By Rabbi Abraham J. Twerski, MD

As I wrap up my psychiatric career, I’d like to share how I got here.

I had served as assistant Rabbi in my father’s shul in Milwaukee for several years. The members of the community, many of them age 50 and above, were all wonderful people. I had grown up among them and I was very fond of them. However, they had little need for what I could offer them based on my yeshivah education. They listened respectfully to my sermons, and that was about it. They had no need for classes in Torah. For the younger generation, Torah education consisted of after-school Talmud Torah, which was for bar mitzvah preparation. That too was often disappointing, because many would celebrate the event with a non-kosher dinner.

The senior population was fiercely devoted to my father, who, as a chassidic Rebbe, was a gifted psychotherapist. He never read a single book on psychology but had a keen understanding of people and mirrored their devotion. He loved his people. His study was always buzzing with those who sought his guidance.

I had anticipated that I would follow in my father’s footsteps. However, after the Second World War, due to the plethora of combat neuroses, psychology and psychiatry had a meteoric rise. It was evident to me that my generation would seek guidance from a mental-health professional rather than a Rabbi, and that I would function essentially as a performer of rituals, which was not to my taste. I had to pursue the mental-health profession, for which I entered medical school with psychiatry as my goal.

My first direction came from my professor of pathology. “Twerski,” he said, “what do you plan to do after medical school?” I told him that I was interested in psychiatry. “Good, good,” he said. “Listen to what they teach you so that you can give it back to them on the board exams. Then forget it all and use your head.”

Medical school was fascinating, as was the year of general internship. I was tempted to forget psychiatry and become a surgeon, but I persisted. I applied to several programs and entered the University of Pittsburgh Western Psychiatric Institute. The latter was orthodox Freudian, where one was expected to say “Ani maamin” that everything Sigmund Freud said was true.

When I returned home for a visit, my father asked me what I had learned. I told him about the unconscious and the defense mechanisms, and that psychoanalytic treatment required four sessions a week and could take several years.

He responded with the following story:

The Jews in Eastern Europe had a precarious existence. The populace was anti-Semitic and pogroms were not rare. In one fiefdom, the poritz was a pacifist and did not condone violence. The peasants sought to stir him up and said that his tolerance of Jews was unfaithful to the church, but he did not allow a pogrom.

Finally, they found his Achilles heel. He had a pet dog who was his constant companion. They said to him, “Your Excellency, you know that the Jews are a very resourceful people. They know how to teach a dog to talk. This is a tightly kept secret. They would not teach your dog to talk because you are not one of them.”

The poritz summoned the leaders of the Jewish community and said, “You know how I have protected you against pogroms. I have a huge favor to ask of you. My dog is my dearest friend. If he were able to talk, I would be the happiest man on earth. I want you to teach him to talk.”

The community leaders said, “Your Excellency, we would do anything you ask of us. We would go into fire for you. But don’t ask us to do the impossible. There is no way to teach a dog to talk.”

The poritz became irate. “So that is how you repay me for protecting you all these years! I will have none of your excuses. You teach my dog to talk, or in 30 days I want all Jews out of my fiefdom.”

The Jews did not know what to do. They fasted and prayed for a miracle to save them. As the 30 days drew to a close, they began packing their belongings on wagons.

One of the lesser luminaries of the shtetl, a humble tailor, came forth. “Let me go to the poritz,” he said.

The Jews said, “You can’t reason with this meshugener. The Rabbanim tried, but he won’t listen.”

“What is there to lose?” the tailor said. “You’re packing your wagons to leave.”

The tailor went to the palace and a short while later came out with the dog on a leash. “Unpack the wagons,” he said.

“But how and what did you say to him? And what are you doing with that dog?”

“I explained to the poritz that a human child is more intelligent than a dog but doesn’t really speak until age three, so he must understand that a dog will not speak for six years.”

“And then?”

The tailor said, “Something will happen within six years to get us out of this. Either the dog will die, or the poritz will die, or I will die. Something will happen to save us.”

My father concluded, “If the treatment takes years, something will happen in the patient’s life to change him. You cannot attribute his recovery to the treatment.”

Although I did not see psychoanalysis as a practical treatment tool, some of Freud’s contributions were fundamental. His elucidations of the unconscious mind and the defense mechanisms are widely applied. Freud was followed by a number of disciples, and each made some valuable contributions.

I even felt a kind of kinship with Freud. We both came to the awareness of the unconscious mind via hypnosis.

I had a patient, a woman who suffered from severe anxiety. All my interpretations of the causes for her anxiety gave her no relief. She said, “I understand everything you say, Doctor, but it doesn’t help.”

I could not accept failure. I said to her, “Would you consider hypnosis?” She said she would consider anything that could help. I told her to think it over for several days. I had to delay the hypnosis because I had no idea how to hypnotize. I took out a book from the library on hypnosis, and I had a buddy, a fellow resident, who was knowledgeable in hypnosis. I decided I would be careful not to make any foolish suggestions and just listen.

The woman happened to be an excellent hypnotic subject, and although she did not reveal any new data, it was evident that what she related had an emotional impact. As treatment went on, I began to use techniques to bypass the critical function of the unconscious. For example, I suggested that her hand would write what was in her unconscious mind, but that she would not recognize what she had written unless she was comfortable doing so. I had her make up stories related to what she was feeling. She gained much insight into the causes of her anxiety, and eventually, she had total relief.

I became more adept at hypnosis, including hypnotic anesthesia, and had several remarkable cases.

The field of psychology grew with new contributions. I was eclectic, taking what I could from every method.

One day, the head of the department summoned me. “Dr. Twerski,” he said, “I think we owe a debt of gratitude to St. Francis Hospital. They are the only hospital in the city providing 24/7 emergency psychiatric services, and they never turn away a patient. They have been unable to keep a medical director. I’d like you to try to help them. Try it for a year.”

I was familiar with St. Francis hospital, having spent two months there during my residency. It was an unusual 750-bed hospital, of which 300 beds were psychiatric. Pittsburgh is the only major city I know of that, by charter, does not have a public hospital similar to Bellevue of New York, Cook County of Chicago, and Philadelphia General. All Pittsburgh hospitals were private and refused to admit “undesirable” patients — i.e., psychiatric cases or alcoholics. As a result, mentally ill or alcoholic patients were sent to jail.

The Sisters of St. Francis recognized this as an intolerable situation and had these patients brought to the hospital. When I arrived to become medical director, there was an alcoholic ward of 30 beds. Some alcoholics “dried out,” only to be admitted ten days later.

I met with the administrator, Sister Adele, and explained to her that I was not the person they were looking for. “You need someone who is available 24/7. My phone is shut off on Friday before sunset until Saturday night.”

Sister said, “Dr. Twerski, we would never think of calling you on your Sabbath.”

I said, “Sister, this is June. I am taking my family to Israel for two months.”

Sister said, “We’ve waited this long, we’ll wait longer.” She walked me to the door and said, “I know you will come to us…”

I took the position as a trial for one year and stayed for 20.

The hospital emergency room was extremely busy. Anything that appeared to be “different” was assumed to be due to mental illness. There were many cases that were due to serious physical illness but were brought to St. Francis emergency room because someone, family or police, thought them to be mentally ill. I wrote a book describing these cases, patients who could have died because their physical diseases were overlooked.

The alcoholism unit opened up a new vista. Medical school taught me nothing about addiction, nor was it taught in psychiatric training. I was introduced to the 12-step program of Alcoholics Anonymous, which was launched in 1936 by an alcoholic, Bill Wilson. I attended many AA meetings and realized that the program was very similar to Torah ethics.

I saw that AA had something to offer that psychiatry and psychology did not. I think that the reason why AA is effective is that there is strong group support and a philosophy of life that is founded on spirituality, which is not the same as religion. It has now been applied to many other conditions.

Upon learning about AA, I told Sister Adele that the revolving door of the alcoholism unit was not helpful to the alcoholics, because just being “dried out” did not give them any tools for sobriety. What was needed was a residential rehabilitation facility where the “dried-out” alcoholic could spend a month in recovery. The nearest facility was more than 300 miles away. We needed a local rehab facility. Sister agreed.

I made contact with local industries and foundations and collected funds to start a program. We obtained a government-supported loan and built a $2.5-million building on the outskirts of town. This opened its doors in 1972 and has grown into a major addiction treatment center.

It gradually dawned on me that there were few Jews in Alcoholics Anonymous. In Jewish culture, “a shikker is a goy.” The denial of alcoholism stood in the way of Jewish alcoholics getting help. They went to psychiatrists and psychologists but not to AA, which they thought was a Christian program because AA meetings were generally held in church basements. The reason for this was that synagogues did not welcome them. There was a small group called JACS (Jewish Alcoholics, Chemically Dependent Persons and Significant Others). I joined this group and began dispelling the myth that Jews are not alcoholics.

When the drug epidemic occurred, Jews were well represented. Families were in denial of the problem, and deaths of youngsters due to overdoses were covered up. We have not yet come to terms with this problem, although more young addicts are receiving help. Residential treatment is expensive and insurance may not cover the cost of treatment.

Many psychiatric problems can be treated — some with medications, some with therapy. Unfortunately, the Jewish family tends to cover up its problems, and many people who could be helped are not given the opportunity. There is still much community education that needs to be done.

I have found that several of the 12-step program principles are very useful in therapy. For example, there are things in the world that are changeable and things that are not. It is crucial to know which are which. If you try to change something that is unchangeable, it is like beating your head against a brick wall. You accomplish nothing and end up with a sore head. It is wise to assume that other people are unchangeable. You can change only yourself. Many marriages fail because one spouse tries to change the other. This is futile and almost always backfires.

There are many challenges in life. Don’t deal with what is unnecessary. Deal with today’s challenges today and leave tomorrow’s challenges for tomorrow.

It is natural to blame someone or something when things go wrong. Blame accomplishes nothing, except to act as an excuse to cover up your own mistakes or your own failure to take corrective action.

It is common to blame one’s parents. Even if your parents were at fault, the only helpful approach is, “Even if you are now what your parents made you, if you stay that way, it’s your own … fault.”

As I began seeing clients, it became evident to me that, regardless of their symptoms and problems, they all, without exception, had a negative self-concept. They did not think of themselves as worthy or likable and lacked self-confidence. I then realized that this was a common feature, even in “healthy” people. In fact, I saw some of these features in myself.

I looked for a universal rule that could apply to all people who sought my help and that was to do whatever possible to help a person feel worthy and better about himself. If you feel the other person is worthy, that feeling will transmit itself and increase self-esteem. In 1976, I published my first book, Like Yourself and Others Will, Too, on the theme of self-esteem, and I have continued my interest in this subject to the present day.

I think that publishing a book is much like eating potato chips: You can’t stop after one. I have by now published 84 books. Like any other American youngster, I grew up on comic strips. I found that the “Snoopy” cartoon strip by Charles Schulz was more than just entertaining. Schulz had the uncanny ability to demonstrate psychological concepts in cartoons, and I used these cartoons to enhance teaching residents and in many of my books.

Many people who have a negative self-image may not be aware of it. They feel themselves to be inadequate and inferior and believe this to be the truth. This is very painful, and the human mind seeks to escape the pain. Sometimes they act grandiose to cover up the feelings of inferiority. In Life’s Too Short, I described the more common defensive reactions to this feeling.

Traditional therapy attributes low self-esteem to faulty parenting. Unfortunately, children may blame their parents for their feelings of inferiority. I did not buy into this, because I had feelings of inferiority in spite of excellent parenting.

At about age 60, I came across a novel interpretation of a passuk in Tehillim (118:12) by Harav Simcha Zissel Ziv, a foremost mussar authority. Conventional wisdom has it that the yetzer hara is a force created by Hashem to deter people from observing the Torah. The yetzer hara operates by tempting people to violate the Torah, and we must do battle all our lives to resist the wiles of the yetzer hara. Torah-observant people follow a lifestyle of obedience to Hashem’s dictates. One can rather easily identify the ideation wrought by the yetzer hara. When a person feels tempted to partake of non-kosher food, to work on Shabbos, to steal, to have a forbidden relationship or to do anything that the Torah forbids, this is the work of the yetzer hara and one can use the Torah tools to resist it.

Rav Simcha Zissel’s unique contribution is that in addition to tempting a person to violate the Torah, the yetzer hara may delude a person into thinking poorly of himself. There is no frank violation of the Torah and, as with every delusion, one is taken in by this false belief.

A poor self-image is the source of many evils. Rabbeinu Yonah says that gaavah, the worst personality trait, is a defense against a poor self-image. The person creates grandiosity to counteract his low self-esteem (Rabbeinu Yonah al HaTorah). The desire to control others is the same. Having power over others may reduce the feeling of inferiority, and this is responsible for many marriage problems. Some people lie to inflate their egos.

Both underachievement and overachievement may be due to low self-esteem. The underachiever lacks self-confidence and resigns himself to failure. The overachiever seeks to prove that he can succeed. Any grade less than 100% is taken as evidence of one’s inability to perform properly.

Rav Simcha Zissel’s insight explains the paradox of low self-esteem. A person with meager personality strengths is not going to be given a whopper of a yetzer hara, whereas someone with great assets may be given a more powerful challenge. Hence, the more capable person may in fact have deeper feelings of inferiority.

Personal achievements may not eliminate the pain of a poor self-image. One industrialist who was a pillar of the community confided, “One wall in my house is covered with tributes and plaques. They mean nothing to me.”

Indeed, the suffering we experienced and commemorate on Tishah B’Av has its origin in poor self-image. The Meraglim said, “We saw giants in Canaan and we felt as tiny as locusts, and that’s how we appeared to them” (Bamidbar 13:33). The Chiddushei Harim says, “The way you feel about yourself is how you assume others perceive you.”

Simchah is essential for true avodas Hashem. The yetzer hara scores a major triumph by making a person feel unworthy, which deprives him of simchah.

A psychotherapist can help you deal with those factors that are causative of low self-esteem that I mentioned earlier but cannot help you in the battle with the yetzer hara. It is crucial that when you find yourself with feelings of unworthiness and inferiority you remind yourself that this is the work of the yetzer hara to disable you. Use sifrei mussar to counteract this.

Always remember the words of the Gemara: “Beloved are the people of Israel, for they are described as the children of Hashem” (Pirkei Avos 3:18). The yetzer hara is at work 24/7/52 to make you forget this. Don’t allow it to succeed. Pray to Hashem for His help in resisting the wiles of the yetzer hara.