing our dyad and I never disassociated him as a person or a subject from his suicide. In this manner, my patient, his suicide, and I became an imprisoning family. I held his suicide as if it were our once-alive, now-dead

stillborn to share. Because it was as if I had born his suicide myself, I carried this responsibility, or this guilt, as a command for atonement, one best made by my commitment to his absence, Also, identifying myself as the creator of his suicidal

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disappearance meant I was to stand guard on alert for his return: in fact, any sightings or remembrances of him, like all homecomings were welcomed unconditionally. Waiting for him in this emptiness, this non-existence of him, I held his absence and his suicide permanently: he would not return to treatment and I would not stop inhabiting our treatment world. In my refusal to psychically separate from what had been and, because of his death by suicide, I committed or condemned myself to keeping close my here-but-not gone patient. In fact, I believed that the existence of his death from suicide demanded unquestioning surrender, this enslavement to his once-there presence. So, I made us into our own ghostly kind of family, one I could neither completely bury nor fully return to life. Perhaps, my patient’s suicide or suicide itself unavoidably or understandably acts as master of those who remain, making the therapist the permanent guardian of both what was, as well as what never will be, rendering her a reluctant pallbearer, one who never visits the grave. In this way, my patient’s suicide ushered in the most unwelcome reality: a death born of a therapeutic partnership that also ended that partnership, thereby forever linking the relationship to the suicide and, in eternal continuity, the suicidal death to me as his therapist. His traumatic death, his suicide, unknowable, and unfathomable, became inextricable from the dyadic life, rendering the suicide an offspring of our therapeutic life. One was never again to exist without the other: my patient, his suicide and me. An unwanted and most unwelcome trio bound by death, unfound in life.

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Suicide transformed a confidential relationship into a secret experience.

Immediately after my patient’s suicide, I silenced and kept the experience hidden from others. Initially I believed this stemmed from a myriad of intrapsychic feelings of shock, sorrow, shame, stigma, narcissistic injury, guilt, and fear. But I believe my hiding in silence also represented an inability to frame my patient’s suicide as an event or to form a narrative, as is often true of trauma. Increasingly, though, this inability to share took on a form of refusal, as part of an insistence on protecting, perhaps to seal off from external reality, an ongoing object relationship with him. In this internal, object world, I found or recreated the confidential and private therapeutic relationship we had in the treatment room, but internally and fantastically reconfigured, monogamously in death more than life. Because of my relationship-creation, I could continue to relate to him in multiple object forms: a dead object, a missing object, a depriving object, a wished-for object, an imagined object, an eternal object, and a rejecting object. So, the treatment relationship, which had been private, became a secret. Without anyone in my life knowing my patient had killed himself, save my consultant and my therapist, a different story of us flourished: one in which I found him, he called me, I saved him, and, in all manners, we lived together. I was not alone. It did not occur to me that these narratives could be projections or projective identifications created by his death, and my sense of loss. It did not occur to me then, as it does now, that in this kaleidoscopic field, I had rendered him into a transference object, giving him the power to signify and evoke other

object losses in my life. The questions his suicide brought close to me, almost suffocating

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me—what did I miss, how could you leave me, what happened to you, what happened to us—because unanswerable, endlessly reified my fidelity to him as an object and kept at a distance another inescapable reality: I had become a forsaken object, a therapist forlorn.

Patient suicide is a co-created death: Patient and therapist as culprits.

Death by suicide often has been framed as a commitment—he committed suicide—in our culture. Death by suicide subverts rituals and routines established for death and mourning. I could not mourn him without mourning the fact of his suicide. Death by suicide, like any trauma, begs for understanding, a reason, a cause—truly any shape of meaning or any kind of resolution; and like most trauma, the unknowable upends the stitching that hold things together. Why cannot and will not ever be answered. There is no undoing this state of things that because of suicide has become undone. In this complex context, social worker education has planted its knowledge base on the training of professionals to identify, assess, and intervene with suicidal patients: without question, therapists want their patients to live and will do anything to ensure that they do. But central to this professional training and education has run the belief, perhaps the expectation, that a therapist has the clinical ability, the professional knowledge and specialized training, to stop a patient from the decision not to live anymore. Undeniably, I felt responsible for my patient’s suicide. The guilt did not disappear. In fact, one of my initial acts was to consult an attorney about my liability, because I feared, and still do, his family holding me accountable either legally, morally, or ethically. In this way, I have considered myself a suspect in a crime, interrogating myself incessantly about what I did and did not do. This internal process was not only a psychodynamic

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process or sign of a commitment to my patient but stemmed from a cultural construction I colluded with that therapists, at the very least, are complicit in a patient suicide. I submitted myself to this sense of complicity, completely. When my patient killed himself, he ended my being his therapist. I have imagined this as a fitting parallel process and intersubjective moment: his death as a subject in our dyad ended my existence as a subject of our dyad. In fact, rendering me an object of his suicide, quite possibly, challenged my contact with any identification beyond culpable provider: the doubt, guilt, and shame suggested that I dare not consider myself anything but this, because of his death. It has been true that in the moments before, during, and after his decision I remained someone, or believed myself to be someone else; someone who knew him, worked with him in treatment, and with whom he shared himself regularly. Because I did not believe it was impossible for him to do this—which is different than believing it was possible—I have been suspicious of every decision I made and every decision I did not make, also. A call and response, its own kinds of vicious, closed echo chamber developed: Why did he do it? Why did I not stop him? Why didn’t he tell me? How could I not know? Because I envisioned our treatment relationship in a collaborative intersubjective field, I could absolve myself of participation or deny my role in his suicide. Because I believed that growth in the treatment relationship is co-created, his death must be also. I cannot be part of one and not the other. This I know: my fingerprints remain everywhere he is not.

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Suicide in the treatment relationship caused parallel processes: Playing at destruction.

The ongoing internal relationship with my dead-patient was characterized by a secret fidelity that included my participation in, or creation of, a parallel process with him. Not unlike a childhood experience of days spent with an imaginary friend, I devoted myself to this real, but also imagined, patient through parallel acts of play. Rendering myself a supplicant to both the real, dead-treatment relationship and the alive, fantastical one, I believe that I rejected either pole of being—reality or fantasy—and sought a sense of closeness to him by inhabiting an adjacent, similar world. For example, after his funeral, I found ways to bury myself. By burying myself in work, in fear, in secrecy, in other’s experiences or depictions of death and suicide, and in isolation, I attempted to shadow my patient in his world, not out of self-punishment but a desire to create a facsimile of his life, by burying mine too. Also, I often wondered if he was not thinking clearly when he took his life, if it was a moment of temporary insanity: I made my own madness in this, my own world of spinning out of knowing what is real. Also, in a parallel process of disappearance, it was as if I needed to disappear along with my patient. These disappearances were imagined in a car crash, created by silences and isolation, and occurred by losing myself in my patient’s lives, far from my own. Thoughts of death, specifically the idea that I could choose suicide just as my patient did, never left me and often consumed me: it was as if a means to be with him was opened-up by the parallel play of destruction and death. In the movie Inception, a man sits on a ledge watching his wife fall to her death: we

watch him long to be with her by deciding whether to jump, too. Because the movie has

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convoluted any certainty of what is real and what is imagined, the viewers do not know if he lives with her by dying; like him, we cannot be certain. The storyline creates an everpresent doubt, an endless wondering: how can we ever know if the world we are living in is real? And, isn’t what is most real of all, how we feel? So, sitting with the character in this choice about how to live and whether to die, a different reality surfaces: isn’t it better to be with her, dead or alive, than apart? So here, too, in the parallel process with my patient, hummed the longing for connection, the fear of separation and these inseparable, twinning inabilities to accept or gratify either.

A relationship of liminality forestalled the acceptance of loss.

An ongoing engagement in parallel processes of being and attempts at non-being created a continuous, internal state of oscillation and existence in a liminal space with my patient. Caught in-between states of being in fantasy or reality, avoiding life and imagining death, or searching for togetherness and denying separation, suspended an integration of internal objects, likely, this suspension acted less as a bridge towards nonbinary poles of existence and more as a means to forestall accepting the death and the absence of my patient. In the service of this unconscious goal, I created or found a liminal treatment relationship with my dead patient. In dreams, he was alive, while my waking state held the nightmare of his death. To imagine him hanging led to obsessively picturing him in the moments, however brief, between ending life and beginning death. The presence of his absence confounded me and the imagined absence of my presence frightened me.

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Suspended in between his death and my life, the absence of his being alive and the presence of his being dead, I created and lived in a metaphysical, non-real world. So, I felt sad but would not allow myself to grieve; I felt loss but would not admit betrayal; I felt fear but allowed for little if any anger. I dwelled in, or insisted upon dwelling in, a transitive place of knowing I had lost a patient but not admitting my patient’s death. Instead I would replay and then rework past experiences into different ones, remembering what had been said and then searching for a different ending, searching for him and for a narrative that did not end with his suicide. In other moments, I would either suspend acknowledgement of his absence by replaying him alive or bind myself to him by imagining me dead. Ultimately, as a form of compromise, I adapted to his suicidal death by forming a different way of being together: I imagined us a part-dead and part-alive treatment pair. This entity made of our aliveness together and of his separation in death did not force me to choose his death or my life: instead, we became our own sort of changeling, not alive and not dead, but both. As a result, my solution to reckoning with him dead but nevergone and me, alive but never-here became its own force of being alive against the unimaginable presence of his suicidal death and the inescapable pain of his absence. It would eventually present as a fantasy, that this state of liminality, of being on the threshold between dead-and-alive could endure and in perpetuity replace, as an its own kind of eternal flame, what had been our way of relating in the treatment room. This mirage would evaporate by the end of the year, this fantastical, magical notion that my challenge or bind to accept either the pain of being alive without him or the sorrow of his

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being dead and gone could be contained by some way of being together, in an in-between world I created.

Suicide authors the treatment story: Wishes, dreams, and fantasies as attempts

at a counter-narrative and expressions of counter-transference.

In Sam Shepard’s (1979) play "Buried Child," Dodge summarizes what he, as a parent, experienced after the death of his child: "It made everything we’d accomplished look like it was nothin’. Everything was canceled out by this one mistake." The play illustrates the fracturing of a family, one unable to recover from the loss of a child’s life where hope and potential are dismantled permanently. "The suicide of a patient," a professor once said, "was not unlike the death of a child." I imagine he meant that its resemblance is born of this truth: suicidal death obliterates any other experience and subordinates other narratives of one’s life. Not completely unlike the parent whose child has died, one might wonder: Am I still a parent? Only to discover that the loss changes her forever into a parent of a dead child. The inconvertible tragedy hangs as a qualifier to one’s story about oneself and, since death destroys life, how could it be otherwise? While the narratives created about one’s life axiomatically suggest or assign the self an inferred or assumed kind of agency, the suicidal death of a patient destroys the notion of having influence or choice in one’s life. So, in its mimicking of other traumas, the suicidal death collapses identity and, in remaining unassimilable, quickly defines identity. Because of the patient’s dependence on the therapist to help him, a suicide makes all other decisions in the clinical process irrelevant and the treatment process itself a total failure. Whatever faith the therapist had in herself is shattered by suicide; doubt in

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herself, doubt in what she believed to be true, doubt in her own goodness as a therapist never remits, it only sometimes quiets and lessens. Also, because of an implicit dependency on the therapist in being a patient, and an unavoidable vulnerability is seeking help, the therapist can never dispel or deny the totality of her power, however inferred, and can never rectify the inherent power imbalance between patient and therapist. She might simply accept it and carry it with humility and responsibility: suicide, never shrinking, never disappearing, dwarfs her trust in that power, shrinking her grasp on it irreparably. As has been true for me since he died: what else matters? And, can anything or anyone—can I—survive his suicidal death? Attempts at answering these sorts of questions preoccupy writers, philosophers, religious doctrines, survivors of loss and trauma: but efforts, like mine, at negating the reality of this experience take root in the psyche of negation, the fear of death, and the imaginative, possibly protective forces, of magical thinking. My inquiry into the traumatic experience of his suicide has raised questions not just about the traumatic impact of patient suicide: I have wondered what was it about this patient, what was it about this specific treatment relationship that evoked such devastation and upheaval so completely in my life? It is known, and thoroughly theorized, that to understand a patient, the therapist must, through some form or another, interpret, identify or experience not only what the patient communicates about himself and his experience of others, including the therapist, but what she too experiences of herself with the patient and what he enacts in her (Racker, 1968).

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In hindsight, there was much that had wedded me to my patient long before his death. I identified with an emphasis on the primacy of family and the work to live with the vulnerabilities of being a parent; I became more aware of my own wishes to be accepted and loved in my life; and I recognized my own longings to be understood and known (and my hopefulness about that being possible): all unconscious material that, looking back, had contributed to my belief in a shared engagement in the treatment relationship and process. A friend once said to me that he believed that he and his therapist were like inmates in a prison yard, never talking in complete sentences, throwing each other codes the other could readily decipher: the closeness to emerge from sharing the same four walls, being trapped by the same governing rules, and transforming the shared space into a vehicle for being known—all were qualities of the treatment process crystallized by the intimacy of being inmates in the same cell of treatment. Later I would experience the inverse: an imprisonment in our relationship, not in life, but in death. At times, I had imagined, falsely, that my patient idealized me: the one, I believed, he told everything to; the one he could count on to be there when he felt alone; the one he trusted for much-desired acceptance. After his death, I suspected that we swapped roles and, for me, he became the same sort of immutable, one-dimensional ideal object. Perhaps it was because of this (mis)belief about my primacy or my centrality in his life, or in a form of projective identification, I associated him to other significant ties: in these associations, I experienced him as a dependent, part-child, part-younger sibling, or a former partner longing for connection.

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In total grandiosity, I relished an essential feeling of being needed. Now, I have revisited this as a fantasy, one I created and believed or needed to believe; and though he likely helped me cultivate it, in hindsight I did so quite dangerously and fatally. The two of us, as in Conrad’s Secret Sharer, made known to the other, the parts of what we both needed to create and make true: only separately discovering other truths too difficult to reveal together. Truly every remembering of my patient returned me to this truth—he killed himself— and every replay of sessions only could be examined through the lens of this story. The recursive reality of this closed system effectively blocked change. Without an ability to author a different narrative in the external world, I compulsively, wishfully created different stories, ones in which I could write him and our relationship into an alternate existence. The sightings of him, the imagined conversations, the attribution of imagined reactions and responses, the fantasies of merger with him in some sense were all forms and evidence of my dreaming (Bion, 1962). But the function of the dreaming, was to dream myself into a new narrative, as the author of a story in which my patient was still alive, going to coffee shops, shopping at stores, attending school conferences, and watching his favorite TV shows. These fantasies not only kept him alive but empowered me as to be the narrator or the subject of his death, rather than the victim or the object of his suicide. Enacting this transformation from object to subject changed my role and place in the narrative from reactor to actor. Symington (2002) has described this shift as changing one’s mental process and the difference between "freedom from" and "freedom to;" in "freedom from"

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one is imprisoned by emotions as constraints, in "freedom to" one experiences the power to create (p. 44). Therefore, as the agent of the story, I was "freed to" fill my waking days and sleeping hours with different stories of merger, connection, finding him, a resolution and cessation of loss. Instead of the story he left me: he killed himself and abandoned me; the story I wrote was this: I lost him and will look everywhere to find him. Perhaps even this process now functions as a mirage of an oasis; one to counter the narrative he made and left for me, the narrative I do not escape or change, but one I have attempted to rewrite simply by continuing to tell it. In sum, the counter-narrative created by these wishes and fantasies functioned as a counter-transference reaction and formed a counter-transference response to my dead patient. Racker (1968) has asserted, "The transference is always present and always reveals itself. Likewise, countertransference is always present and always reveals itself . . . its manifestations are sometimes hard to perceive and interpret" (p. 106). In this way, it has been assumed that countertransference to the patient outlives the work with the patient in the clinical encounter; or rather, that the clinical encounter with the patient exists outside the therapeutic session. Certainly, I have found this to be true. Throughout my experience of him before and after his suicide, my countertransference fantasies never changed: I wished for connection with my patient when he was alive, just as much as when he was dead. To assume these fantasies are functions of denial missed the forces of the transference/countertransference at work and highlighted the arbitrary demarcation about termination often formulated concretely about treatment. Perhaps, my counter-transference fantasies have indicated that even as suicide creates

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death, wishes and dreams communicated in the therapeutic relationship survive even when life ends (Racker, 1968).

Patients interpret and respond to the therapist’s experience of loss:

The co-creation of being alive.

While in treatment, it is typically the therapist who interprets the patient’s experience. Hoffman (1998) has expanded on this idea by claiming that the patient, as an empowered agent, is the interpreter of the therapist’s experience. With the steady, newly developing communications from patients about their own experiences with death, I experienced patients interpreting my experience of death and loss, as well. Recognizing that the patient is a subject in an intersubjective object relationship tilted my receptivity towards these patient communications as interpretations. In large, I believed my patients made thoughtful, compassionate efforts to usher me into, out of, and through their own graveyards, rendering an offering of themselves as experts in living with death. In this role as interpreter of my experience, my patients, not unlike what typically has been expected of the therapist, acted as facilitators of different object ties; ones that expanded my capacity for object relating when my internal object world entirely collapsed into death and a preoccupation with a dead object. Also, patient communications and patient out of a need to find me psychically alive for further use, initiated an infidelity I had cemented to my dead patient. Quite possibly, these unconscious communications provided the ballast for becoming the therapist they needed me to be or the therapist I needed me to become: and, in this matrix, likely one did not exist with the other. Ogden (1995) has stated that the patient’s

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"sense of deadness and aliveness" experienced or constructed in the intersubjective analytic field, constitutes the essential work of building internal structure in the patient’s object world, (p. 695); clearly this can be said of the therapist’s work, as well. Undoubtedly, my patients’ need for me to be alive, alongside their experience of my deadness, and mine, facilitated their construction of me/my construction of them as "alive" objects intersubjectively created by patient/therapist need to live, as well my/their intersubjectively experienced fear or dread of being "dead" (Ogden, 1995, p. 695). In other words, I was forced to become a therapeutic subject, as a result of interjecting my patients’ projective identifications, or as a result of receiving and accepting their transference communications. Ogden (1992) has argued, "The subject cannot create itself" and that "the development of subjectivity requires experiences of specific forms of intersubjectivity" (p. 624). In short, during this period in which I felt dead inside, my patients generated the engagement and interactions that created my ability to be more alive, as a subject of our work, not an object of my life. Perhaps it was because I felt my life was needed when I was with my patients, my deadness did not swallow me whole.

Rejecting the acculturation of suicidal loss: The important function of others to contain and sustain divergent experience.

The trauma of my patient’s suicide severed my ability to connect with others and amplified a disintegration of belonging to any formalized, communal means of mourning. Although, I wondered whether my experience of feeling an outcast was internally or externally created, I believed it was likely a function of both: as a result, I cast around for

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a transitional space, one in which I might experience a location of culture (Winnicott, 1960) to hold me. The medical community did not speak to me or my experience, the professional net of colleagues from agencies or in private practice did not feel safe; the legal field seemed a temporary, but insufficient port; and the spiritual or funereal rites, too, reified my orphaned state. Marginalized by my own shame, fear, sorrow and guilt, there was a double bind: no one seemed safe to trust and nowhere offered a place for me to belong. It was my psychodynamic community, most especially my consultant in concert with important, essential others—my former consultants, my therapist, my fellow doctoral colleagues, and several professors—along with the essentiality of the lives of my children, functioned as holding environments for an experience characterized by isolation, madness, and fear. These custodial others provided containment and sustenance divergent from the systemic norms for mourning that did not speak to suicidal loss for the therapist. Each one took me in like a foundling, into a transitional space in which I could make use of them as good objects, ones I desperately needed. From inside the walls of what Balint (1968) identified as a basic fault (felt in myself) these usable objects did not codify, direct, formulate, or tyrannize my experience: no matter how unbound or bereaved I might seem. Ultimately, this proved a most subversive of act, empowering me to become a subject, not only an object, of my patient’s suicide. This freedom to discover or find myself, even as I existed in a place of negation (Kohon, 1999) ironically fostered an area of creation (Balint, 1968): one in which other object ties, ultimately could be found, when I was most alone and very lost.

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This psychodynamic community, figures who functioned (Bollas, 1996) as meaningful personal and professional individual relationships also formed a collective body of essential others who proved uniquely and dynamically poised to accept, recognize, and endorse my pluralistic states of being. As I encountered what the writer William Styron (2010) best described as "darkness visible," my forms and states of being, lost and unbound, were contained by a much-needed elasticity, that characterized the acceptance by and from these significant others. In this way, and, in no small measure, they were steadfast with their generous object offerings to survive and with their provisions and ministrations of tender attending, formed by a love, forgiveness, and acceptance unlike any singular others.

Limitations of the Study

This autoethnographic study has been limited by the constraints imposed to complete the research, constraints that falsely constructed both a beginning and an ending to the experience. The notion of starting and finishing an experience, along with the concept of closure, were formulations made in the service of the need to codify the research. For example, the focus of the study implied or required that elements, characteristics, or experiences in the treatment relationship before my patient died were not influential in my experience of his death, which was not true. Also, the binding of the study into the time span of the year following his suicide falsely demarcated this as a notable point to end reflection when in fact, the experience of his suicide has no end. In fact, the experience of his suicidal death never ceases to enter my imagination, my work, my daily

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life: and the finitude of each day or of this research has prevented a true capturing of this reality. Finally, the study has been missing an exploration of the role of the study itself: further inquiry into the function of creating and enacting the study might reveal it as an attempt to make meaning, an effort to become a usable object, or a refusal to accept loss of becoming an abandoned object. Undoubtedly, the study has limited itself through its inability to be recursive in its analysis.

Clinical Implications

Clinical implications for the study that have indicated a potential to question clinical assimilations or codified dimensions of clinical experience have included: clinical education; professional training; clinical process and technique; clinical reifications about death and suicide; and conceptualizations about the therapist’s responsibilities. Such questioning might best take shape in the form of: clinical education on patient suicide as more than a singular, intrapsychic and physical event; clinical training that expands upon current reductive assumptions about assessment and prevention implicating the therapist as an instrument of ensuring life; clinical process and technique that includes discussion of and sharing about patient suicide as an ongoing clinical experience for the therapist; recognition of and critical inquiry into the therapist’s experience as a subject; and, the work to acknowledge the workings of death, and suicide, in the field, whether conditionally, provisionally, psychically, or metaphysically.

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Research Implications

Autoethnography research has given primacy to story and narratives of the self, underscoring the need for personal narratives to function as an essential means by which therapists can learn and understand themselves and their work. Autoethnography has provided an instrument for challenging positivist, binary theories of being and non-being, that conceptualize patient suicide and the therapist’s experience as an internal or physical event. The significance of autoethnographic research has been found in its ability to provide a lens into meaningful discourse, critical study, and an expansion of the clinical field, rescuing it from the understandable pull towards reductive ways of studying human experience. The writer Chimamanda Ngozi Adichie has cautioned against the dangers of a "single story," encouraging a politic of multiple narratives. Autoethnography has invited stories into the study of the clinical field, created a conversation of clinicians, and upended collapsed narratives about suicide in therapeutic work by invoking the voice of the therapist as a subject; one to become more known, perhaps as part of coming to know ourselves.

Conclusion

The difficulty in looking beyond the aftermath of my patient’s suicide and the challenge, inherent in working to extrapolate meaning, or offerings with potential merit to the clinical field, has presented, on the one hand, an absolute impossibility, yet, on the other hand, there has been a longing to create or discover anything salvageable, anything worthy of remembrance and safekeeping. As has been noted, it was my patient’s life that

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held value and meaning. And has been catalogued and discussed, the reckoning with his traumatic death has suggested not an attempt at creating sympathy for me or valorizing my experience, so much as a desire to transform his absence and my emptiness into the fullness of another kind of presence—for myself and ideally others of a shared experience too. Perhaps, this study has indicated that if the presence cannot be him, let it be in the traces of him and found in the remains of our treatment. In this study, there has emerged some urge for an honest and painful recognition of what might have been more easily denied and never spoken of as a therapist: patient suicide in the treatment relationship. Towards that aim, an organizing theme to ground this study has centered on expanding and re-shaping clinical conceptualizations of suicide as an intrapsychic experience and a physical event. Instead, this study has theorized that the therapist’s experience of patient suicide inculcates and obfuscates her grip on reality and ultimately collapses and alters her clinical, personal and psychic arenas of experience; and, as she reconstructs her treatment relationship with her dead patient it continues in a different object experience. What this means for clinicians is multi-dimensional. First and foremost, this study has asked that clinicians anticipate that in the tragedy and the trauma, what exists becomes a tyranny of patient suicide. Contrary to cultural myths or professional tropes, this study has indicated that the clinician will not envelope herself with a pablum-like comfort, that she "did all that she could," to help her patient. Nor, according to this study, will she mourn his death like any other loss in her life. In fact, mourning her patient will be interrupted and blockaded by the immutable quality of the suicide: because it defies

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acceptance, she will continue to grapple with the reality of the suicide, never solvable, never knowable, and never understood. Instead she, her patient, and his suicide have formed an unexpected, unalterable trio, their own kind of Pythagorean trap: she and her patient always rigidly bound together, becoming two parts of an equation whose sum forms an unimaginable horrible third-part, his suicide. In her attempts to reckon with the certainty of death wrapped tight by the unexpected, the ambiguity of suicide, the clinician has faced an unavoidable and perpetual negotiation that comes with the unwanted object: keep it or let it go. It is unlikely, according to the findings of this study, that she can or will be able to do either. These forces of being/non-being found and created by the patient, the suicide and her then are left to bind themselves to one another in an effort to make meaning, recursively, creating their own object-field, together. Secondly, this study has indicated that when confronted by these unresolvable negotiations with suicide, the therapist might not turn to her colleagues for consultation or help, as she might have with other therapeutic failures or impasses. Instead she becomes vulnerable to keeping the relationship, once confidential, now a secret. Perhaps this becomes true in part because she has been unable to identity what exactly she needs and how to speak about or the trauma that did not happen to her—there are different but clear victims of suicide—and confusingly she finds herself having identified as both victim and participant, stuck in a conflict about this impossibility and a confusion about which is more true. Unfortunately, her capacity for imagination disappeared when she needed it most. Since the unalterable cannot be reimagined: what was private becomes hidden and what cannot be found—another to share the terror with, or the belief that it is

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possible to share—was created. She shares the suicide with the one object she can and does: her patient. In a sense, this study has suggested that the therapist likely does what she has been trained to do, she keeps what happened in the relationship between her and her client. What has changed, is that the person whose confidence she keeps, has died and, as she drowns in guilt, shame and sorrow, she is no longer sure she can consider herself his therapist. But in some ways, what was true of clinical work has remained the same: the therapist believes that the one person who truly understands her experience of the relationship is the patient. This study has argued this is exactly what she does, only now in a conditional, metaphysical, reminiscent terrain of being as a therapeutic pair. The study has revealed the clinical implications of suicide for the therapist who conceptualized the treatment relationship as a co-created, collaborative partnership—in life and death. For she who conceived of her work in a social constructivist paradigm, the therapeutic engagement, imagined as an intersubjective field of relating, replaced the Hegelian master-slave dynamic with a belief that two subjectivities interact in the service of therapeutic change. Once the therapist’s patient has committed suicide, the therapist then inevitably experiences her participation in his death; however democratic and egalitarian her convictions about co-creating therapeutic action and change proved in the treatment room, she cannot then conveniently or honestly deny her collaboration with his suicide. Clinically, this participation and collaboration has tied her to his murder, an accomplice, if not a collaborator; not the one to blame, nor one outside the killing field, either. Importantly, the therapist can never be concretized as an inviolable self, wholly

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innocent, all-good or simply benign. While the therapist was not responsible for her patient’s death, clinically she finds it impossible to grant herself immunity, defensively framing decisions made in the treatment room as collaborative and those outside the therapist’s vision as singular or individual. Axiomatically, she cannot have it both ways theoretically or experientially: when he murders himself, he murders her. Choosing to die as a patient is just as much a collaboration as choosing to live as a patient. Just as there is no infant without a mother (Winnicott, 1960), there is no therapist without a patient. So, this study has discovered that with one traumatogenic turn after another, the therapist whose patient has killed himself, has found herself without a way to accept, assimilate or make sense of his suicide. As a result, she becomes stuck in a refusal, a fear, or an inability, of making known the traumatic loss, vulnerable, therefore, to repeating compulsively what she knows, keeping the patient and their relationship her own. This relationship, now with a dead patient, seeks a kind of object homeostasis, either both subjects dead or both alive. The study has indicated that the therapist seeks a compromise formation, one in her mind not completely divorced of reality: she lives, seduced by her dead patient, and, in his absence, she engages herself, fantastically with suicide and death. Instead of getting on, at least intrapsychically, with the work of living without him, possibly in a refusal to repeat, remember, and work through this traumatic death, (Freud, 1914) this study has indicated that parallel processes of play at destruction and construction facilitate a continued form of object relating. This study has indicated that these parallel processes of relating function to subordinate the mourning process in the service of an ongoing, different object experience: one in transition from an alive dyad to a dead one, thereby half-dead and

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half-alive. What this finding has illuminated for the clinical field is this: the therapist’s experience of liminality, of being in a transitive state of object-being, occurs not only as intra- or inter-psychic phenomena nor only in the context of object-relating in a transitional space. Instead, the study has suggested that the treatment relationship as an entity, a whole object dyad made of two part-objects, exists in a transitional space: one with the potential for life and the potential for death; This transitional space existed both between the patient and therapist and between the dyad and other realms and being and existence. So, the clinician whose patient kills himself can relate to him objectively as a deadobject and to her outer world subjectively as an alive-object, but cannot become a subject, unless she has begun, not completed, her introjection or her rejection of a dead-object and death in her object relations. What has proven apparent is that the treatment relationship after patient suicide remains in a constant dynamic state, with dyadic internal and dyadic external work, at integrating death and life. This work creates a state of liminality inside the relationship as it incorporates outside reality. As the dyadic loss of one subject becomes the other’s object, the other’s object becomes her own subject of death. The study also has suggested that as the therapist faces the work to integrate the reality of suicidal death, she continues to object relate with her patient as dead to them/but alive with her. Her countertransference responses to him and to his suicide remained active as communications of her ongoing object experience. These countertransference expressions, that included fantasies, wishes and dreams, seemed to activate defensively in order to protect her from the traumatic loss, by functioning as a

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counter narrative to the narrative her patient has written for her, one he authored without her consultation. In other words, the therapist whose patient kills himself, has found herself in an unwelcome and unacceptable state of submission and of subordination, of her sense of agency, and of her sense of freedom because of the domination of the patient’s suicide. So, the therapist, who brings her own resistances to the treatment relationship, when the patient was alive and now that he is dead, manically becomes defended against recognition of the patient’s empowerment: to recognize his suicidal death would be an acknowledgement of his agency. Since this also would require a recognition of her therapeutic powerlessness, this study has indicated that she instead attempts to render herself the master of their separation with a false self, one who protects the frightened, vulnerable, abandoned true self (Winnicott, 1960). Because, in true parallel process, she has decided that, just as the patient has hidden his true self experience, perhaps she must too: by grandiosely, falsely, fantastically, wishing and dreaming herself into being with an alive patient, one whom she sees, talks with, and imagines on the cusp of return to the treatment room. Without other object experiences, this study has suggested that patient suicide renders the therapist vulnerable to an unending madness, one she associates with her patient and in an act of identification having wondered if he was mad, too. Without question, the study has proven that the therapist’s other patients minister to her in loss, offering different object ties: ones empowered to treat the therapist as much as the therapist treats the patient, in a dyadic, collaborative effort at remaining alive.

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This study has indicated that one treatment experience to emerge in the work of patients of becoming themselves has included the therapist becoming not perhaps herself, but the therapist her current patients need her to be. Whether she is an object created or found, the patients make the therapist an object to be used: in this way, she, too, makes usable objects of her patients, ones to help her find a way to live, not so much without her patient, but with him, now differently (Winnicott, 1969). Thus, the co-constructed work of being alive in the world, not as she was, but as she can be now, was ushered in by the agency of her other patients: new subjects born of loss and born of other important patients. Finally, the study has indicated the need for and importance of a professional, relational, cultural matrix of psychodynamic others: ones who functioned to contain, sustain, and accept the therapist’s experience of suicidal loss. In this containment, the therapist needed their holding her and her experience of patient suicide as divergent from normative, reductive conceptualizations of physical death: and she needed their acceptance of her psychodynamic, continuous, metaphysical experience. Without a container committed to pluralistic conceptualizations of the therapist’s experience and without clinical-others receptive to multiply-determined understandings of suicide, the therapist’s experience cannot be more represented, understood, or made usable for her fellow clinicians in the field; those likewise grappling with and likely similarly devastated by the trauma of patient suicide. But, too and most of all, she needed these others to survive. Hopefully, this study has offered itself to collaborate with these potential clinical others by simultaneously and perhaps endlessly seeking out these clinician-containers, ones who might be able to deconstruct old modes of thinking about

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suicide and to construct new paradigms of knowing about and being with the therapist whose patient kills himself. Perhaps a different study would have addressed what needs to be learned about patient suicide, in order that this death event be avoided, prevented, or integrated into an epistemology about the therapeutic experience of suicide in the clinical field. This sort of study would have made the therapist’s experience an instructive offering and a cautionary, retroactive inquiry about patient suicide and therapeutic failure. It bears stating that this study has assumed that sort of research to recursively address an axiomatic truth: patient suicide remains an unalterable, unbearable loss never unlinked from the therapist’s sense of lack and failure and never without her wish for a different ending. Instead this study, in many ways, has attempted to articulate what remains unformulated, split off, and rejected in the aftermath of patient suicide. These findings have posited that inquiry into the therapist’s subjective experience warrants attention and recognition; and it indicated that such an inquiry offers clinical value towards the potential of formulating an intrapsychic, psychodynamic understanding of patient suicide; and, of the therapist as both a subject and an object of an ongoing, metaphysical traumatic loss. In sum, this autoethnographic study represented an attempt at creating a forum to understand the therapist as a subject of patient suicide: perhaps, to offer an honest and true recognition of her patient as a subject of his life demanded this intersubjective recognition of her subjectivity, too. In retrospect, this study has hoped to create a usable, rather than a discarded and abandoned therapeutic object. In one sense, it offered to

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salvage, resurrect or identify what remains of the dead, in an ardent wish for something or someone to withstand such horrific loss: in this sense, there has been a hope that other clinicians might integrate these findings as a ballast for their own survival of tragic patient death. In his work, Underground: A Deep Time Journey, Mcfarlane (2019) has stated: "We all carry trace fossils within us—the marks that the dead and the missed leave behind . . . Sometimes in fact, all that is left behind by loss is trace—and sometimes empty volume can be easier to hold in the heart than presence itself" (p. 78). Indeed, this study has articulated a longing for a transformative act to fill the emptiness his suicide left in my heart, with the presence of his life, and the continuation of mine, without him. But, perhaps, what emerges here most clearly, has been a wish fulfilled, buried inside a studied dream, one that has been revealed by every finding. Despite my patient now dead from suicide, perhaps finally, inexhaustibly, and undeniably, I have accomplished the impossible, unforgettably and permanently memorialized, I have found a way to keep him alive.

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