Dishonesty dialogues IV

Pt: I really don't know why I tried to kill myself...in fact, I don't really remember it real well. I had been drinking, which isn't something I usually do... and... I don't know.
Ther: (Looking at BDI score) You score on this depression evaluation is low. It suggests that you are just barely depressed, at least according to your answers. That puzzles me.
Pt: What does?
Ther: That according to you and what you've told me, you aren't depressed clinically. But on the other hand, I have the records of your suicide attempt, and it was a pretty serious one. How am I to make sense of this?
Pt: (laughs) I don't know.
Ther: Another puzzle. You seem to be quite comfortable with what appears to be a very serious problem. How do you know you won't do it again, when you can't make sense out of it happening the first time? And you're laughing! What in the world is funny here?
Pt: I guess it's easier to laugh than to cry.
Ther: Does that mean you felt like crying but you made yourself laugh instead?
Pt: No.... uh...
Ther: Then we have still another puzzle. What happened?
Pt: It just struck me as bizarre that I would try to kill myself and have no idea why I did that. And I'd rather laugh because it's more comfortable.
Ther: (Has lots of questions) You'd rather laugh than what?
Pt: Rather laugh than be scared.
Ther: I'm uncomfortable with you trying to hide your perfectly legitimate anxiety about killing yourself by laughing it off. I don't take near-death lightly, and I don't believe you normally do. So how am I to understand this? (Thinking of Freud's paper on Gallows Humor and TA theory about the same topic). I'm thinking that sometimes people laugh about horrible or unavoidable misery by making a joke about it, like when somebody about to be electrocuted makes a joke about electricity.
Pt: Yeah... I can imagine doing that.
Ther: So it's possible that you could laugh about your suicide attempt the same way?
Pt: Sure.
Ther: Does that mean it's unavoidable and so you might as well try to lighten it up?
Pt: (long pause) Well, the fact is... (long pause) Look, I'm 53 years old. My kids are moved out, my job really sucks now, at least for the last couple of years. I broke up with the guy I was in love with because it was clear to me that he wasn't gonna leave his wife, and I can't tolerate being "the other woman" like I thought I could. My mother has moved away, and she was my best friend. All this happened in the last couple years. So I'm thinking, what's the point in going further with this? I'm really not that depressed.... but I really am unhappy with my life. There's just nothing in it that I care about anymore, and I don't have any religious beliefs that would stop me from dying.
Ther: So it seems likely that sometime in the next weeks or months I'm gonna read in the paper about you dying.
Pt: God damn it, you just want to cut to the bottom line.
Ther: Well, you're not psychotic, so I can't hospitalize you. Clearly you have a right to make the decision to die, and as long as it's not be reason of mental illness I don't have a legal right to stop you. I understand now what you are talking about.
Pt: My life has just gotten emptier and emptier, and it doesn't look better down the road, what with ill health and old age and all the rest of what's coming. So, I think, why should I hang around until I get old, drooly, helpless, incontinent.... all that stuff.
Ther: What bothers me about what you're saying is that while all that "stuff" is true, it's only half true, so I think there's something more here.
Pt: Why do you say "half true"?
Ther: Well, you paint a very bleak picture. How come your life is so bleak? Or do you think all of us oldsters should just pack it in before the going gets any rougher?
Pt: A lot of shit has happened to me...
Ther: Oh, I see. Just you, then.
Pt: I guess you could say that.
Ther: And your belief that life is bleak and then bleaker is predicated on your belief that nothing can change and make it better, is that right? You're making a joke about electrical services?
Pt: (laughs) Yeah, I guess so.
Ther: I have a thought experiment I'd like to suggest, if you're interested.
Pt: Sure.
Ther: You're capable of keeping a decision you make, aren't you? I mean by that, if you really meant it, you'd keep your word?
Pt: Yes. I would never break my word.
Ther: Once I had a patient who was locked into a miserable marriage of many years duration. She told me "the only thing that keeps me going is knowing I can always kill myself". I guess that seemed a better or more acceptable decision than moving awy and changing her name to "Smith". Anyway, I suggested she consider making a permanent, life-long, no-suicide decision, which she did eventually. A couple years later she filed for divorce. She told me "I could stand anything if I thought I could always check out any time. But when you look at your spouse and think 'I'm gonna be around maybe another 30 or 40 years, and you think, Not like this!' So I had to get a divorce."
Pt: (Is silent for a while, looks thoughtful)
Ther: Making a decision like that is really a major undertaking. It has the power to force you to change your life. So I certainly wouldn't suggest you rush into anything like that. The homework assignment, should you choose to accept it, is to imagine you had made such a permanent decision. And for the next week to consider what you'd have to change if you were stuck in being alive for another 40 years.

There are a number of places in this conversation where the evasions and dishonesties could have been usefully focused. For instance, early in the exchange the patient laughs and responds "I don't know" to the question as to why she might be suicidal, yet it's clear that she does in fact know quite well and has thought about it a great deal. In another exchange about her laughing inappropriately she first gave as a reason that she was laughing "instead of crying", but 2 sentences later she said she would "rather laugh than be scared". Clearly she wants to think of herself as naive (in the first instance) and in the second instance as sad instead of frightened. Many other issues are worth attention, such as her underlying passivity and expectation that life will somehow reward her for being good, and clearly it hasn't; her suppressed resentment is a feature that later in her therapy became an important issue.