Clinical Commentary 45

In 1849 Henry David Thoreau famously wrote ‘the mass of men lead lives of quiet desperation’ and perhaps he was commenting on living with despair: becoming aware of a void and the need to fill it. In the case below we are presented with a patient whose life is suffused with this feeling. We learn that the patient adopts the ‘prone position’, and perhaps in many ways lives his life in the prone position. I would like to thank the clinician who generously shared this piece of work, especially as the patient has been suicidal in the past and over a long period of time this seems to have been gradually replaced with a deep seated desperation which our commentators discuss in different ways. Our first commentator feels the void through the absence of transference interpretations, the second wonders whether to place the patient in a group and our third notices a sense of impoverishment and unresolved mourning. Through these commentaries we are given a glimpse of what it really means to work with an entrenched sense of hopelessness spanning many years but we are also given hope in the patient's capacity to recall a dream which our commentators explore.

Katya Orrell

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Clinical Material

(The clinical material below has been carefully disguised to preserve the patient's anonymity.)

I have seen B twice per week for over a decade. He is now in his late 50s. His presenting problem was depression. He would spend his days prone on his sofa. He felt suicidal a lot. We began sessions once per week then moved to twice a week by year two as it was clear that the gap between sessions was hard for him. In the early years of our work together, B often missed at least one of our two weekly sessions or arrived very late. His absence left me worrying he had killed himself.

B's mother had died from cancer when he was 25. His father had lived into his 90s and died a few years ago whereupon B inherited enough money to buy a flat. His father undermined B, making him