King Solomon, Eshel reminds us, that wise king, that son of Batsheva and David, that man who was permitted to build the Temple (denied to his father, King David, who had too much blood on his hands), Solomon prayed to God for a Hearing Heart (Lev Shomeah). His prayer is unfulfilled, Eshel suggests, because a hearing heart must be earned, not given, by, per Eshel, opening one's heart to another human being.
Eshel shifts easily from ancient Hebrews to Dante's Medieval genius, the Inferno. She recounts the scene in the lowest circle of Hell, the Circle of betrayal, a sea of frozen tears. We see Ugolino gnawing at the skull of Archbishop Ruggieri (for eternity, we recall). This Archbishop imprisoned Ugolino and his four sons and starved them. His sons died at their father's feet and after four days, Ugolino's “hunger had more force than grief.” The father ate his sons (Canto 33, 186-188).
But, after this recounting by Ugolino to Dante, Ugolino resumes his eternal gnawing of Ruggieri's skull. Eshel suggests that Dante, unable to bear witness further, needing to forward his own redemption, resumes his journey with Virgil's guidance, and in Ugolino's eyes, abandon's this man. For Eshel, it is Dante's absenting himself that denies what Ugolino needs: someone to be with him in this most painful moment.
Yet, this book should be read for its compelling case histories of deeply disturbed, wounded people and the psychoanalytic techniques Eshel uses to redeem them of their suffering. The case histories read like other classics, such as Milner's Hands of the Living God, or Winnicott's The Piggle (1980), (Szajnberg, 2017) which bring alive the moments in the session when transformations occur. She cautions us that there are long, overly long periods when little appears to improve, when misery may increase, but remaining close to the patient's material, a state of mind, is the analytic frame that benefits these wounded souls (Giovacchini, 2000).
And she is frank that it is not easy to bear the life experiences of such pain and misery.
For the case histories alone, this book should be read, especially by those who choose to work intensively with the deeply troubled soul.
Eshel presents us with two aspects of technique: first the more experience-near concepts such as “with-nessing” (as opposed to witnessing), “two-getherness,” “two-in-oneness,” analytic “presencing.” Later, she reviews the more experience-distant (particularly later) ideas of Bion (such as his mathematical attempts to codify analysis in his later works or use abstract letters to signify deeply felt experiences) and Winnicott . Eshel even tries to convince us that there is a new paradigm shift1 in psychoanalysis that she calls “quantum” (psycho)analysis. But, the philosopher of science, Stephen Toulmin (trained as a physicist, student of Wittgenstein) wrote in 1978 and 1984 that psychoanalysis often falls back on physics to explain itself, from the earliest hydrodynamic metaphors of Freud, through quantum mechanics and possibly even the most recent “field theory” (borrowing from a nineteenth century fields of electromagnetism discovered by Maxwell and colleagues at Cambridge). Toulmin's well-argued point is that these are all metaphors or analogies: reifying them into concrete statements that psychoanalysis is “hydrodynamic,” or “field theory” or “quantum theory,” misleads us. In fact, Eshel hints to us that she began developing her clinical techniques with primitive more disturbed patients as early as three decades back, well-before she armed herself with quantum mechanics or paradigm shifts. Let these arguments rest and not interfere with the fine clinical work Eshel articulates. I draw analogies to other attempts to compare psychoanalysis to physics, as Toulmin articulated in his classical monograph.
While paradigm shift has become notorious from Kuhn, his last book, The Essential Tension, was intended as a course correction on its misuse. Kuhn argues there that most science is “normal' science (not paradigmatic). This is not bad science, just the very pedestrian, patient slogging-through repetitive work, while remaining aware of mismatches between data and theory. That is not a model for clinical work: an “essential tension” between the normative daily details, while remaining aware of the surprising moments (Winnicott) that occur to shift our “paradigm” of the patient's inner life.
Eshel's moving, compelling clinical accounts sound familiar to this reader. This may be because I was first introduced to Winnicott by Bruno Bettelheim in the late 1960s through the mid-70s, who suggested I re-read the Transitional Object/Phenomenon paper. Perhaps because this was Chicago, new ideas were investigated with critical care: Kohut taught Klein in the 1950s; in the 1970s, I studied Winnicott with Alfred Flarsheim (one of Winnicott's analysands) and Peter Giovacchinni and Gene Borowitz. We took up the challenge of working with primitive mental states (I use this phrase rather than more specific diagnoses for now) and learned that Winnicott's techniques, Klein's ideas, and Giovacchini's tactics could meet the regressed or regressing analysand at his or her level of need.
However, Bettelheim cautioned us (in our work with children at the Orthogenic School): while we may never fully grasp the child's descent into Hell, we can reach down, extend a ladder or arm and help the child clamber out. This is a variation, I think, from Eshel's technique. In other terms, Flarsheim taught (and here he was talking from Winnicott's couch, so to speak) the analyst suspended in evenly hovering attention can mesh his or her primary processes with the analysand's. Then, the analyst periodically sits back and, now with secondary process, asks: “What just happened? What's that about?” referring to what occurred when the two primary processes were enmeshed. In the state of secondary process, the analyst can winnow out what part of the primary process came from his (neurotic) countertransference contributions from what was evoked by the analysand (a different version of countertransference, perhaps we can call this counteridentification or response to projective identifications).
But, this, to quote Rabbi Hillel, is commentary. The nucleus of this review is “Read the book, be moved by the case histories, listen to the inner work of the analyst.”
Eshel spends at least two chapters on tough technique issues that should also be a warning to us. First, she describes her inner (non-neurotic) vicissitudes that she sorted out in order to help the patient. Giovachinni described this as a form of the analyst internalizing the pathology, metabolizing it (that is reforming it) and then presenting something back to the patient. (That “something” could be as simple as not attacking after
being attacked.) David Rosenfeld (1992), in his last book on psychosis, emphasized that he could not have done this work without ongoing therapy or supervision. (He travelled to London and Paris for the supervision.) While Eshel doesn't mention what supported her heroic efforts, she does express gratitude to supervisors in the past. Second, Eshel gives some vignettes about her falling asleep during session as a consequence of something going on with the patient. She reflects on this and uses
Two cautions to those of us who choose to work with primitive mental states (and this is a choice, not an obligation): we must know ourselves well, and when not well-enough, do the internal work in order to be more available to the analysand. First, Eshel nor this reviewer would countenance falling asleep (for one's personal reasons), then foisting this on the patent. Second, Eshel, like Winnicott, did not shy away from regressions. Yet, we need to distinguish regression in service of the ego (Kris) (or self), versus regression due to errors in our technique. Neither Eshel (nor WInnicott) would countenance an adverse regression due to errors in technique; no reason to attack the patient twice! Anecdotally, colleagues in Britain have reported that some therapists believe that unless one digs to the deepest depths of regression, an analysis is neither complete nor satisfactory. This runs contrary to Ticho's (1972) classical paper distinguishing analytic from life goals.
For an internal autobiographical account of what it is like to undergo such dedicated analysis, one can read The Last Asylum, by Barbara Taylor (2015). It is reminiscent of Cardinal's The Words To Say It. Their compelling accounts of their own deep miseries, alcoholism, drug use and recovery (which included for Taylor, stays at one of the last asylums in the U.K.) is a powerful counterpart to Eshel's elegant and touching account.