On not knowing the colour of a patient’s eyes

My supervisor asks me, as she often does, what the patient I am describing looks like. I hesitate, realising that, even though I have been working with "Jamie" for some time, I feel unable to describe him. I make vague allusions to his height, the kind of clothes he wears, the timbre of his voice, but something is missing. I struggle, and my supervisor prompts me with more questions, questions I continue to struggle to answer. We identify it at the same moment, falling upon the element of his description that is missing. It is his eyes. I have no idea what colour they are. I am shocked at this realisation, and, as we talk more, I realise I have no memory of seeing his eyes. They tend to be adhesively fixed on the carpet, with occasional glances at the hands he knots together as he speaks.

I bring this awareness into the next session, and realise how crucial this lack of eye contact is to my struggle to work with Jamie. I dare to talk about it with him, wondering what makes it so hard for him to lock eyes with me, what does he fear he will see in me or, perhaps more pertinently, what does he fear I will see in him? Jamie is deeply depressed, perhaps one of the most profoundly depressed men I have worked with. I see him twice a week and have come to dread the mornings that begin with his shuffling into my consulting room. He is familiar with the unspoken rules of our work – that I will not prompt him at the start of the session, that we will allow silences to develop where they need to develop, that my role is to hear him, to make some interpretations, but not to advise or counsel him. Unlike other patients, he appears absolutely fine with these terms of engagement. His story of abuse is familiar in some of its component parts, while also being one of the most unsettling and disturbing stories I have heard. He is a child of incest, his parents being siblings. They themselves were abused by their parents and from an early age (perhaps since birth) Jamie was abused by both his father and his mother. His father died when Jamie was twelve, at which point the abuse perpetrated by his mother intensified, taking on more sadistic and violent elements. He ran away from home at the age of fourteen, eventually living on the streets and falling into prostitution for a number of years. Alongside this he developed a drug habit, occasionally falling into petty crime to help feed this addiction. It was in his mid-twenties that Jamie's life was changed by entering a drug treatment programme. In the course of this he disclosed his history of abuse for the first time. By his early thirties Jamie's life bore little resemblance to what had gone before. He had entered full-time education, lived in his own flat, and appeared, on the surface, to have put his troubles behind him. He faced a further onslaught of trauma when he was diagnosed as HIV-positive, a fact that hastened his entry into psychotherapy.

When I talk to Jamie about how hard he finds it to lock his eyes with mine, he appears surprised. "I didn't know that's what I was doing," he says, and I come to realise that how he relates to me is how he relates to the world: with his eyes lowered, never daring to look life in the eye. This is symptomatic of Jamie's main presenting symptom: his profound depression. Despite the changes he has made in his life, and the colossal journey he has made from a life shaped by abuse to one that appears to resemble some kind of normality, his life is overshadowed by a heavy, numbing sense of desolation. His achievements mean little to him, his relationships are shallow and unsatisfying, and his nights are dominated by nightmares that are cinematic in their ability to replay the most harrowing aspects of his abuse. Despite the fact that his HIV is asymptomatic and it is likely his status will not reduce his lifespan, he relates it as if this were the 1980s, when a diagnosis was a form of death sentence.

The work with Jamie has a sluggish, dense quality, with all exchanges between us feeling as if they are being conducted in slow motion. He begins the session with a recap of how he has been feeling since our last session—usually tired, sad, or anxious. I respond, wondering what sparked these feelings, how they impacted on him, what connections he is able to make between his feelings and memories. He continues to look down at the carpet and a long silence develops, a silence I have become terribly familiar with. It is a silence that carries a dead weight, a silence that seems to obliterate thought and creativity in me. With other silent patients I seem far more able to remain alert and alive in the absence of words. At times the silence can feel creatively intimate, a shared space of reverie in which two separate unconsciouses are communicating. In Jamie's silence I can feel nothing that is terribly alive. Instead, I drift off, out of the room, finding myself daydreaming about anything other than Jamie, for when I do think about him I realise how easy it would be for me to sleep. Instead of engaging in the unconscious, I find myself at the edge of becoming unconscious.

I have to work hard with Jamie to recover myself, to pull myself back into the consulting room and fend off these deadening countertransference responses that threaten to sever any therapeutic connection between the two of us. Now that I have registered his lack of eye contact, it is clear that Jamie is working hard to address it, occasionally lifting his gaze to mine. It is obviously a tremendous burden for him, this most ordinary but most agonising of attainments. I am struck not by the colour of his eyes but by their deadness. In looking into his eyes I am reminded of the hollow, fathomless eyes of babies glimpsed over the years in television reports of famine in Sudan, Ethiopia and Somalia, their gazes blurred by the most primitive and annihilatory of traumas. I realise that these are not eyes I wish to look at for too long, so potent is the danger of being colonised by his sense of utter desolation and defeat. I alert myself to the risk of turning away my eyes from his, of Jamie experiencing my fear of the deadness he carries within him.

He attends every session, is never late and times his breaks to coincide with my own. This should gratify me, both narcissistically and as an indicator of his ability to use the therapy well. Instead I feel somewhat persecuted by his attendance, like a mother with a hungry baby who has come to think of herself as depleted, with nothing nourishing to give. I wonder whether he is ready to lie down on the couch, but reject the thought, fearing that such a move would sever any potential connection between us both. Our eyes would never then meet and I would never learn, as I think I have to, to bear the deadness of his gaze, and to develop ways of enlivening the gaze that meets his.

At times Jamie talks about suicide. He has made some attempts on his life but there has always been a passivity to these attempts, as if his depression chips away at itself, negating the agency he needs in order to make any kind of a mark on the world, even the most terrible mark of suicide. He berates himself for these failed attempts, providing as they do to him yet more evidence of his worthlessness—he cannot even kill himself properly. I sometimes feel perversely twinned with Jamie, as if we are enmeshed through a sense of failure. I feel like a worthless therapist, with all my interpretations, my attempts to stir something alive in him, my efforts to contain and help process his trauma, all coming to nothing. I look to my supervision to provide some kind of life support system to this agonising lifeless work, but even find myself despairing of this, fearing that nothing can help dilute the despair that pervades our work. There are occasional glimpses of hope: an interpretation received and understood, or a relationship pursued in the external world. But never enough to relieve me of the fear that psychotherapy is, at best, a kind of sticking plaster, providing some form of structure to Jamie's world but doing so little to help him process the trauma he has experienced. I carry on with him, and know that he will probably continue with his therapy for years without either of us feeling that a corner has been turned, or his life has been transformed. I know that I feel terribly guilty about this. It is an awful thing to be faced with a patient who is more attached to despair than to hope. The attachment provides Jamie with a sense of self, albeit a perverse, desolate, and funereal one.

* * *

All psychotherapists and counsellors are familiar with what Christopher Bollas describes as "that familiar sinking feeling" (1989, p. 179) whenever a patient begins to tell their story of having been abused. Kluft describes those feelings of "bewilderment, exasperation and a sense of being drained" (1984a, p. 51) that accompany the hearing of a story of sexual trauma. These feelings are hugely magnified when the patient presents with the degree of deep, unmoving depression that Jamie brings with him. Depression and abuse are inextricably linked. It may be fended off through manic defences, or displaced into a variety of somatic, bipolar, or perverse symptoms, but it tends to run like a thread through the fabric of a male survivor's psyche. Childhood sexual abuse is associated with an increased risk of depression (Bifulco et al., 1991; Hanson et al., 2003; Widom et al., 2007). Fergusson and Woodward (2002) reported that a history of childhood sexual abuse increased the risk of depression by approximately four times. It is also a significant antecedent of suicidal behaviour (Bebbington et al., 2009), with childhood physical and violent sexual abuse representing the greatest risk factors for future suicide attempts (Joiner et al., 2007). Girls who have been sexually abused have a threefold increased risk of suicidal thoughts and plans, compared to non-abused girls. Boys who have been sexually abused have a ten-fold increased risk for suicidal plans and threats, and a fifteen-fold increased risk for suicide attempts, compared to non-abused boys.

Transgenerational abuse

I consider Jamie to be a victim of transgenerational abuse. It is unlikely that his parents were the first in his family to have broken the incest taboo. The process of the unconscious transmission of trauma between generations is found especially in families where there is an inhibition against thinking (Gardner, 1999). Maternal trauma of childhood sexual abuse has been identified as a risk factor for intergenerational abuse (Leifer et al., 2004b), with the risk being estimated at thirty per cent (Paredes et al., 2001). Belsky's (1993) ecological theory suggests that child abuse is determined by factors in the parent's history and personality, and by environmental, familial, and social factors that sup- port or create stress for the parent. Attachment theory suggests it is the working models of the self, others, and self/other relationships that are transmitted across generations and account for continuity in abuse (Leifer et al., 2004a). Brothers (2014) suggests that one method of trans- mission from one generation to the next is through traumatic attachments. These attachments form within systems that, at some point in their histories, have been plunged into chaos by trauma. Once established, they tend to coalesce into patterns of relating so inflexible and resistant to change that they profoundly affect parent–child interactions over generations.

Hopeless patients

Freud's (1917e) seminal work Mourning and Melancholia differentiates the state of melancholia and the natural state of mourning, and uses this comparison to explore the psychic mechanisms of depression. This work has been followed by a rich parade of clinicians exploring both the psychogenesis of depression and the possibilities of treatment (Klein, 1940, reprinted 1975; Spitz & Wolf, 1946; Rado, 1951; Jacobson, 1954; Joffe & Sandler, 1964; Mendelson, 1974; Kohut, 1977; Bowlby, 1980; Bifulco et al., 1991; Steiner, 2005; Verhaeghe, 2008; Leader, 2009). It is clear that in treating patients such as Jamie we have a responsibility to measure the scale of the mountain we are seeking to climb.

Working with Jamie was, at times, like being in a stale marriage. We were both committed to the relationship (Jamie, perhaps, more than me) but could never ignore the hopelessness that permeated so many of our exchanges. I found myself questioning (not, it must be said, for the first time) whether there are victims who never become survivors. Are there men for whom the earliness of the abuse, the violence that accompanied it, and the close proximity of their abuser combine to shatter the potential for full psychic recovery? I think the most I could do for Jamie was to provide him with a safe space to which he could bring his despair. I presume he experienced some relief through this process, even if the relief was buried under the agonising weight of his daily miseries. The process of attending regular sessions, being listened to, and being in the presence of a benign, caring other may have done much to ward off the more worrying of his suicidal thoughts, giving him something of a reason to not destroy himself. How much the therapy enabled him to process the many impediments to contentment, if not happiness, I am less sure.

Beyond supportive psychotherapy

This is not to diminish the importance of the therapy. It is to contextualise it as something different from (but not necessarily less than) a psychodynamic process that, through the process of unconscious symptomology being made conscious through interpretation, leads to a processing of trauma. It is hard, of course, to know whether the therapy was staving off feelings of suicidal despair to the point where it was keeping Jamie alive. I think (and feel) there were times when it was. A key question concerns what, then, this form of psychotherapy with despairing and suicidal survivors actually is. It could be termed "supportive psychotherapy", although I think it important to avoid such a term diminishing the technical challenges of such work. In their paper "Beyond 'handholding': Supportive therapy for patients with BPD and self-injurious behavior" Hellerstein et al. highlight the ways in which supportive therapy has become synonymous with nonspecific treat- ment, with "just being nice to patients" (2004, p. 1). They outline the rigour with which this approach has been developed from perspectives as seemingly diverse as psychoanalytic (Kernberg, 1993) person- centred (Pinsker, 2014), and cognitive behavioural (Linehan, 1993) modalities, while also noting some key elements that demarcate it as its own unique form of treatment. They stress the need, for example, to avoid prolonged silent listening, neutrality, confrontation of resistance, or transference interpretations.

I came to learn with Jamie that his ego strength was too minimal for him to withstand these forms of interaction. His capacity for symbol formation was weak, with many forms of interpretation being experienced by him as aggressive attacks. He was easily wounded by my attempts to challenge his perception of the world as murderously threatening, devoid of joy or meaning. It was not as if the world was threatening. The sadistic and perverse elements of his parents' abuse of him had left him unable to hold in mind the metaphoric world of the phrase "as if". The world was threatening. Transference interpretation was particularly difficult for him to withstand, as his early experiences of trauma had blunted his capacity to differentiate between others as symbolic representations of early objects. With a less disturbed patient I would have been able to interpret his frustration at, for example, my imminent holiday, as being linked unconsciously with his loss of a good enough parental figure and the absence of safe attachment figures both in his childhood and his adult life. Jamie had to remain in the realm of the concrete - anything more symbolic was too intimidating for him to pro- cess. He was able to feel and express the loss of me over the break. He was not able to connect it with what it represented because this would have involved him connecting with emotions to do with his parents. He lacked what Bick (1968) called the "psychic skin" with which to think about his parents without a primitive fear that their abuse would resume.

It took me some time to realise and appreciate the fragility of Jamie's object relations and the impact this had on my capacity to be the kind of psychotherapist I was accustomed to being with my less ill patients. It should be said that the greatest learning I had in adapting my psychotherapeutic stance came not from my original psychoanalytic training but from the practice of many of my supervisees. I have the privilege of supervising the psychotherapists and counsellors at Survivors UK, the country's leading provider of individual and group therapy for male survivors of sexual abuse. The team is an eclectic one, coming from a broad range of trainings and orientations. What unites the clinicians there is a deep understanding of the sexual trauma of men and an abiding belief in relational therapy, regardless of theoretical orientation. I found myself soaking up many of their approaches in my work with Jamie, particularly those of the more creative clinicians whose work with highly disturbed patients over the years had equipped them to hold and contain many different versions of him.

I learned, as I have had to in my work with patients with intellectual disabilities (Corbett, 2009, 2011, 2014) that much of our original clinical trainings do not in fact prepare us to work with those whose experiences of severe and cumulative trauma have placed them at the very margins of human experience. The longer I have worked in the fields of trauma, abuse, disability, and dissociation, the more I have come to realise that too purist or singular a view of psychotherapy can only work with a relatively narrow band of patients. While I continue to think of myself and my work as decidedly psychoanalytic in framework, I have not been afraid of making use of other psychotherapeutic processes to reach those who, like Jamie, have found their connection to symbolic thinking fenced off by severe trauma.

A great deal of my work with Jamie used techniques such as:

- clarification - pointing out when a dysfunctional behavioural pat- tern was being repeated (a more direct, less interpretative way of understanding repetition compulsion);

- psychoeducation - providing guidance on symptoms of trauma that confused and frightened him;

- de-intensification - providing relief from the grip of emptiness, terror, and suicidal ideation.

Instead of going to the heat of the transference, interpreting unconscious enactments as they were being lived out between Jamie and I, I tended instead to "strike while the iron was cold" (Pine, 1984), waiting until the unbearable terror of the moment had passed, arriving at a moment of calm to look back safely at elements of our relationship he was in danger of feeling overwhelmed by.

Addiction to near death

At no time in my work with Jamie did my approach feel like "merely" supportive psychotherapy, twinned as it was with a psychoanalytic understanding of his deep attachment to despair. Betty Joseph introduced the concept of "addiction to near death" (Joseph, 1982) to describe a form of masochistic pathology she had observed in working with disturbed adolescents. Joseph came to understand her patients' wishes to gain a perverse, masochistic form of pleasure in attempts to destroy the self and the therapeutic relationship. She described this destruction as evoking libidinal satisfaction, despite its concomitant pain (an "awful pleasure"), evoking an addictive edge that can become immensely difficult to dislodge:

There is a very malignant type of self-destructiveness, which we see in a small group of our patients, and which is, I think, in the nature of an addiction – an addiction to near-death. It dominates these patients' lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so-called thinking, and the way they communicate with them- selves. It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this. The picture that these patients present is, I am sure, a familiar one— in their external lives these patients get more and more absorbed into hopelessness and involved in activities that seem destined to destroy them physically as well as mentally. (ibid., p. 449)

Joseph alerts us to the perverse pull towards desolation that overtakes the patient and threatens to submerge the therapy: "It seems to be like a constant pull towards despair and near-death, so that the patient is fascinated and unconsciously excited by the whole process … It is clearly extremely difficult for such patients to move towards more real and object-related enjoyments, which would mean giving up the all- consuming addictive gratifications" (p. 456). This places a useful slant on Jamie's despair, indicating counterintuitively that the agonies he brings to me provide him with a powerful secondary gain. The severity of his traumata and the paper-thinness of his psychic skin combine to make this aspect of his psyche tremendously difficult to interpret. His concretised defences would translate even the most tentative interpretation into an aggressive, murderous attack. We tread carefully with patients as ill as Jamie, and have to work hard to manage the complex countertransference responses that his addiction to anguish evokes. There were many times when I found myself harbouring feelings of murderous rage towards him, pushed, as I felt I was, to the edge of thought by his allegiance to desolation. His adhesive attachment to suicidality, self-hatred, and unmovable grief came to feel like a challenge to the hope I wished to embody to him. The higher he built his wall of hopelessness, the more shut out and, inevitably, angry, I became.

Counterresistances

Glover and Brierley's (1940) concept of the therapist's counterresistance is a useful one in considering the ways in which some of our more affective responses to our patients can be counterproductive. Chu discusses how "Patients in therapy may activate thoughts, feelings and fantasies in their therapists which their therapists attempt to fend off. Thus therapists' counterresistances, particularly in trying to cope with angry reactions or sadistic fantasies towards patients, can lead to therapists using such defences as reaction formation, avoid- ance or withdrawal" (2008, p. 212). Chu quotes Strean's explication of counterresistance as involving "over solicitousness; unnecessary reassurances; … postponing confrontations, questions or interpretations regarding a client's tardiness or absence, glossing over … the negative transference; and denying the existence of pathology, conflict or resistance in the client" (2014, p. 85).

I had to be aware that Jamie needed to evoke in me something akin to what Winnicott called hate in the countertransference (Winnicott, 1949). In order for us to reach the eventual aim of the therapy – Jamie's introjection of a good object through the movement from the paranoid/ schizoid to the depressive position – it was not enough for me to attune only to the benign, positive, good-enough aspects of his psyche; I had to be aware of and open to the rage and hatred residing in him, the powerful residues of the incestuous triangle into which he had been born. At times my hatred of Jamie provided an invaluable insight into what it was like to live under an omnipresent cloud of self-loathing, what it felt like to be an object devoid of real, reciprocal love. By withstanding the waves of hatred that seemed to lie at the very essence of Jamie's DNA, I was providing an important buttress to him, a model of a good object which, over time, he could begin, slowly and incrementally, to introject.

Levels of interpretation

Much of the work with patients such as Jamie, whose primal experiences of trauma render them unable to use traditional notions of psychoanalytical psychotherapy, requires us to tune into what Alvarez called the right analytic wavelength (2012). She has formulated a level of interpretation that seeks to vitalise the deadened state of mind. This stands apart from the two other levels she has identified as being explanatory/ locating or descriptive/naming interpretations, levels of interpretation that fit more neatly into a classic notion of analytic neutrality. What Alvarez is describing is a form of interpretation that recognises the need for something more enlivening, something that acknowledges the atrophied and deadened aspects of a patient's psyche, and that seeks not only to wake these parts up, but which also reminds the patient that the analyst has not been deadened by the patient's trauma. This was particularly pertinent when faced with Jamie's state of torment about his HIV status.

HIV and its impact

Rates of sexual abuse amongst people who are living with HIV/AIDS are significantly higher than for the general population (Batten et al., 2002; Kalichman et al., 2002; Leserman, 2005; Gwandure, 2007). Some survivors contracted HIV during the course of their abuse, while others' self-esteem has been so eroded by their abuse that they continue to place themselves in situations of high vulnerability to infection. As well as reporting greater anxiety, depression, suicidal ideation, and symptoms of borderline personality, survivors are significantly more likely to have had unprotected intercourse than those who have not been sexually assaulted. Prevailing norms of masculinity that expect men to be more knowledgeable and experienced about sex, put men, particularly young men, at risk of infection, because such norms prevent them from seeking information or admitting their lack of knowledge about sex or protection, and coerce them into experimenting with sex in unsafe ways, and at a young age, to prove their manhood (Gupta, 2000). Psychotherapy with survivors who are HIV-positive adds another layer of trauma into the therapeutic matrix—a layer that can challenge the therapist to engage with intricate issues of illness and mortality (Cole, 2001). Samuels et al. (2011) discuss the role that childhood trauma plays in the resistance to engaging in psychotherapy exhibited by patients with AIDS. We have entered the "protease era" in which the meanings associated with HIV/AIDS can be considered in a different context: that of life continuing rather than inevitable or impending death. And yet for many male survivors (among others) the condition continues to carry the weight of associations with death, perverse sexuality, and decay. Much like the experience of having been sexually abused, an HIV/AIDS status can be a signifier of shame, a condition that evokes unconscious terrors of contamination and infection. The experience of living with HIV/AIDS cannot be separated from the social construction of HIV/AIDS as a stigmatised disease (Sontag, 1989; Petersen & Benishek, 2001) that carries projections of society's anxieties about illness and contagion (Joffe, 1999).

The stigma of infection

For Jamie, his HIV status was a stigma that seemed to him to be enmeshed with his status as a victim of incest. It had a different quality, however, being something that sparked immense fears about others being able to see that he was ill. This was a dangerous fantasy for him. In fact he rarely looked physically unwell, but seemed, through a dysmorphic process, to often see himself as underweight, haunted-looking, and ravaged by sickness. The word "stigma" carries a sense of physicality, referring as it originally did to a tattoo mark branded on the skin of an individual as a result of some incriminating action, identifying the person as someone to be avoided. From the 1600s it came to mean "a mark of disgrace", a visible emblem of those sins and disgraces that might otherwise have remained invisible. For those who become suicidal when they first receive their HIV diagnosis, suicidal thoughts are often rooted in the fear of isolation and discrimination that will come as a result of others finding out about the disease, rather than as a result of the disease itself (Carr, 2002).

Jamie often described his diagnosis as carrying with it an inevitability that stemmed from his experiences of childhood abuse. All roads seemed, in his mind, to have led to this condition he equated with dis- ease and, ultimately, death. Small wonder that the weight of his diagnosis on top of the impact of a childhood saturated by perversity and abuse resulted in a presentation of almost catatonic depression. With- standing the pain of a life lived in the shadow of abuse and illness exerted a terrible price upon Jamie's capacity to find anything joyful or life-affirming in his existence. There were times when he needed me to identify wholly with his despair, when I too had to be subject to the suffocating claustrophobia of his anguish, to the point where I found myself wondering about the worth of our work. There were other times when it was more important for me to identify with the pleasure principle than the death instinct (Freud, 1920g).

It was at these moments that I made use of Alvarez's (2012) notion of the enlivening interpretative stance, in an attempt to connect with those slithers of dynamism that occasionally emerged through the cracks of Jamie's melancholy. A moment of eye contact or the reporting of a hopeful conversation with a friend had to be amplified by me, otherwise they tended to be consumed and erased by the force of his depression. I had to, at times, take on the role of auxiliary ego, holding in mind those moments of hope that would otherwise have evaporated within the hothouse of his harsh superego. While taking seriously the enormity of his medical condition – bearing in mind the need for work with patients who test positive for HIV/AIDS to involve a sensitive, careful, and thorough biopsychosocial assessment with specific, detailed attention to the impact of the diagnosis (Rubenstein & Sorrentino, 2007) –  I had to be careful to avoid an over-identification with those aspects of his condition that touched on his sense of himself as someone who did not deserve to live. The work with Jamie was often exhausting, so intricately did I have to navigate my way through the cracks of his fragile ego.

The capacity for hope

One of the questions I am posing in this chapter is whether there are men who never recover from the trauma of sexual abuse. It is a difficult question to answer. There are men whose experiences of trauma have removed from them much capacity for spontaneity, joy, and security, but for whom therapy can provide an essential sense of holding and containment. The power and impact of this should not be underestimated. For these men psychotherapy has to adopt a different shape, rhythm, or set of aims from psychotherapy with healthier patients. Recovery from trauma involves a process of mourning. For the male survivor this includes the mourning of loss of childhood, the removal of psychic and bodily integrity, and a catastrophic assault upon masculinity. Zetzel (1970) makes the ability to mourn a criterion for psychoanalytic treatment. I suggest that the ability to mourn depends largely on the capacity for hope. It is the absence of hope that loss can be survived that kills off the energy required to process major trauma. Schachtel (1959) distinguished two forms of hope. One is compared to Pandora's Box, the patient coming to his sessions with utter passivity, close to despair. He has limited resources with which to open the box contain- ing his traumata. Any hope of the lid being lifted lies in the therapist. The patient himself has no power. A second type of hope stems from a person's capacity to actualise his life, a more hopeful view of the potential potency of the patient who is able to make use of his own reserves in the service of the therapy. The therapist is not expected to do all the heavy lifting.

The work of regeneration

Alvarez has "looked for a word or concept (for) the birth and development of hope in a child who may have been clinically depressed all his life. The nearest I can get is … the 'work of regeneration' or, to para- phrase Daniel Stern and George Herbert, the 'slow momentous discovery that his shrivelled heart can contain greenness'" (1992, p. 173). In discussing the treatment of a patient who held little or no hope that therapy could help him, Ogden said "he did not have to like therapy or feel that it could help him. He just had to be there" (1982, p. 123). Through this statement, Ogden is reinforcing the notion that there are times with hopeless patients when the therapist has to act as a container for hopeful feelings that do not exist within the patient, and there are times when we have to make this conscious for our patients. The fact that they feel depleted of all hope of effecting change does not mean hope cannot reside in another. The fact of one part of a dyad feeling dead does not have to kill off the other part of the dyad.

This is the type of patient that McDougall (1992) calls the "anti- analysand", whose resistance to finding meaning threatens to disable the therapist's main rejoinder to hopelessness – that is to say, the therapist's own hope. Once this has gone, how possible is it to carry on? A vital quality of depressive despair is "the sense of being trapped in a way of living that is anguishing and can't be changed" (Bonime, 1982, p. 174). It is vital, diagnostically, to be able to recognise this aspect of a survivor's pathology in the place where it tends to resonate most strongly: our countertransference. When we feel as if we are entrapped by the despair of our patient, we need to consider both what the aetiology and the function of such despair is. I suggest there can be an aggressive component to the level of almost catatonic depression that patients such as Jamie present. It renders us impotent to resist its pull, echoing the powerlessness felt by the patient at the hands of his abuser. It destroys the capacity to think and removes from us access to creativity. Without creativity the consulting room becomes a sterile and barren place. The spontaneous, playful turn-taking of therapist–patient exchanges is suffocated by the weight of despair and, if we allow our minds to mirror the mindlessness of our patient, therapy loses its mutative potential.

The deeply depressed and despairing patient issues us with a challenge to survive. His hopelessness becomes a perverse re-enactment of abuse, in which he passively assumes the role of silent, oppressive abuser and we become the broken-down, muted child. We thus need to demonstrate our resilience through survival. At times this will necessitate the use of Alvarez's enlivening levels of interpretation, affect- filled interventions that promote liveliness in both us and our patient. At other times this will require simply remaining in our chair, keeping our eyes open, and staying alive. The cumulative power of aliveness in the face of deadening depression should not be underestimated. Over time the patient will introject the continuing survival of the therapist, gradually letting in those nano-bytes of aliveness that have previously served to illustrate the difference between the deadened patient and the enlivened world.

- ALAN CORBETT is the editor of the Institute of Psychotherapy and Disability Monograph Series, and the author of a number of books, chapters, and papers on aspects of working psychoanalytically with trauma, abuse, and disability. He has been Clinical Director of Respond, ICAP, and the CARI Foundation, and is a member of the training committee of the Guild of Psychotherapists. He is also a psychotherapist and supervisor in private practice.

This is Chapter Five from Psychotherapy with Male Survivors of Sexual Abuse: The Invisible Men, published by Karnac Books.