Editorial

Working with severely disturbed patients, as Marguerite Valentine writes in this issue, is one of the most challenging and difficult areas of practice. If suicide is a risk, or takes place, immense anxiety is generated, in individuals and in systems. The three papers which begin this issue tackle this individual and systemic anxiety dispassionately and movingly. They also probe the ethical and management dilemmas which suicide poses. Rose Hamilton, meditating on a suicide that took place a year ago, asks whether it is possible to contain very damaged patients without medication, in a therapeutic milieu. She considers the impact of a suicide on herself as a worker in a residential setting, questioning her ‘idealized image, of both the institution and client group’. Hamilton, publishing under a pseudonym because of the delicacy of the situation, notes that working with suicidal clients in a therapeutic milieu ‘often led to creativity in the work, and a more profound level of connection with the residents; this made the act, I believe, even more penetrating’. Next, Marguerite Valentine, describing the suicide of a male patient in her private practice with a five-year psychiatric history, explores the ‘maddening’ experience of the work, and tracks her evolving countertransference responses to her patient. She explores the ambience of the sessions, her developing realization of the patient's involvement with the psychiatric system, and her thoughts about what may have been in his mind when he took his life. With Gertrud Mander's paper we move from the direct impact of the interpersonal encounter into something more modulated - the encounter with a text, and with a more optimistic view of suicide: David Malan's view of the suicidal impulse as a treatable condition, and reversible when the therapist allies himself with the ‘Cord of Life’, which Malan sees as most active when a suicide attempt fails. Nevertheless, Mander poses difficult questions, such as can the follow-up