Mental Health, Psychotherapy and Judaism
by Seymour Hoffman, Ph. D.
Copyright
Seymour Hoffman, Ph. D.:
Mental Health, Psychotherapy and Judaism
© 2011 Seymour Hoffman and Golden Sky (an imprint of Mondial)
This book or parts thereof may not be reproduced in any form, stored in a retrieval system, or transmitted in any form by any means—electronic, mechanical, photocopy, recording, or otherwise—without the prior written permission of the publisher or the author, except as provided by United States of America copyright law.
Cover: © Golden Sky
Published at Smashwords.
ISBN: 9781595692214 (print edition)
ISBN: 9781595692320 (eBook)
Library of Congress Control Number: 2011934329
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Introduction and Dedication
For too many years there was a distinct chasm between therapists and rabbis, as each buttressed themselves behind their profession’s truths and disparaging goals.
In the past two decades this has changed with an enhanced regard and understanding of the influence of that common element of human nature, loosely referred to as spiritualism. People in the helping professions as well as in the general public give credit to the interaction and influence of this vaguely understood aspect of humanity, whereas rabbis and theologians have come to appreciate the skills and experience of community workers in the field of mental health and family care.
Nefesh Israel is an organization of observant clinicians which recognize the advantages of pulling together with men of the spirit, pooling resources and giving scope for members of both fields to cooperate, enrich each other, even while recognizing the differences in their orientation, purpose and methods.
Dr. Hoffman’s efforts in this book are a fine example of how this cross-pollination is put into effect on a day to day basis. The subjects are both practical and enlightening, demonstrating through many case histories and analysis, how the religious authorities and the mental health professionals-psychologists, psychiatrists, social workers and therapists, can work for mutual benefits. However, the difficulties still existing, the prejudices and pre-conceptions that remain in certain circles towards clinician, are also given exposure.
Nefesh Israel is proud to sponsor “Mental Health, Psychotherapy and Judaism”, our fourth publication and the first in English. (The contents of this book do not necessarily reflect the views of Nefesh Israel). This book is affectionately dedicated to Dr. Judy Guedalia, co-founder and co-chairperson of Nefesh Israel.
Dr. Guedalia, or Judi as everyone calls her affectionately, is never boring. She can, in fact, be outrageous, hilarious, or irreverent, but underneath it all there’s a warm Jewish heart and a polished and skilled professional, which keeps her and Nefesh Israel on the right track. Judi has made her mark in her field of neuropsychiatry; she has been exceedingly capable in diagnosing and treating more patients that she cares to remember. She has won the respect of her colleagues and readers of her articles in professional journals as well as in the more popular papers where her case studies appear regularly. Her pioneering work with terror victims is only one example of her break-through work.
Judi has never been afraid to take a strong stand when she found injustice, abuse or charlatans whether among ordinary citizens or professional and/or religious leaders. Nefesh Israel has been at the forefront, due to her concern and conscience, in bringing to light and combating misdemeanors of every sort. The backlash Judi has personally absorbed from such forthrightness, has not been easy, but then Judi is not easily thwarted.
When Judi got sick the hundreds of prayers and tehillim which rent the heavens on her behalf from all over the world surely must have made a difference. We all continue to entreat HaKadosh Baruch Hu to continue to shine His countenance on her, on Nefesh Israel which she co-founded and nurtured and on Klal Yisrael.
Leah Abramowitz, M.S.W., Co-chair of Nefesh Israel and Director, Geriatric Institute at Shaare Zedek Medical Center.
Leah Abramowitz, M.S.W., Co-chair of Nefesh Israel and Director, Geriatric Institute at Shaare Zedek Medical Center.
Foreword
Psychotherapy and Judaism have an important relationship and also an extended historical connection. The headquarters for Judaism’s understanding of the importance of psychotherapy was originally stated by King Solomon in Proverbs chapter 12, verse 25: “If there is anxiety in the heart of man ‘yashchena’ and thereby turn it into joy through a good “davar.”
The Babylonian Talmud in three separate places, Yuma, 75a, Sotah, 42b and Sanhedrin, 100a, cites the verse from Proverbs and discusses the meaning of “yashchena.” The Talmud states that a disagreement exists between Rav Ammi and Rav Assi. One rabbi states “you should force it out of your mind.” The other rabbi states “you should talk with others about it.” It appears they are presenting entirely different approaches to dealing with emotional difficulties. One recommends forgetting about it and pushing it away, while the other appears to recommend doing the opposite — sharing it with someone else by speaking about it. However, if we interpret their disagreement according to present day psychological knowledge and understanding, we may interpret their opinions in a different light. It appears to me that actually they are in agreement that psychotherapy is important to alleviate anxiety and stress. What they are disagreeing about is the preferable method of treatment. The rabbi who states “forcing it out of your mind “(cognition) is actually recommending using cognitive restructuring, and behavioral and strategic approaches.The other rabbi recommends specific “talking therapy” with psychodynamic understanding. This interpretation is corroborated in the second part of the verse in Proverbs by the use of the word “davar.” “Davar” can mean a “thing”, like a procedure in cognitive or behavioral therapy, or strategic therapeutic actions to effect change. It can also mean from the same root, “d-v-r”, talking -allowing the person to talk out his problems and understand his unconscious motivation. With the appropriate timely interpretation this brings joy. The person is now able to have greater ability to effect positive change in his or her emotional conflicts that are causing stress. He or she has the ability to be more flexible and open in making choices to improve intrapersonal and interpersonal life. That joy is sometimes called the “Aha phenomenon” as in “Now, I really understand.” The individual has internalized the cause of his distress and can now choose to act differently.
Research in all the mental health disciplines has shown that people go to their religious leader first when individual or family problems develop. It is therefore incumbent in Judaism upon the rabbi to be well-trained in mental health issues so that he can differentiate issues that he can help with and those where a referral to a professional is necessary. Mental health practitioners need to turn to rabbis who understand emotional disorders when they need halachic guidance. The increased cooperation between rabbis and mental health professionals is a desideratum. Cooperation and collaboration between rabbis and therapists is one of the important issues discussed in articles that Dr. Hoffman has offered us in his valuable book.
In my opinion, there is no specific Jewish psychology or psychiatric treatment protocol, just as there is no specific Jewish way to treat pneumonia, or to surgically remove a gall bladder. However, the Bible, Talmud, Chazal and later rabbinic commentaries had great insights into human nature, drives, desires and coping mechanisms. Examples of such insights are documented by the author of this book and by Greenberg and Shefler in their interesting and informative article.
I believe that mental health professionals, psychotherapists and clergymen, as well as those interested in the interface between mental health and Judaism will find this slim volume a pleasant and worthwhile read.
Joshua H. Werblowsky, M.D., D-L.F.A.P.A.
Clinical Associate Professor of Psychiatry, Drexel University College of Medicine and Lecturer, Schlesinger Jewish Medical Ethics Institute.
Preface
Religion (halacha) and Mental Health (Psychotherapy) share a common concern and goal — the quality of life and its improvement and enrichment. Religion provides man with a purpose, direction, ethical and moral rules and values to make his life more meaningful and worthwhile. Psychotherapy’s purpose and function is first, to give the troubled person relief from suffering, to ease his psychic pain, and then to equip him better to live in peace, affection and stable equilibrium with himself, his immediate objects and the world around him.
However, there are basic differences between the two disciplines. While psychotherapy is anthropocentric, religion is theocentric. While the former’s goal and measuring rod is man’s psychological well-being (however defined by the mental health expert), the latter’s goal and measuring rod is man’s ethical behavior and obedience to the will of God. Halacha (Jewish Law) does not recognize man’s rights but the duties of man to God. Religious values therefore, may at times differ and be incongruent with the values held by mental health professionals. Behavior that may be unacceptable from a religious perspective may be acceptable, if not preferable, from a mental health perspective.
Professor Kate Lowenthal, (2006) in a comprehensive and informative article entitled, “Orthodox Judaism: Features and Issues for Psychotherapy”, makes several cogent and relevant points:
The ultra-orthodox community and their rabbis have been negative about using mainstream psychotherapy and counseling services. Jewish tradition has always endorsed the obligation to seek medical treatment, and the doctor is empowered by G-d to heal. Medical treatment for psychosis – particularly medication – is seen as appropriate. For the “minor” disorders (depression, anxiety), and for social problems, there are reservations among orthodox Jewish authorities regarding seeking counseling and psychotherapy.
There are several areas in which the values of Orthodox Judaism may conflict – or appear to conflict – with the needs of psychotherapeutic work. These conflicts and apparent conflicts are primary reasons for the reluctance of many orthodox rabbis to endorse unconditionally the use of counseling and psychotherapy. Orthodox counselors and therapists will have received training and guidance in dealing with these issues, and will liaise closely with the rabbinate in their day-to-day work, so their work is usually endorsed by the rabbinate.
Jewish law does not condone homosexuality, masturbation, extra-marital or pre-marital sexual relations. Thus any indication that these practices can be condoned or supported is not appropriate for orthodox Jews, even though of course all these practices can and do happen. Therapists who do not share orthodox Jewish values and beliefs may think or suggest that an orthodox Jewish client is being made guilty or anxious as a result of religious prohibitions about sexual behavior. Appropriate therapeutic support can only be given by a therapist who understands that the religious prohibitions are givens, and the feelings and conflicts of clients must be dealt within the context of the clients’ probable acceptance that the laws about sexual behavior are right, even if s/he does not find them easy or convenient.
Marriage is regarded as a holy and desirable state, and every attempt to preserve a marriage is regarded as praiseworthy and religiously meritorious. Nevertheless, there is no rabbinic support for domestic violence or other forms of abuse. Again it is important for therapists to be aware of the complex issues in religious law, and to have appropriate rabbinic contacts.
There are assertions that obsessive-compulsive disorder (OCD) is more common among orthodox Jews than in other groups, but there is no reliable prevalence work, and Lewis (1998) has concluded that while obsessionality as a personality trait is more likely among the religious, probably as a result of the religious valuing scrupulosity, OCD as a psychiatric disorder is not more likely in any of the religious groups studied, compared to the general population. Greenberg & Witztum (1994) concluded that religion can provide the framework for the expression of OCD symptoms, but is unlikely to be a direct cause.
It seems most judicious that rabbis should consult and refer religious patients to mental health practitioners who are religious or at least are sufficiently knowledgeable of Jewish law and customs and respect the values of their patients, and that the latter should consult with and refer their clients to rabbis who have a basic knowledge and understanding of psychopathology and psychotherapy, when there is a need for halachic guidance.
* * *
This slim volume focuses on the interface between psychotherapy and Judaism. The topics considered are varied and relate to theoretical as well as practical issues. Reports of effective therapeutic treatments involving rabbis and psychologist, markedly differing opinions of various rabbinic authorities regarding psychotherapy, examples of psychological wisdom and insights of rabbis and religious leaders in effecting change in people, description of the workings of a unique mental health clinic under ultra-orthodox auspices, and responsa of contemporary rabbis to psychotherapy-halachic questions and issues, are some of the topics discussed in this volume.
In the addenda, examples of “Therapist-Friendly” and “Therapist-Unfriendly” views and comments of prominent rabbinic figures are presented as well as the clearly articulated views of a prominent orthodox Jewish psychiatrist and psychoanalyst, on the relationship between Torah and psychotherapy.
The last article, by two prominent Israeli mental health practitioners and authors, discusses the views and responses of two psychologically sophisticated, insightful and revered haredi rabbis to ultra-orthodox people suffering from religious symptoms of obsessive-compulsive disorder.
It is hoped that rabbis, therapists, mental health practitioners, as well as those interested in the interface between psychotherapy and Judaism, will find interest and benefit from reading this book.
References
Greenberg, D. & Witztum, E. (1994) The influence of cultural factors on obsessive compulsive disorders: Religious symptoms in a religious society. Israel Journal of Psychiatry and Related Sciences, 31, 211-220.
Lewis, C.A. (1998) Cleanliness is next to G-dliness: Religiosity and obsessiveness. Journal of Religion and Health, 37, 49-61.
Loewenthal, K M (2006) In: The Psychologies in Religion. Springer Publishing, UK.
Chapter 1
First Mental Health Clinic Under Ultra-Orthodox Auspices
Haredi (“one who is in awe of G-d”) is the most theological conservative form of orthodox Judaism. Haredi (ultra-orthodox) life is very family-centered and families tend to be large, reflecting adherence to the Torah commandment “be fruitful and multiply” (Genesis,1:28, 9:1,7). Depending on various factors, boys and girls attend separate schools and proceed to higher religious study in a yeshiva (orthodox Jewish institute of learning) or seminary respectively, starting anywhere between the ages of 13 and 18. A significant proportion of young men remain in yeshiva until their marriage often arranged through facilitated dating. Many also continue to study Torah in an institute for married men for many years after marriage. In many haredi communities, studying in secular institutions is discouraged, although some have educational facilities for vocational training or run professional programs for men and women. Television, films, reading secular newspapers and magazines and using the internet for non-business purposes are forbidden.
Many haredim view manner of dress as an important way to ensure Jewish identity and distinctiveness. In addition, a simple, understated mode of dress is seen as conducive to inner reflection and spiritual growth. As such, many haredim are wary of modern clothing (some of which may compromise their standards of modesty). Many men have beards, most dress in dark suits, and wear a wide-brimmed black hat and wear a skullcap at all times. Women adhere to meticulous modesty standards, and hence wear long skirts and long sleeves, high necklines and some form of head covering or wig after marriage.
Haredi Judaism advocates segregation from non-Jewish culture, although not from non-Jewish society entirely. It is characterized by its focus on community-wide Torah study. Engaging in the commercial world is often seen as a legitimate means to achieving a livelihood, but participation in modern society is not perceived as an inherently worthy ambition.
* * *
The ultra-orthodox community and their rabbis have been negative about using mainstream psychotherapy and counseling services. Spitzer (2003) regards it as essential that orthodox and Hasidic patients with psychiatric and psychological disturbances are seen only by professionals from a similar cultural background. Spitzer and others argue that the behavior and feelings of orthodox patients cannot be understood by others, and appropriate help and treatment can only be developed by those with a full immersion in the cultural and religious values and practices of the community.
The mental health facilities where we are employed are under ultra-orthodox auspices and the administrative and professional staff is comprised of haredi/religious employees. The facilities provide free psychiatric and psychological services to the haredi community and take into consideration the special religious needs and requirements of their clients. As expected, the staff is required to dress in modest attire and separate waiting rooms are appropriated for men and women where one can find religious books and religious reading material. In the staff meetings, male and female members sit at opposite sides of the room and in different parts of the dining room at lunch time.
Since receiving psychiatric and psychological treatment is generally viewed by the haredi community as a stigma, the clinic is called a community clinic and not a mental health clinic. It provides psychiatric (medication) and psychological (psychotherapy) treatment as well as social services to adults and children and a separate day treatment program for men and women. Psychotherapy includes individual, couple, family and group therapy. Because of halachic (Jewish law) considerations, separate treatment groups are held for women and for men. However, an exception was made when a highly respected arbiter was convinced by the co-leader of a parents’ group of schizophrenic children that the presence of both parents in these group meetings was essential and gave his permission to permit both parents of the children to participate in the group meetings with the proviso that they were over the age of forty-five, refrained from discussing intimate matters and that there was no mixed gender seating.
The clinic arranged five highly successful and relevant bi-monthly lectures to which the staff and other mental health practitioners treating religious clientele participated. The presenters, experts in their field, discussed a variety of topics relevant to the haredi community, which stimulated a great deal of interest and discussion. The topics included: 1. Issues and problems in treating haredi patients; 2. Group therapy for haredi/religious pedophiles; 3. Treatment of sexually abused survivors; 4. Eating disorders in the haredi community; 5. Treatment of religious patients with Same Sex Attraction
* * *
The Day Hospital Treatment Center provides a facility for more seriously disturbed patients who require more intense treatment than the clinic can provide. The patients spend five hours a day at the center, five days a week, and receive individual and group therapy, psychopharmacological treatment and adjunctive therapies. They also receive free breakfasts and lunches. The male patients can participate in religious services and attend lectures that are delivered by volunteers. Receiving psychiatric and psychological care in this supportive and caring environment, which is consistent with their religious values and life styles, frequently prevents psychiatric hospitalization. A psychiatric inpatient facility is presently being built to serve patients who require hospital care.
* * *
Although the haredi community has become in recent years more open to seeking mental-health treatment in times of need, there still remains much stigmatism regarding mental disorders, especially when one enters the “shiduchim” (marriage arrangement) phase of life. Though there exists a tendency in religious and even secular communities a general inclination to direct young men and women who suffer from physical defects and/or psychiatric disorders not to disclose them, this tendency is very prevalent in the haredi community. Revealing their personal defects and disorders before the marriage may result in a drastic decrease in the number and quality of “offers” they receive. Young haredi men and women in the “shiduchim phase” come for treatment in a state of great distress as they are concerned what will happen after they get married and their “terrible secret” becomes known. Treatment in such cases is very difficult because revealing the “secret” before marriage and thereby enabling the patient to lessen his/her anxiety, is frequently not a viable option.
To illustrate the above dilemma, two cases that were brought to supervision are presented below:
A 23 year old haredi student who recently got engaged sought psychological treatment so that “he will be able to discontinue taking psychiatric medication before his marriage” that was scheduled to take place in several weeks. His rabbi cautioned him not to reveal to his fiancée that he was receiving psychiatric and psychological treatment and dismissed several of his concerns and reservations regarding marrying his intended as insignificant.* [* In contrast to the attitude and behavior of the rabbi referred to above, Rabbi, Dr. Abraham Twerski, a prominent Torah scholar and psychiatrist, wrote in the ultra-orthodox magazine “Hamodia” (January 29, 2009) a response to a woman who sought his advice after finding herself in a similar situation as the young husband mentioned above: “I have repeatedly pleaded with people not to withhold important information precisely because of situations like this. Your husband’s parents felt that if they revealed that he was taking medication, that would ruin his chances of finding a wife, so they withheld the information “for his sake.” But did they help him despite their intentions? Parents! I plead to you. Have pity on your children. Do not cause them suffering by withholding information. As you see it can cause them misery rather than happiness.”]
Unbeknownst to him, his fiancée was also being treated at the clinic which he discovered two weeks prior to the wedding when he saw her entering the clinic. He requested from his therapist to provide him information whether his betrothed was a patient at the clinic and what was her psychiatric problem. The therapist explained to him that he was not at liberty to provide him this information because of professional ethics and suggested that he “come clean” with her regarding his psychiatric condition, inform her that he saw her at the clinic and request her to “come clean” with him, in order that they can begin their marriage on the “right foot”-openness, honesty and trust between them. Unfortunately, the patient did not act on his therapist’s suggestion and a month later, the couple separated.
A young haredi, single woman sought psychological treatment for anxiety and panic attacks. Her anxiety was exacerbated by her relentless concern and worry regarding how her husband to be will react to her psychological symptoms. It was clear to her that if she wanted to marry a suitable haredi man, she was obligated to hide the fact that she suffered from these psychological problems and that she was in psychological treatment. As her haredi therapist explained to me in supervision, ‘When one meets a prospective candidate for marriage for the allotted five meetings, one is obligated to ‘wear a mask’, if one wishes to get married.”
The therapist found herself in a quandary-on the one hand she believed that being secretive, deceitful and untrusting with one’s intended is highly destructive and a poor formula and basis for a successful and lasting marriage; on the other hand, in the haredi community, there is the unfortunate reality that being open and forthright will sabotage any possibility for the patient to find and marry an appropriate mate. When the patient mentioned to her therapist that she met with a man several times and both seemed interested in marriage, the therapist decided to encourage the patient to “come out of the closet” and inform him of her situation since her many positive qualities will outweigh her minor defects. This way she would be able to set aside her intense fears and anxieties and begin her marriage in a positive way. The patient, after considerable hesitation and deliberation, agreed and discussed with her therapist how to reveal her secret in the most effective manner. The patient was also informed by the therapist that she was available to meet with the both of them if they requested a meeting. In the following meeting, the patient reported that her suitor was appreciative that she informed him that she was receiving psychological help for her anxiety and panic attacks and scheduled to meet her the following week.
A frequent complaint of the female patients is of being overwhelmed with the burdens of running the household and being depressed. Upon further probing, they speak about serious marital discord and alienation that has been going on for many years and feelings of impotence to change the situation. Many complain about the absence of the husband to help in household chores and in taking care of the children. In spite of serious marital difficulties in the beginning of their marriage, many of these women continue to have more children. One of the women when asked why she continued to have more children after they were having serious marital problems responded that, “it was not respectable to have few children.” A considerable amount of women (and men) attend the clinic without the knowledge of their spouse for fear that they would object to their coming or that this information may be used against them in the future, which places stumbling blocks at attempts for possible reconciliation and rehabilitation of strife-ridden marriages.
* * *
Other frequent symptoms that bring haredi men and women to the clinic are obsessional fears, thoughts and preoccupation regarding religious rituals and behavior and compulsive behavior on their part to deal with it. Generally the religious content concerns issues related to cleanliness related to prayer and tasks involving ritual immersion, separation of meat and milk products and utensils, and various aspects of prayer. Frequently these symptoms require the close cooperation of religious authorities (Huppert, Siev, and Kushner, 2007; Greenberg and Shefler, 2008), and at times, their direct intervention. (Slanger, 1996).
Below are presented two brief vignettes of the brief interventions of rabbis in the treatment of OCD with religious content. (Greenberg and Shefler, 2008)
A woman was very concerned that she found signs of the cross wherever she walked, in the pavement, the window frames, etc., and that as a religious Jewish person she should avoid these signs of Christianity. She went to see her rabbi, renowned for his saintliness and understanding of mental health issues, and described her difficulties. In response, as she sat before him, he put one index finger across the other to form the shape of a cross, raised it to his lips and kissed the shape. His non-verbal response was to make it clear that there is a distinction between a religious symbol and everyday objects, and she was not to seek such symbols where they did not exist. His message was made even more powerful, as he was modeling “kissing the cross” to show that such everyday objects need cause no alarm and should be confronted.
A young man had approached his rabbi about his repetitions in prayer. His rituals of repetition concerned the most important section of the daily prayers, the Shema (declaration of the unity of the Creator). His rabbi’s reply was that he was to stop saying all three paragraphs of the Shema completely for two weeks. He returned to the rabbi after two weeks, and was now told to restore the third paragraph alone, with no repetitions. He returned two weeks later and the second paragraph was restored, the next visit all was restored except the first and most important sentence, the Shema. Finally, he was told to restore the Shema but to be careful not to repeat any parts of the prayer. For eight weeks this young man had left out the most important line of his daily prayers.
“The role of the rabbi differs from that of a therapist in several ways. The rabbi is an expert in Jewish law and has the authority to make decisions on religious matters. The therapist, on the other hand, is an expert on OCD. He may have status but not authority over the patient, whom he advises.” (Greenberg and Shefler, 2008).
* * *
It goes without saying that all decisions that are made in references to the patients that have religious ramifications, pass through a “halachic prism” before being acted upon.
To illustrate the above: The professional staff of the clinic and the educational staff at the girl’s school, decided after many deliberations, that a 10 year old girl should be removed from her home because of the detrimental effect the parents were having on her, and be placed in a foster home. However, before implementing this decision, a recognized halachic authority was consulted, and after meeting with the staff, ruled that it was preferable that the child remain in her home and continue to receive psychological treatment rather than break up a Jewish family. The staff accepted the rabbi’s decision and arranged for the child and parents to continue to receive psychological treatment at the clinic.
* * *
Below are two interesting anecdotal examples of the influence of halachic considerations in the implementation of psychological treatment.
A young haredi clinical psychology intern reported in supervision that she was seeing a middle-aged mother of four who was constantly being plagued by obsessional fears and thoughts that “her husband would die,” “her son would be run over by a car,” etc., which were seriously impeding her daily functioning. Even mentioning these thoughts increased her anxieties and fears since she feared that her utterances may cause it to happen. After considerable deliberations, the supervisor suggested a behavioral intervention (“habituation”)-that she request the patient to verbalize aloud her fearful thoughts in the treatment room and tape-record them and listen to them at home twice a day. The supervisee, however, raised an halachic issue: By prescribing this intervention technique, she and the patient will be going against the rabbinic caveat/prohibition, “A person must never open his mouth to Satan,” and “Contract is made to the lips”(ie., one should be cautious what he emits from his mouth, as speech has power and influence and may cause the feared event to eventuate.) Since the supervisee was hesitant in executing a therapeutic intervention which may possibly compromise the religious values of the therapist and her patient, the supervisor felt obligated to raise this issue with a rabbi who permitted this intervention since the goal was to enable the patient to extricate herself from her oppressive symptoms.
A young religious clinical psychology intern raised an interesting ethical/religious dilemma in supervision. A haredi young man confided to her that he is a homosexual, has had relationships in the past with men and is presently waiting for his mother to arrange a “shidduch” for him. His reason for wanting to get married was to please his mother with whom he has a strong symbiotic relationship, and who is pressuring him to get married and who is unaware of his sexual proclivities. The therapist had made many attempts to dissuade the patient from following this course with little success. The therapist raised the question whether she is obligated to inform the mother and his prospective intended about his sexual proclivities and orientation since there is a biblical prohibition, “Thou shall not stand idly by the blood of thy neighbor” (Leviticus, 19, 16), which is interpreted by the rabbis as an obligation to attempt to save and protect one’s neighbor’s life, possessions and emotional and spiritual wellbeing.
After consulting with a rabbinic authority, the supervisor informed his supervisee that she is not obligated to inform the patient’s mother and intended since a psychologist differs from a layman in that he is professionally obligated to keep confidential material and risks causing damage to his status, income, the therapeutic relationship and is also liable to possible imprisonment, if he betrays the confidence of his clients. He suggested that the therapist inform her patient that he plans to schedule a family meeting and inform his parents that she has strong doubts and reservations that their son is emotionally and psychologically ready and capable, at this time, to marry and assume the responsibility of being a husband and father, and that she was very concerned about the possible damage that will result by this action to him, his intended and future children.
Conclusions
A recent study by Professor Eliezer Schnall of Yeshiva University and colleagues (2010) concluded that the mental health needs of the Orthodox community are not being sufficiently addressed and the service gaps are particularly pronounced in the haredi Orthodox and Chasidic communities. Schnall called the results a “wake-up call,” and said there is still a stigma in the Orthodox community attached to mental illness that prevents people from seeking help. An additional factor impeding good mental health services is their cost, he said.
The study showed that the most common problem for which Orthodox Jews seek mental health services is marital difficulties. More services for children and teenagers are needed, and there is a lack of services for substance abuse problems, the report found. Most respondents in the study said few of their patients were referred by their rabbis. Researchers said this indicates the need to train Orthodox rabbis to recognize mental illness and understand that proper treatment can help.
The establishment of a clinic under ultra-orthodox sponsorship is a bold and pioneering step that should be applauded, as it facilitates and encourages members of the haredi community that are in need of psychiatric and psychological treatment to obtain help in a “religious-friendly” environment where their religious values and customs are respected and accommodated. In addition, it enables ultra-orthodox psychology interns and other haredi mental health workers to train and gain clinical experience in an environment that is consistent with their value system and way of life.* Establishment of more mental health clinics under haredi auspices should be encouraged.
[* In regard to this, see Garr, M. and Marans, G. (2001) Ultra-orthodox women in Israel: A pilot study project in social work education, Social Work Education, vol. 2, Issue 4.]
References
Greenberg, D. and Shefler, G. (2008) Ultra-orthodox rabbinic responses to religious obsessive-compulsive disorder. Israel Journal of Psychiatry and Related Sciences, 3, 4, 183-192.
Huppert, D. H., Siev, J. and Kushner, E. S. (2007) When religion and obsessive-compulsive disorder collide: Treating scrupulosity in ultra-orthodox Jews, Journal of clinical psychology, 63, 10, 925-941.
Schnall, E., Feinberg, S., Feinberg, K., & Kalkstein, S. (2010, August). Psychological disorder and stigma: A 25-year follow-up study in the Orthodox Jewish community. The 118th Annual Convention of the American Psychological Association, San Diego, CA.
Slanger, C., (1996) Orthodox rabbinic attitudes to mental health professionals and referral patterns. Tradition, 31, 1, 22-33.
Spitzer, J. (2003) Caring for Jewish Patients. Abingdon, Oxford: Radcliffe Medical Press.
Chapter 2
Behavior Change Via Cognitive Change: Rabbinic Views
The issue of what causes behavior change in people has been debated for decades. The psychoanalytically oriented practitioners and theoreticians insist that insight is a prerequisite to real change and that change without insight is an illusion. On the other hand, the non-dynamic cognitive-behavioral and strategic therapists argue that enduring behavior and attitude changes are made more likely by first getting a person to engage in new behavior. Insight, in their view, is frequently a by-product, rather than a cause of change.
“Many people who are depressed believe that they “just need to become motivated” but the very symptoms often block such motivation. Therefore, if the person waits to become motivated they wait in vain. Ironically, engaging in an activity even when you feel unmotivated to do so can lead to feeling motivated. We call this working from the outside-in.”1
The latter view seems to be consistent with that of the author of Sefer Ha’Hinukh, who in explicating the 613 Commandments makes the point many times that “one’s heart is influenced by one’s actions.”
Similar views are found in the Talmud. “Rabbi Judah said, ‘Man should always occupy himself with learning Torah and its Commandments, even for ulterior motives, for eventually he will do it for idealistic reasons’.”2
In his commentary to the Ethics of the Fathers Maimonides3 recommends that a person who wishes to dispense a large sum of money for charity should dispense it in small amounts rather than in one large sum, in order that the trait of generosity become instilled in him or her.
(Likewise, Milgram points out in his classic study on obedience that prohibited and evil behavior, when repeated, tends to become the norm. “Once the individual has begun to do evil, he continues doing evil, rather than say to himself, ‘Everything I have done to this point is bad and now I acknowledge it by breaking it off’.”4
The Talmud says, “If a person transgresses a prohibition and repeats it, it becomes to him as if it was permissible.”5
The concepts of cognitive transformation and cognitive dissonance were also used by the rabbis in understanding and modifying human behavior. Ibn Ezra, in discussing the Tenth Commandment, “Thou shalt not covet…your neighbor’s wife” states:
Many people will be puzzled by this command. Is it conceivable that there should exist a man who does not, at some time or another, covet a beautiful object? Let me now give you a parable. A country yokel in his right senses will not covet a beautiful princess, since he knows it is impossible to possess her, just the same as he will not seriously desire to have wings like a bird. For this reason the thinking person will neither desire nor covet. Since he knows that the Almighty has forbidden him his neighbor’s wife, such a course of action will be even further from his mind than from that of the country yokel in regard to the princess.6