Clinical Commentary 48: Commentaries

In early 2023, the Doomsday Clock, symbolising the threat of nuclear apocalypse, showed the closest time to catastrophe in its more than 70-year history. Although its authors assess only one side of this danger, we have all felt a shift in recent years. Wars and numerous terrorist attacks around the world, pandemics and Brexit, the rise of the right-wing and populism, global warming and various environmental disasters are just a small list of ‘earth shocks’ that have already led to global change. And even if external life appears unchanged, no one can isolate themselves from these tectonic shifts inside—for example, the number of prescriptions for antidepressants in England has risen by 30% in the last 6 years (Burns, 2022).

The frangible inner world of our patients is a barometer, sometimes accurately reflecting changes in external ‘pressure’ and the clinical material presented in this issue is no exception. The patient described here has recently undergone many serious changes in his life, the psychic burden of which is weighed down by his difficult history. All three commentators accurately capture these, thoughtfully describing the various causes of the patient who is ‘hard to reach’—his ‘addiction to near death’, disorganised attachment, psychotic functioning and lack of containment. In one way or another, however, all agree that bereaved loss has a profound impact, proving Shakespeare right once again: ‘Give sorrow words: the grief that does not speak whispers the o'er-fraught heart, and bids it break’ (Shakespeare, 2004). They also agree that despite the great changes in the therapist's own life, he manages to maintain contact with the libidinal part of the patient. Whether we can save the world from catastrophe is an unanswerable question, but it is in our power to strive for peace within ourselves and our patients, neutralising external and internal destructiveness wherever possible.

I am grateful to the psychotherapist who has offered clinical ma