“Psychoanalysis in the Hasidic Community: Nafshi Travels to Ohio”
An interview with Dr. Andrew (Nachum) Klafter
By Baruch Weinstock, Motti Salomon, and Ben Menachem
Original Article: Nafshi Magazine, April 2024
(translated from Yiddish)
The story began when the authors of these lines—Baruch Weinstock and Ben Menachem—found themselves together in a large dining hall after a long day at the Nafshi conference for Orthodox Jewish therapists. Most of the tables were already full, and we were looking for a place to finally sit down after spending hours on our feet talking with every imaginable kind of mental health professional from all backgrounds and circles.
We made our way deeper into the hall until we noticed a table occupied by only two men.
"Please, have a seat," I said to my colleague, offering him the chair while I made my way toward the buffet to grab something to eat before my heart gave out from hunger.
As we began eating, the conversation between the two men at our table caught our attention.
"So you're a therapist who practices psychoanalysis?" one asked. It sounded like he was trying to get to know the man beside him, whom he had apparently just met.
"Actually, I'm a psychiatrist," the other replied.
The answer surprised us. His warm, approachable face. His yarmulke resting prominently on his head. His easy, friendly manner of speaking. A psychiatrist? A physician specializing in mental health who can prescribe medication? And he also does psychotherapy? That sounded intriguing.
"Excuse me—a psychiatrist? Where do you live?" I interrupted their conversation without waiting for permission. There is such a shortage of psychiatrists, I thought to myself. Perhaps I'd just stumbled upon a hidden treasure.
"Nice to meet you. My name is Nachum Klafter. I live in Cincinnati, Ohio, and I work with many Orthodox patients, including many in Kiryas Joel."
Interesting, I thought. Someone has already discovered him.
Later I learned that Dr. Klafter is actually one of the most respected and best-known psychiatrists serving the Orthodox community. Everyone in the field knows both him and his work.
Our plan to eat dinner and head home before nightfall disappeared almost immediately as the conversation developed. We discovered that Dr. Klafter has developed many original ideas in psychotherapy and psychiatry, especially regarding the integration of psychotherapy and medication—working simultaneously as the physician who prescribes medication and as the therapist providing treatment.
What fascinated us even more was learning that he practices psychoanalysis, the oldest form of psychotherapy, whose roots go back to the very beginnings of psychology over a century ago.
"We need to talk," I declared to Dr. Klafter after more than an hour in the dining hall. "And we need to talk properly."
And talk we did.
Nafshi's Motti Salomon, LMHC, immediately recognized the value of interviewing Dr. Klafter, and it wasn't long before we found ourselves boarding a plane to Cincinnati, Ohio. We flew out at nine o'clock that morning on American Airlines and returned home that very evening on United. The entire day was devoted to one thing: the conversation. It was well worth the trip.
What follows is a nearly verbatim transcript of our lengthy interview of Dr. Klafter at his private office, in Cincinnati, OH.
-DR. KLAFTER’S PERSONAL BACKGROUND-
Ben Menachem:
Let's begin with a little of your personal history.
Dr. Klafter:
I was raised in a religious Reform Jewish home. Observance of mitzvot wasn't taught in a technical, halakhic way. But religion and spirituality certainly had a strong place. I grew up with a basic faith in God and in the Jewish people, and a very strong Jewish identity. My parents are still my primary role models in my life for character and virtue.
As I became older, however, I realized that so much of Judaism was unknown to me. I didn't know Hebrew. I had no tools for studying Judaism deeply in terms of the Talmud, midrash, and other texts. I had no real knowledge of halachah. But what I did know was the ethical and moral side of Judaism—good character, values, honesty, integrity, and similar ideas. Most of this I learned at home, but it was reinforced in my Reform Jewish education.
But I always wanted to know more about my religion. While I was in college, I remember thinking how unfortunate it was that I knew so much about philosophy, psychology, history, and literature, yet knew very little about Judaism beyond a superficial level.
Eventually I decided to study Jewish religion and philosophy in college. I was deeply drawn by its beauty and intellectual depth, and I decided to continue my studies in Israel. I spent time there during college, and then I went back for traditional yeshiva education. Today I am fully observant and study on a regular basis.
My family is proud of the path I chose. I see my yiddishkeit as a continuation of the path my parents started me on, not a deviation. My parents also eventually joined an Orthodox synagogue, and one of my sisters has also become fully religious. I love Hasidut and Kabbalah. I study Hasidic works regularly, and from time to time I even incorporate Hasidic ideas into my psychotherapy.
-INTEGRATING TORAH AND HASIDIC THOUGHT INTO PSYCHOANALYSIS-
Ben Menachem:
Can you give us an example of using Hasidic thought in therapy?
Dr. Klafter:
There are many examples. I'll tell you one story that comes to mind right now:
I worked with a woman who had been abused and humiliated from early childhood for many years. She had become completely broken. She possessed virtually no sense of self-worth. As therapy progressed she gradually began discovering herself. She developed strength. She developed a sense of personal agency.
But she also became intoxicated by this new feeling of freedom. She began doing destructive things simply to prove that she was now her own master—that nobody could ever tell her what to do again.
I explained to her an idea from Chabad philosophy. In Chabad thought there is the concept that the or ha-sovev kol almin—the transcendent Divine light—which is "limited by its own limitlessness" (mugbal be-bli gvul). Because it is infinite, it cannot simply enter finite existence; in a sense, its very boundlessness becomes its limitation. So she, like this Divine light, is restrained by needing to stay un-restrained.
I told her that after spending so many years being controlled by other people, she had finally gained the ability to refuse domination. But she had not yet gained the freedom to choose healthy boundaries for herself. She had freedom from limits, but not yet the freedom to set limits. Without that, genuine stability and peaceful freedom remain impossible.
The fact that I introduced the idea through a higher spiritual concept—instead of directly criticizing her behavior—had an interesting effect on her. I think she understood this as a sort of natural principle and then saw how it applied to her, and this made it easier for her to think about it non-defensively.
It opened her up. She became able to appreciate why boundaries are actually valuable. She actually began researching religion and other life philosophies or spiritual paths, and she realized that she needed to find some balance.
-CHANGES IN MENTAL HEALTH-
Ben Menachem:
Tell us a little about how you've seen the field of mental health change during your career.
Dr. Klafter:
I've been doing essentially the same work here in Cincinnati, for the past twenty-four years, ever since I completed my medical training. The changes have really been significant.
There is no question that we now see a much greater demand than ever before. There simply are not enough psychiatrists or psychologists to meet the needs of the community, not even in Cincinnati where we really have a very strong mental health system in my opinion.
The field has continually expanded the number of professionals qualified to provide psychotherapy. Years ago, social workers and mental health counselors became much more prominent and became available to provide psychotherapy. And more recently, nurse practitioners and physician assistants have become credentialed to prescribe psychiatric medications in an effort to meet the demand.
I also believe there are genuinely more people suffering from serious psychiatric disorders today. It's not simply that we're diagnosing them more accurately. There is good evidence that there actually is more depression now than there used to be.
There is certainly more borderline pathology than there used to be.
I'm not convinced autism has truly become more common, by the way, even though many people claim this is so. My sense is that we are just becoming more adept and identifying and diagnosing autism.
But with depression and personality disorders, no one is exactly sure why these changes have occurred. There are theories. My theory is that perhaps part of it has to do with the breakdown of the family. Many people no longer grow up in the same kind of warm, stable homes that were once more common, and without a tightly knit community. And people are further away from their extended families. It’s very few children that have both parents in the home, grandparents and aunts and uncles nearby, and neighbors who know them well and are also present for extra support.
But I don't think that this explanation alone is sufficient, because we also see rising rates of psychiatric problems within the Orthodox and Hasidic community, where families and communities are still very strong and intact. Our Orthodox community certainly provides support that is uncommon in the general population, and we do see that certain types of problems (homelessness, for example) are much rarer. The strength of family life, communal support, and mutual encouragement protects many people from the worst manifestations of mental illness.
Another possibility is simply that the world itself has changed. The climate and environment are stressed, and this may have an impact on people that we don’t yet understand. The world has become larger. We also know vastly more people than previous generations did, but those relationships are often much shallower.
It may actually have been healthier to know fewer people—provided those relationships were deep, dependable, and intimate—than to know hundreds of people who each live largely in their own isolated worlds.
Another change I've noticed is that people are returning to deeper forms of therapy. Interest in psychoanalysis continues to grow. People increasingly want to understand themselves at the deepest level rather than merely relieve symptoms.
There have also been developments in biological psychiatry.
After many years with relatively few genuinely new psychiatric medications, a new antidepressant—Auvelity—has recently been approved. It represents one of the first medications in many years that works through a genuinely new mechanism. Ketamine has likewise become an important treatment option, and also TMS (Transcranial Magnetic Stimulation).
Perhaps the most encouraging change is that people are less ashamed than they once were of needing psychiatric help. The stigma surrounding mental health treatment has decreased considerably. People speak much more openly about therapy and healing.
-POLITICS AND A POLARIZED CULTURE-
Ben Menachem:
The ideology commonly called "wokeness"—an outgrowth of extreme liberalism—sometimes encourages people to identify proudly with their problems instead of trying to heal them. Do you think that contributes to the increase in mental illness?
Dr. Klafter:
No, I really don’t think so. People generally do not want to remain mentally ill or dysfunctional. People want to feel well. They want to succeed. They want fulfilling lives.
There may be isolated individuals who become invested in identifying with their illness, but they are certainly not the majority, and I don't believe our society generally encourages that.
I have actually been actively involved in opposing what I consider the excesses of wokeness. There has been a serious controversy within the American Psychoanalytic Association. A relatively small group has argued that the Association should officially adopt positions on current political issues—climate change, race, the Israeli-Palestinian conflict, and other political issues. They want to transform a professional psychoanalytic organization into a social organization. I've written in the psychoanalytic literature arguing against that position and spoken about it also.
My view is that politics simply does not belong in a professional organization of this kind. If someone wishes to establish a group called "Therapists Against Israel," or any other political organization, they are certainly free to do so. People are entitled to hold whatever political views they believe in. But they should not take a professional association representing a therapeutic discipline—whose members hold many different political beliefs—and turn it into a partisan political action group.
I see wokeness as a new form of communism. But instead of only economic class, it is also about race, gender, and sexuality. Most Americans, in my opinion, recognize it as misguided and primarily as an attempt to acquire power and influence. Communism dominated large portions of the world for a time. I don't believe wokeness will succeed in the same way unless something catastrophic happens that fundamentally transforms society.
It also encourages an unhealthy self-absorption—"I deserve everyone's attention." "Everyone should listen to everything I feel." "Everyone should be focused on me." I don't think it will ultimately succeed, although, of course, none of us can know the future. But no, I don’t think it is significantly changing our work as mental professionals.
-COMBINING MEDICATIONS AND PSYCHOTHERAPY-
Ben Menachem:
Years ago psychiatrists generally both prescribed medication and provided psychotherapy. Today psychiatrists usually prescribe medication while therapists provide psychotherapy. Why did that change?
Dr. Klafter:
This major change began during the 1980s. Insurance companies realized they could pay considerably less for psychotherapy if it were provided by social workers and psychologists rather than psychiatrists.
At the same time, psychiatrists remained the only professionals authorized to prescribe medication.
Insurance companies therefore continued paying psychiatrists relatively high rates for medication appointments, but they sharply reduced the amount they would pay for psychotherapy, and this led many psychiatrists to focus on medications rather than therapy.
Patients would come in periodically for brief medication visits with their psychiatrists, and see a social worker or psychologist for regular therapy. They also set limits on how many therapy appointments people could attend. So finances were the first major reason psychiatrists largely stopped providing psychotherapy.
The second reason is practical. Only psychiatrists can prescribe medication. Many different professionals can provide psychotherapy. There aren’t enough psychiatrists to see everyone. Psychotherapy is also difficult work and it requires extensive supervision and training. If one is not highly trained psychotherapy becomes emotionally exhausting. In earlier years there were also far fewer psychiatric medications available. Psychiatry training programs devoted much more attention to psychotherapy than they do today.
So, psychiatrists are encouraged and rewarded financially to only prescribe medications, and in many ways it’s more convenient, and this isn’t entirely a bad thing because it probably helps more patients get access to care.
Ben Menachem:
So, why do some psychiatrists still provide psychotherapy treatment?
Dr. Klafter:
Even today physicians still receive some psychotherapy training during medical school. The difference is that the emphasis is no longer placed there. Most physicians eventually devote themselves almost entirely to medication management. Personally, I could easily spend my entire day conducting brief medication appointments. But that's not what gives me satisfaction. I really enjoy helping people through psychotherapy. Simply prescribing medication would never provide me with the same sense of purpose.
Ben Menachem:
Is it actually better for one person to provide both psychotherapy and medication management, or is it preferable for those roles to be divided between two clinicians?
Dr. Klafter:
Ideally, there are advantages when the same person does both. But for the entire population of patients, this simply isn't practical. There aren’t enough psychiatrists to see this many patients in therapy, and most psychiatrists don’t provide therapy. I certainly have patients for whom I only manage medications and they see social workers, licensed counselors, or psychologists for psychotherapy.
However, if someone has a particularly complicated mood disorder or another complex case, I'll often recommend that they also see me for psychotherapy also. Therapy allows me to understand them much more deeply, which ultimately improves the medication treatment as well. It is a limitation when one clinician provides therapy while another prescribes medication.
But this problem is actually minor compared with the much larger problems in the American healthcare system. We spend extraordinary amounts of money on healthcare today as a country. Despite that, health outcomes and life expectancy are lower than in many other developed countries. Infant mortality is also higher than it should be. Meanwhile, insurance companies become wealthier every year. That is a scandal, or should be a scandal.
I believe the United States should adopt universal healthcare. It would actually cost less overall. And government provided healthcare is also excellent care. Look at community clinics in the Orthodox world, such as Ezra in Kiryas Joel. They provide high-quality care funded through Medicaid. No one seems to mind that their healthcare is paid for by the government. Why shouldn't other communities have access to something similar?
-WHAT IS PSYCHOANALYSIS, AND WHO BENEFITS FROM IT?-
Motti Salomon:
Which kinds of patients benefit the most from psychoanalysis?
Dr. Klafter:
Psychoanalysis is not designed for one particular diagnosis. The more important question is whether the person is stuck in life, and whether less intensive treatment hasn’t worked well. Regardless of the diagnosis, we determine whether this is someone who could really move forward with psychoanalytic treatment.
For example, many people with OCD don't need psychoanalysis. But others with OCD will benefit from it enormously. The same is true of narcissism. Some people with narcissistic personality organization truly need psychoanalysis; for others, this isn't necessary. The determining factor is usually not the diagnosis itself but the severity of the disorder. How profoundly has it affected the person's life? How entrenched has it become? How resistant is the mind to change? For certain patients, psychoanalysis is the treatment of choice.
Motti Salomon:
One of the defining features of psychoanalysis is free association—asking patients to say whatever comes into their minds out loud, with no editing.
Has the concept of free association changed since Freud's time? Couldn't an ordinary psychotherapy conversation provide essentially the same information?
Dr. Klafter:
Even in the early years of psychoanalysis, analysts didn't spend the entire session listening to free association. They talked with patients much like therapists do today. Likewise, contemporary psychoanalysts don't become robots whose only task is to facilitate free association.
The emphasis on free association originally developed because, before psychology became a profession, there were simply conversations and advice-givers. Psychoanalysis wanted to minimize the therapist's personal influence and focus as much as possible on the patient's own inner experience. Their patients had already gotten very good advice from people but they weren’t able to get better from just getting advice.
As for the second part of your question—the answer is no. Ordinary psychotherapy cannot reach certain depths of the mind that psychoanalysis can. One of the clearest examples is dream work. Psychoanalysis devotes enormous attention to understanding dreams as unique windows into the unconscious. Those meanings generally cannot be accessed in the same way through ordinary psychotherapy.
Of course, people accomplish a great deal through regular therapy, and I do a lot of regular therapy myself with patients. But psychoanalysis creates special opportunities that ordinary therapy often does not.
A patient may suddenly hear himself say something that surprises him. He may become startled by his own words.
Or he may say something deeply important and then sit quietly, waiting to see how the analyst responds. Sometimes the analyst intentionally does not respond immediately, allowing the patient to remain alone with his own thoughts. That kind of psychological space is unique to psychoanalysis.
Another important difference is frequency. When someone is in psychoanalysis, he is generally seen four times each week. This is why analysts will dramatically lower their fees, because only the wealthiest people could pay our regular fee four times per week. This frequency enables the treatment to be far deeper.
Two sessions per week are much more than simply doubling one weekly session. Three are much more than three isolated weekly appointments. Four sessions each week create an entirely different kind of treatment. It becomes a continuous psychological process rather than a series of disconnected conversations.
Ben Menachem:
How long does psychoanalysis usually continue at that frequency?
Dr. Klafter:
It depends entirely on the patient. Traditionally, the average length of a full psychoanalysis has been about five and a half years. That's a reasonable estimate, although there is tremendous variation. For someone who is himself becoming a psychoanalyst, undergoing analysis is a long-term professional investment. It's like an athlete who continues training throughout his career. The work itself becomes part of one's professional development.
For other patients, psychoanalytic therapy may last only two or three years. Once they feel they have grown substantially, resolved the issues that originally brought them into treatment, and are ready to move forward with life, they stop—with the understanding that they can return several months later simply to see how things are going.
Ben Menachem:
Four sessions a week is an enormous commitment. What exactly are you trying to accomplish over that period?
Dr. Klafter:
People who come for psychoanalysis are often people who cannot truly begin living.
Or they experience such intense anxiety that nearly every aspect of life feels impossible. They're paralyzed. They fear almost everything and even the things they do accomplish come at tremendous emotional cost.
Psychoanalysis is like placing a tiny microphone inside the mind and using the patient's speech as the speaker through which you can hear what's happening inside.
Try it yourself. Sometimes you'll discover that there are things you simply cannot say aloud. Not because you don't know them, but because speaking them feels unbearable. Or because you're afraid you'll become overwhelmed and unable to think.
Psychoanalysis gradually enters those hidden places and helps us understand what is preventing the person from living fully.
-WHAT ABOUT OTHER TYPES OF THERAPY?-
Ben Menachem:
Many patients with anxiety improve through CBT. Are the anxious patients who come to you people whom CBT could still help?
Dr. Klafter:
Every form of psychotherapy helps people.
CBT helps. Psychodynamic therapy helps. Supportive therapy helps. IFS helps.
There are many valuable therapeutic methods. But each one helps in different ways. CBT teaches people how to quiet the constant "noise" in the mind. That is a good thing. For certain conditions, that may be entirely sufficient.
But the patients who come to me have usually already gone through CBT. They've often experienced EMDR. Many have already traveled through what feels like seven different levels of therapy. Each approach has usually helped them somewhat.
But the core problem remains. It has become woven into their personality. Generally speaking, anxiety is a sign that something deeper is painful. Even after substantial healing, some very deep difficulties may remain and they come back into prominence after a while. There are people whose lives are genuinely transformed only through psychoanalysis.
Today it's actually difficult to obtain a psychoanalytic appointment. Many people who don't truly need psychoanalysis receive excellent treatment long before they ever reach an analyst. There is now a very rich world of psychotherapy that exists before psychoanalysis becomes necessary.
-WHAT IS THE ULTIMATE GOAL OF PSYCHOANALYSIS?-
Ben Menachem:
What is the ultimate goal of psychoanalysis? Is it discovering hidden trauma? Is it identifying distorted thinking?
Dr. Klafter:
In a single phrase: The goal is emotional freedom.
By that I mean identifying every factor that contributes to unhealthy emotional suffering and working through it so the person is no longer paralyzed. Sometimes that factor is trauma. Sometimes it is a habitual way of thinking. Sometimes it is a defensive strategy that developed to protect someone from painful feelings or perceived inadequacy. Sometimes it is simply the way a person was raised.
We are not looking for trauma for its own sake. Nor do we search through childhood merely because childhood is interesting. Our primary focus is always life and experience in the present. We look back only when the past is actively interfering with life today. In reality, we spend far more time talking about the present than about childhood. The past is important only insofar as it helps us understand what is happening now.
Motti Salomon:
That's an important point for people to understand. Many people imagine that trauma therapy is simply reliving old memories. They don't realize that therapy is really about what's happening in the present. Sometimes the present is constrained by the past, but the work itself is focused on today's life.
Ben Menachem:
Once you've identified what's blocking someone's emotions, what happens next? How does that actually help?
Dr. Klafter:
The process works because the more openly and clearly a person can talk about something, the more fully he understands it, and the less afraid he is of it. The more conscious he becomes of an emotion—even a very painful one—the less overwhelming that emotion gradually becomes.
In psychoanalysis we call this “working through.” For perhaps the first time, someone faces the problem directly. He looks at painful memories instead of avoiding them. He begins to understand the way his own mind works. He observes the mental processes that occur when he becomes ashamed, frightened, or angry. He gradually develops the ability not only to think and feel, but also to observe himself thinking and feeling. He becomes psychologically more mature.
Many people devote enormous amounts of emotional energy to keeping certain thoughts or feelings out of awareness. That energy is no longer available for living. When those painful experiences are finally faced, they become less frightening. The psychological barriers that have consumed so much energy begin to dissolve. The person suddenly has emotional vitality available for living instead of merely defending himself.
Simply becoming open about a problem makes it far less terrifying. There is a principle I often tell patients: Very few things are actually as difficult as we imagine they will be. Most painful experiences turn out to be easier to endure than the fantasies we create about them.
Another way psychoanalysis helps is through the relationship with the analyst. If you've never experienced a relationship in which another person genuinely understands you, then you've probably never fully learned to understand yourself.
Psychoanalysis is, in many ways, a process of becoming acquainted with yourself. Of learning to listen to yourself. Of developing a healthier relationship with yourself. Patients are often surprised to discover entirely new aspects of themselves.
I have patients who told their very first joke in my consulting room. They discover, for the first time, that they have a sense of humor.
They begin recognizing parts of themselves they never knew existed. As they become more integrated internally, they also become capable of deeper relationships with other people. A whole person is capable of greater intimacy.
Psychoanalysis also changes cognition. People carry countless assumptions in their minds about what makes someone good or bad, about what other people value, about what makes a person worthy of love. Many of those assumptions are very immature and distorted. Everyone begins life thinking like a child. Those childish ways of thinking need to mature. Analysis gradually transforms those assumptions until they become more consistent with reality.
It even improves a person's relationship with God. People often hold immature ideas about God that interfere with developing a genuine relationship with Him. As they gain greater compassion for themselves and a more realistic understanding of who they are, they also begin to understand more clearly what God actually expects of them.
And through psychoanalysis, a person becomes more understanding toward other people as well. Some people worry that therapy makes people selfish— that they'll become gentle with themselves but harsh toward everyone else. In reality, the opposite usually happens. As people become more realistic in understanding both themselves and their emotions, they naturally become more compassionate toward others as well.
Motti Salomon:
Therapy doesn't eliminate boundaries. If anything, it strengthens the person so that healthy boundaries become internal rather than externally imposed.
Sometimes, though, there is a period during therapy when patients actually become more rebellious or aggressive, is that true?
For example, someone raised by harsh or abusive parents may suddenly discover inner strength. Before they've fully matured, they may become disrespectful or angry toward those parents.
Dr. Klafter:
Exactly. Growth is not always smooth. People may first discover the courage to stop living in fear before they develop the maturity to understand their parents' limitations or forgive them. Like the case I told you about earlier. First they gain the freedom to think and act independently. Only later do they develop the wisdom to realize that disrespect ultimately helps no one.
When therapy is good, we shouldn't fear freedom. Good therapy increases choice. Yes, for a time the person may now have the freedom to be disrespectful, or irresponsible, or rebellious. But eventually, the person develops the freedom to choose responsibility and to help others. But, now, all of the genuinely good choices he now makes also arise from his own freedom rather than from fear.
-DOES BEING MORE AWARE OF ANGER MAKE PEOPLE WORSE RATHER THAN BETTER?-
Motti Salomon:
How do you guide patients through that difficult stage—when healing initially brings anger and conflict into their closest relationships?
Dr. Klafter:
We just continue the treatment. We try to understand why finally allowing yourself to feel long-suppressed pain leads to acting in those ways. Often the patient has spent years fearing those feelings because he believed that if he ever truly felt them, he would become consumed by anger.
Then he finally allows himself to experience the old pain—and, indeed, he does become angry. And it’s very uncomfortable, for others, and for himself.
At that point we reassure him: "We'll work through this together." "Let's understand why the pain leads to aggression." "Perhaps the anger is protecting you from feeling the grief..." "Perhaps it shields you from longing for the parents you wished you had." I believe most people move through this phase.
In fact, some of the most painful moments in therapy ultimately become the foundation for healing entire families. And you are talking about a very specific type of situation, a very obedient over-controlled person who is anxious and unhappy. But in reality, most of my patients were not already acting like saints beforehand.
If someone temporarily becomes disrespectful or rebellious against their parents during treatment, that does not mean the therapy is failing. Often it simply indicates that he has reached an important stage on the road toward becoming a psychologically healthier person.
-IS DIAGNOSIS NECESSARY? DOES A LABEL CREATE MORE STIGMA?-
Motti Salomon:
I’d like to get your opinion on diagnosis. How important is diagnosis to you?
Is it really necessary to assign a specific diagnosis, or is it enough simply to know that "something isn't right" and that the person wants help?
Dr. Klafter:
Very important, actually. I believe diagnosis is extremely valuable for many reasons.
First, the diagnosis itself has therapeutic value. Simply realizing that other people struggle with the same condition can be profoundly healing. Many patients believe they are the only person in the world who experiences what they experience. Learning that their suffering has a name—that it has been recognized, studied, and treated successfully in many others—can itself be enormously reassuring.
Diagnosis is also important for the therapist. If your car is making a strange noise, it's much easier to repair it once you understand what's causing the noise. The same is true in psychiatry. Diagnosis helps us focus on the most important aspects of treatment.
For me personally, as a psychiatrist specializing in treatment-resistant disorders—patients who have failed to respond adequately to standard medications—accurate diagnosis is probably the single most important part of my work. Patients come to me with severe depression that hasn't improved despite multiple medications. The same is true for severe anxiety, OCD, bipolar disorder, and many other conditions. Whenever treatment repeatedly fails, my first suspicion is often that the original diagnosis was incorrect.
Another important point: I don't believe a diagnosis diminishes a person's dignity.
Quite the opposite. I believe it restores dignity to people who have come to think of themselves as fundamentally defective. It helps them understand that what they're experiencing is a human condition shared by many others.
Ben Menachem:
Doesn't that depend on the diagnosis? For example, if someone is diagnosed with a personality disorder, doesn't that inevitably take away some of his dignity?
Dr. Klafter:
Many people certainly feel that way. But I really don’t.
Imagine someone with Borderline Personality Disorder. He goes from therapist to therapist. He lives with profound sadness. He struggles with suicidal feelings. He experiences intense rage. He constantly feels rejected and abandoned. He carries tremendous trauma. He misuses drugs or medication. He hurts himself. He hurts the people around him. He feels that no one understands him.
Then, for the first time, someone explains the diagnosis. “I think you are suffering from a very complex, developmental syndrome called Borderline Personality Disorder, which many people suffer from and which I am trained to treat. I think you have been feeling so much pain and aloneness for so long, and so afraid that if you get close to anyone they will abandon you, and all of your energy is spent trying desperately to avoid feeling alone or abandoned.”
He learns how the syndrome develops. He understands why he reacts the way he does. That gives him back his human dignity. He realizes that he isn't simply an evil or defective person. Rather, he experiences rejection with extraordinary intensity. Loneliness is almost unbearable for him. Those painful emotions drive the disorder.
He comes to understand that his destructive behaviors are desperate attempts to feel whole again—to regain emotional stability. Sometimes people do terrible things. But those behaviors often arise from a profoundly human desire to stop suffering.
Knowing that there are medications and specialized psychotherapies that can genuinely help means he may no longer act out in a way that he loses friendships over his rage when there is a delay in getting back a text message.
This knowledge may help no longer repeatedly wound his parents or his children. That understanding restores dignity.
We also have to be honest. Borderline Personality Disorder is a difficult condition. Some therapists choose not to treat it, either because it is demanding work or because they have not received sufficient training. But there are also clinicians like me who genuinely enjoy working with borderline patients and know that meaningful recovery is possible.
I actually think every diagnosis offers more freedom than stigma. When I was a young psychiatrist, receiving a diagnosis of narcissism wasn't considered particularly shameful. Today it has become heavily stigmatized. I think the media's fascination with Donald Trump has contributed significantly to making narcissism seem like the worst possible personality disorder.
In reality, it isn't. Many people have narcissistic traits. People with narcissistic personalities often possess remarkably gentle and vulnerable parts of themselves. The media has turned narcissists into monsters. But it’s very distorted and unfair.
-PERSONALITY DISORDERS-
Motti Salomon:
There really isn't medication for personality disorders. Medication for anxiety or depression often reduces many personality symptoms indirectly.
But I've noticed something interesting. Some anticonvulsant medications seem to help certain personality disorders. Do you think those medications are actually treating the personality disorder itself?
Dr. Klafter:
I think you are noticing something real. But my suspicion is that many of the patients you've observed actually had underlying mood disorders that had never been properly diagnosed. Those mood disorders eventually became expressed through what looked like a personality disorder. Because anticonvulsants often work well for mood disorders, treating the underlying illness naturally improves many of the apparent personality symptoms. That doesn't necessarily mean the medication is directly treating the personality disorder itself.
Ben Menachem:
Can you explain a little about Histrionic Personality and Borderline Personality? They sound very similar to me.
Dr. Klafter:
Someone with Borderline Personality Disorder spends much of the day struggling simply to remain emotionally regulated.
Someone with Histrionic Personality Disorder is driven by an intense need for romantic excitement, attention, and emotional drama.
Ben Menachem:
Could it be that many people in the Orthodox community who are labeled "borderline" are actually histrionic? After all, dramatic behavior is such a common feature in the Hasidic community.
Dr. Klafter:
Probably not. I think what you are saying is that interpersonal drama and highly expressed emotion are more common in Hasidic culture. But I still think that we can easily discern personality disorders in different cultures because of the pain and difficulties people are feeling.
I also want to say something about the term “manipulation” which I hear many people use when they describe certain personality disorders. Personality disorders involve a lot of emotional turmoil, because people with a personality disorder relate to others in a way that causes them to experience a lot of powerful, often unpleasant, emotions. That isn't because they're consciously manipulating others. It's usually not manipulation at all.
Rather, their minds compel them to relate to people in ways that create these emotional reactions. The behavior grows out of insecurity, not calculation. They're trying, often unconsciously, to feel stronger and safer by influencing the emotional environment around them. That is very different from deliberate manipulation.
-PARENTS, CHILDREN, AND THE MYSTERY OF DEVELOPMENT-
Ben Menachem:
How much importance do you place on parenting in understanding psychological development?
Dr. Klafter:
Parenting is certainly very important and we think about it a lot. Whenever we want to understand how a child develops, we naturally look at the child's upbringing. It is unquestionably a significant influence.
But most psychoanalysts would view parenting as one part of a much larger puzzle. A child's inborn temperament interacts with the parents' style of parenting. It is the combination that often creates difficulties.
In extreme situations—severe abuse or other devastating experiences—the direct effects of a parent’s behavior on development are obvious. But many situations are far less straightforward. Sometimes you see a family with six children. Five of them are psychologically healthy and thriving. One child struggles profoundly. What explains that? Often, we simply don't know. It remains something of a mystery.
The most likely explanation is that this particular child's temperament was simply not a good match for the particular parenting style that worked perfectly well for the other children.
I actually want to speak out in defense of parents. Too often they are blamed unfairly. People assume that if a child develops emotional problems, the parents must have caused them. Life simply isn't that simple. Human beings are much more complicated than that. Parents influence children, of course. Children also influence parents. Each child evokes something different from the adults raising them. Every family develops its own unique emotional system.
Reducing everything to parental fault is neither accurate nor helpful.
Ben Menachem:
So psychoanalysis today is no longer simply blaming mothers?
Dr. Klafter:
(Laughing.) No.
That stereotype has been outdated for decades. Modern psychoanalysis is much more interested in understanding complexity than assigning blame. We're interested in understanding how different factors come together to shape a person's emotional life.
Genetics matter. Temperament matters. Family relationships matter. Trauma matters. Culture matters. Chance matters. Everything interacts.
One of the biggest misconceptions people have about psychoanalysis is that we're searching for someone to blame. That really isn't the point. We're trying to understand.
Understanding creates freedom. Blame rarely does.
-A FINAL MESSAGE OF HOPE-
Ben Menachem:
If someone reading this interview is struggling emotionally, what would you want him or her to know?
Dr. Klafter:
First, don't lose hope. Many psychological conditions that once seemed hopeless are now very treatable.
Second, don't assume you've already exhausted your options. People often tell me, "I've already tried therapy." But "therapy" isn't one thing. There are many different therapies.
Likewise, medication isn't one thing. Sometimes the diagnosis is wrong. Sometimes the medication is wrong. Sometimes a particular psychotherapy or therapist isn't the right fit.
Sometimes all of those things need to change. Most importantly, don't define yourself by your symptoms.
Mental illness is something a person has. It is not who the person is. People are much larger than their diagnoses.
When treatment is done well, people often discover strengths within themselves that they never imagined they possessed. That's one of the most gratifying parts of my work.
_________________________________
Closing: The interview concludes with brief thanks from the editors, who note that they had intended to spend only a short time with Dr. Klafter but found themselves remaining for hours because of the richness of the discussion. They express appreciation for his generosity and for sharing both his professional knowledge and his personal journey with their readers. Dr. Klafter expressed his gratitude to Nafshi for such an enjoyable experience.