The limits of personality

mental turmoil Yoram Yuval Keshet Publishing, 384 pages, NIS 85

By Amiya Lieblich

This book does the almost impossible: it bridges in a successful and instructive way between therapeutic stories, described with real literary talent, and the analysis of the cases in contemporary scientific concepts, in a way that explains the most complex and advanced issues in psychology, psychiatry and neuroscience; In other words, he builds a bridge between the scientific and the literary, between the experimental and the humanistic, thus his greatness. The author is not inferior in his literary talent to Ervin Yalom, for example, but his book is Israeli in every way, and his stories, even the New York ones, are well embedded in the Israeli-Jewish society and the local culture. The backbone of the book is treatment stories from the office of Dr. Yuval, a psychoanalyst and psychiatrist who received most of his training in the United States and continues his work now in Israel. These stories are examined mainly through three perspectives: psychoanalytic theory, mostly in its initial version, i.e. Freudian; current medical research on the brain, its operation, and the ways to influence it, and the "bible" of psychiatry; Also known as the DSM-IV, the book of psychological and psychiatric diagnoses that the American Psychiatric Association publishes every few years.

Almost every chapter deals with a therapeutic topic, "disease", the exact definition of which, along with the list of its typical symptoms and the recommended methods of treatment, appears later in the chapter. However, the cases are presented first and foremost as readable stories: a woman who has everything and is looking for happiness, ex-soldiers suffering from post-traumatic syndrome, a girl who tries to commit suicide (the episode is called: "Flying to the Stars"), a young woman who starves herself almost to death, a mother who is afraid to leave her house , or the rabbi suffering from bipolar disorder (mania-depression) - all these and many others emerge as flesh and blood characters from the pages of the book. The "treatment", i.e. the course of the relationship between them and the therapist, is described as the story of the act, as a psychotherapy that is mainly guided by a psychoanalytic worldview, but includes many variations, including behavioral or cognitive therapy. Some of the cases illustrate disorders that are extremely difficult to describe to those who did not know them closely. Such, for example, is the "borderline personality disorder", which because of its "borderlineness" is so difficult to present and explain (as I myself have come to know more than once in front of my students at the Hebrew University). In the sixth chapter, which bears the poetic name "Farewell to Infinity", and brings the story of Orna Yacovi (pseudonym, of course), a severe and widespread disorder is causing skin and tendons. I have never read, certainly not in Hebrew, such a clear, correct, concise and humane explanation of hers. This, then, is the first advantage of the book: its stories are human, touching in their truth, written with clarity and talent, and bring the patients closer to our world and our hearts. In his stories, Yuval sometimes addresses - in short, and with a blend of professional authority with unfailing tact - also the family members and friends of the sufferer, explaining to them the deviation in the behavior of the one who lied to them, warning of dangers and recommending courses of action.

We have already read "clinical" stories. However, those before us are indiscriminately embedded with theoretical and empirical information, and miraculously: they do not detract from the narrative of the text. And so, even a definite refuser of reading scientific material will be "forced" to learn from them a chapter in psychology, physiology and medicine of today. Among the academic fields that accompany and explain the clinical stories, the first is psychoanalysis, followed by the theory of psychiatric drugs and neuroscience, which are obviously related to each other.

Yuval is a psychoanalyst, and learned to accept a lot of Freud's teachings, which, despite the harsh criticisms leveled at it, he finds in it an effective and powerful tool for understanding his patients, his behavior as a therapist, and everything in between. Through these "cases" the readers will learn about repression, transference and countertransference, the meaning of dreams, the Oedipus complex and much more from the classical foundations of the Torah. However, contemporary issues and contemporary psychoanalysts also appear between the pages of the book, according to what the therapist deduced from them in order to understand those seeking his treatment.

Yuval is also a doctor who keeps up to date with brain research and medicine, and contributes with his explanations (and not only in the third part of the book called "Neuroscience") to the understanding of the disruption that occurs in the physiological processes in many disorders, and above all he explains in a reliable and consistent manner the action of the more popular drugs (such as Prozac) or less, their advantages and disadvantages in treating different disorders and different patients. Many years of study and research in psychology gave rise to a deep reservation in me from the "medical model", the main of which is diagnoses that label a man or a woman, lead to cure through drugs and hospitalization and create a stigma that is difficult to shake off. Literature of therapeutic advice also went bankrupt a long time ago, at least in my opinion, and in most cases I do not believe the reported success stories. I believe that there is a continuum between the "healthy" and the "sick", and people can change slots from time to time; Because many diseases are nothing more than the epiphanies of social ills and that each person has his own life story and one should not make an equal decision between one and the other. However, from the presentation of the first cases in this book I found myself listening to Yuval's words attentively, without the usual reluctance I feel when reading psychiatric literature. Yuval is an excellent and reliable teacher and explainer, there is never any point in condemning or stigmatizing the patient in his words, but rather conveying a humane and moral message like no other. He does not surface problems, he does not say "depends", as many scientists in his field will constantly say. Sometimes he presents several therapeutic alternatives that are before the therapist, and shares his experiences with the readers (in borderline disorder, for example). On other occasions, he also shares with the patient his dilemmas, and pits different treatment methods against each other for his choice - by means of conversation or medicine, and even the infamous electric shock (what is commonly called a "shock"), with which he reveals to the patients the price (such as side effects) of Any of the treatment methods. Either way, he reaches a decision, gives the feeling that he knows, that he has clear and learned answers based on current material in the relevant sciences, until his authority and advice are willingly accepted.
Several issues that trouble psychologists, psychiatrists and the general public these days receive a clear and convincing explanation on the pages of the book. Such, for example, is the issue of the therapist's retirement, the complete avoidance of producing satisfaction through his/her patients, in which the author has a clear and ethical position that can be a teacher of embarrassments for any beginning therapist. A second example deals with suicide and the question of the freedom to commit suicide, in which the author also presents his reasoned positions, which support life at any cost.
I will elaborate on the third issue, of the "repressed memories", and more precisely the "traumatic memories that were forgotten and resurfaced" versus "false memories". Is it possible that an adult suddenly remembers the facts that he experienced in his childhood or youth and were completely forgotten until now? The story of Michal, who was sexually abused as a child and "forgot" her, is embedded within the relevant research, such as that of the well-known Elizabeth Loftus, against the various theories proposed by Freud on the topic of childhood amnesia, and through all of these the author raises the problem in a sensitive, and in my opinion brilliant, way.
This is almost the only issue in the book where I clearly heard the author's doubts and felt the limit of his knowledge. He also says to the patient herself: "There is still no objective way to know for sure if what you remember happened as you remember it..." and at the same time he conveys to her that he believes her, and helps her overcome the guilt she carries with her from the incident and his memory. However, despite the uncertainty, later in the chapter, he provides an excellent physiological explanation of the hippocampus and amygdala as memory centers with different properties in the human brain, and clarifies the entire issue from a scientific point of view.
Overall, this is a book that puts all mental disorders on defects in brain activity, and in that sense it might be called biological reductionism. However, body and soul are but two sides of the same coin in the writer's seminary. A brain disorder can occur as a result of difficulties in the patient's environment, for example neglect, abuse or difficult experiences the patients have had in their lives. The author's strong and consistent position is that any change in behavior results from changes in the brain. But such changes in the brain can appear not only under the influence of chemical drug treatment but also under the influence of normal conversations between people, corrective experiences we go through, and of course the process of psychotherapy or psychoanalysis. When a patient is debating whether to take Prozac as recommended by the therapist because she is afraid that the drug will "change her brain", Yuval replies that the conversation between them does the same. Whether the therapist prescribed medication for the patient or talked to him, the author believes that "psychological therapy, similar to a love story, thrives in an atmosphere of openness, honesty and trust." And in another place: "The goal of psychological treatment, like the goal of drug treatment, should be one: to increase a person's freedom of choice."

As mentioned, the writing is clear and intelligent, without falling into the trap of simplification. Sometimes I thought that a dose of feminism would not be harmful here, and in this short review I will not be able to elaborate. Sometimes I asked myself if there really wasn't room for more doubts and question marks. However, these reflections were mostly erased later on in the reading, and thanks to the impression of the scholarly substantiation of the therapist's steps. Sometimes I felt that there was a big jump between the description of the beginning of the acquaintance, the diagnosis and the course of the initial treatment and the subsequent chapters and up to the "end of the story" that appears almost at the end of each chapter (and is almost always crowned with success). And yet, the need for brevity is clear (if the author gave a full report of each case, he could not have written down twenty treatment stories in one volume), and I did not feel that there was any sloppiness and oversimplification in the presentation of things, but quite the opposite. The language of the book is simple, and thus there is another contribution to its special readability; At the same time there is a feeling that it was written for readers with memory. More often than not, the author lists two or three aspects that will appear in the chapter, and without mentioning them explicitly expands on one, and after a few pages comes to the second or third - but they will always be found later, as he promised. I therefore felt that the author considered me an intelligent reader, and on my part I developed an attitude of trust towards him, of someone who can be trusted.
Indeed, the protagonists of this book are not the ones seeking help, but rather the figure of the therapist-narrator emerging from it. There will be those who deal with the lineage of Yuval's relationships (he is the grandson of Yeshayahu Leibovitz), as the publisher does, and even the author, with true modesty, here and there between the pages of the book. I wish him to meet him. His therapeutic attitude is one that I would like to impart to my students. He is a sensitive and empathetic therapist (as we say) who constantly tests you His own reactions and draws conclusions from them for the course of treatment. And at the same time, he bases his clinical decisions on knowledge of psychology and physiology, an up-to-date knowledge that he certainly invests a large part of his time in. His decisions are not a result of intuition, and his character is not a revolutionary, And he does not have sudden enlightenments of a new era, all his actions are a learned Torah, Constant study, in the relevant fields of knowledge. At the same time, I have no doubt that he is a simple person, "Menches", to whom love and morality are always a candle. "Introduction to Psychology", which, like the rest of the academic introductory classes, is supposed to provide the students with the infrastructure for the rest of their studies. Introductory books for psychology are a thriving business in the United States, and the best known of them in universities in Israel is "Hilgard", for its updated editions, which has been memorized by generations of students. The course lectures also usually follow the chapters of the book in an orderly manner, which present in a dry and scientific manner the basic topics: perception, learning, human and social relations, child development and more.

In recent years there has been a possible trend towards waiving the introductory course. The students who come are more sophisticated, and can go directly to a more in-depth study of each of the chapters, without the "introduction", whose very structure requires superficiality. Moreover, students who choose to study psychology see in their mind's eye the therapist and their patients, as they engage in what seems to be the most fascinating of all professions: healing the human soul. And here they are required to learn about the behavior of the mouse or the pigeon, about the structure of the cell and the brain, and more, mercifully Litzlan, Kahana and Kahana statistics lessons. Even before a year of their studies is complete, they are almost in a state of war, hostile to their teachers and the textbooks, and fighting for their grades in a battlefield where the study materials are not that interesting to most of them.

When I read Yuval's book, a refreshing "aha" feeling came over me. It seems to me that only profit will be made from the introduction of this book as the introductory book to psychology in universities and colleges in Israel, or alternatively - the main reading book in the psychopathology course. A weekly discussion of its chapters, the knowledge and wisdom behind them, will enrich the students and their teachers. It's just a shame that there isn't an orderly list of sources at the end.

Prof. Amiya Lieblich is a lecturer in the Department of Psychology at the Hebrew University

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