© The Psychoanalytic Quarterly, 2013 Volume LXXXII, Number 4
PI A T EN T–ANA LY ST “WITHNE SS”: ON ANA LY TIC “PRE SEN CING,”
PA SSION, AN D COMPA SSION IN STA TE S OF
BREA KDOWN, DE SPA IR, AN D DEA DNE SS
By a EOf r she l
This paper focuses on the analyst’s “presencing” (being there) within the patient’s experiential world and within the grip of the psychoanalytic process, and the ensuing deep patient–ana- lyst interconnectedness, as a fundamental dimension of ana- lytic work. It engenders new possibilities for extending the reach of psychoanalytic treatment to more disturbed patients. Here patient and analyst forge an emergent new entity of intercon- nectedness or “withness” that goes beyond the confines of their separate subjectivities and the simple summation of the two. Using a detailed clinical illustration of a difficult analysis with a severely fetishistic-masochistic patient, the author de- scribes the kind of knowledge, experience, and powerful effects that come into being when the analyst interconnects psychically with the patient in living through the process, and that relate specifically to the analyst’s compassion.
Keywords: Analyst’s “presencing,” patient–analyst interconnect- edness or “withness,” passion, compassion, fetishistic-masochistic perversion, early breakdown, suffering versus feeling pain, trans- formation O → K, “dreaming” the patient.
Ofra Eshel is a Training and Supervising Analyst and faculty member of the Israel Psychoanalytic Society and Institute (IPA), and is the cofounder, coordinator, and a fac- ulty member of the Israel Winnicott Center. An earlier version of this paper was presented at the conference of the Leonard J. Comess Fund at the New Center for Psychoanalysis in Los Angeles, California, in May
926 OFRA ESHEL
Not passion but compassion. Com—means “with.” What kind of withness would that be? Translate it. —Carson (1995, p. 51)
The lines of Anne Carson’s poem beautifully capture the main theme of this paper. I would like to describe the way in which I have come to view analytic “withness” and the move from passion to compassion within the terms of the psychoanalytic process. It has been my experience for more than a decade that psychoanalytic work that is grounded in the analytic presence and the ensuing patient–analyst “withness,” or interconnected- ness, opens up yet another dimension of analytic functioning that en- genders new possibilities for extending the reach of psychoanalytic treat- ment, particularly with more disturbed patients.
WH KI A T N D OF ANA LY TIC PRE SEN CE
AN D “WITHNE SS” WOULD THA T BE?
I will begin by introducing the main terms of this way of thinking. The starting point is the analyst’s “being there” or “presencing” within (with- in) the patient’s experiential world and within the grip of the analytic process as a fundamental therapeutic means. I first developed this ap- proach with regard to massive acting out, acting in, and enactment, ar- guing that the fate of these acting situations in the therapeutic work is determined largely by the analyst’s willingness and ability to give him- or herself over to “being there,” staying within the intense impact of the acting situation and communing with it (Eshel 1998a, 1998b). Later, I expanded these ideas to the treatment of difficult-to-reach schizoid, nar- cissistic, and severely perverse patients, and to various difficult treatment situations (Eshel 2005, 2009, 2010, 2011, 2012, 2013a). Essentially, “presencing” is the analyst’s deep acceptance of the necessity of becoming an embedded, elemental, and sustaining func- tioning presence within the treatment process—thereby experiencing, withstanding, processing, and gradually transforming, from within, the repetitive cycle of pathological self–other relations and defenses. “Pres- encing” may develop into its full potential in the treatment of difficult-
PATIENT–ANALYST “WITHNESS” 927 to-treat patients and in difficult treatment situations and enactments. It is a primary quality of presence, a multiple-function presence or deep availability that focuses on experience-near attunement, receptive ca- pacity, holding, containing, and protection, rather than proffering inter- pretations of the analytic relationships and especially of patient–analyst separateness. I believe that, while “presencing” involves the above capacities and functions, the experience of “presencing” is a quality that is superordi- nate to these capacities and functions and must be considered an aspect of the analytic experience in its own terms. It is primarily an intercon- nected relatedness, rather than an interactive relationship, and it con- centrates on the ontological (being) quality of the analytic experience that is lived through with the analyst, rather than on epistemological and interpretive qualities. This seems to me closely related to Ferro’s (2005) description of “the analyst’s way of being in the session… without any particular inter- pretive caesura” (p. 44). The analyst gives himself over to becoming part 1 of the patient’s ongoing emotional reality and mental processes. Patient and analyst “live an experience together” (Winnicott 1945, p. 152, italics in 2 original; see also Ogden 2001). Winnicott’s and Green’s unique words come to mind in this regard, as compelling arguments for the analyst’s presence or “being” in the clin- ical situation. Winnicott (1971), in a memorable interpretation that he
1 In this context, I would like to refer to Bollas’s (1987) distinction between two fundamental genres of transference. One genre involves the patient and his objects; the other derives from a receptive capacity (in both analyst and patient). It is a state of being in which the analyst functions as a part of the patient’s mental process, which facilitates the creation of new internal objects and self experiences. “The psychoanalyst’s counter- transference task within this transference is to allow himself to be assumed by the patient and not to interpret unless the patient needs it” (p. 256). I find that working with this kind of countertransference is closely related to my idea of “presencing.” 2 Ogden (2001) beautifully amplifies this aspect of Winnicott’s thinking: “‘Live an experience together’—what makes the phrase remarkable is the unexpected word ‘live.’ They do not ‘take part in,’ ‘share,’ ‘participate in,’ or ‘enter into’ an experience together: they live an experience together. In this single phrase, Winnicott is suggesting (though I think he is not fully aware of this as he writes this paper) that he is in the process of transform- ing psychoanalysis, both as a theory and as a therapeutic relationship” (pp. 226-227, italics in original).
made two hours into a long session, poetically and simply expresses this “presencing” quality:
All sorts of things happen and they wither. This is the myriad deaths you have died. But if someone is there, someone who can give you back what has happened, then the details dealt with in this way become part of you, and do not die… [And in a foot- note, he added the following:] That is, the sense of self… is lost unless observed and mirrored back by someone who is trusted and who justifies the trust and meets the dependence. [p. 71]
Forty years later, Green (2010), in his last paper on Winnicott, uses this passage to elaborate on the concept of being in Winnicott’s work, and in particular, the vital aspect of how being develops in opposition to destruction, dying, or not-being. “Green leads us to realize that… [this] is much more than either holding or containing” (Smith 2010, p. 3). Drawing on Winnicott’s latest (posthumous) writings, Green (2010) emphasizes
… a connection between dying and reflection as a form of res- urrection, through the presence of the other, felt as an oppor- tunity for survival—the other having integrated the dead frag- ments into a new, living unity… sending back the situation with what has been newly integrated by him or her… In this situation, the other tries to stay as close as possible to the subject, without being confused with him… But in an earlier stage, there is no difference between subject and object. [pp. 14-15]
These powerful words on the experience of being and its standing in opposition to destruction, dying, and not-being are especially relevant to patients who overwhelm their analysts/therapists and themselves with physical and/or psychic death and not-being, such as the patient I de- scribe in the clinical illustration later in this paper. Through the analyst’s “presencing with-in” (and the often evolving therapeutic regression, in Winnicott’s and Balint’s sense), patient and analyst enter another realm of experience—of patient–analyst intercon- nectedness or “withness.” The patient is able to transfer/project unbear- able, split-off inner experiences into another psyche that is there to be
used as an area of experiencing, processing, and transformation. Patient and analyst thereby forge a deep experiential-emotional interconnected- ness, and thus a living therapeutic entity that is fundamentally insepa- rable into its two participants. Viewed in this way, it is not a one- or two- person psychology, but a process whereby analyst and patient intercon- nect psychically and become an emergent new entity that goes beyond the confines of their separate subjectivities and the simple summation of the two—an entity (unit or being) of “withness,” interconnectedness, or “t(w)ogetherness”: two-in-oneness. This new entity transcends the duality of patient and analyst, trans- ference and countertransference. In this respect, it is closely related to Ogden’s (1997) conception of the intersubjective analytic third, and I share his thinking that “do[es] not view transference and countertransference as separate entities that arise in response to one another; rather, I under- stand these terms to refer to aspects of a single intersubjective totality” (p. 25). However, I differ from Ogden in the emphasis that he places on the analyst’s own subjective past experiences and memories, which are evoked in the analyst’s mind in the session. I reach out toward the an- alyst’s embeddedness in the patient’s subjective reality, especially as a necessary, functioning presence. The analyst thus becomes part of the patient’s state of being and experiencing, to the extent of becoming psy- chically akin to a transplant or to chimeric antibodies (Eshel 2012); or, put differently, of receding toward the vanishing point in a perspective drawing. It is this very specific quality of the analyst’s “presencing” and interconnectedness that engenders a new possibility for being and expe- riencing, where that possibility had been absent or foreclosed. I have described this process as quantum interconnectedness (drawing on physicist David Bohm’s phrase, quantum interconnectedness of distant sys- tems) in order to convey the profound implications of this quantumlike psychoanalytic counterpart. It evokes the quantum physics revolutionary ideas of the inseparability of observer and observed, the crucially forma- tive effects of the process and the conditions of observation, and the unbroken wholeness that underlies our perceived world of separateness at the particle level (Bohm 1980; Botella and Botella 2005; Eshel 2002,
2005, 2006; Field 1996; Kulka 1997; Mayer 1996). 3 This unified coun- terpart in psychoanalysis may be described as the implicate order (Bohm
- of psychoanalysis. As in quantum reality, treatment thus creates psychic reality, and goes beyond the exposing or deciphering of the patient’s already existing re- pressed or concealed psychic reality. This point of view focuses predomi- nantly on a different kind of knowledge, experience, and way of being in the analytic process—not that of a patient-centered, one-person mode or an interactive, two-person mode, but on the knowledge, experience, and powerful effects that come into being when the analyst/therapist interconnects with the patient’s psyche in living through the process. It is a shift in emphasis from the unveiling of meaning and relationships within already existing scripts to a process of being and becoming, as a consequence of the experience of patient and analyst living the experi- ence t(w)ogether. Such interconnection means changing the patient’s (and analyst’s) already existing psychic space. Their interconnected psychic existence— through the analyst’s readiness to be given over to this interconnection— creates an actual, nonlinear (synergic and transcendent) new possibility of getting in touch with, wit(h)nessing, experiencing, containing, and af- fecting hitherto unknown, dissociated, unthinkable aspects of being and relating. Hence its importance, even its necessity, in working with more disturbed patients (Eshel 2001, 2004a, 2004b, 2005, 2006, 2009, 2010, 2011, 2012, 2013a). Over the years, I have encountered various terms used by a number of psychoanalysts that emphasize profound forms of patient–analyst connectedness. Recent contributions include Ogden’s (2009) formula- tion of what he views as Bion’s second principle of mental functioning: “It takes two minds to think one’s most disturbing, previously unthink- 3 Elsewhere (Eshel 2002) I have elaborated on the specific significance of this quantum process. Whereas classical physics (and classical psychoanalysis) are based on as- sumptions of linear causation, determinism, continuity, and sharp separation between the observer and the object under observation, quantum physics is based on essential inseparability and indeterminacy at the most fundamental levels of particles. I believe that this fundamental claim of quantum physics finds its counterpart in this dimension of the analytic process in which patient and analyst form an interconnected unit that is, in principle, inseparable.
able thoughts” (p. 100). Another formulation is Botella and Botella’s (2005) intriguing description of the analyst’s “functioning or working as a double,” which goes beyond “already-known” countertransference meaning and thus gives access to the patient’s unrepresentable areas that would otherwise remain traumatically unknown and unreachable (pp. 82-83). The conceptualizations of the Barangers’ work of confluence (2009) and Ferro’s bipersonal field (1999, 2009, 2010; see also Ferro and Basile 2009) both emphasize the formation of a new identity—the ana- lytic field—which is created between patient and analyst within the unit that they form in the session. “Such a description illustrates the funda- mental point that the field must get ill with the patient’s own illness in order to be then cured of it” (Ferro 2010, p. 418). While I com- pletely agree with this fundamental point, the analytic experience of “presencing” and “withness” or interconnectedness is not located between patient and analyst, but is as much as possible within the patient’s world. (I have pointed this out earlier with regard to Ogden’s intersubjective third.) To further support this distinction, I will add here Vermote’s (2013) recent formulation of an integrative model of psychic functioning for dealing with the unknown. Drawing heavily on Bion’s writing, Vermote discerns three distinct zones of psychic functioning with varying degrees of differentiation, different major psychoanalytic models, and clinical implications for the analyst:
- Reason—Oedipal, understanding Ucs. System (Freud, Klein);
- Transformation in Knowledge—container-contained, reverie, dream-work, alpha-function (Bion, Marty, de M’Uzan, Bollas, Botella and Botella, Ogden, Ferro);
- Transformation in O, when dealing with the most non- thought, unknown, undifferentiated zone of psychic func- tioning (Winnicott, Milner, late Bion, late Lacan). Rather than epistemological exploration (knowing), the focus here is on the unknown and unknowable, ultimate, emotional re- ality-O, the primacy of being at-one with the patient’s emo- tional reality, and a lived, new experience. For me, it is in this zone of analytic functioning that Bion’s (1970) radical words acquire their full meaning: “at-
one-ment with it [O] and evolution… In practice this means not that the analyst recalls some relevant memory but that a relevant constellation will be evoked during the process of at-one-ment with O, the process denoted by transformation O
→ K” (pp. 30, 33, italics added).
In my view, the emerging dimension of the analyst’s “presencing” and “withness” or interconnectedness that I am proposing reaches down to this third, most undifferentiated and fundamental analytic func- tioning and transformation in O. “Presencing” and interconnectedness go beyond the level of interactions and patient–analyst relationships (ob- ject or subject relationships), even beyond intersubjectivity, to offer the opportunity for getting in touch with basic (environmental) relatedness and formative experiences of being and becoming (in terms of modern physics—to influence at an elemental, nano-level [Eshel 2013b]). In Winnicott’s (1954a) words on therapeutic regression, it
… reaches and provides a starting-place, what I would call a place [italics in original] from which to operate. The self is reached. The subject becomes in touch with the basic self-processes [italics added] that constitute true development, and what hap- pens from here is felt as real. [p. 290]
In this context, I would add Nacht and Viderman’s (1960) inclusive conception of the analytic situation as a whole and the pre-object universe in the transference situation, which encompasses the movement toward a more primal form of analytic experience.
Sometimes, in the course of analysis we reach a deeper, more secret and unchanging level of the psychic structure, character- ized by an intense need for absolute union [italics in original]… Let us accept that the same aspiration… remains buried and unknown in recesses of each individual psychic structure… We agree that the dynamic of transference, in the strict sense of the word, is drawn from man’s perpetual search for ob- ject relationships… But the analytic situation as a whole goes beyond the elementary dynamic of transference, perhaps to in- clude the original primitive experience of Being and to express its essence. From this point of view it is legitimate to describe the analytic situation as an ontological experience [italics added]. [pp. 385-386]
Thus, working within this dimension of analytic presence and in- terconnectedness has less to do with object relationships than with the emergence of a new place or psychic space-time, and a new possibility of experiencing and becoming, via the analyst’s being with-in and staying interconnected to the patient’s unbearable core of experience. In terms of time, it is an actual process of becoming that is neither the past nor the present. Rather, it is a past–present convergence, past–present actu- ality, where the past that has invaded the present is altered by the on- going history of the patient–analyst lived moment. In other words, the past that actualizes within the patient–analyst’s new psychic space does not merely repeat itself in the present, but can be experienced, pro- cessed, and transformed in statu nascendi (Eshel 2004b). 4 The critical question here is to what extent the analyst is prepared to open the boundaries of his or her psyche to the patient and the pa- tient’s world, especially in difficult, unbearable and devastated/devas- tating states, and allow the patient and him-/herself emotional contact and interconnectedness at a deep, formative level. Over the last fourteen years, this dimension of analytic “presencing” and interconnectedness has become an integral and especially important part of the way I practice, think of, and envision clinical psychoanalysis. I have attempted to describe the clinical scope of working within this framework, and its various, sometimes even radical expressions (Eshel 1998a, 1998b, 2001, 2004a, 2004b, 2005, 2006, 2009, 2010, 2011, 2012, 2013a). In the present paper, I will focus on compassion, which is the analyst’s “withnessing” or interconnectedness with the patient’s ago- nizing states of distress, annihilation, and hopelessness.
COMP SIO A S N
Compassion, from the Latin com, “with” + pati, “to suffer,” means to suffer with (and, I would add, to suffer within), to be present within an- other’s suffering and become at-one with it. It is different etymologically from words that may be regarded as synonymous, such as pity (from the
4 Here I intend actualize in its two meanings: “In the present and in the process of actualization, that is, trying to bring into existence what didn’t happen” (Pontalis 2003,
p. 45).
Latin pietas, meaning “duty”) or mercy (from the Latin merces, meaning “recompense”). 5 In addition, the word patient is derived from the same Latin word pati, to suffer. Hence, as the etymology of the word suggests, compassion is being-with the patient and being the patient. Thus, the withness of compassion is what distinguishes it from other feelings of sorrow for the suffering of others, such as pity and mercy (and also from such feelings as kindness and generosity). Compassion involves and shares, while pity and mercy are often considered more dis- tinct, more distant and impersonal, and may include aloofness, feelings of superiority, and condescension toward another’s suffering. The distance and impersonal nature of pity and mercy are defiantly expressed by Yehuda Amichai, one of Israel’s leading contemporary poets, in his poems “God Has Pity on Kindergarten Children” and “God Full of Mercy.” The latter of these poems is quoted below:
God-Full-of-Mercy, the prayer for the dead. If God was not full of mercy, Mercy would have been in the world, Not just in Him. [Amichai 1962]
According to Arendt (1965), pity is concern for the misery of another unprompted by intimacy with, or love for, the sufferer, while compassion is a love directed “towards specific suffering” of “particular persons.” Pity “may be the perversion of compassion” because the person who pities “is not stricken in the flesh” and keeps a “sentimental distance.” Arendt maintains:
For compassion, to be stricken with the suffering of someone else as though it were contagious, and pity, to be sorry without being touched in the flesh, are not only not the same, they may not even be related. Compassion, by its very nature, cannot be touched off by the sufferings of a whole class or a people, or, least of all, mankind as a whole. It cannot reach out farther than what is suffered by one person and still remain what it is sup- posed to be, co-suffering. Its strength hinges on the strength of passion itself, which, in contrast to reason, can comprehend
5 See Collins Dictionary (2002, pp. 690 and 561, respectively).
only the particular, but has no notion of the general and no ca- pacity for generalization. [1965, p. 85, italics in original]
Compassion has hardly been addressed in the psychoanalytic litera- ture. The few papers on compassion—five that I located, most of them written in the last decade—display great variance with regard to the es- sence and meaning of compassion in the context of psychoanalytic treat- ment, although all take a very humane stance. Bernstein (2001) attributes this avoidance of compassion in psycho- analytic work to the “fear of compassion” or of “being human, though a psychoanalyst” (p. 209). He argues that a misreading of Freud has per- petuated two compelling shibboleths: the fear of countertransference and the abstinence rule, which deprived psychoanalysts of the privilege of using all their feelings—especially the feeling of compassion and of behaving compassionately with their patients. Bernstein briefly describes two difficult treatments of disturbed female patients, arguing that the early one failed because he was then unprepared to allow himself to act as a compassionate human therapist, while in the second case, fifteen years later, he was able and willing to assume compassionate responsi- bility. Feiner (1993) attributes this inhibition of psychoanalytic compassion to the dialectic between compassion and standards. In this regard, Nacht (1965) had already suggested that in every case the analyst’s attitude of benevolent neutrality has to gradually change and be replaced by a new presence (a deep-down goodness, described in his previous papers). But with patients whose ego functions have been disturbed by real, severe trauma and much suffering, it has to include a truly authentic attitude of gratifica- tion on the part of the analyst (in certain aspects of the analytic relation- ship), stemming from genuine compassion for the misery that underlies the patient’s incessant and outrageous aggression and demanding-ness. Young-Eisendrath (2001) views the amelioration of suffering during and after treatment and increased compassion for self and others as the two main objectives of a successful psychoanalytic treatment. She posits that the two means by which compassion is cultivated are the “unob- jectionable, idealizing transference” (p. 276), filled with hope of tran- scending the suffering, and the investigation of the patient’s suffering within the patient and analyst’s interdependent relationship of discovery.
In the tradition of self psychology, Kohut (1978, 1984) deals with compassion in relation to empathy. Orange (2006) relies on Kohut and on Feiner for psychoanalytic thinking about compassion, and also on the implications of complexity theory. In her view, compassion is that part of empathy that makes the analyst willing and able to descend into the patient’s realms of suffering and shattered life. This enables emotional understanding and integration of the patient’s suffering, as opposed to dissociation and fragmentation, and affirms the human dignity of the patient. The above articles, however, relate to compassion from interactive, relational, two-person psychology perspectives. Even Orange’s recent paper on the subject of compassion is, as she herself writes, “a more relational version of what I once called the psychoanalytic function of witness” (2006, p. 7). But while the term witness applies to an interac- tion between two subjectivities (Stern 2012; see also Reis’s attempt to broaden the conception of witnessing, 2009a, 2009b), I wish to propose here the notion of psychoanalytic “withness”—the being there, within the experience of suffering, becoming at-one with it, in deep patient–analyst interconnectedness. It is the unique conceptual space opened up by Bion’s writing, es- pecially his later writing, that has facilitated my thinking on passion and compassion and the movement from one to the other—although, as Sandler (2005) writes, “The words compassion and passion are used by Bion in some seminal texts. Nevertheless, they do not attain the status of concepts. Bion uses the word ‘compassion’ in its vernacular, colloquial sense” (p. 146). First, I encountered Bion’s (1963) remarkable words on passion:
By “passion” or the lack of it, I mean the component derived from L, H*,* and K. I mean the term to represent an emotion experienced with intensity and warmth though without any sug- gestion of violence… Passion is evidence that two minds are linked and that there cannot possibly be fewer than two minds if passion is present. [pp. 12-13]
Later on, Bion (1970) goes further and presents his profound con- ception of at-one-ment and the analyst’s being and becoming O, the
unknown and unknowable, ultimate emotional reality of the patient (al- though Bion does not relate it to compassion): “With this [O] the analyst cannot be identified; he must be it” (p. 27, italics in original). Lastly, there are Bion’s (1991) compassionate, touching words: “I do not think we could tolerate our work—painful as it often is for both us and our patients—without compassion” (p. 522). All these ideas of Bion’s have infused themselves into my thinking of compassion as patient–analyst “withness” within the violence of the suffering—com-passion that incorporates passion experienced with inten- sity and warmth, though without any suggestion of violence; that goes beyond the analyst’s projective-introjective identification, and is the ana- lyst’s “being” and “becoming” at-one with the patient’s inmost emotional reality. The clinical importance of the analyst’s “becoming” has recently been elaborated in Grotstein’s (2010) compelling writing on infantile trauma and chronic resistance (particularly negative therapeutic reac- tion), which require
… the indivisibility of the transference ↔ countertransference in the analyst’s reverie [in the treatment of those traumatized patients]… [It is] the necessity for the analyst to experience his own inner version of what the analysand is suffering from; to “become” the analysand’s anguish and agony. Bion (1967, 1970) termed this phenomenon “transformation in O within the ana- lyst.” [p. 25, italics in original]
Despite the paucity of psychoanalytic writing on compassion, over the last few years, psychoanalysts in Israel have produced some intriguing writing on this subject and in particular on compassion as a patient–ana- lyst, interconnected occurrence. Kulka (2008a, 2008b), linking self psychology and Buddhism, views compassion as “the repeal of the individuality partition between sub- ject and subject.” Thus, “compassion is not an interpersonal state, but a supra-personal state; not a feeling, but an ethical decision for non- dual interconnectedness, an existential transcendence that turns man into pure presence” (2008a, pp. 118-119). “Compassion, that which in- fuses foundational parts of Eastern cultures, is the abolition of duality,
repealing the separation between water and fish… between one human and another, between humans and the world” (2008b, p. 1). Ettinger (2006), artist and psychoanalyst, relates compassion to the primary maternal connectedness in the matrixial borderspace. She distin- guishes between empathy-within-compassion and empathy-without-compassion. The former means empathy (to the patient) within compassion (also toward the patient’s significant primary figures), and this is in contrast to empathy-without-compassion—an empathy to the patient only. In Et- tinger’s view, empathy (to the patient) without compassion (also to the patient’s archaic and actual significant primary objects) “endangers the matrixial sphere itself,” creates internal splitting, and “leads to a fixation in a ‘basic fault’ positioning” (Ettinger 2010). I, however, would like to return from these inclusive views of com- passion as interconnectedness of all beings, and of compassion toward the patient’s significant objects, to compassion only in patient–analyst in- terconnectedness. I will concentrate on the analyst’s difficult, sometimes even exceedingly difficult struggle to give over him-/herself—with all his or her might, mind, heart, soul (Eigen 1981)—to being and staying within the painful, annihilated-annihilating realness of the patient’s suf- fering, in deep interconnectedness, in patient–analyst suffering. “This collapse into being with another, the deepest states of the other” (Eigen 2006) is the heart of my clinical illustration. One last note on compassion. Perhaps another reason for the avoid- ance of the subject of compassion in the psychoanalytic literature is that the word has become saturated with religious connotations, especially Christian and Buddhist. Yet I venture to mention the compassion in the Jewish morning prayer that a religious Jew recites every morning imme- diately upon awakening—thanking God, “for You have returned my soul within me with compassion; great is Your faithfulness.” Though I am not a religious person, I relate deeply to this wondrous intertwining of God’s great faithfulness and the compassion of returning the soul each morning, each day, after the terrors of the night of “trou- bling thoughts, evil dreams and evil fancies… lest I sleep the sleep of death” (these words are from the prayer recited before sleeping). It is even enigmatic, this great faithfulness and faith of God’s in returning
the soul with compassion. 6 And this compassion that is interwoven with faithfulness and faith in the process reverberates in my analytic use of compassion.
CILLUST A SE RA TION : “FOR Y OU HA VE RE TURNE D MY SOUL
WITHIN ME WITH COMPA SSION ”
The clinical material presented here is taken from a four-times-a-week analysis of a patient with severe fetishistic-masochistic perversion, which I have described in an earlier paper on perversion (Eshel 2005). I will now proceed to later periods in this analysis, which I have not yet written about.
P. started analysis when he was in his late thirties. He was referred to
me by a psychiatrist who had first treated him with medication. The psy- chiatrist told me that his severe perversion had intensified over the last few years, to the point of becoming life-threatening. In the year before he came to her, he had approached several sex therapists who were all so alarmed by the severity of his disturbance that they refused to treat him. When he turned to this psychiatrist, she prescribed medication for compulsive disorders in an attempt to minimize the compulsive nature of his perverse behavior. However, this was unsuccessful and produced harsh physical side effects, some of which she found rather puzzling. She therefore stopped the medication and told him that, in her opinion, psychoanalysis would be the only treatment that might help him since it is the most profound form of treatment. It should be mentioned that this man had not previously had any- thing to do with psychology or psychoanalysis, and I do not believe that he had even heard the word psychoanalysis before. His agreeing to this proposal was thus an indication of his despair and hopelessness. After several unsuccessful attempts at finding him a psychoanalyst, the psy- chiatrist approached me, knowing I take difficult cases. She seemed hesi- tant to specify the nature and extent of his perverse behavior, lest I, too, refuse to treat him. However, at the time, I had been crystallizing my 6 In Hebrew, the word emunah, which appears in the morning prayer, means both “faithfulness” and “faith.”
thoughts about extending the reach of therapeutic work through the depth and intensity of psychoanalysis, and about analysis as a unique pro- cess of becoming—drawing on the powerful notions of a new opportunity for development (Winnicott), a new beginning [in] the basic fault (Balint), and an area of faith (Eigen). Thus, I thought, psychoanalysis should be able to offer a real treatment option for this person’s distress, and I agreed to accept him for analysis.
P. telephoned me the next day. During the initial session, he told
me that his severe perversion had started as a shoe fetish of licking and kissing shoes “with a woman’s feet in them,” along with a masochistic element of wanting them to trample on his fingers, a wish that he re- called having had since kindergarten. It escalated over the years into a masochistic fetish as the shoe “turned into a tool of destruction,” and in the past few years it had become a particularly severe and violent mas- ochistic perversion. Over the first months of analysis, he gradually presented me with extremely harsh descriptions, told matter-of-factly, of his almost nightly visits to prostitutes, usually a different one each time, to be humiliated and abused by them in increasingly extreme ways with all sorts of instru- ments of torture. He would lie down naked; sometimes he would wear a mask, masturbating until he ejaculated; and he would leave beaten, trodden upon, wounded, bleeding, and burned by cigarettes that had been extinguished by shoes grinding them into his naked body—and he would already be yearning for the next abuse. He sought treatment because he knew that, in his own words, “if it goes on like this, it will end in a hospital—in a serious injury or in death.” After a few months of analysis, when he realized that I would not throw him out of treatment because of what he told me, P. said, “This is the last stop for me. Psychoanalysis. After that—it’s the graveyard.” Since then he has clung to treatment despite some very difficult periods that we have gone through. In his “ordinary” life, he was a dreary accountant, in a nonsexual marriage with a woman he knew from work, an accountant like himself, whom he told nothing about his perversion. At the end of the first year of analysis, he told her the “truth” about himself and his secret life. She
found it unbearable, reacted with shock and repulsion, and decided that they should separate. He left the house, hurt, and they were divorced. As mentioned above, I described this analysis in an earlier paper on perversion, up to the cessation of the perverse practices in the third year of analysis (Eshel 2005). I emphasized the importance of the analyst’s abiding “presencing” and interconnection with the perverse patient, thus being with-in and listening to the perversion beyond its pathology, for its survival function and for the profound loneliness and despair it carries. I pointed out the fundamental function of the evolving process of therapeutic regression in Balint’s and especially Winnicott’s terms in the analysis of the perverse patient—namely, to understand it primarily as a situation of need resulting from an early maternal-environmental failure (rather than manipulative acting out), with the ensuing treat- ment priorities of holding, analytic reliability, and attentiveness to the patient’s need states and dependence. Thus, in Winnicottian terms of regression, the analyst’s intercon- nected “presencing” can be seen as enabling the transformation of the patient’s withdrawal and massive self-defensive organization—in this con- text, the perversion—into regression to dependence in treatment, which carries with it a new opportunity for correcting the patient’s past experi- ences and for emotional development (Winnicott 1954b, 1964, 1988). Before proceeding to the third year of P.’s analysis, I would like to re- count an example from the earlier period that epitomizes these qualities of experience, as presented in my 2005 article. The patient, here in the second year of analysis, arrived at the first session following my holiday break. (The gaps created by the analyst’s vacations are most troublesome in these treatments.) As soon as I opened the door, I noticed his swollen face.
He lay on the couch, and after a brief “How are you?” told me quietly and bluntly, in detached detail, that he had gone to a whore that morning, a cheap one who charges only 100 shekels (about $25), a most violent type, who went wild and slapped him and beat him madly, incessantly, for five minutes, and he came very fast and hard, went home, washed up, and came to the session.
the first time in this analysis, I felt great tiredness and For disgust, although he had already recounted far more violent and bizarre scenes—perhaps because of this inundating, wretched cheapness. I was thinking to myself: What is the point of all the hard work, of this entire analysis, the great investment of money and years? Better go to a whore every day, get beaten up for five minutes, pay 100 shekels, and be done with it. And I withdrew, fell silent. Then I noticed that he became very agitated, in sharp con- trast to his former quiet and detached manner. As if he’d heard my thoughts, he said: “Nothing can be done. I ask you: What? What is there to say? When I’m butchered, I exist. It’s like the Alien got inside my belly and stayed there, breaking out every time, and that’s it. Nothing left to do. There’s no solution; ev- erything just gets worse. I’m finished. I was born and I’ll die this way. I’ll be dead before I’m forty.” He sat up, shaken, suddenly looking so withered, shapeless and pitiful, with his beaten-up, swollen face. And I realized he sensed and knew that I had abandoned him, left him wounded and lost on the battlefield, and had gone off to save myself. Thus I returned to this despicable, despairing, and des- perate place, his and mine, and said: “You are so desperate be- cause you felt that I’d given up. And when we both give up, there’s nothing more to hold on to. It’s really very despairing, but we are going on.” He lay back quietly, tears in his eyes for the first time in analysis (perhaps in his life), and said, “Death can be so cheap. You should lock me up inside the treatment.” [Eshel 2005, pp. 1089-1090, italics in original]
I will now proceed to the third year of analysis. Toward the end of the third year, after the perverse practices had ceased, analysis was filled with great agitation and confusion, and with massive holding on to the treatment and to me instead of to the perversion. It led to a deeper regression in the analysis. In the sessions, P. would speak feverishly, ad- dressing his words to me, frequently calling me by my first name, Ofra— which he had never done previously—in the sessions and also in voice- mail messages that he now began to leave. I will present some detailed vignettes, using his own words, as I feel that they most closely depict the
actual experience and convey the turbulent nature of the analytic situa- tion at that time. It was a Monday session—always a particularly difficult session after the weekend break. P. began:
Don’t remember a period in my life like this, don’t know what’s happening to me, mentally and physically exhausted. Don’t know what’s happening. [He sighed and was silent.] My entire old world is collapsing, dissolving and disappearing, the whole world of evil, and I’m facing a new world, don’t know what to do. I don’t have the tools to cope with it.
I said: “Tools need time to develop.” But my words remained sus- pended in space. He went on:
Don’t know, don’t know what’s happening… Don’t know, Ofra, just don’t know what’s happening to me, how all at once this thing that I used to fall into has disappeared—where has it gone to? All sorts of strange things, don’t know, don’t know what’s happening in my head [he put his hands on his fore- head]. Don’t know, don’t know, not anything I know—all sorts of things are flying in the air. Maybe I’m going mad, don’t know, it’s as if my brain is emptying out, as if things are flying in the air, like in a hurricane, as if something is making things fly out of my brain. In the last few days, things are unclear to me; I’m not in control of what’s happening to me, it’s as if I’m falling apart, the first time in my life, falling apart completely. Don’t know what to do—I’m going mad.
I said: “You’re not going mad. You’re changing, changing a lot.” He said:
I’ve never had thoughts like these, never in my life. The very ele- ment of violence has disappeared. I’m standing at the entrance to a new world, and I don’t know how to behave. What to do with my brain and my dick. Don’t know what I want from myself. We talked so much, Ofra, and all of a sudden something big col- lapsed all at once, not gradually. What a huge jolt.
He became silent and lay quietly, as if sleeping, until the end of the session.
After about eight turbulent months, his confusion diminished. “Ap- parently, I have to get used to this new situation, that I’m not so much of a fetishist any more, and I need to calm down a bit,” he said. He con- tinued to abstain from his perverse activities. He frequented the cinema, listened to a lot of music, started exercising on the days that he was not in analysis, and began to look for and date women through Internet dating sites. He called this period “the age of uncertainty” because pre- viously everything had been familiar to him and under his control. He said: “I’ve never been out with a woman, I’ve never touched or been touched by a woman. I’ve never slept with a woman. I’m very scared of it, it’s new. It’s hard to get out of the gutter.” (He said this even though in fact he had been married for years. Here I would like to add that this was a man who could not bear to be touched. In the first year of treat- ment, when I asked him about his descriptions of the cruel fetishistic- masochistic practices, why the whores had to dig their high heels into him and extinguish their cigarettes on his body with their shoes rather than with their hands, he replied that he could not bear to be touched by a human hand.) Nonetheless, despite his deep misgivings and fear, he now proceeded from telephone calls to dates and began meeting an increasing number of women. These meetings were usually for no more than a single eve- ning. In the course of time it became easier for him to meet women; some of these dates were even enjoyable. And still, deep inside, he felt cut off and vulnerable, and an immense inner emptiness was growing and taking hold of him. It seemed that the fetish that had disappeared had left behind a vacuum and profound emptiness. Was this what he had foreseen when he spoke repeatedly about his perversion during the first year of analysis? “It sustains you more than anything else. You won’t let anyone or anything take it away from you. If you give it up, it will be unbearable, since there won’t be anything else.” Now, in the fourth year, he was saying:
It’s amazing, amazing, how the fetish took over my entire life, and now there’s nothing, nothing. Don’t know what’s going on here. With women it doesn’t seem real; I don’t really want it. Last night I talked to that woman who approached me—don’t know, it seemed pointless, like, what, what, for what, suddenly
everything seemed pointless, strange, strange… Don’t know what to do, Ofra—altogether feel completely cut off. Don’t know where everything I’ve fantasized till now is, where everything that filled me all those years has gone… Everything hurls me into a world that has no center. I’m so empty inside… Feel so unreal, so unable to exist in the world of the living—and mainly, so ill.
P. gave himself time until his birthday, which was very close to the
end of the fourth year of analysis, to try it out. In his own words:
The transition between worlds is a tremendous jolt. Ilan Ramon⁷ didn’t survive the transition between worlds. I’m going through a jolt that is just as great. It will end either in death or in a dif- ferent life.
But after his birthday, throughout the fifth year of analysis, pro- found despair, unfathomable emptiness, and death seemed to possess him and to have become the only reality—dreadful and absolute. This was a terrible, excruciating year in analysis. He reverted to searching the Internet for the most ferocious fetishistic-masochistic websites with extreme violence and self-destruction. He masturbated to horrendous fantasies, even though he did not revert to actually performing perverse activities. He said:
It’s a kind of total self-destruction, without any brakes, as if I don’t have a drop of self-love in me, a drop of compassion [com- passion here is his word], a drop of self-pity, a drop of anything, anything. It’s unbelievable, Ofra, unbelievable—only dread, ha- tred, violence, feelings of inferiority, and fear of criticism.
He requested a year’s unpaid leave from work because he could not live with the huge disparity between his internal world and his external “normal, false,” and painstaking way of functioning: “I’m normal there, that’s what doesn’t let me get better. My death is the normal life that I built all those years around the fetish.” He lived on his savings, and his entire existence was drawn into the treatment, collapsed into the treat- 7 Ilan Ramon was an Israeli astronaut who was killed when the space shuttle Columbia was destroyed upon reentering the earth’s atmosphere in 2003.
ment. He wanted to be “hospitalized in treatment,” and to be. To exist. To feel real. But now it seemed that the defensive shield of the perversion had been totally breached. “Fetishistic energy isn’t an energy of life; it’s en- ergy that repairs death. It’s between life and death—dead-alive, more dead than alive; death-in-life,” he said. Indeed, I, too, had written on perversion as an “autotomous,” massive splitting defense in the service of psychic survival, so that “not all of me shall die.” “The perverse act seizes and clutches, preventing in its corporeality, in its actuality and inten- sity, a collapse into dread, psychic deadness and total internal annihila- tion. Perversion is the pervert’s last-ditch attempt to halt the fall into the abyss” (Eshel 2005, pp. 1078-1079). But now this last-ditch attempt to halt the fall into the abyss had col- lapsed. Perversion no longer repaired death, no longer secured survival. Throughout this year, death was the very heart of his existence. It was ev- erywhere, all the time, invading every hour with menacing forcefulness. He came to every session, never late, never asking for any change of time, arriving psychically and physically ill—“the fetish and violence are destroying every bit of goodness in me,” or lifeless, empty, without the strength and will to live. Frequently, he would sleep during the ses- sions—a still, motionless, and soundless sleep. He would leave me many telephone messages, at least one a day, and on Wednesdays and weekend breaks, when we did not meet, he would leave several messages. His words in the sessions and in the messages were full of despair, harrowing emptiness, and death, and no attempt on my part to understand and interpret had any significance, meaning, or impact. He would say over and over again:
I have nothing to say to you, Ofra; I simply have nothing to say to you. Everything is one huge nothing. I’d rather be sucked into a black hole. Everything’s a load of bullshit; everything’s empty words. It’s better to be sucked into the nothingness, Ofra, and finished—to disappear completely. I just don’t have any plans, I don’t want any plans, anything—just nothing, Ofra, nothing, I have nothing to say. Everything is so pointless, including your words… They’re so meaningless, there’s nothing in them, Ofra, nothing, nothing.
Suddenly, unexpectedly (and perhaps not so unexpectedly), during this period harsh details of his very early childhood were revealed. Until now, whenever he had asked his mother about his childhood, she had answered, “Everything was fine.” But now when he asked, she said, “It was very hard,” and told him about the dead baby. It turned out that his mother had had six pregnancies. Two of them ended in miscarriages before the birth of his brother, who was eigh- teen months older than he; as a result, she was prescribed total bed rest during that pregnancy. She did not work at all during those years since she was pregnant most of the time, and the pregnancies were difficult. P. thought that his father had wanted a lot of children. When his mother was pregnant with him, she fell while carrying his brother in her arms and thought that she was going to miscarry again. But he was born a year and a half after his brother, with a heart defect (persistent truncus arteriosis), for which he was operated on at the age of seven. In the year after his birth, “when I was very small,” he said—his mother did not remember exactly when—she gave birth to another son in her sixth month of pregnancy, and the baby died twelve days later. She remembered only that they had told her something was wrong with it. She did not remember whether she ever saw it, did not remember whether she stayed in the hospital for the twelve days until the infant died. It did not have a name. She did not remember whether they buried it—but “somewhere inside [his] head,” he remembered she had once told him that his father and his grandmother (her mother) “had taken care of the matter and buried it.” When he was twenty months old, his mother became pregnant with his next brother, who was born when he was two and a half years old, and she almost died in childbirth. I suggested we were beginning to understand that, during those early years, his mother had undergone dreadful experiences, misery, suf- fering, depression, and death. I said that a baby is born into the psyche- and-body of its mother and comes into being and grows there. And he was born to a mother who became distraught, alive-dead, and his yearning as an infant and small child to attach to and grow within her psyche and body had overwhelmed and filled him with her agonized feelings—with depression, death, a dead baby.
At first it seemed that these words held meaning for him. “I’m a tiny baby that terrible things have happened to,” he said. Two and a half years later, he would say: “I went mad when I was a baby,” but now this emergent understanding very quickly turned into a terrible, lethal attack on my capacity to really meet, take in, and feel the desperation of the fundamental nothingness and death within him. It became something that came from without, illusory, “as if”—too far from that baby and small child overwhelmed by traumatic, annihilating impacts. The more there were words and the greater the understanding, the wider yawned the gap he felt was between us; and there was no real con- tact with death and dying. He said repeatedly:
I’m a dead baby and a perverse adult. All day I’ve been thinking that I want to die tonight, don’t want to get to tomorrow. And that’s it. I hope I’ll die tonight. Simply feel completely redun- dant, Ofra, completely redundant. You’re so healthy, Ofra, and I’m so sick. There’s no point of connection between us. There are big words and a big illusion and big lies, but nothing apart from that. After the session with you, I hope I’ll go to sleep and won’t wake up. Won’t wake up.
I said: “Then your body-psyche will decide whether we will be able to go on.” And at the end of each session, I did not know whether he would survive and come to the next session. There no longer seemed to be even a fragile remainder of his sense of life and hope, but only a state of devastating despair. Analysis was now a meeting place with a terminal object (in Bollas’s sense, 1995, p. 76)—indeed, a terminal and annihilating object and the despair of his first year of life. 8 Was this his way of making me meet and experience the terminal, annihilating, invasive presence of a depressed, dead-alive m/other in the grip of depression and death, who induced
8 I would like to add here the recent, intense description of annihilation by Eigen (2010), which is closely related to the agonizing experience expressed here: “Annihila- tion is not a static state. It goes on and on and on. It’s electrifying. I don’t have the words for it. It’s like being in an electric chair with the current continuously on, or being suffocated but you never die. You keep getting more and more suffocated… I felt that this is partly what babies must feel, in their own way… screaming and screaming and then the scream fades away” (pp. 26-27).
depression and death, and who could not be extricated from death? Or might it be that damage that begins so early cannot be repaired—as he repeated over and over—except in death? To die, and then perchance to begin anew? I was reminded at that point of the last words of Otto Weininger, a brilliant young thinker, imbued with self-hatred, hatred of his Jewish an- cestry and hatred of women. A year after he published his book Sex and Character and converted to Protestantism, at the age of twenty-three, he wrote in his final notes: “An honest man, when he feels that he is irrepa- rably deformed, goes willingly towards death” (Sobol 1982, p. 121). He wrote this and then killed himself. I was becoming exceedingly worried. I suggested, for the first time in my clinical work, that he should go back to the psychiatrist who had referred him to me and get medication that would afford him temporary relief from this terrible suffering. But he replied angrily and bitterly:
How can you say that to me? I thought you were holding the hope, you and psychoanalysis. I don’t need anything else to keep my body alive; for that there’s the fetish, big time, and familiar for so many years. But I don’t exist. I’m not. There’s nothing here. I’m dead. That’s the fundamental thing—I’m dead.
His words, I felt, cried out the very real, ongoing desperation of his being… “In the very ill person there is but little hope of new opportunity” (Winnicott 1954a, p. 281). Inwardly, I struggled to find some hope while faced with this overwhelming, immense desperation. I seized upon two of Winnicott’s later writings on “Fear of Breakdown” (published posthu- mously in 1974) and its continuation, “Psychology of Madness” (1965), which are of great importance to me. Winnicott relates to the disastrous impact of being broken down in infancy, at a time when “the ego orga- nization… is threatened. But the ego cannot organize against environ- mental failure in so far as dependence is a living fact” (1974, p. 103). It is that extreme agony of early breakdown, which Winnicott also calls madness X, and that Eigen (1999, 2004), following him, calls agony
X. This early breakdown was so unthinkable and indescribably painful that it could not be experienced, and a massive defense organization,
which the patient displays as an illness syndrome, was organized against it. In my patient’s case, it was the ferocious fetishistic-masochistic perver- sion that turned him from a passive victim of unbearable early damage and destruction into an active “doer” of them, over and over again, while beneath it there yawned an abyss of inner death and emptiness. I reminded myself that, according to Winnicott, in those depths of annihilation and the agony of early breakdown, or madness X, are buried both the traumatic experience and a “basic urge*”* to experience it, and thus “to be recovered in experience… remembered in the reliving of it” (1965, p. 126) in treatment. This evokes the fear of breakdown or of the return of the original madness, but also evokes the patient’s great need to reach this original, unthinkable state of breakdown, to risk reex- periencing and reliving the early agony—this time in treatment, with the analyst and his or her different holding and “auxiliary ego-supporting function” (Winnicott 1974, p. 105) that will make recovery possible. I thought that we were now within this process, touching the core breakdown, madness X and profound devastation. But I was not sure whether he would be able to survive the extreme horror of it. Can one survive contact with such excruciating breakdown and annihilation? Winnicott (1974) refers to his patient whose suicide he did not manage to prevent: a patient who wanted to die because of her deep feeling of inner death that had already happened to her psyche in early infancy, although her body continued to live. She killed herself in despair of finding a solution, thus consigning her body to the death that had al- ready happened to the psyche. In the face of P.’s relentless death threats, I tried to extract a promise from him that he would not commit suicide during the next six months. I said, “I won’t continue the treatment unless you promise not to kill yourself.” He replied, “What, you’ll abandon me just like that, after five years like this?” I said:
You’ll always have a place in my thoughts, I’ll always care about you, and I’ll always think about what’s happening to you and how you feel—whether you are alive or dead. And I think that that’s the way you’ll feel about me. But I won’t continue the treatment if you don’t promise that you won’t kill yourself. There’s no point to it if you’ve already chosen death.
He said: “And if I promise and don’t keep the promise?” I said: “I trust your promise.” He did not promise. But he did stop threatening to kill himself. Yet both in the sessions (he never failed to attend each session) and in the many phone messages he left me, he wished he would not wake up in the morning. He repeatedly said:
I felt sick looking at the Internet sites of violence and evil last night. I wished that I wouldn’t wake up in the morning. Noth- ing’s happening; I’m completely dead. I’ve completely despaired of you, of the treatment. Two years without actually engaging in fetishistic activities, and the fetish in my brain is winning, is taking over. And I’m dead, Ofra, simply dead. I’m simply dead. That’s it.
I would reply: “These are very troubled words. Thank you for not despairing of sharing these feelings with me.” But I felt that my words were also an attempt to protect myself from the intensity of this violent, repetitive desperation to which I had no answer. I now come to the point at which something different transpired. It was a Monday session, after the weekend break. At the beginning of the session, he said that he was dead. True, for more than two years he had not engaged in any more fetishistic activity, and this month he was not even entering these Internet sites, but he was dead. Nothing was happening inside him. Over the weekend, he had tried meeting women again, but these meetings did nothing for him. “Nothing’s happening. I’m dead, just dead,” he said, and fell silent. His words reached deeply within me. Is death really victorious? I no longer tried to extricate us from this state with agreements and promises or with interpretations. I said:
We’ve done things. Things have happened. We’re trying to do the best we can in this fateful encounter of ours, but we really don’t know whether we’ll succeed in crossing this huge dead place. It’s like sailing on a tiny boat in an ocean of death…
He remained silent, collapsing into a sleeplike state, until the end of the session.
I sat behind him, and Ansky’s play The Dybbuk (1914) came to my mind—how the possessing spirit, the dybbuk, was exorcised from Leah, but then she died. And here, the fetish has gone—but will he live? And I saw a sort of pietà—not Michelangelo’s well-known, frontal, seated pietà, but a figure of a woman walking with a dead body in her arms. I saw her from the side, did not see her face, and she was wandering about. I felt terrible distress, which changed to acceptance, and then I felt sorrow, very quiet, profound, pure sorrow—without words, even to myself. It was as if this sorrow had become all-being. I sat within this immense sorrow, in silence, until the session was over. At the end of the session I woke him, and he went away, heavily, stooped. Outside it was dark. Late that night (more than two hours after he had gone) he called me, sounding excited. He said:
After I left you, I wandered around. Eventually I got to the gutter district. I went to the same place where that prostitute had been [a prostitute who three years earlier, after an act of sadomas- ochistic fetishism, had kissed him and asked, “Why are you like this?”]. She wasn’t there. There was someone else, someone I think I did fetishistic acts with a long time ago. I paid her a reasonably small sum, and she agreed to a kiss and to do it with her hand. [As I mentioned, this was a man who had not been able to bear the touch of a hand, particularly a nonviolent touch, and certainly not on his sexual organ.] She had high heels, but it made no difference, and she had breasts, and a mouth like that. It went very quickly and very smoothly, perhaps too much so. When I finished I trembled terribly, and I burst out laughing. I said, “Wow, it went so easily!” She didn’t understand what I was talking about or why I was trembling. So that’s it—it wasn’t like other times, it was nice to get it out like that, it’s a shame that I have to pay for it and do it in the gutter. But perhaps it’s a stage—I don’t know; perhaps it’s a stage. I’m still talking to you from the gutter district of Tel-Aviv.
I said, “You sound excited.” “Yes,” he replied, “I’m happy. It’s so strange.” The next morning, he left me a long phone message, as follows.
I had to tell you how I feel this morning. I came home tired last night and went to sleep. I think that a lot of tiredness had ac- cumulated inside me last night. What happened this morning… There were many times that I wanted very much to come to treatment or to hide there. But this morning I got up, and I don’t remember such a real feeling or one so intense as this feeling. I think the only thing in the world I wanted when I opened my eyes this morning was to come and hide in treat- ment. Don’t know whether it was to hide in you or with you—it’s all the same. It’s unbelievable how much I wanted to come to you! [He laughed.] Then I said to myself, it’s not so terrifying, in any case it’ll be several hours until you get there, and it’ll be different then. But that’s it, that’s it. I wanted to tell you, but I didn’t want to disturb you early in the morning. So I waited a couple of hours, telling myself, “She said I could call.” Okay, we’ll meet at 2:00.
From that point onward, although there were other difficult periods, there was a beginning of new movement and a new sense of aliveness, at first hidden but gradually becoming more apparent. I think about Winnicott’s unforgettable words: “But alas, there is no end unless the bottom of the trough has been reached, unless the thing feared has been experienced” (1974, p. 105, italics in original). And I add: there is no end unless the bottom of the trough has been reached*, un-* less the thing feared has been experienced in a compassionate holding, within the analyst’s “presencing” and interconnecting with the patient’s grip- ping, unbearable agony, devastation, and death. Analyst-and-patient t(w)ogether there, with-in. For me, it was a very deep moment of com- passion.
P. called the year that followed “a mad race of hope and illusion.”
Now, suddenly, he no longer masturbated at night to a fetishistic-mas- ochistic fantasy.
What amazed me was that I had within me some amazing inner strength that I’d never before experienced—I’m sure I’ll still pay for it—something that stopped me from performing a fe- tish. Strange things are really happening. The shoe in the fan- tasy has disappeared, as if something has blotted it out. I don’t know what to say.
He began relationships with two women (he was still afraid of a rela- tionship with only one). He met them, ate with them, listened and talked to them, related to them, entered their houses and their beds. “They are surrogates for learning to live with a woman,” he said. The dreadful emptiness gradually faded, but when he tried having sex with either one of them, his penis was dead. Yet, although he was extremely embarrassed by these repeated ex- periences with both women, he refused to imagine a fetish fantasy with them, though he was sure that by doing so he would have had an erec- tion. He repeated over and over, determinedly, “I want different sex. In those moments with them, I felt. I was deeply depressed, I was sad, but I was there. I really was. I existed.” It was also when masturbating that he “bamboozled the automaton” and “created an alternative parallel track.” He would now say repeatedly, “We’ll live and we’ll see.” He also began to dream. One of the two women left him because he refused her suggestion to take Viagra. He met another woman named Doreen, beautiful and sev- eral years older than he. P. felt that “something real is beginning to bud there,” and she became his only partner. After three months of “feelings of terror—terror, not simply fear—in bed,” his penis began to function. At the session exactly two years after the session described earlier in which the “bottom” of psychic death had been reached (I was surprised to see that it was on exactly the same date, January 21), he said to me:
I’m waiting for the stage when my search will find myself [sic]. As for the tiny boat in the huge ocean, I’m relying on you— and perhaps on myself. It’s hard to believe that things change so much.
I was surprised to hear that he had retained within himself the memory of the tiny boat and the ocean. After nine months of the relationship with Doreen, during which
P. told her about the perverse fetishistic-masochistic world he had been in—and she did not leave him—he said to me in our Monday session, after the weekend break: It’s seventy-three hours since we met. We’ve given me a brain- washing. Now I need a heart-washing—I want to learn to love. I
want to connect, heart and soul. Inside me, in a sort of bizarre quantum leap, things have been happening that I don’t know where they came from or where they’re going to, but fuck it, I’m not complaining. Every time I say wow! things have been happening, I don’t know from where. I also think I’m not trying to destroy them—but even if I did want to destroy them, I doubt whether I would succeed. And all weekend long, I’ve been saying to you, “Houston, we have a problem.” Once a spacecraft caught fire, and once a spacecraft was saved. I intend to be saved. Just as once I used to say, “There’s nothing inside me and I have nothing,” this time I want—this time there is inside me, and I have. I want to feel more… I think that what I’m missing now is love. My brain’s racing like mad; my dick is already here but it’s not happening yet in my heart. Still—deep-deep-deep-deep, it’s not happening yet. Houston, we have a problem here. You have to reply.
And I replied: “Houston hears; Houston’s thinking. It’s really a dis- tant and dangerous journey, opening up like that and wanting so much to feel.” He said: “All weekend long I said to myself and to you, ‘I’m on a journey that began without me but will end with me.’”
CO LUDI N C NG THOUG HTS: UN LE SS THE B OTTOM HA S BEEN REA CHE D
This difficult treatment demanded of me to be with-in and profoundly interconnected to the patient’s descent into breakdown and total sense of devastation, deadness, despair, and hopelessness. My patient’s dedi- cation to the analysis, and Winnicott’s unique words on experiencing the patient’s early breakdown, were there with me. Winnicott (1974) maintains:
The breakdown has already happened, near the beginning of the individual’s life… but… this thing of the past has not happened yet because the patient was not there for it to happen to. The only way to “remember” in this case is for the patient to experi- ence this past thing for the first time in the present, that is to say,
in the transference. This past and future thing then becomes a matter of the here and now, and becomes experienced by the patient for the first time. [p. 105, italics added]
“All this is very difficult, time-consuming and painful, but it at any rate is not futile” (Winnicott 1974, p. 105). This also applies to empti- ness: “Emptiness occurring in a treatment is a state that the patient is trying to experience, a past state that cannot be remembered except by being experienced for the first time now” (Winnicott 1974, p. 106). I emphasize that in order for the patient to be there and experience these agonizing feelings, the analyst must be there, with-in. Only then, can the deadly breakdown that has already happened be experienced and lived out t(w)ogether in the treatment. I wish to add here the pertinent distinction between suffering and feeling pain, made by Federn (1952), Bion (1965), and Mitrani (1995). According to Federn (1952), suffering is the expression of an active function on the part of the ego in which the pain-inducing event (frus- tration with or loss of the object) is taken within the boundaries of the ego and the full intensity of the event is appreciated, consumed, and digested, thus undergoing transformation by the ego and, in turn, trans- forming the ego. Feeling pain, on the other hand, is a process in which the pain-in- ducing event cannot be endured and worked through within the bounds of the ego. The pain is not contained within the ego but merely touches upon the border of the ego, affecting it painfully, and with every recur- rence, it meets the ego boundary with the same intensity and with trau- matic effect. Therefore, such pain poses a threat to the ego’s integrity. Federn attributed this inability of the ego to suffer pain to a primary failure of the ego resulting from a lack of narcissistic cathexis. Later, Bion (1965, 1970) related to patients who “feel the pain but will not suffer it,” and added: “The intensity of the patient’s pain contrib- utes to his fear of suffering pain” (1970, pp. 9, 19, italics in original). Mitrani (1995), following Federn and Bion, elaborates on the mother’s inability to contain: “It would seem that the baby’s painful experience has touched the mother, but has not been introjected by the mother, who, it seems, cannot bear to suffer her baby and who is therefore un- able to mitigate its experience” (p. 86).
I think of my patient and what transpired during the analysis in these terms of feeling pain, catastrophe, despair, and dying—bombarding ex- periences that the mother could not take into herself; she could not bear to suffer her baby’s agony. Now these feelings were relived here, powerfully and desperately bombarding the boundary of my psyche. Bion’s (1959) powerful words receive critical emotional realness here:
From the infant’s point of view she should have taken into her, and thus experienced, the fear that the child was dying. It was this fear that the child could not contain… This patient had had to deal with a mother who could not tolerate experiencing such feelings. [p. 104]
But worse than that, my patient, as a baby, had had to deal with a mother who was herself overwhelmed by unbearable traumatic feelings, thus overwhelming him, violently, fatally, with the deadening impacts of her psychic reality. She was not the “dead mother” described by Green (1986; see also Eshel 1998a) whom the child must find a way to enliven. Rather, she was a mother who inflicted devastating, catastrophic feelings, depression, death, a dead baby—all of which possessed and threatened the child’s psychic existence, thus rendering him a traumatized, ravaged, near-death infant-child. 9 Bollas (1995) similarly notes:
The sadomasochists are still trapped by their need continuously to remaster an early trauma, although they have converted the anxiety of annihilation into the excitement of its representation… These sadomasochistic alliances enact the near-death of the self, in which the child self avoids its killing but forever feels the near-hit as a kind of narrow escape… That the self did indeed
9 The new concept of epigenetic transmission is rooted in such traumatic environmen- tal conditions or traumatic attachment in early life (Jacobson cited in de Zulueta 2012). This may explain Boris’s (1987) fateful words: “Some infants, more than others, may have an idea that they ought to die, if not now, soon, if not acutely, chronically… But as analysis shows, primal programmatic urgencies continue throughout life” (pp. 353-354). Gonzalez (2010) similarly describes the foundational, deadening impacts of a profound condensation of life with death that began in early childhood.
once nearly meet its end, that there was something awful in the environment that caused such mental intensities, is an unexam- ined feature of the sadomasochist’s life. [pp. 209-210]
I would say, in keeping with Winnicott’s ideas of fear of breakdown (1974), that the advances of the third and fourth year of P.’s analysis “end[ed] in destruction” (p. 105) because there was no reconnecting to the full intensity of the patient’s breakdown and annihilation. But these unbearable core experiences could not be escaped. Therefore, in the fifth year, all these menacing, unbearable, uncontained, and unsuffered feelings were overwhelmingly relived in the treatment, bombarding the boundaries of his psyche and mine over the entire fifth year, in a des- perate plea to be taken in, suffered, and transformed. I was there with these feelings, speaking about them and speaking them, thinking and understanding them, struggling to ensure survival— more and more in the grip of these feelings, but not yet there in the patient’s inmost devastation, not “unless the bottom of the trough [had]… been reached, unless the thing feared [had]… been experienced” (Win- nicott 1974, p. 105, italics in original). I was experiencing the terror of breakdown, suicide, and death, but not yet death itself, until the time that I starkly took them into myself and was with the dying child-man, holding the dead body in the arms of my psyche—thinking, feeling, and “dreaming” the death (Bion 1992,
p. 216; Eigen 2001; Grotstein 2007, 2009; Ogden 2004). Thereby, this desperate, attacking plea turned into suffering and profound, immense sorrow within me. It became a wordless, deep, psyche-to-psyche intercon- nectedness and com-passion; and the death that was taken in and became experienced and suffered for the first time by me-with-him was transformed, and could then become, within him, a different, new possibility of being and experiencing. Acknowledgments: The author is grateful to Moshe Halevi Spero and Donnel Stern for their thoughtful reading of this paper; to James Grotstein for his perceptive discussion of it at the conference of the Leonard J. Comess Fund at the New Center for Psychoanalysis; and to the three editorial reviewers of The Psychoanalytic Quarterly for their thorough and thought- provoking reviews.
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