A modern boost to Freudian therapy

If Sigmund Freud were alive today to observe the new trend, he probably would have puffed on his deadly pipe and lain down on his famous upholstered couch to ponder the matter. But the Austrian-born, Jewish father of psychoanalysis wouldn’t have to worry that the growing use in Israel and around the world of short-term cognitive behavioral therapy (CBT) would replace his long-term techniques of treating mental illness by probing the unconscious, using transference, overcoming sexual drives and interpreting dreams.

Proponents of CBT – a talking therapy that aims at solving problems involving dysfunctional behaviors, emotions and thoughts that is systematic and goal oriented – do not aim at replacing Freud’s techniques. But they would use CBT, which was developed by American-Jewish psychiatrist Dr. Aaron Beck as a method to get relatively quick (and thus less-expensive) results. And they could also integrate the psychoanalytical process with CBT.

A leading US expert on CBT and its use for treating phobias, obsessions and general anxiety disorder (GAD) came on aliya from Ohio in May and settled with his wife Riva and children in Jerusalem. Dr. Michael Portman (meport18@gmail.com), a psychologist and social worker whose textbook on GAD (Generalized Anxiety Disorder Across the Lifespan) was published not long ago by Springer, and his article on the subject was printed in Psychiatric Annals. Both were widely praised by mental health professionals. The family thus joins his father, a retired obstetrician/gynecologist, and his mother, an artist, who moved to the capital 12 years ago.

He is setting up a private practice, working to raise the good level of his Hebrew to one in which he can treat patients and plans to teach CBT to others and give lectures so its use will become even more widespread in Israel. He is already a member of ITA, the association that registered qualified CBT therapists. 

“I have a bachelor’s degree in psychology and a master’s in social work from Ohio State University, a master’s in psychology from the New School for Social Research in New York and a doctorate in social work from the University of South Africa. Until his aliya, he was a full-time clinical social worker at the Cleveland Veteran’s Administration (VA), giving individual and group therapy to US veterans from the wars in Korea, Vietnam, Persian Gulf, Iraq and others, including Holocaust survivors, suffering from serious mental disorders. He was also on the faculty of Case Western Reserve University and had a private practice specializing in the treatment of mood and anxiety disorders.

“I worked for my country at the VAT, and now in Israel, I can work for my people,” he said in an interview at his parents’ home with The Jerusalem Post.
One of Portman’s mentors in CBT was the now-nonagenarian Beck, who encouraged him to settle in Israel and still corresponds with him via e-mail; Beck himself seriously considered aliya when he was in his 20s but continues to reside in Philadelphia. “Dr. Beck became discouraged by psychoanalysis because it did not use enough empirical knowledge.” The new immigrant noted that “there is growing mutual admiration on both sides, even though the approaches and theories are very different. There are a number of hybrid approaches. We don’t go into a person’s past until he is blue in the face. At the heart of it is trying to realize that it is not events and persons that led to symptoms but to use rational assessment, replace nonadaptive thoughts with more adaptive, healthier thinking.”

Tens of thousands of trained professionals were taught by Beck, who founded a University of Philadelphia Medical School institute in his name.  “His work created a paradigm shift, as psychiatry had been so dominated by psychotherapy for so long. It was revolutionary, but Dr. Beck was not ostracized. He applied it to the treatment of depression at first and then went on to anxiety disorders. He even used it with children. CBT is being used successfully to alleviate schizophrenia, even though it was first written off as a credible treatment for it. But such patients would continue to receive medications for it.”

People with schizophrenia and other lifelong psychiatric illnesses may get the same dose of medication when also undergoing CBT, but the two target different parts of the brain, Portman said. CBT improves social skills and motivation and gives patients a better perspective on the fact that it is a chronic condition, he added. It is also increasingly used to treat bipolar disorder, in which depression rotates with ecstatic highs.

For an example of how CBT actually works, think of a person who made a serious error at his workplace and, ashamed about botching up an assignment, concluded that he’s a failure and can’t do anything right. If he persuads himself that this overblown conclusion is correct, he can become depressed and avoid doing things he is good at. This confirms his feeling of being useless, creating a self-fulfilling prophesy. A CBT therapist can, in a limited number of sessions, help the patient to break this cycle by learning to think and act differently and more freely in similar situations. He can then lose his bad self image and his negative thoughts and actions.

Unusually, Portman wears a black kippa and describes himself as haredi, although he refines it as “haredi lite” or “American haredi.” There are almost no native Israeli haredim who do what he does because most eschew academic secular studies, except for penitent Jews.
 
This makes him especially suitable to treat haredim and the modern Orthodox – who are known to suffer at higher degrees than the non-observant from obsessive-compulsive disorder – and to treat them with CBT. As Orthodoxy involves a great deal of ritual observance, those with a tendency towards obsession find it easier to express it “legitimately” as ritual observance such as by endless handwashing before meals or after leaving the toilet or cleaning the house before Pessah. “People who want to marry worry about the prospective spouse finding out about it. Thus before a religious person has a shidduch [match], they will be much better off – happier and healthier – if they get treated, preferably with CBT. “I wouldn’t recommend somebody not marrying someone else if he or she had OCD problems if they are treated and the OCD is under control; I would not recommend marrying someone who has not been treated, as obsessions can cause chaos in a family,” said Portman.
As for mental illness, he has seen “everything in the frum community [haredi world] – domestic violence, marital conflict, unfaithfulness, abuse. The modern world has penetrated the religious world whether we like it or not. Haredi Jews were hiding out of guilt and fear. They have to be courageous and not accept or create stigmas.”

As there are few haredi psychologists and psychiatrists in Israel, Portman feels he will help meet a need. The late esteemed rabbinical arbiter of his generation, Rabbi Moshe Feinstein, “said that ideally, one should go for medical help to the best professional, whether he is observant or not. If your value system and the professional’s is the same, that is ideal, but if the professional is not competent, going to him is not recommended. But today, a haredi will not turn for help from someone who is not a religious Jew, as a non-religious professional would probably not understand his value system and might regard his behavior due to religious practice as being ‘abnormal.’ He would otherwise have to tease out genuine religious commitment from obsessions that go along with religious practice,” Portman said. “Rabbis both in Israel and abroad have become aware of OCD and make referrals when they see a problem to competent religious therapists.”

Portman has noticed since settling in Israel (and during frequent visits beforehand) that those who treat mental disorders here mostly use psychodynamic therapy. “Freud is very big there; CBT is less used. Jews seem naturally to be attracted to psychotherapy as practitioners of thinking fields. Yet overanalyzing the past and family relationships can make it more difficult for a patient to feel better. Freud’s theories were based totally on insight, but with CBT, we believe in behavior change. CBT is structured, time limited and based on self mastery. Unlike psychoanalysis, it is solidly evidence based; we can see how many improve and recover.”

He notes that CBT “works” for almost every mental problem, not only anxiety, pain and mood disorders but also severe mental illness as well. Although it is not a universal cure. GAD, he continued, is a chronic disorder that waxes and wanes, and stresses make it worse. GAD “has one of the lowest response rates of any anxiety disorders, so we therapists have to be more creative. That’s why CBT can be helpful. Now, about half to 80 percent of people treated with CBT with various disorders  improve, but the rest don’t improve no matter what we do.” Medications, however, can be used effectively in tandem with CBT and/or psychodynamic therapy. Success or improvement rates using CBT are significantly better for obsessive-compulsive and similar disorders than for GAD, he said.

Portman said he was drawn to study and use CBT not only because it is evidence based, but because he doesn’t “believe in interminable treatment. It is more cost effective and collaborative, with the patient participating. I wouldn’t tell a patient that I have arcane knowledge that he doesn’t possess. Ideally, he should do ‘homework assignments’ to improve the effect rather than just when we are together once or twice a week.”

His “big passion is applying CBT to generalized anxiety disorder. My research protocol has been totally devoted to it. Everybody worries about their kids or about their health or financial problems, but GAD is marked by persistent, chronic and excessive anxiety when there is no basis for the worry.” GAD, he continued, is the most prevalent anxiety disorder but very misunderstood. It affects 3% to 5% of the population, and women are twice or three times more likely than men to suffer from it. Genetics may have a role in about a third of sufferers.

“I advise such people to worry about something just 20 minutes a day and then finish or to postpone worrying. Relaxation techniques such as slow breathing can be very helpful. I tell them to focus on the present moment so they won’t be worried about the future. All this can be incorporated into CBT.” GAD patients, said Portman, have difficulty dealing with uncertainty. They don’t like ambiguity. Life is uncertain by nature, but normal worries can become excessive.”

GAD, which affects all cultural groups and people of all ages, more often than not starts in one’s late teens or early 20s, but it can begin in children as well. A significant portion of those with the disorder suffered physical abuse when they were young. Attachment problems, such as overprotective parents, may also be involved. “There is probably a subset of Holocaust survivors who have GAD, which was originally called ‘anxiety neurosis’ by Freud, but that lumped it together with other things. Only the psychiatrists’ manual DSM-3-R) set it apart from panic disorders, for example.”

Although GAD usually begins at a young age, it is diagnosed late – on average in one’s late 30s and sometimes even in middle age. It may go untreated for decades, even though it impairs normal functioning,” Portman stated. “The suffering steadily builds; it doesn't come out of nowhere. We see more women; we don't know if men suffer as much but are more likely to avoid treatment or act it out in aggression or drinking alcohol.” What is certain is that GAD can be very debilitating, and 90% of sufferers have another disorder with it such as social anxiety disorder or depression.”

Portman concludes that while he has such a strong belief in the efficacy of CBT, he is “not bashing the psychoanalysts. “I have the highest respect from them, but we need to spread the playing field to reach the widest patient audience.”