Pick Your Brain: A Philosopher, a Neurosurgeon and a Psychologist Debate the Human Mind

Smadar Reisfel
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Smadar Reisfel

(1) The neurosurgeon

These days, the name of Prof. Itzhak Fried can be found in almost every textbook about the brain written anywhere in the world. He is responsible for breakthrough experiments in brain research, carried out in his capacity as a neuroscientist at UCLA and as head of the functional neurosurgery unit at Ichilov Hospital in Tel Aviv. As such, he deals with both the theoretical and therapeutic aspects of the mind.

What is “mind”?

“Is that all you want to know?”

Also if God exists. If there’s time we will try to solve the Israeli-Palestinian conflict, too. But no more than that...

“Well, the mind is what I feel when I perform brain surgery on patients who are fully awake. The physical scene in the operating room is a marvelous illustration of the body-mind question. When we open the skull and expose the brain, we stretch a sheet along the head, so that on one side you see it from within I mean the brain with its nerve cells and blood vessels and on the other side you have the person who is talking, telling stories and joking with the surgeons.
“There is a close interaction between the two sides. When I touch the flesh on the one side, I affect the mind on the other side. For example, an electrical stimulus of a particular area of the material brain can stimulate in the person reporting from the other side the abstract memory of the madeleine cookies he dipped in his tea as a child. If we stimulate a different region, he sees something or hears music. The patient exists in a state of ‘dual consciousness’: he experiences his present state in the operating room and simultaneously experiences a different state of being which is connected to the particular stimulus he is receiving.”

And then you know you have touched the mind?

“We touch the mind when, by stimulating the brain, we succeed in arousing sensory experiences involving all the senses, in evoking memories and hallucinations. A person sees people across from him, even though they are not physically in the room, or hears a passage from a song by Led Zeppelin. I have had patients like that. You can arouse hallucinations in them: a button on a surgeon’s robe suddenly looks giant to them or assumes a distorted shape. We can even generate will. When we stimulated a particular region of one patient’s brain, she said she felt a desire to move a hand. The desire arose with the stimulus and ended when the stimulus ended.

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Dr. Yaron Senderowicz.Credit: David Bachar
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Dr. Ilan Kutz.Credit: David Bachar
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Professor Itzhak Fried.

“Humor can also be aroused. One of my patients burst into laughter when we stimulated a certain region of her brain while she was looking at a picture of a horse. When we asked her why she was laughing, she replied that the horse was terribly funny. She rolled with laughter when we gave her a passage to read describing a rainbow while we stimulated the region, and even when we did not give her a task only the electrical stimulus to the brain she still laughed. She said she found us extremely amusing. What are feelings, memories, desires and emotions if not representations of the mind? We find these representations in the brain and are able to influence them.”

So the mind of a brain researcher is electrical?

“Totally. I am a reductionist. In other words, I think we can understand the mind by means of its basic components, the simple biological elements. The height of that reductionism is the ability we now have to monitor and document the activity of a solitary neuron in response to different stimuli. That presents the possibility of locating the mind at the level of a single cell.”

Are you referring to the discovery you called the “Jennifer Aniston neuron”?

“While performing brain surgery on epileptics, we insert an electrode into single neurons and are able to monitor their activity. An active neuron fires electrical signals which, when converted into sound, are like gunshots. We showed a patient a photograph of Jennifer Aniston, and a neuron we were monitoring flashed a few times. We showed her a photograph of Julia Roberts silence. There was also no response to pictures of women who are not famous or to pictures of places and animals. Another photograph of Jennifer Aniston again produced flashes. It was the first time we saw a response by a single neuron to a particular image, so we named the phenomenon the ‘Jennifer Aniston neuron.’”

You also examined a distinctive response to the Simpsons. For brain researchers, you’re not very serious, are you?

“We use cultural icons because people respond to them more than to unknowns. In the case of the Simpsons, we showed people a film composed of a collage of familiar images and film clips: thefamous ‘Hollywood’ sign on the hills of Los Angeles, Martin Luther King Jr.’s ‘I Have a Dream’ speech, part of a Madonna clip, the Simpsons and so on.”

It can’t be that a separate neuron is devoted to each image in our life.

“Obviously it’s not a lone neuron. First, the theory is that there are thousands, or hundreds of thousands, of nerve cells that respond similarly to the neuron we examined. It’s manifestly out of the question that one neuron is devoted to each image, so that when that cell dies the person no longer recognizes the image.
“Second, the hypothesis is that this cell is only the top of a pyramid, below which are more neurons, each of which reacts to a small part of Jennifer Aniston: the shape of her eyes, her cascading hair, her chin line. At an even lower level of the pyramid there are neurons that are sensitive to more basic traits such as color, light-and-shadow relations and the like.

“The neurons that are sensitive to blue, for example, are not distinctive to the concept ‘Jennifer Aniston.’ They also respond to the blue of the sea and the Israeli flag. But when we show someone a picture of Aniston, or even only mention her name, a wave of neural reactions is triggered, starting from the most general neurons. Subsequently it gradually spreads to more specific neurons, until the highest cell of Jennifer is aroused and fires. On the one hand, that cell is very specific to Aniston, while on the other hand it is general in the sense that it identifies and fires at her every appearance: whether she is standing or sitting, happy or sad. You can say that in a certain sense the cell represents the abstract idea of the image, which is why I call such cells ‘concept cells.’”

Does the fact that you found a cell that is excited by Jennifer Aniston constitute an understanding of the mind?

“It is not full understanding of the mind but a cumulative understanding of its constituent parts. The mind is in the details, and we are starting to understand the mechanisms that are responsible for feelings, memory, desire, even belief, all of which are representations of the mind. The representations are located in the brain, and it turns out that we can influence them. We hope, somehow, that amid all these details, which neuroscientists all over the world are collecting with antlike industriousness, a great truth is lurking, which has so far eluded us but which maybe some neuroscientist Einstein will see. Maybe he will construct a model to explain human consciousness, perhaps a ‘standard model’ of the type that physicists are constructing as a meta-explanation for everything. Maybe we will find a ‘God particle’ in the brain.”

Do you think we will succeed?

“I have my doubts that we will ever be able to know everything about the mind. We may never understand all its complexity not because there is something beyond matter, but because there is a limit to what our brain can understand. In the last analysis, the brain is limited by patterns of time and space. For example, we understand what is meant by three dimensions, and I once heard someone say he could see in six dimensions. Let’s say ... But no more than that. Our brain is not built for more than that. One can define the incomprehensible, what exists beyond the limits of understanding of the brain, as God, and that also defines belief. Does that something listen when we [pray] on Yom Kippur? That is already a different question.”

Let’s talk about the connection to psychology. Does brain research make psychology superfluous? Can it deal with guilt feelings or low self-esteem?

“I don’t think brain research makes psychology superfluous it complements it. It’s not a matter of hostile camps. To understand a problem in the mental sphere, you have first of all to conceptualize it with the help of cognitive tools. You cannot immediately descend to reductionism without understanding the phenomenon at the phenomenological level and without understanding the regularity of the phenomenon. Psychology does that in a way the neurosciences cannot. For example, the results of models that were developed in psychology about memory guided the brain research dealing with memory. It’s hard to believe that someone who wants to understand the statement ‘To be or not to be’ can do it with the help of fMRI. Brain scans of Hamlet will not produce insights about the structure of tragedy or about the human quest for meaning. Those are realms of psychology and literature.

“Psychology and brain research can be mutually complementary at the treatment level as well. Take depression, for example. In its moderate form it can be dealt with by psychotherapy. If you think about it, this is a type of interaction between therapist and patient, a process in which two brains interact and one influences the other by means of words, concepts and feelings. In its more serious form, we can try to influence depression by means of medicines that work on particular regions of the brain that have to do with emotional functioning and moods.

“A brain surgeon is called on to intervene only when the situation is extremely serious. There is a treatment called ‘deep brain stimulation,’ which is now undergoing broad clinical experimentation. It is a focused treatment, in which an electrode is implanted in the region of the brain that is thought to be responsible for a state of mind, while elsewhere in the body a subcutaneous pacemaker is inserted. The pacemaker sends electrical impulses to the electrode, and they act on the neural networks that play a part in regulating the emotions.”

Charles Darwin said, “He who understands baboons would do more toward metaphysics than [John] Locke.” Does philosophy still have its place today, in an era in which questions about awareness, language, etc. can be answered with the aid of biology and brain research?

“Philosophy cannot ignore the findings of brain research. When we ask where our knowledge of the world comes from we turn to Locke, who maintained that the mind is ‘tabula rasa’ an empty slate and learns about the outside world only from experience. Whereas Descartes thought the mind knows these things innately and that all human knowledge is already contained in it at our birth. It is worth looking at the findings of the brain sciences, which show, at the actual level of neurons, that part of our knowledge is shaped by experience, but that the possibility to absorb the experience depends on the pre-given structure of the brain and on the way in which we are capable of perceiving things. In other words, there is room for a synthesis between philosophy and the brain sciences.”

Electric language

Are you a researcher of the mind or a healer of the mind?

“Both. It is my privilege, and I am very happy about it, both to try to understand the mind and also to treat and influence it. I would not feel right if I only did one of them. As a brain surgeon, I perform mechanical acts on the material entity of people: I remove a brain tumor, sever an epileptic source, or intervene electrically in the brains of Parkinson’s patients. But all those actions have implications for the mind, and then you can stop, observe and ask questions. In practical terms, this research is possible because when we insert electrodes in the brains of sick people as part of their treatment, we have the opportunity to use them also to understand the brain’s activity. With the patient’s consent, of course.”

Let’s do a practical summing up: What is the contribution of brain research to treating the human psyche?

“First, brain research generated tremendous momentum for treatment possibilities in serious clinical cases. Take epilepsy, for example, in which hyperactivity by neurons in the brain causes sudden seizures. That is a symptom that can be cruel, and can make one’s life miserable if it occurs frequently and if the seizures cut the patient off from reality or jolt his body forcefully. By identifying the epileptic focal point we can now physically neutralize the neurons that are involved in this electrical tempest and thereby restore the brain to normal activity.
“We now routinely treat serious motor disorders, like those that are part of Parkinson’s, by electrically stimulating the brain. Recently we showed that electrical stimulation at a certain point in the brain can improve learning and memory, so maybe we have found the ‘golden gate’ into the memory region. This has the potential, of course, to treat illnesses that affect cognitive functioning, such as Alzheimer’s. Owing to the ageing of the population, Alzheimer’s, a disease in which the mind constantly dwindles, is becoming a global problem. So the ability of the neurosciences to understand it is critical.

“In addition, brain research and its methods made possible the breakthrough into the exciting new field of ‘brain-machine interface.’ The general idea is to harness the neurons’ electrical activity to operate instruments or machines that can replace damaged organs. This is not a future vision it’s starting to happen now.

“The more acquainted we become with the electrical language of the brain, the better we can read its various expressions and understand them. Childhood memories have a different neural pattern of activity than the memory of what I just ate; a dream has a different pattern from desire. For example, we identified a small group of cells that is activated when the desire to move arises in us.

Moreover, we saw that the desire to turn to the right generates one pattern of activity, while the desire to turn left generates a different pattern. Because it is possible to differentiate between the different thought patterns, we can, for example, decipher the desired direction of movement of a paralyzed person who can’t move his hands. A robotic hand that is attached to him can be activated by the distinctive electrical activity of the thought.”

Finally, a seemingly unrelated question: What is your favorite book?

“’War and Peace.’ Tolstoy had a marvelous ability to write from both a broad panoramic point of view and from a specific personal angle; the skill to shift from the sweeping epic to solitary individuals, and the wisdom to enter the depths of the psyche, down to details, as in ‘Anna Karenina.’ It seems to me that this is also a useful metaphor for brain research: large panoramic mental processes that in the last analysis are composed of minute details.”

(2) The philosopher

For Dr. Yaron Senderowicz of the Department of Philosophy at Tel Aviv University, who heads the interdisciplinary track for the study of consciousness (together with Prof. Ilan Golani), the mind is quite a routine concept. I went to see him to get his thoughts about the present-day relevance of philosophical questions about the mind.

Does it make sense today to ask philosophical questions about the mind, in an era in which biology and the brain sciences are uncovering the mechanisms of awareness, language and emotion?

“The question of the reciprocal relations between philosophy and science is an ancient one, and more relevant today that ever before. There are some who think that the two realms are unconnected and that philosophy should distance itself from science, which in this view is uninteresting and irrelevant. That approach is relatively marginal nowadays. Others think that philosophy and science are two side of the same coin and that every attempt to separate them is artificial. Willard Quine, for example, argued that philosophy needs to draw on findings from psychology and sociology in order to achieve deep understanding of issues that deal with modes of thought and learning and with the way we apprehend things. There is no doubt that biology and the brain sciences advance our understanding of questions related to the mind. There are studies and experiments that offer reinforcements to or refutations of philosophical approaches. Nevertheless, I believe that philosophy is not dependent on the sciences and will always have its own autonomous existence.”

Let’s focus for a moment on the reinforcements, on the scientific studies that prove philosophical propositions.

“Let us look at what is known in philosophy as ‘the problem of other minds’: How do we understand what is going on in the minds of others? What makes it possible for us to attribute thoughts, feelings and desires to others? Basically, there are two approaches to this question. One is the ‘simulation hypothesis,’ which argues that we infer things about the other from what occurs within us. We hypothesize how we would think and behave in the situation of the other and then attribute this to him. This was the approach taken by philosophers such as David Hume and Immanuel Kant, and also by Friedrich Nietzsche, who said that understanding the other is accomplished by imitation. In other words, the same mechanism that operates when a person brings into being thoughts, feelings and desires also operates when he attributes them to others.

“The second approach is known as the ‘theory hypothesis.’ It maintains that each of us, unconsciously of course, has an inner psychological theory that makes it possible for us to attribute thoughts, feelings and desires to the other. The philosophers associated with this approach are Ludwig Wittgenstein and Daniel Dennett. Without going into details, the main difference between the simulation hypothesis and the theory hypothesis is that the latter maintains that we have two separate mechanisms: one to create thoughts and the second to attribute thoughts to the other.

“Advocates of the simulation hypothesis cite as support for their arguments people with brain damage who cannot experience a particular emotion, such as fear. It turns out that these people also cannot identify that emotion in others, so it follows that the same mechanism that serves to generate the emotion also serves to attribute it to others.

“Another scientific discovery that supports the simulation hypothesis is that of ‘mirror neurons.’ These are neurons that fire when we perform a particular action, but also when we observe someone else performing the same action. This imitation system apparently makes it possible for us to identify with those we face and it could also be the one mechanism that both generates the emotion and attributes it to others. To be fair, it must be said that other scientific findings exist that actually support the theory hypothesis. So in this case at least, science has not yet decided between the two approaches.”

What will happen in the future, when further studies in cognitive psychology and biology will make it possible to decide the issue? What will remain of philosophy?

“Philosophy is a culture of thought, and as such makes it possible for science to vest things with meaning. It deals with the investigation of truths, which do not always have a scientific answer. For example, questions of morality, identity and also the question of body-mind relations. Seemingly, science decided that question in the 1950s and 1960s, when behaviorism, and afterward functionalism, showed that the mind is only a collection of its activities. Afterward, the cognitive scientists and the brain scientists argued that the mind is the concrete activity of the brain. Their findings, which presented the brain as matter, drove the last nail into the coffin of Descartes, who is the most famous representative of the argument in favor of a separation between body and mind. The Cartesian mind was dead.

“But, as often happens in philosophy, old ideas return; ancient philosophical insights that had supposedly disappeared from the world reappear, sometimes in a new interpretation, and continue to resonate in the culture of thought. In a gradual process, one leader of which is the Jewish philosopher Saul Kripke, Descartes’ insight is returning. Dualism is making a comeback not in its original form but in a new mode that raises the difficult question of consciousness: Is it possible to define consciousness in material terms? It might be possible, for example, to describe in full all the behavioral and functional characteristics of pain, but we have no possibility of describing the qualitative aspect of the experience of pain, the condition of ‘being in pain.’ It is the same with love. Science is familiar with the hormones, the physiological indices and the brain activity that constitute what we call ‘love,’ but is incapable of describing the distinctive personal experience of the phenomenon. This approach rejects absolutely the possibility of suggesting a reductive explanation for the qualitative aspects of conscious experiences.”

Do you think science will ever be able to do that?

“I will never say about a particular question: science will never solve that. Immanuel Kant thought that it would never be possible to solve the question of the beginning of the universe in time using scientific tools. Yet, 250 years later, scientists formulated the Big Bang theory. In short, we can never know for certain whether a particular question science cannot solve today will remain in that state forever. In any event, philosophy raises for discussion issues that, even if they cannot be proved empirically, are sufficiently important and interesting to induce us to make progress toward understanding them. A case in point is discussion of the ‘problem of personal identity.’ Are we persons who are identical to our bodies? Or are we a psychological entity that is influenced by the body but is not identical to it and is characterized by our memories, inclinations and preferences? In principle, that entity can even possess traits that conflict with our biology, such as a man who feels he is a woman.

“Or maybe ‘identity’ does not exist at all. That is the traditional approach of Buddhism, namely that the thought that anyone has a permanent identity is an illusion. If we liberate ourselves from it and take less interest in ourselves, our ego will be weakened and we will even enjoy a sense of relief. The representative of this approach in Western philosophy is Derek Parfit, who by the way was born in China.

“Which of these possibilities is correct? Can that be determined by means of the conventional scientific tools? Philosophy seeks to answer questions of this kind with tools of conceptual analysis, for example, which do not ignore the results of science, but at the same time transcend what the scientific framework allows.”

Can philosophy influence the mind?

“From my point of view, the answer to that question is almost trivial: Yes! I remember to this day the moment when, as an undergraduate student in philosophy, I understood the meaning of Kant’s ‘transcendental ego.’ It was a shattering experience, which in an important sense changed my life. I understood that in the depths of my private consciousness of identity, of each of us, resides a non-personal element that makes it possible for us to recognize ourselves as one of the beings in the world of objects in which we live and act. That was a completely new awareness, which in a slightly paradoxical way combined humility with an extraordinarily powerful experience. I became open in a new way to the responsibility I still feel toward myself and toward my fellow human beings. That discovery, which was a direct result of what I now call ‘conceptual work,’ completely changed the way I understood myself and my mental world, even though it was many years before I was able to give it systematic form. I am not unique in this. I believe that a great many of my colleagues, in the course of their search for similar or other philosophical insights relating to the mind underwent a similar experience of a deep, life-shaping change. That is the power of philosophy.”

(3) The psychologist

Dr. Ilan Kutz’s clinic is made of an array of materials: huge glass windows that overlook the Yarkon River in Tel Aviv, a wooden floor and walls hung with oils and aquarelles. In the center of the room, a glass desk rests on four stone legs. In short, the keyword here is multiplicity. A multiplicity of different things that coexist harmoniously. Kutz is a psychiatrist and a psychotherapist (whose treatment involves talking and listening) and a painter; he also writes and lectures about psychological aspects of biblical stories. I thought it would be useful to put psychotherapy on the psychiatrist’s couch for self-examination.

Can a psychotherapist heal the mind, alleviate its suffering, touch it?

“Experience shows that it can, but I have no idea how it happens. Psychotherapy is a very peculiar profession. We treat patients and our work is often fruitful. We also have a great many theories about why it works, but I am far from sure that we really understand why. Psychotherapy is an amorphous process, which encompasses much theoretical knowledge and demands experience and skill, but gut feelings and intuition also play a large part. It’s a process that’s hard to define.”

Please describe the treatment.

“Psychotherapy is a little like literary criticism. The patient brings his text, and the therapist tries to understand the subtext. The text is the plain meaning, from which we seek to derive the comparative, allegorical and esoteric meanings. For example, we try to decipher why the patient chose a particular opening sentence. Let’s say, ‘First of all, it’s important for me to say that my married life is excellent ...’ In some cases, that actually attests to a difficulty the patient is trying to protect himself against. Or why he is downplaying a particular significant event. For example, ‘Today, Maman died. Or perhaps yesterday, I don’t know.’ [the opening line of Camus’ “The Stranger.”] A therapist takes an interest in the patient’s language. He opens a musical ear to the language and its tones, to the grammar of the individual sentences and to the superstructure of the story. A patient uses a particular word in a sentence, and my task is to understand why he chose that specific word. Why say ‘confined’ and not ‘closed’? ‘Stride’ and not ‘walk’? That’s one of the reasons I am drawn to the Bible: the text is dense, and every word in it whose plain meaning is also not always clear to us today can be read in different ways and interpreted in a different manner.

“In a therapeutic situation, as in literary criticism, it is important to know who the narrator is. Man is a gallery of beings, a theater of characters, and a different being comes to the front of the stage each time. A person can sometimes be civilized and sometimes primitive, sometimes rational and other times emotional, masculine and feminine, childish and mature. All these beings exist in parallel, and it is important for the therapist to grasp which of them is talking to him at any given moment. When I discern in the person who has come to me whether he is a decorated soldier or a wily lawyer the character of a small, frightened child, it enables me, and then him, to address the childlike parts of his mind, which are generally hidden.

“In addition to the textual language there is also, of course, body language. Occasionally I am asked to give advice over the phone, and I really don’t like to do that. There is a tremendous difference in interaction. Not even Skype with video allows the required quality of interaction. For me, as a portrait painter, that is self-evident. The facial features, the precise expressions and even the hue of the skin are critical for deciphering the patient’s frame of mind. Physicians, too, know this from their work. Problematic conditions and diseases are diagnosed according to the appearance of the face and the body.”

So you can judge a book by its cover.

“The cover and what it says and does not say. The next question is what is done with this array of data that emerges from the communication conducted through text and body but that is related to the psychological theory the therapist espouses. The interpretation of the data proceeds according to the theory of knowledge with which the therapist is familiar and which he uses and feels comfortable with. That is why different therapists can analyze similar data in different ways.”

And that decipherment renders the treatment successful?

“Freud thought that the success of the treatment and the mental relief it brings stem from the fact that we bring the unconscious to consciousness and turn the hidden into the revealed. But today we know that this is not the main thing; because even when we know the hidden reasons for the problematic phenomena, and even when we are conscious of what was previously hidden, the suffering does not disappear.”

What is the main thing?

“In my view, and in the view of many others, the most important thing is the bond, the close relationship between two people who are part of a shared process aimed at understanding, accommodating and treating the suffering. It is not knowledge that resolves distress. The relief lies in the fabric of the bond created during the process and in the special human interaction, which allow a person to feel in the deepest way that someone is standing by him. The basic bond of trust the patient forges with the therapist, who listens to him, understands him and accepts him, vests the patient with a feeling that he has a ‘secure base’ a term coined by the psychologist John Bowlby. From here springs a sense of self-worth, and this is what makes it possible to be released from the patterns of suffering that have been with the patient his whole life.

“Freud was a giant in grasping the extent to which childhood influences adulthood. That was a tremendous revolution. But he missed the whole subject of what we call ‘early attachment.’ Bowlby identified that primal bond, created between infant and parent, and understood that the bond’s character forges the personality structure and influences the course of his life. So, on the one hand Freud grasped that everything stems from childhood, and on the other hand he focused on the Oedipus complex in other words, what happens after the age of three and did not see the immense importance of very early attachment. Well, the truth is that Sophocles’ Oedipus was an infant whose parents neglected him and condemned him to death in other words, he had a horrific early-attachment experience. All his ordeals and his ‘Oedipal’ fate stemmed from being deprived of early love.”

So treatment is a type of “late attachment” that makes possible the correction of a problematic early attachment?

“Good and proper attachment, and the patient’s ability to develop trust in the therapist, can reconstruct and then bring about repair of the pattern of early attachment. The experience of closeness and intimacy provides an opportunity to modify the persistent patterns of thought and behavior we have lived with for so many years.”

In the end, then, it is of no importance which theoretical school of psychology the therapist follows.

“In the deep sense of the treatment, that is really not the crucial element. What is important and even critical is the bond itself. It is good if the therapist is acquainted with all kinds of theories and techniques, but the most important element is the bond that is forged with the therapist: that is the base on which all the psychological theories and therapeutic techniques rest. That is also the reason why there are no perfect psychotherapists. Different patients need different therapists, in accordance with the ability of the two to forge the proper intimate bond. To the best of my knowledge and experience, and based on studies done on the subject, what most determines the effectiveness of therapy is how much the patient feels that the therapist cares about him.”

If the main thing is caring and the intimate relationship, you could just as easily go to a good friend. That’s what my father used to say: “Use the money to buy a car.”

“A friend can definitely show a great deal of caring and empathy and also offer illuminating insights. But friendship is also a limiting relationship. There is always the concern that the friend will be shocked, flinch or grow tired because of what he will find out. In contrast to a friend, a decent therapist does not require friendship with the patient. He is interested in the patient’s difficulty, not in socializing with him. That is why openness in a framework of friendship can be problematic: either I will not succeed in being totally open, or I will be open and the friend will reject me or will want something from me in return. In professional therapy, the deal is clear and the roles are preset: the patient shares his distresses and the therapist listens and supports and helps, in return for payment. Besides, a therapist, unlike a friend, knows when it’s right to shut up. Even if he has brilliant insights, he sometimes chooses not to respond, but to wait for the right time, when the patient will be ready to listen or understand. The timing of the response can be critical.”

Therapy as art

To what degree is psychology as a sphere of knowledge updated and changed with time?

“Understanding of the mind’s mechanisms has been growing constantly, especially in recent decades. At first there was only psychoanalysis, which was structured like a religious order: A therapist who did not accept the principles of the faith and did not sanctify the rabbi was not accepted into the order or was denounced as a heretic. It is only in the past 20 years that psychoanalysis has opened its gates to new theories, such as Bowlby’s theory of early attachment. These days we talk about interpersonal psychology in other words, about the therapeutic process as an interaction of equal value between therapist and 
patient. I believe that the transition from a silent, passive therapist who is in a superior position, to a therapist who is the patient’s partner in the therapeutic journey is the most important development in classic psychotherapy in recent decades.

“Another innovation, which intrigues me personally, has to do with Buddhist philosophy and the paths it offers to understanding the human psyche.

Buddhism contains elements that are very similar to those of Western psychology in terms of the attempt to reduce human suffering by deepening insight into and understanding of the ways in which we limit ourselves and make ourselves miserable. This approach, which is increasingly penetrating Western culture, is based on meditation as a path to self-observation, both as a method to investigate the mind and as a means to alleviate mental suffering. Meditation can supplement and enrich the Western psychotherapeutic approach in understanding and treating specific distresses, such as post-trauma, as well as in broader subjects relating to personality identity conflicts and existential questions.

“In general, in terms of treatment there is now a quite diversified recipe of methods, which makes it possible to suit different approaches to different problems and to different personality structures of patients. Some are better suited to introspective methods of investigation, while others feel more comfortable with approaches that integrate artistic expression, such as psychodrama or the plastic arts. There is group therapy and individual therapy, there is dynamic psychology, cognitive-behavioral psychology and supportive psychotherapy, and more where those came from.”

And there are, of course, the developments in biology and brain research.

“Those are wonderful discoveries, which are revealing to us things about the mind we didn’t know or support certain theories we propounded. I am happy, for example, about psychological experiments that illustrated Bowlby’s attachment theory, showing that minor changes in childhood bring about later changes such as anxiety and adjustment disorders. Later, biology discovered the hormones that are involved in that attachment oxytocin and prolactin and showed that they exist in the father as well as the mother. It was also found that psychiatric drugs from the SSRI group moderate the negative effect of deficient early attachment. And those are just a drop in the ocean, of course.
“The brain sciences contribute to our understanding of the mechanisms by which the mind operates, and they will continue to enrich the therapeutic realm. Already today we are being aided by neurobiological methods that operate by directly stimulating the brain in order to treat depression, post-trauma and other disorders.”

The biological discoveries to which you refer come from the sphere of science. Buddhism, and in fact most theories of the mind, belong more to the realm of philosophy. When you described how therapy works you evoked literary criticism. Is a psychotherapist a scientist, a philosopher or an artist?

“Sometimes he is all of the above. As I sit across from a person in distress who has come to me, my brain works at several levels. I listen to the language the person uses, observe and take in his body language and watch the theater of characters he acts out. At the same time, I have in my head a range of psychological theories I have learned, which are, as you said, philosophical conceptualizations about the human psyche. In addition, as a physician who is au courant with studies in the brain sciences, I cannot but think about what is happening in the patient’s brain, biologically. So that in every treatment I skip from one role to another psychotherapist, biologist or physician and sometimes I make intuitive diagnoses, like a shaman.”

Can you cite an example?

“Someone tells me he is taking all possible medicines, but still felt distress. It’s possible that what he needs is psychotherapeutic treatment, because the things that are oppressing and blocking him require clarification by means of generating communication and expressing emotions, and medicines alone will not make them disappear. The opposite also happens: someone has received psychotherapeutic treatment for years, but something in her is still ‘stuck’ and her suffering continues. The right psychiatric drug might bring her relief, and then the psychotherapeutic process can acquire momentum and make progress.

“That is why I tend to think that a good therapist needs to possess something creative of the same sort that exists in an artist. Both therapist and artist require natural talent and a strong attraction to the field they are engaged in. What they do relies on acute and distinctive senses, and often also on intuitions that are hard to explain. Like an artist, a psychotherapist needs to make a great many decisions: what to emphasize and what to understate, whether to intervene or whether it’s best to refrain, when to be stubborn and when to allow the process to flow freely. And of course, in art as in therapy, talent is only the starting point. Much study, training and experience are required to enhance the natural givens and achieve proficiency and depth.

“But as in art, so too in psychotherapy; after the knowledge is acquired and the rules learned, the framework is understood and the procedures internalized, the moment comes to pass in which it is possible, and sometimes desirable, to break the rules. Not in the ethical sense of relations between therapist and 
patient, of course, but in making the rules flexible and improvising with them. In certain cases, it is precisely by deviating from the rules that a breakthrough can be achieved and a transformation fomented in the patient. But that requires a highly skilled and responsible therapist. It’s like painting. At first you learn the rules perspective, colors, light and shadow and you paint ‘correctly.’ Afterward you can let go of the rules and follow the heart. That’s when it succeeds.”

What's going on in your mind?Credit: Yael Boganim
Sigmund Freud.Credit: AP