Psychoanalytic Inquiry

A Topical Journal for Mental Health Professionals

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The “Lechol Nefesh” Project: Intensive and Long

Term Psychoanalytic Psychotherapy in Public
Mental Health Centers

Ilan Amir & Gaby Shefler

To cite this article: Ilan Amir & Gaby Shefler (2020) The “Lechol Nefesh” Project: Intensive and
Long Term Psychoanalytic Psychotherapy in Public Mental Health Centers, Psychoanalytic Inquiry,
40:7, 536-549, DOI: 10.1080/07351690.2020.1810528

To link to this article: https://doi.org/10.1080/07351690.2020.1810528

Published online: 22 Oct 2020.

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PSYCHOANALYTIC INQUIRY
2020, VOL. 40, NO. 7, 536–549
https://doi.org/10.1080/07351690.2020.1810528

The “Lechol Nefesh” Project: Intensive and Long Term

Psychoanalytic Psychotherapy in Public Mental Health Centers
Ilan Amir, M.D., and Gaby Shefler, Ph.D.

ABSTRACT
“Lechol Nefesh” (“For Every Soul”) is a Non Profit Organization established in
Israel in 2010 by a group of members of the Israeli Psychoanalytic Society with
the objective of setting up unique therapeutic units for the provision of long-
term, intensive psychoanalytic psychotherapy in the framework of the public
mental health clinics. These units offer a therapy program of 2–3 sessions per
week, for a period of at least 3 years, to patients whose emotional state has
shown no improvement or stabilization despite their having received the full
range of standard treatments. Patients are accepted without any diagnostic
limitation, the only requirement being that they attend sessions regularly and
consistently. They are also asked to participate in an evaluative research project
designed to assess the program’s effectiveness.
This article presents the underlying theoretical and clinical thinking and
the work methods of the units, as well as a detailed psychotherapy descrip­
tion of one patient. In a brief presentation of the outcome study carried out
over a period of more than 3 years, we discuss the findings for the 18
patients who participated.
The research results present a clear and statistically significant finding
that long-term, intensive psychoanalytic psychotherapy is a valid and effec­
tive treatment option for this group of patients. Moreover, there is a clear
and direct correlation between the provision of psychotherapy and
a dramatic reduction in the number of psychiatric hospitalization days.
These two main findings, and particularly the significant savings resulting
from the reduced number of hospitalizations, have enabled the organiza­
tion to expand both the number of units and the number of patients in
treatment.

Freud (1919) stated in no uncertain terms that psychoanalytic treatment is a life-saving intervention for
patients with severe and complex emotional problems. In his article “Lines of advance in Psycho-analytic
Therapy”, he writes:“ … at some time or other the conscience of society will awake and remind it that the
poor man should have just as much right to assistance for his mind as he now has to the life saving help
offered by surgery; and that the neuroses threaten public health no less than tuberculosis … when this
happens, institutions or out-patient clinics will be started, to which analytically trained physicians will be
appointed, so that men who would otherwise give way to drink, women who have nearly succumbed
under their burden of privations, children for whom there is no choice but between running wild or
neurosis, may be made capable, by analysis of resistance and of efficient work … ” (Freud, 1919)
In the middle years of the 20th century, significant attempts were made to offer psychoanalytic
psychotherapy to patients suffering from chronic mental illness (Arieti, 1957; 1966, 1976; Searles,
1976, 1985; Fromm- Reichman, 1939, 1947, 1953, 1955, and others). However, the only records of
improvement in the patient’s clinical state were found in journals and clinical observations. No empirical
research was carried out and consequently no empirical evidence for the benefits of such therapy could
be presented.

CONTACT Ilan Amir, M.D. n_amir@012.net.il 61 IL Gordon Street, Apt. 5, Tel Aviv, 6438811, Israel.
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
 THE “LECHOL NEFESH” PROJECT 537

The 1980’s and 1990’s were marked by impressive developments in both the technology and the
methodology of psychotherapeutic research, with several studies reinforcing the view that that
psychoanalytically oriented therapies constituted a viable treatment modality based on empirical
evidence (Leichsenring, 2005; Shedler, 2010).
In addition, the realization that profound and far-reaching changes in the patients’ emotional
state remained largely out of reach despite pharmacological and cognitive treatment served to revive
professional interest in the use of psychoanalytic treatments for severe emotional disorders
(Gunderson & Gabbard, 1999; Martindale, 2000) along with a renewed need for empirical evaluation
of the results (Alanen et al., 2009).
Nonetheless, there is still controversy in the public mental health services regarding the value and
the legitimacy of this type of treatment. We believe that this lack of recognition stems partly from the
difficulty in establishing an appropriate setting for psychotherapy within these services. Absent such
a setting, the potential benefits of psychotherapy will not be realized.
Project “Lechol Nefesh” was founded in 2010 by a group of members of the Israel Psychoanalytic
Society (IPS) in order to provide a solution for this issue. Units offering long-term intensive
psychoanalytic psychotherapy were established within the public mental health clinics. The patients
treated at these units are given 2–3 psychotherapeutic sessions a week for a period of at least 3 years.
They are accepted without any diagnostic limitations, the only condition being the patient’s will­
ingness and capacity to attend sessions regularly and consistently. It should be stressed here that all
the patients referred to these units are patients whose troublesome emotional state has shown no
improvement despite undergoing the full range of treatments available at the clinics. The units are
staffed by psychiatrists, clinical psychologists and clinical social workers, who attend weekly clinical
and theoretical seminars, and individual supervision. The professional guidance of these units,
namely the running of the seminars and the provision of individual supervision, is provided on
a volunteer basis by psychoanalysts who are members of the IPS and the Tel Aviv Institute for
Contemporary Psychoanalysis.
Our research team provides professional feedback on the therapeutic activity of the units and
monitors the influence of the long-term intensive psychoanalytic psychotherapy on the patients’
emotional state, ability to function and quality of life. In addition, we have assessed the cost-benefit
criteria for this type of treatment.
In this article we will try to show how long-term intensive psychoanalytic psychotherapy, offered
within a framework that provides holding and containing for both patient and therapist, can enable
emotional growth and significant change even for patients diagnosed with a wide range of psychia­
tric disorders including treatment-resistant paranoid schizophrenia.

Case presentation
“You can’t be a doctor without listening to the patient, this is a fake.”
Reuven’s psychotherapy takes place in one of the units run by “Lechol Nefesh” and has continued
for the last 6 years. In this case study we will first illustrate how psychoanalytic listening, evolving
with the help of a containing supervision, enabled the therapist to think Reuven’s pain and
emotional experience. Later we will show how the containing and emotional holding of Reuven
enabled him to reach states of mental functioning and processing that translated into moments
where his emotional experience attained meaning, and where he in turn was able to feel under­
stood and contained by the treatment and the therapist. We will also attempt to show how this
unique psychotherapy and the concomitant emotional growth allowed Reuven, who had been
diagnosed with chronic and treatment-resistant paranoid schizophrenia, to breach the massive
walls of alienation, suspicion, lack of trust, lack of functioning, and mainly a multi-layered
delusional system that had covered and protected him while isolating him from the world for
many years.
538 I. AMIR AND G. SHEFLER

Reuven, a man of about 50, was one of those long-term chronic patients for whom the closed
psychiatric ward had become his permanent place of residence. It was as though he were part of the
ward furniture. He would spend most of the day lying on the floor doing nothing, unshaven,
barefoot, in stained clothing. With his head resting on his arms, he would mutter to himself in
a monotonous voice, rambling on about fake doctors, terrorists, homosexuals, spies and doubles. For
many years he has been in a chronic psychotic state, wandering from one hospitalization to the next,
sometimes by force or under a court order, resistant to the entire range of pharmacological and
psycho-social services offered him.
David, the therapist, is a senior clinical psychologist in the ward where Reuven was hospitalized
and a member of the Lechol Nefesh project.
The connection with Reuven began one day when he stopped David in the hallway, and
whispered in his ear that a day earlier he, David, had been kidnapped and killed, and then been
replaced by a double. Later on David invited Reuven to join a therapeutic group under his leader­
ship, and when Reuven was given permission to speak he would repeatedly say that the doctors
treating him were “fake”, while providing weird explanations for this claim, involving the FBI, the
CIA, Interpol, Nazis, a Jewish Hitler and the Inquisition. Reuven would explain how each of them
had obtained his “fake” license, the license which enabled them to give him, Reuven, painful
injections in his legs and in general to study medicine at his expense. During this period Reuven
approached David several times and asked him to arrange some sessions.
David had always been curious about this patient, and when he joined the Lechol Nefesh project
he decided to offer Reuven treatment within the unit. Since then, for more than 6 years Reuven has
been attending twice-weekly sessions regularly. David has also become Reuven’s “case manager”,
responsible for all his dealings with the hospital, obtaining medications, handling disability allow­
ance claims and so forth.
The information in Reuven’s medical file is fragmentary. It is known that he was hospitalized for
a long period in a “maximum security” ward, after he injured a nurse during one of his hospitaliza­
tions. Until a few years ago he was a drug user, and apparently he was jailed several times. He is
diagnosed as a paranoid schizophrenic with no remission, a patient with a psychosis “resistant” to all
medications, an individual who is barely functioning and unable to handle even his most basic
personal affairs.
It is difficult to obtain a clear picture of Reuven’s past. On one occasion the therapist described
Reuben’s life as follows: “Perhaps Reuven was born in Morocco, where he was raised by his religious
grandparents, and perhaps he was born and raised on a kibbutz in the Jordan Valley, like many of
his friends during his military service, where he served in an elite commando unit, or maybe he
served in the Air Force as a pilot. The woman (his mother) in whose home he goes to stay on his
breaks from the ward, at times when his mental condition permits, is actually a double, a spy who is
pretending to be his real mother. His real mother remained in Morocco, and perhaps she is
a Holocaust survivor from Treblinka. This home is not his real home. He actually lives on
a kibbutz with his wife and children, and maybe he lives on a secret military base in the Shuf
mountains in Lebanon.
It is possible that Reuven has siblings. During his sessions he speaks about a sister who is married
to Vladimir Putin, and sometimes he mentions other siblings, a twin brother, “many Reuvens”. The
therapist has the impression that the home is run “in a crazy way”. A very low income, a father who
runs a stall in the market, who was perhaps also in prison at some point. When Reuven was 12 his
parents divorced, and he was sent to a kibbutz, or maybe to a boarding school. When he speaks
about his mother, he often speaks about a woman who walks around the house naked, and who
favors his drug-addicted brother who is like a partner for her.
In the early stages of the therapy, David felt swamped by a torrent of confused, incomprehensible
words and sentence fragments. Reuven’s language was unclear and strange, words were distorted and
sometimes invented, sentences had a beginning but no clear end or ended unexpectedly. David was
overwhelmed, confused and frustrated after every session, unable to recall or reconstruct what
 THE “LECHOL NEFESH” PROJECT 539

happened and exhausted by his futile attempts to listen and to make sense of Reuven’s speech.
Whenever he tried to find some kind of logic in these utterances, or to hold onto parts of a sentence
which could perhaps create a sense of order, he found himself even more disoriented. Moreover, all
his attempts to link Reuven’s words to details drawn from Reuven’s history produced an incoherent
picture and only created further bewilderment.
Example:
Reuven enters the room with a broad smile, says something positive about the Independence Day
holiday of the previous day and adds: We watched the fighter planes. Mom was delighted.
David: Mom was happy? Because of the planes?
Reuven: Yes. She was thrilled … . and we ate livers.
David: You had a barbecue … … .
Reuven: We ate livers … … livers counter-warfare against spying by means of
anti-spying. Against spying by the Shit method.
David: What method is that?
Reuven (becomes serious; It is marine spying, under the sea … .everything that moves in the sea …
David feels that he enjoys .passes to me. If somebody … .(unclear speech) … . bits of oil, shit,
giving his explanation): everything … . and the sewage pipes, they can check the shit with the
medical spying method, and that’s how they can find out.
David: Is that how they collect information? The spies?
Reuven: They also said that Israel has gas, right? That’s also spying.
David: The drilling platforms in the sea?
Reuven: They’re not for drilling. They’re for spying. They’re for spying by the
marine method. Wire tapping facilities.
David: Who is listening?
Reuven: The enemy is listening to conversations and radio messages … . (unclear
speech) … . the undersea commando method, the Rosh Hanikra sys­
tem … . the name of my commander.
When David presented this material to Tamar, his supervisor, she too felt overwhelmed, as if she
were being bombarded and under fire on the battle field. Parallel to the therapist, Tamar also felt that
she was unable to think, to understand, to find any kind of connections or sense in Reuven’s words.
During the supervision sessions she found herself reading and rereading the report, making
a tremendous effort to concentrate, and coming out with a headache.
Tamar understood that she, like David, felt that her container is overflowing, that she is being
attacked by Reuven’s breakdown, by the flood of unintelligible and empty words, by the therapist’s
entanglement in Reuven’s psychotic experience. She gradually came to see that the flooding, the
tension and the sense of being under attack that David felt in the sessions, were Reuven’s way of
communicating, by means of projective identification, something of his own experience of the
psychotic breakdown. By attacking the therapist’s capacity to think, to do the work of reverie,
Reuven was telling him about the meaning-attacking object within him.
In retrospect, when Tamar thought about the headache that “attacked” her, she realized that this
sense of being attacked, of “my head exploding”, this sensation of her head being crammed with
a jumbled pile of beta elements, is an expression of Reuven’s “head-ache”, the pain that could not yet
be thought in the therapy.
For obvious reasons Reuven cannot trust David, since he is a member of the ward staff and
therefore belongs to the group of “fake doctors” and homosexual spies. At best, Reuven manages to
make David experience first-hand the suspicion and the terror that he, Reuven, inhabits.
In this way David, like Reuven himself, will become a captive of these terrors and a victim of their
power. And there are moments when the therapist is actually a double pretending to be a therapist,
who is out to steal Reuven’s valuable treasures and to gain access to his secrets. It does not help
matters that David is also Reuven’s “case manager” and is responsible for his everyday affairs.
540 I. AMIR AND G. SHEFLER

At this stage, when the therapist attempts to relates to Reuven’s lack of trust and to his anger at
the doctors and also toward the therapist himself, Reuven continues to obscure his utterances in
a fog of words. “Psychedelic invoration”, he tells the therapist when the latter is trying to discuss
Reuven’s battles against the injustices being done to him. “ … .by Dali, the artist, and also Nikolai
Ceausescu, the sixth psychedelic Nikolai.” Reuven must get rid of and eject from himself everything
that is unbearable, including distancing the therapist from the possibility of touching his pain.
In supervision, the therapist relates that he feels unable to reach Reuven, who rejects and ignores
him while expelling his own internal world. There is a sensation that he is living in a dream, maybe
within the surrealistic world of Dali, which slips into his speech. According to Bion (1962), in the
absence of the capacity to give meaning to thoughts with the help of alpha functions, Reuven is
unable to wake up from his dream. He is living in a dream without the capacity to do the work of
dreaming.
In searching for additional ways to help the therapist understand Reuven’s nightmarish world,
Tamar finds that her understanding of Reuven and of the therapeutic relationship are enhanced by
Bion’s (1967) thinking and his understanding of psychosis. Gradually she begins to explore further
ways of listening to Reuven’s experience, trying to perceive what lies beyond the jumbled, incoherent
words and abandoning the attempt “to find logic”.
Both David and Tamar begin to attend more carefully to the moments of more severe break­
down – the moments of unclear words and fragmented sentences, or the places where Reuven
“demolishes” the characters, they are not the “real” people, they appear under a different identity or
become doubles, or where the therapist becomes a double. In this way they try to identify where and
when the change occurs and then to deduce the nature of the pain that Reuven cannot bear at these
moments. What is this pain that he must dismantle by projecting his feelings onto “the unreal
people”?
Bion (1987) regards supervision as a place where movement is engendered within the therapist. In
his Los Angeles seminars (Bion, 1987) he says that during supervision sessions, he listens to the way
in which the patient lives between himself and the therapist at a given moment. Tamar and David
are attempting to give more space to how he feels during his work with this patient, and she takes
him back to the terrifying experience of working under fire and being bombarded by shells, like on
the battlefield. David is also trying to listen to himself more intently, to be more aware of the
counter-transference, to delineate his own feelings during the therapy sessions more precisely.
As time goes on, he becomes more adept at listening with his own intuition, and he realizes that
within the incoherent flood of language, Reuven sometimes implants a word charged with meaning,
or an expression carrying an unbearable emotional load. Gradually, David succeeds in extracting
these items from Reuven’s torrent of speech. He becomes aware of words that sound unfamiliar to
him even in the context of Reuven’s inexplicable language. Similar, perhaps, to the work we would
do on a dream, in the language of Freud.

Example
Reuven (speaking about his mistrust of the doctors in the ward): This is what’s called being an
American at the expense of a patient. That’s what I learned from a patient today. Communism, it’s
sociological. That’s what they told him and he is not a rapist.
David thinks about the word “rape”. And then he remembers a remark made to Reuven by one of
the women on the staff that he shouldn’t touch her without her permission.
David: You were hurt by the remark that Etty made to you.
Reuven: What do you mean hurt? But I’m not a rapist. I just touched her like this.
Ferro (2006), following Bion (1970), writes that the therapist’s mind should be open and receptive
to all the sensory and the para-mental stimuli that arise, and that he should remain in an
“unsaturated state”, as this illustrates the growth of the container.
 THE “LECHOL NEFESH” PROJECT 541

Increasingly, the supervision sessions allow David to free himself from clinging to facts, to
“reality”, and to listen to the events in the room, without actually needing to know. He begins to
see that at the moments when the fog is thickest, when Reuven breaks down in order to prevent
David from thinking – that these are actually the times of greatest distress, the times when Reuven
needs his efforts at listening more than ever. He learns to stay with Reuven until he can understand
what is happening.
Reuven’s trust in the therapist gradually evolves, and he is prepared “to sell him his secrets”. The
therapist is awarded the rank of “commander”. It is true that he may be thrown out of the IDF if he
“screws up”, but in fact Reuven is developing a more substantial sense that David is protecting him
and taking care of his rights and interests. In one of the sessions, he says: “You will get a Nobel
prize in Stockholm. You give me a listening ear.” He also allows himself to express this in a more
direct emotional way. One day, after David had been away due to illness, Reuven tells him: “I
missed you.”
As part of the intensifying bond between Reuven and David, Reuven brings him various objects to
keep in his room – another way of transmitting to his therapist how he experiences himself, and
perhaps also a way of marking his place in the room and his desire to feel that the room also belongs
to him, that he has a home, and to secure his place with the therapist. He brings a wooden crucifix
with a small figure of Jesus, places it in the earth of a plant on the therapist’s closet and says “I want
this to be here”. And then he explains: “This is Jesus … . a holy saint. He also suffered greatly and
people thought that he was mad. He suffered a lot, and they crucified him.”
In the same session, Reuven allows David to reach his pain.

David: What is this actually, Reuven?

Reuven: It is Jesus on the cross. Crusaders. Crusades. Do you know what a crusade
is? The Inquisition made a crusade … .the crusade of Mordechai Vanunu
(Israeli former nuclear technician and peace activist, later convicted of
spying against Israel.) OK, I’m tired. We’re done.
David: Do you want to go?
Reuven (remains I’m not in the army. I never even served in the army. I got an exemption
seated quietly for another because they found traces of heroin in my urine. I was just telling you
few minutes): stories before. I wasn’t in the Air Force, or in the commando unit.
David: They didn’t recruit you for the army. You were in a very difficult period.
Reuven: Yes. I think about that a lot.
David: You are ashamed because you weren’t recruited.
Reuven: It’s not good that I used heroin and drugs … … .
As time goes on, Reuven brings the therapist more gifts to keep in the closet. In supervision,
Tamar and David understand that Reuven is turning this closet into a container for parts of his
internal world, similar to a box that children in therapy leave in their therapist’s room for safe­
keeping. Reuven brings a kippa (skullcap) as a gift, a broken camera, secret documents, a clock and
sunglasses. “These are ‘terminator’ sunglasses” he tells David. “You need these.” Some days later,
when he sees the glasses on David’s table, he says: “That’s strange, a few days ago I brought a pair of
glasses to one of the therapists … . and since then all the ‘therapists’ have got glasses like these.” In
the supervision we understand that perhaps he is giving the therapist a tool to defend himself against
the killings in his inner world, but this thought can still lead to breakdown.
Increasingly we see indications that Reuven has internalized the receptive containing offered
by David. Reuven rejects him less frequently and is gradually becoming more capable of reacting
and relating to David’s interventions. During the sessions there is a sense of movement and
more moments of emotional dialogue. It is also becoming clear that in those moments where
David succeeds in grasping Reuven’s emotional experience, he organizes his thinking and his
speech becomes coherent. At such times David notices that both the dialogue and Reuven’s way
542 I. AMIR AND G. SHEFLER

of speaking are changed. His speech is less dry and monotonous, and he sounds more varied and
emotional.
As the work in the supervision becomes more focused, David and Tamar are increasingly able to
see at which moments the breakdowns in Reuven’s speech are connected to something intolerable in
his relationship with the therapist. Meltzer (2002) claims that emotional growth depends on the
development of the patient’s capacity to assign meaning to his ongoing experience of the therapist’s
presence or absence within the transference.
The following dialogue is part of a session that illustrates this emotional development.
Reuven: Listen, your vacation was treachery (raises his hand as if to show the therapist that he
should not interrupt)
David: Treachery?
Reuven: Treachery … .What treachery? Listen.
Reuven Mammiato – there are 70 or 100 Mammiatos. There is one in Japan, one in Russia, one
(continues): in Germany.
David: 70 Mammiatos?
Reuven: Yes … . whose sisters … . and “Shlomim” (In Hebrew Shalom is a Hebrew word with
several meanings – Hello/peace/a name). We had this at the time of “Doom”. “Doom”
is a terror organization … so Doom set out after your vacation. Why? Charlie Chaplin’s
daughter, she was at home, she your whole vacation … . your vacation was a betrayal of
Charlie Chaplin.
David: My vacation causes a lot of problems … … .
Reuven: You don’t have an authorized signature on your vacation. The signature of the hospital
director, Shmaya Angel (Translator’s note: a well-known Israeli mafia leader). It has to
be signed Shmaya! … .Not because of the terror … .that’s what they learned, the
vacations and the treachery, the terror … .
David: They’re exploiting the fact that I’m not here … .
Reuven: In order to promote themselves … . they’ve gotten used to destroying, killing, murder­
ing … .a vacation is a betrayal of the motherland! It is state terror it … .
Toward the end of the session, Reuven suddenly asks David: You are Iraqi, right? (points to
David’s cheek)
David: Are you talking about the scar I have here?
Reuven: Yes. It’s from the mosquito system, mosquitoes that bite, and it looks like a flower. Are you
Iraqi?
David: Why? Do only Iraqi people have this illness?
Reuven: Yavchush. The government called this system Yavchush.
David: Why are you asking about the Iraqis?
Reuven: Because they love Morocco … .(Reuven is Moroccan)
David: Maybe you’re just asking if you have a place with me even when I’m not here.
Reuven: I want you to remember our conversations and to think of me. Like on MTV. He fought
against … . He thinks about his wife.
David: You’re right. If you know that I’m thinking about you even when I’m not here, that will
give you a feeling of security, just like the authorization from Shmaya.
Reuven nods.
At this moment David allows Reuven to get closer, to touch the scar on his cheek. In supervision,
he and Tamar also talk about the possibility that Reuven’s concern about the insect bite is connected
to David’s vacation. A bite is also a “sting”. (Translator’s note: in Hebrew these two words, “akitza”
(insect bite) and “oketz” (sting) are derived from the same root). Perhaps Reuven is talking about the
pain of separation and also about his feeling that there is some kind of “sting operation” here. The
therapist is supposed to be with him, not to go on vacation.
 THE “LECHOL NEFESH” PROJECT 543

The issue of “fake doctors” is a good example of the shared growth taking place between David
and Reuven. Here an emotional space has opened up for David under the influence of his relation­
ship with Reuven, and this development has in turn created further growth within Reuven. David is
beginning to think about Reuven’s anger at the “fake doctors” in terms of Reuven’s need to obtain
a fair deal, understanding, dialogue, as a kind of protest at the fact that they didn’t listen to him. As
time goes on, David finds himself in agreement with Reuven’s opinion that the doctors who treated
him only with medications all those years were indeed in some sense “fake”. In one of the sessions,
when David relates to Reuven’s complaint about “fake doctors” in terms of his need to be listened to,
Reuven answers: “You can’t be a doctor without listening to the patient, this is a fake.”
At the morning group meeting that week, Reuven announces that he is feeling better because now
he has a “contact person”. From that moment on, he no longer speaks about “fake doctors”.
We can also see changes in Reuven’s capacity to deal with situations of anger or disappointment
with regard to his treatment, primarily when dealing with money issues. Previously, Reuven would
“blow up” the session and walk out when the topic of money arose. Now a dialogue has become
possible, and Reuven can allow the session to take place and to continue.
A brief note on the topic of money in this treatment: There is a court ruling that Reuven is
incapable of handling his financial affairs, and the Public Fund for Care of the Institutionalized has
been appointed as his custodian. For many years, Reuven’s inability to handle his finances was an
unending source of problems. He would borrow money from the staff and other patients, while
accusing the ward staff and the Fund of stealing his money and handing it over to other patients who
had ties with the Russian mafia. Because David was also Reuven’s “case manager”, the issue of
money became part of the therapeutic work. By working through the implications of this topic for
their relationship – Reuven’s total dependence on his therapist, the question of the therapist’s loyalty,
to what extent he protected Reuven, and his position in comparison to other patients – David
succeeded in becoming the voice of reality for this patient. Reuven learned to handle his money
more sensibly without over spending his budget. He paid off his debts and even managed to save
some money. Recently he told David: “You have taught me about savings and finance – before this
I was really crazy.” This is a significant insight, for at such moments Reuven succeeds in distin­
guishing between the psychotic and the non-psychotic parts of his personality. When he speaks
about saving, he is speaking about a new function that has been born within him, the ability to retain
something, to hold it and not to let it leak away.
About two years after the start of the treatment, Reuven was released from the closed ward and
moved to a day-care center. From that moment on, now for a period of over 4 years, he comes to the
ward only twice a week for his therapy sessions. After twenty years during which Reuven had spent
most of his time in the closed wards of psychiatric hospitals, and in the closed psychiatric wards in
prison, this is the longest period that Reuven has not needed hospitalization.

Research and evaluation

Our research had two objectives: first, to evaluate the effect of intensive long-term psychoanalytic
psychotherapy on severely disturbed patients under treatment in the public mental health centers.
Second, to compare the results of this psychotherapy to the “treatment as usual” normally provided
in these centers. We hypothesized that intensive long-term psychoanalytic psychotherapy would
bring about significant results, and that these would be more beneficial than those achieved by the
usual treatments
To examine these hypotheses, we planned and implemented a nonrandom comparative prospec­
tive results research which followed the project from its inception. The research was restricted to
a comparative results research project. Process research was excluded in order not to burden the
patients and the therapists with additional research tasks.
Out of approximately 40 patients referred to the therapy unit, 18 participated in the research
project (age range 18–64). All those referred were accepted after an intake session where we
544 I. AMIR AND G. SHEFLER

Table 1. Socio-demographic characteristics.

Study Group Compare Group
(n = 18) (n = 31)
Gender Females 8 19
Males 10 12
Age 20–29 4 5
30-39 6 3
40–49 2 7
50-59 4 8
60+ 2 8
Diagnosis Psychotics 8 7
Per. Disorders 10 24
Employment or studies Unemployment 9 14
Full 2 5
Partial 7 11
Missing 1

explained the therapeutic contract and obtained their consent to participating in the research
program. These 18 patients managed to remain in the framework of the program and to attend
sessions regularly and consistently, while the others dropped out of the therapy during the first
weeks and months. This group were compared to 31 patients selected by the “matched pairs”
method, so that each participant in the project was matched to at least one patient with similar socio-
demographic and psychopathological characteristics.
The socio-demographic characteristics of the participants in both groups are shown in Table 1.
Table 1 shows clearly that the socio-demographic characteristics are similar for both groups. With
regard to diagnostics, it appears that the ratio between psychoses and personality disorders indicates
that the patients in the study group are more severely ill than those in the compare group.
Each participant was asked to complete three questionnaires prior to the start of therapy, and to
repeat this procedure every six months.

1. Outcome Questionnaire, Lambert et al. (1996)

Valid and reliable 45-question questionnaire designed to examine changes in the patient’s clinical
and psychodynamic state by means of repeated assessments during the course of psychotherapy.

2. Symptom Check List – 90 (SCL-90), Derogatis et al. (1973)

Valid and reliable questionnaire to be completed by the patient himself and widely used in research
on psychotherapy and psychopathology.

3. Beck Depression Inventory (BDI-II), Beck et al. (1996)

Developed by Beck, Mendelsohn and Arbeo, in a new and updated edition designed to measure
symptoms of depression

Results
Due to space limitations, we will present the findings for the full scale of each of the measuring tools
used.
Figure 1 clearly shows a marked and statistically significant improvement in the SCL- 90 Full
Scale scores of patients in the study group in comparison with those in the compare group.
 THE “LECHOL NEFESH” PROJECT 545

Figure 1. SCL-90 full scale.

Similar findings were obtained in the sub scales of SCL 90 in each of the following scales:
psychosis, paranoia, obsessiveness and interpersonal relations, where an improvement in these
areas is particularly significant for this group of patients.
Similar results were obtained in the Beck Depression Inventory Questionnaire (Figure 2) and the
OQ 45 full scale (Figure 3).

Figure 2. BDI.
546 I. AMIR AND G. SHEFLER

Figure 3. OQ45 full scale.

The research results, as shown in Figures 1–3, provide a clear and statistically significant
indication that long-term, intensive psychoanalytic psychotherapy is a valid and effective treatment
option for reducing the suffering and the psychiatric symptoms of severely ill patients who are
unresponsive to the usual basket of treatments offered by public mental health centers.
In one of our most surprising and significant findings, a majority of patients showed some clinical
and symptomatic deterioration at the end of the first year of treatment. It appears that this
deterioration results from the regression process, while simultaneously embodying the start of
a change in the patient’s defense mechanisms.
In addition to the standard measuring scales, we also examined the average number of annual
hospitalization days in psychiatric institutions of the study group in the five years preceding the
project and in the five years following the start of the project.
As shown in Figure 4, during the five years prior to the start of the project the average number of
hospitalization days per patient for the study group was 75.5 days per year, whereas for the five years
after the start of the project the average number of hospitalizations days per patient per year was
reduced dramatically to 1.22.
We also measured the cumulative days of hospitalization for the 18 patients participating in our
research program. During the 5 year period prior to starting psychotherapy, the patients had
accumulated 1600 days of hospitalization. In contrast, for the 5-year period after starting therapy
(and, we can add, also for the three years of follow-up after the research ended), we measured only
50 days of hospitalization.
 THE “LECHOL NEFESH” PROJECT 547

Figure 4. Number of hospitalization days of study group before and after start of project.

Discussion
In this article we have tried to demonstrate how long-term intensive psychoanalytic psychotherapy,
provided within an appropriate framework, can provide a treatment with dramatic and far-reaching
effects, even for patients diagnosed with a wide range of treatment-resistant psychiatric disorders
and illnesses including extended psychotic crises.
The research results also indicate that this unique type of therapy offers these patients a real
chance to break out of a life cycle of illness, repeated hospitalizations, despair and nonfunctioning,
and to move to a life that offers value, meaning and the capacity to function. In our view, an
appropriate therapeutic setting is one which provides intensive psychotherapy (2–3 sessions weekly),
for a period of at least 3 years. Such therapy should be made available at the public mental health
centers, within the framework of special units that specialize in this type of treatment and can
provide individual supervision, and weekly theoretical and clinical seminars. These findings are of
major importance when seen against the background of the drastic decline in psychoanalytic
psychotherapy in general, in institutions and public mental health centers in particular and especially
for chronic psychiatric patients.
Based on our experience to date we have found that the most significant and important prog­
nostic factor for the success of the therapy is not the psychiatric diagnosis or the patient’s psychiatric
history, but primarily his capacity to persevere with the program and attend therapy sessions
regularly and consistently. This factor could not be predicted in the majority of cases. It is also
noteworthy that the percentage of dropouts among those patients who were referred to the program
and actually started therapy stood at 50% at the start of the project and today, thanks to the
experience gained, has been reduced to 20%.
From a theoretical point of view, there is no one central theoretical approach that defines the
work of the units, since the psychoanalysts who serve as the heads of units, group or individual
supervisors are affiliated with several theoretical schools (Freudian, Kleinian, Winicottian,
Bionian, Relational, Kohutian and others). We have seen that the capacity to think the patient
through a wide prism of divergent theoretical viewpoints has proved tremendously helpful to the
therapists in containing and handling the difficult and complex psychopathologies of their
patients. To quote one of the therapists: “the fact that about 15 therapists and supervisors
548 I. AMIR AND G. SHEFLER

thought my patient over a long period turned out to be a critical factor in my ability to
treat him.”
In our view, the crucial element of the therapies has been the therapists’ capacity to enable
the patients to feel understood, visible, safe and held within a specific type of therapeutic
framework – respectful, accepting, patient, non-judgmental, non-directive, stable, intensive and
long-term.
Over the years, we have come to regard the psychotherapy as a type of psycho-dialysis. It allows
patients struggling with chronic mental and emotional insufficiency to get rid of the emotional
toxins that they could not expel autonomously. And just as patients with chronic kidney dysfunction
are not restricted to a specific number of weekly dialysis treatments or a pre-determined period of
dialysis, even when there is no cure in sight for their illness, neither should we expect or aim for “a
cure” for our psychiatric patients. Consequently we have focused on the attempt to activate the
psycho-dialytic function of the psychoanalytic psychotherapy.
For the public mental health centers and the health insurance companies, the most significant
result of the research was clearly the halting of the “revolving door” of repeated hospitalizations
common to many of the patients participating in the project. This reduction in hospitalization days
resulted in a massive saving, from 1600 hospitalization days in the 5 years preceding the therapy to
less than 50 days of elective hospitalization of only one of the patients in the 5 years following the
patient’s participation in the project. These figures do not include the substantial saving in
hospitalization days for Reuven, who was released from a chronic 20-year-long hospitalization
two years after beginning psychotherapy. He was not included in the study group because at the
time his mental and emotional condition prevented him from completing the questionnaires and
participating in the research.
Due to the results of the research, and particularly to the reduction in hospitalization days, it has
become possible to expand both the number of units and the number of patients in treatment within
the framework of the Lechol Nefesh project.
The project opened in 2010 with one unit treating approximately 20 patients, and today there are
five active units treating approximately 100 patients between the ages of 4–70.
Thus we have succeeded in establishing long-term intensive psychoanalytic psychotherapy as
a legitimate and valuable treatment modality, within the public mental health services. Indeed, we
may say that we have come closer to Freud’s view of psychoanalytic psychotherapy as a valuable
treatment “for every soul”, including for those who are in severe mental distress and lack the means
to pay for private psychotherapy.

Acknowledgments
We wish to thank our colleagues (listed here in alphabetical order) for their valuable and consistent support and
contribution in making this project possible: Mr. Ron Finkenberg, Ms. Talia Fruhauf, Prof. Gili Goldzweig, Ms. Pumpi
Harel, Mr. Yair Kfir, Dr. Ido Lurie, Ms. Naomi Miller, Dr. Ayelet Plus, Ms. Rachel Reubinoff, Ms. Yael Samuel,
Dr. Henri Szor, Ms. Yfat Ziber.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Ilan Amir, M.D., is psychiatrist and training psychoanalyst at the Israel Psychoanalytic Society; lecturer at the Tel Aviv
University Psychotherapy Program; and chairman of the NPO “Lechol Nefesh”.
 THE “LECHOL NEFESH” PROJECT 549

Gaby Shefler, Ph.D., is associate professor in clinical psychology, senior clinical psychologist and training psycho­
analyst at the Israel Psychoanalytic Society. Formerly: Chief psychologist at the Herzog Ezrat Nashim Hospital in
Jerusalem, director of the Freud Center for Psychoanalytic Studies and holder of the Sigmund Freud Chair for
Psychoanalysis at the Hebrew University of Jerusalem.

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