Goodbye, Dr. Freud
A group of senior psychologists, including university department heads and directors of hospital wards, have banded together against the mental-health establishment. They claim that treatment methods in Israel are outmoded, that licensing examinations for therapists are based on scientifically invalid theories, and that the heads of the system constitute a closed guild that is interested mainly in preserving its own status.
There was method to H.'s madness. Once a month, sometimes twice, he was seized by existential anxiety and imagined himself dying of a serious illness: cancer would appear in various parts of his body - the brain, the liver, the lungs. "He chose only serious forms of cancer," his wife relates, "not any old cancers that can be easily cured." Every suspicion of a new cancer would send H., a well-known businessman, rushing to the emergency room, to a private clinic, and finally to have a general body scan. The negative results neither cheered him up nor relaxed him for more than a week or two. Then would come another uncontrollable attack and a request for a new scan. His physicians did not object, as long as he paid out of his own pocket. But his family was on the verge of collapse. He barely functioned at work, and in social situations seemed to be led by others.
It all started 10 years ago, when E., the wife of H., went into psychoanalysis and persuaded her husband to go, too. "And that is what destroyed him," his wife says. H. had always complained about nonexistent illnesses, but after he went into therapy his anxiety level soared. "He slowly went crazy," his wife says. "He had anxiety attacks that he was going to die, and the sicker he became, the more his therapist flowered, in his opinion. One day a friend suggested that she try cognitive-behavioral treatment for him. "It sounded to me like idol worship," she says, "but in April of this year he wanted to enter a mental hospital, and I saw no other way out."
Cognitive-behavioral therapy consists of point- specific intervention in defined mental disorders, such as depression, obsessive-compulsive disorder (OCD), eating disorder, post-traumatic behavior, social anxieties and behavior disorders. In the cognitive-behavioral approach, the therapist deals less with whether the patient feels good and more with the question of whether the symptoms related to the disorder have diminished or disappeared.
Thus, in May of this year, H. went to see Dr. Sofi Marom, head of the cognitive-behavioral unit at Geha Mental Health Center in Petah Tikva. Since then, his wife says, he has undergone a metamorphosis. "I received a new person. Not that the illness went away, but he knows how to cope with it. He is getting medicines and everything is under control. He is functioning, living and working, and the children have a father again."
Ofakim, the Society for Scientific and Applied Clinical Psychology - a group of about 60 senior psychologists, heads of clinical tracks in universities, directors of hospital departments, professors, senior lecturers and psychologists from the public service - is now doing battle to have this form of therapy established in Israel. For the first time in this country, mental-health experts have organized and set themselves the goal of changing psychological treatment here and opening it to new approaches. Ofakim was formed about a year ago, after the failure of attempts at dialogue, oral and written, with the psychological establishment in Israel.
Is it possible that six months of this treatment succeeded where years of psychoanalysis failed?
"One has to differentiate between treatment of those with acute problems, such as depression and anxiety, and treatment of people who go into therapy because they want to fulfill and understand themselves," says Dr. Gary Diamond, head of the Department of Clinical Psychology at Ben-Gurion University in Be'er Sheva. "Many people go to public clinics with specific disorders that affect their quality of life. Today we know they can be helped within a very short time, relatively. There are specific treatments that have been scientifically studied, and they work."
So psychoanalysis does not work?
"We are not against people receiving psychoanalytical therapy, but they have to be able to receive other therapy as well."
In recent decades, classic Freudian psychoanalysis - in which the therapist is a "blank slate" with no personal involvement, and the patient engages in free association - has lost its hegemony in the West. A study carried out not long ago by the American Psychoanalytic Association covered 150 selected academic institutions in the United States and 1,175 different courses in which psychoanalysis is taught. The results were surprising: 86 percent of the courses are not taught in the psychology departments. Even more astonishing, it turned out that psychoanalysis is a hit in departments of art, literature, philosophy, film, history and gender studies, and is also studied in conjunction with post-colonialism, French postmodernism, queer theory and so forth. Nowadays the world's leading universities offer a broad range of psychological approaches, headed by the cognitive-behavioral approach.
Dr. Joop Meijers, head of the Department of Clinical Child and Educational Psychology at the Hebrew University of Jerusalem, came to Israel 30 years ago as a senior psychologist. "Already then the central stream of psychology in Holland was cognitive-behavioral," he says, "and it only grew stronger. Nowadays, 99 percent of the public services use a cognitive-behavioral approach or similar approaches whose effectiveness has been scientifically proved."
Do the Dutch know something we don't?
"It is not only in Holland. In Scandinavia, Britain, Germany and the United States the dominant stream is the one that has been scientifically proved."
Why, in your opinion, are we not there yet?
"We have our ancestral traditions. Maybe there is something very Jewish in the psychodynamic approach: the Jews love to study the drash [homiletic interpretation] and don't like the peshat [literal interpretation], because it's not riveting enough for them."
Most Israelis actually like to adopt fashions from abroad.
"The body that is responsible for training is not yet willing to allow equality for treatments using different methods. That body is interested in preserving its modes of activity and ensuring the livelihood of its members and the veteran practitioners, the great majority of whom are psychoanalysts themselves. A year ago, at a professional conference, a psychodynamic colleague told me: 'I am not naive - I know this is a life-and-death struggle. Either we will be or you will be."
Skipping the exam
The body in charge of training and examinations is the professional committee that operates under the auspices of the Ministry of Health and the Council of Psychologists, and also acts as an advisory body to the health minister. It numbers seven clinical psychologists who volunteer their time. "The method of training and the character of the examinations are the prerogative of seven people," says Dr. Yamima Goldberg, the chief psychologist of the Ministry of Health, who chaired the professional committee until 1996, summing up the problem.
The standards for admission to the field of clinical psychology (the therapeutic branch) were set long ago: a master's degree at least, residency of four years and a licensing examination. When psychological treatment, in Israel and elsewhere, was largely psychoanalytical, so was the examination. Its first section tested the candidate's therapeutic ability, the second section his ability to diagnose mental disorders. The diagnostic section, however, remains unchanged. Here the candidate must demonstrate diagnostic expertise based on the psychodynamic approach. Even those who did not study this approach have to come up with 20 cases and diagnose each according to five tests. The scientific validity of some of the tests is in doubt, while others are irrelevant to the material that was studied.
Dr. Moshe Almagor, formerly head of the clinical psychology program at the University of Haifa, failed this examination. He obtained his first and second degrees (cognitive and family) at Bar-Ilan University and his PhD at the University of Minnesota in Minneapolis, before doing his residency in a Minneapolis hospital. He returned to Israel in 1983. "I was the first PhD who had to take the licensing examination, and I failed it. Before me, everyone who had a PhD from the United States and did residency there, did not have to take the examination."
Almagor likens the committee to a closed guild, which does everything "to preserve itself and reduce as far as possible the number of incoming members. In my honor, they brought the country's senior psychoanalysts to the examination, but there were significant differences of opinion between us and terrible short circuits in communication. They didn't understand what I was talking about. In the end, they were compelled to adjust the examiners to my specialty, and on the second try I passed the examination."
Dr. Iftah Yovel, a cognitive-behavioral psychologist who teaches in the Department of Psychology at the Hebrew University, returned to Israel two years ago after completing his doctoral studies at Northwestern University in Illinois and his post-doctorate and residency at Harvard Medical School. Yovel also passed his residency examination in the United States, but chose not to take the one in Israel. "I lecture at the Hebrew University, but I did not go through the licensing process, because I think it is an abomination," he says. "They want me to take 20 batteries of tests, which in any case no one uses in practice. My specialization is cognitive-behavioral, but they will tell me, 'First be a psychodynamic psychologist and only afterward cognitive-behavioral.' The stagnation in the profession has left us at least 40 years behind the rest of the world, and we continue to behave as though nothing has changed. Some people are better suited to one type of treatment, others to different treatment. All the best places in the world have already understood this, but here we are not considered clinical psychologists because we don't know how to administer the Rorschach."
Dr. Danny Koren, head of the clinical program in the Psychology Department of the University of Haifa, is a psychodynamic psychologist but joined the Ofakim group in order to express protest and deep disappointment at the way the system works. "I got off the fence in order to correct a longstanding wrong," he says. "The gunpowder was there all along, and now the match was needed."
Koren received his PhD from Boston University in the psychodynamic approach and is now a visiting professor there. But when he returned to Israel 10 years ago, he was not recognized as an expert by the professional committee, even though he had completed residencies both abroad and in Israel. The reason, he says, was not a lack of professional knowledge. "In that period," he notes, "senior psychologists, leading experts in their field, who had studied at excellent universities abroad, came to Israel, but their expertise was not recognized here. There is a militant and not very smart leadership here of people whose main goal is to prevent psychologists with different types of expertise from entering the profession."
Another who failed the examination is Dr. Oded Ben Harosh. He obtained his PhD from the Massachusetts School of Professional Psychology and did a post-doctorate at Harvard and his residency at a Cambridge hospital in cognitive-behavioral therapy. "I also studied the psychodynamic approach, but I don't use it because I don't believe in it and don't see its relevance for my therapy."
Ben Harosh, who specializes in treating OCD, returned to Israel two years ago and opened the Israel Center for Obsessive-Compulsive Disorder in Mesilat Zion, outside Jerusalem. "I do not believe that in order to define schizophrenia I have to use that whole battery of tests, which take a great deal of time and get into details that are irrelevant for the actual treatment. The diagnosis can be made in a one-hour clinical interview. I did not sit for a clinical examination before the professional committee, because I do not consider myself a clinical psychologist in Israel, even though my doctorate is in clinical psychology. I am against the meaning that the term has acquired in Israel, where clinical psychology is identified with psychodynamic psychology. So in Israel, from the point of view of my specialization, I actually do not exist."
Joop Meijers calls the five tests in the diagnostic section of the licensing examination the "holy pentagram." They include the famous Rorschach inkblot test, the HTP (house-tree-person) pictures test, the TAT (thematic apperception test) to evaluate interpersonal relations, and two intelligence tests: Wechsler and Bender. The debate among psychologists over the tests' scientific validity is a turbulent one, and divides the profession into three groups, as explained by Prof. Golan Shahar, a psychoanalyst who was until recently head of the clinical psychology program at Ben-Gurion University: "One group thinks that the tests are simply nonsense and a waste of time and that they lack any scientific underpinning; a second group thinks that the Rorschach is God's gift on earth, the X-ray of the personality; and a third, smaller, group (to which I belong) thinks that the Rorschach is effective on a very limited and narrow basis, but that some of the information it provides is scientifically valid. The first group contains fine, well-known scientists, who usually do not do diagnostic work themselves; the second group contains well-known diagnosticians who do not engage in research."
How can it be that with regard to the same test, some say it is scientifically valid and others it is not?
"A study was conducted that examined more than a hundred parameters that are diagnosed by means of the Rorschach: 95 percent of them were discovered to be scientifically invalid and only 5 percent were found to be valid. The point is that in Israel the Rorschach is considered God's gift and people are denied [certification of] expertise, even if they come from the best universities in the world, because they are not in command of the Rorschach. There is no justification to make it the criterion of psychology."
And the other tests?
"HTP is commonly considered a bad test, and even the professional committee is thinking of abolishing it, but in the meantime it remains in use. The scientific validity of the TAT is a little better than that of the Rorschach, but not much, and is not suitable for diagnosing psychopathology. Bender and Wechsler are superb tests of intelligence but have no scientific validity at all. In Israel they are used to diagnose personality, and in a great many of the diagnostic questions the question of intelligence is simply not relevant. Let's say that a 16-year-old is a genius, but has suicidal tendencies - how, exactly, will this kind of test help him? The effectiveness of these tests ranges from 2 to 5 percent. It's like obliging every physician to be a world expert in X-ray and granting them a license on that basis. The obligation to be examined in these tests is foolish, because even if they possess a certain validity, does every clinical psychologist have to use them? My answer is no. If Iftah Yovel, who did his residency at Harvard, has to show expertise in the Rorschach in order to be licensed in clinical psychology when he can help dozens of people who suffer from serious anxiety disorders, that is a scandal. The emphasis on these tools became a mechanism of the establishment to exclude people who are not in command of them."
Are they used in psychological practice?
Golan: "In most cases, no. In practice, very few people in the world specialize in diagnosis."
Dr. Eva Gilboa-Schechtman, a cognitive-behavioral psychologist and head of the clinical psychology program at Bar-Ilan University, agrees with Golan. "A complex distortion has been created here," she says. "Diagnostic methods are taught during almost the whole period of studies and residency, and afterward most psychologists do not use those methods. It's a waste of the residency and of a great many hours of instruction and study, and in my estimation, these tools are not up to date. This is not to say that in practice the clinicians do not make correct diagnoses."
But not with those tools.
Prof. Haim Omer, founder and in charge of the parental guidance clinic at Schneider Children's Medical Center in Petah Tikva, and a lecturer at Tel Aviv University, is even more outspoken than his colleagues. The scientific validity of the accepted diagnostic tools in Israel is very doubtful, he says. "A couple getting a divorce comes to court and the question of child custody arises. There are good, clear tools that show which of the parents is more suited to raise the child - for example, the parent who is always coming to the child's kindergarten to see how he is doing is clearly preferable to the one who never shows up. Social workers go to the kindergartens to check this. But the court does not rule on the basis of this kind of examination. At a certain stage, the court will ask for the opinion of a clinical psychologist, and he will come with the battery of Rorschach and similar tests, for which both parents have to pay money, and that is the basis for the decision about which parent gets custody of the child. These tests have zero validity, but they are the grounds for the final decision. It's outrageous. It is an agreed bluff. Every resident has to administer 20 batteries of such tests, and each battery takes 15 hours of work, which adds up to 300 hours of the residency. But when they are asked in the public clinics if the 20 people who were examined needed the tests, it turns out that the great majority did not."
If the patients don't need them, why are they given?
"In order to teach the residents to administer them."
It sounds hallucinatory.
"On top of that, in many cases the patient has already left the clinic because he has completed the treatment, or has started to undergo therapy by a psychologist, even though the results of his diagnostic tests have not yet arrived, because deciphering them takes such a long time."
An example of how testing can turn out to be detrimental to the patient is offered by Dr. Danny Derby of Hadassah Medical Center-Ein Karem University Hospital, who regrets to this day a diagnosis he made during his residency. "I put my signature on a test that eventually reached the courts. It was a post-traumatic patient who stopped functioning as the result of a terrorist attack. I wrote that he was immature, but I didn't know that in the court, lawyers would use this against him and say that the man was immature to begin with, and that was why he was not functioning, not because of the attack. I felt very uncomfortable and wrote the court that my words were taken out of context, and the problem was solved."
According to Meijers, "There is a group of people - veteran clinical psychologists - who for many years have engaged only in diagnosis, from which they make a lot of money, and they will not easily give it up. I am considered a troublemaker because of my opposition to the tests. One psychologist told me that I am ruining their livelihood."
The insurance companies like it
The members of Ofakim are charismatic and articulate, but perhaps the cognitive-behavioral therapeutic approach they are promoting is just another American trend. A method in which everything is translated into money and efficiency: one that is tailor-made for the insurance companies and the tottering public health services, which dictate the cheapest, fastest form of treatment, dealing only with the symptoms, and which may not be effective in the long term.
"If it were the case that long treatment is better than short, I would agree," Meijers responds, "but there is proof that short treatment is just as good, so there is no justification for offering lengthy therapy. Therapy that lasts for five years is extremely expensive, and if there is no proof that it is better than short therapy it is not even ethical to suggest it. In this case, the interests of the public, which is represented by the insurance companies and the government, is congruent with what the studies say."
The Ofakim group cites scientific studies to support its claims, but the trouble is that today's studies supersede and supplant yesterday's. "What characterizes science is skepticism," Meijers says, "and every result is always temporary. But research is the least bad tool for learning something new - there are worse tools - and some of the psychodynamic theories are structured in a way that makes it impossible to investigate them and arrive at positive or negative results. They are grounded in faith, and you can't argue with faith. With the results of research you can - even have to - argue."
Prof. Golan Shahar, from Ofakim, is in fact identified with a critique of the cognitive-behavioral approach. "I think its treatments are too short," he says. "But the differences between me and my colleagues are decided by the collection of data and by scientific examination - in contrast to the confrontation between us and the establishment, where the argument is decided by whoever wields more power."
Why did this furor erupt now?
"Because people who advocate the method of scientific proof occupied key positions in academe, otherwise it would not have happened. The universities are interested in scientifically proven psychology."
Not because it's a trend in the States?
"That type of argument is convenient but irrelevant. What is relevant is whether there is therapy and how we decide whether the therapy is effective. Is it because my grandfather worked like this, or because scientific data have accumulated? The point is whether you offer the patient approaches that are in use today and about which information is available."
Therapist in the center
The allegations of the Ofakim group suggest that there is a group of psychologists here whose main occupation is self-preservation. Prof. Shahar prefers gentler terms: "The patient does not always come first. Too many [practitioners] give consideration to what I, as a psychologist, know, and what tools I use, and less to what the patient needs and what is best for him. The result is that in many disorders people are treated in a way that is unsuitable for them, which is scandalous. We have become a profession that is concerned about itself and not about the patient, a profession that spends most of its time dealing with and training psychologists, or preparing them for examinations, and not looking for the best therapy for the patient."
Dr. Gilboa-Schechtman, from Bar-Ilan, who is also director of the child and youth trauma clinic at Schneider, maintains that an effective method of treatment is crucial in a situation in which the public health system is collapsing. "People in need of therapy wait months or years, or turn to a private system, or get no therapy at all. In most of the public clinics, years-long psychodynamic therapy is administered, but it's not certain that this is what's needed."
According to Omer, the damage caused by prolonged waiting or by inappropriate treatment is immense, particularly in his field of specialization, children and youth: "For example, children with behavior disorders are sent to years-long psychodynamic therapy, which has no proven effectiveness, and no one thinks they should be told that other, more effective, treatments exist. There are children who react very badly to dynamic therapy, and if they also have a tendency toward criminal behavior, it makes the problem far more acute."
In what way?
"Because dynamic therapy covers them with an umbrella of privacy, and it turns out that in cases such as criminality that has the opposite effect, and the risk is great. Parental supervision has to be increased, instead of protecting them. The privacy umbrella derives from ignorance of what has been done in research over the past 40 years. The therapists have no idea that their treatment is harmful."
The absence of studies that support psychodynamic therapy is due to the principle of preserving privacy and the confidentiality of what is said in the therapist's office, as the basis for creating trust between him and the patient. Psychoanalysts also claimed that it is complicated to investigate processes that take place over years and are based on free association (though Freud himself insisted that psychoanalysis is a science). In the past few decades, researchers have been trying to validate scientifically what happens in psychoanalytic therapy.
In contrast, some of the short-term psychodynamic processes have been, and continue to be, studied by major universities abroad - but this development has not yet reached Israel. "Today, for someone to be accredited in clinical psychology," Prof. Omer says, "he has to prove that he takes no interest in the innovations of clinical psychology in the past 35 years. He has to prove that he is free of influences that come from research and knowledge."
According to Dr. Meijers, adoption of cognitive-behavioral therapy is also economically efficient: "There are studies that show that if the psychodynamic method gets results after three years, the cognitive-behavioral method gets the same results in far less time. In Holland and Britain, the insurance companies said they wanted to give the maximum service to the maximum number of people, and in order to do that the duration of the therapy had to be reduced, so they switched to cognitive-behavioral therapy. Since then, more people there are getting better therapy."
Like a religion
One concern of Dr. Koren, from the University of Haifa, is the unjustified professional superciliousness. In his view, "Our profession behaves mostly like a religion, on the basis of a belief that what we offer has a status of absolute truth. People believe we are engaged in things that are beyond science and are so sublime and touched by genius that there is no way to check them. Science is cold and rational, whereas psychology is humane and holistic. In the name of this excuse, the profession wants on the one hand to draw close to medicine, but on the other to be totally unsupervised, and does not feel the need to make itself available for examination and review."
Prof. Gabi Shefler, a psychodynamic researcher from the Department of Clinical Psychology at the Hebrew University and director of the Sigmund Freud Center for Psychoanalytic Research and Study - he himself studies time-limited psychoanalytical methods - agrees that the dominant approach in Israel has always been the psychoanalytical one, with all its ramifications. But that approach collapsed in the United States a decade ago.
Why didn't it collapse here?
"I'm not so sure the Americans are so happy it collapsed. Psychology in America is far more shallow and superficial. It is true that in part it is based on scientific evidence, but cognitive-behavioral psychology does not yet provide an answer to a large portion of the cases."
So we are one of the last bastions of psychodynamic psychology in the world.
"Psychology in Israel is extremely conservative. With us, everything moves slowly, but at the same time, there have been many changes over the years."
Why is it difficult to investigate psychodynamic approaches?
"It is difficult to conduct research observation of an intimate process between therapist and patient, because the number of variables is very large."
Is it the case that your approach maintains that there is nothing to investigate, that one just has to believe?
"Freud was a distinguished researcher and scientist. He did experiments, which were not all that successful. He thought in terms of naturalistic, positivist science, as in the natural sciences, in which there is a thesis and antithesis, in which there is a group and a control group. When the therapy is short, a control group is possible; in long-term therapy, you don't completely know how it works."
Dr. Yamima Goldberg, the chief psychologist of the Health Ministry, believes that the examinations that are given at the end of residency provide the best and most correct diagnosis, and address everything the clinical psychologist is supposed to know at this stage.
What about those who studied abroad?
"If I were going to work in the United States, I would not expect them to salute me and change their examinations. I would study what they demand."
But isn't the result the fixation of just one therapeutic approach in Israel?
"Not so. I don't think there can be a clinical psychologist without the Rorschach. That is a basic tool."
Most psychologists say they don't use that tool in their practice.
The Ofakim group says it is not so reliable scientifically.
"It depends who says so. I know it to be one of the most valid and reliable tools that exist. In any event, half a year ago the professional committee decided to establish an additional subcommittee to examine all the tests again, and that examination is now under way."
Why are there not enough residents and instructors for the cognitive-behavioral sphere?
"I don't agree with that. I only think that changes take their own time, and there is no barrier to anything; that is simply not so."
Ofakim claims that the process of choosing the members of the professional committee is not completely transparent.
"It is not an honorary position. These are people who work very hard, on a voluntary basis, one day a week. The members are chosen from the field and from academe. Very often we ask who would like to be on the committee and don't always find people."
Does the field of psychology in Israel suffer from stagnation and conservatism, compared to the rest of the world?
"I do not think that is the case."