Sanity and Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem 9780300131994

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Sanity and Sanctity

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S   S   Mental Health Work Among the Ultra-Orthodox in Jerusalem D G, M.D.,  E W, M.D.

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Yale University Press

New Haven and London

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Copyright ©  by Yale University. All rights reserved. This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond that copying permitted by Sections  and  of the U.S. Copyright Law and except by reviewers for the public press), without written permission from the publishers. Set in Caslon type by Tseng Information Systems, Inc. Printed in the United States of America. Library of Congress Cataloging-in-Publication Data Greenberg, David, – Sanity and sanctity : mental health work among the ultra-orthodox in Jerusalem / David Greenberg and Eliezer Witztum. p. cm. Includes bibliographical references and index.     ––– (alk. paper) . Ultra-Orthodox Jews—Psychology. . Cultural psychiatry. . Psychology, Pathological—Crosscultural studies. . Orthodox Judaism—Psychology. I. Witztum, Eliezer. II. Title. ..   .''—dc – A catalogue record for this book is available from the British Library. The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources.

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         

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To my wife, Shari my children, Esther and Itai, Yoel and Shlomit, Binyamin, Yonatan, and Daniel my mother, Zelda, and my late father, Harry —D.G. To my children, Galia, Dan, and Uriah my father, Shmuel, and my late mother, Yaffa

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—E.W.

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C

Preface ix . To Begin, Just Say, ‘‘How Are You?’’



   :                 -                                          

. The Initiation of Mental Health Care for the Ultra-Orthodox  . Changing Attitudes in Cultural Psychiatry  . A Match Is Arranged Between Cultural Psychiatry and Ultra-Orthodox Judaism  . Varieties of Religious Identification  . The Parable of the Turkey      :                          

. Beliefs and Delusions  . Visions and Hallucinations: Angels in Today’s World  . Nocturnal Hallucinations  . ‘‘A Big Man Dressed in Black Is Hitting Me’’: Deconstructing the Narrative  . Phenomenology and Differential Diagnoses of Nocturnal Hallucinations  . Normative Rituals  . Ritual as Psychopathology, or Is the Code of Jewish Law a Compulsive’s Natural Habitat?  . Religious Ritual and OCD: Is the Torah a ‘‘Perfect Medicine’’ or Does It Cause OCD?       :                        

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. The Baal Teshuva and Mental Health, or Why the Camel Changed His Burden, and How He Felt About It  vii

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. Mental Illness and Religious Change: The Chicken or the Egg  . ‘‘A Very Narrow Bridge’’: Pyschopathology Among Baalei Teshuva in a Fringe Hasidic Group  . Mysticism and Psychosis: The Fate of Ben Zoma  . ‘‘Jerusalem Syndrome’’: Tourists Who Freak Out and Break Down in the Holy City        :                             

. Ultra-Orthodox Attitudes Toward Mental Health Care  . Improving Mental Health Care for the Ultra-Orthodox  . Treating Depression in the Community by the Community     :         

. The Soldier of the Apocalypse  . The Healing Power of Ritual  . Paradise Regained: Breaking Through the Mask of Catatonia      :       

. Betrayal: The Prince and the Wise Man Revisited . Broken Souls Are Not Easily Mended 

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Notes  Glossary  Bibliography  Index 

viii / Contents



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P

A central text in this book is the parable written by Rabbi Nahman of Bratslav that begins, ‘‘There was once a prince who became mad.’’ There must be few among us who have ever known mad princes, yet Rabbi Nahman’s parable can speak to us all, hasid or nonhasid, religious or nonreligious, Jew or non-Jew. So too, we have written this book in the belief that the meeting between two Western-trained psychiatrists and the ultra-orthodox Jewish community of Jerusalem can be read in a wide perspective. It describes a meeting between people with different ways of life, attitudes, and beliefs, including judgmental perceptions of the ‘‘other.’’ Both the book and the encounters that led to it have been a journey for us in which we were drawn into a study not just of the ultra-orthodox community but also of our own Jewish heritage. Our investigation has revealed to us aspects of our identity that we had not thought about and attitudes that challenged our cherished views of ourselves as tolerant, enlightened people. Such issues, regardless of specifics, are pertinent to all mental health encounters between people of different backgrounds or cultures—indeed, to all health encounters and beyond. It is now nearly two decades since we began to treat members of the community, and it is with pleasure that we thank the professionals who have collaborated with us on aspects of our work over the years: Haim Dasberg, Yoram Bilu, Onno van der Hart, Gaby Shefler, Danny Brom, Yehuda Goodman, Samuel Heilman, and Jean Pisanté. Tuvia Buchbinder has been a most constant and thoughtful colleague throughout. ix

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The idea for the book was born over coffee on a sunny Friday morning in Jerusalem with a suggestion from Donald Cohen. Since then, he has followed its progress to completion with the care and attention that are unique to him. We would also like to thank Susan Laity of Yale University Press for her careful editing. The index was created by Yoel Greenberg. As busy clinicians, it has not been easy to find the mental space in which to think and write. Someone has to believe in you to make it happen. Thank you, Shari.

x / Preface

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 To Begin, Just Say, ‘‘How Are You?’’ The scene is the office of an Israeli psychiatrist. An ultra-orthodox Jewish man is sitting in the patient’s chair. ‘‘How are you?’’ asks the psychiatrist. ‘‘May God’s name be blessed,’’ replies the patient. ‘‘Er, how are you feeling?’’ continues the psychiatrist. ‘‘Blessed is He and blessed is His name,’’ comes the reply. The psychiatrist may be forgiven for presuming that his question will lead to a description of the patient’s condition. The patient may be forgiven for replying to this greeting in the customary way among ultra-orthodox Jews. He is not being evasive. He is fulfilling the injunction in the Talmud: ‘‘When one person asks another how he is, he should mention God’s name, as it says (in Ruth :): ‘And Boaz came from Bethlehem and said to the reapers: ‘‘May God be with you,’’ and they replied: ‘‘May God bless you’’ ’ (Talmud Brachot a).’’ * The misunderstanding appears minor. But let us consider what each participant in this conversation may be feeling. At best, the psychiatrist will be nonplussed, unsure of how to continue, for he does not understand what the patient’s reply means. He will know the Hebrew words themselves: Baruch Hashem. Their literal meaning is, ‘‘The name is blessed.’’ If he is not informed concerning the ways of ultra-orthodox Jews, the psychiatrist will probably be ill at ease, either unaware that ‘‘the name’’ is a metonymy for God’s name or uncertain about what it means for a name to be blessed—and he certainly won’t com-

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* Unless otherwise indicated, all translations are the authors’. 

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prehend how this reply answers his question. He may even find the answer so surprising that he will wonder whether the patient is confused: Does he think he’s answering my questions? Is he suffering from thought disorder? Alternatively, even if he understands the meaning of the patient’s reply, the psychiatrist might view the response as evasive. The patient, he might think, has difficulty expressing his feelings. If the psychiatrist is aware that this reply is the standard response of an ultra-orthodox person to such a question, he may reach the more general conclusion that all ultra-orthodox Jews are trained to avoid discussing their feelings. A further reaction may be irritation. Why doesn’t the patient answer my question? Wasn’t it simple enough for him! Why must he hide behind his religious terminology? Consciously or unconsciously, the psychiatrist may become angry for reasons relating to himself and his own religious feelings: Why must the patient foist his religious beliefs on me? Why must I be tolerant of his religiosity if he is not tolerant of my nonreligious position? The patient, too, will be feeling uncomfortable. To begin with, he does not usually speak in Hebrew. His daily life and study are conducted in Yiddish, and questions such as ‘‘How are you?’’ are normally exchanged in that language between coreligionists. ‘‘Vee geyts?’’ (How is it going?) is the usual greeting ‘‘Boruch Hashem’’ (May God’s name be blessed) is the standard reply. The words are Hebrew, but the pronunciation is not the modern form used in daily life in Israel; it is the Ashkenazi pronunciation current in Eastern Europe for centuries. The ultraorthodox patient is aware that he has stepped out of his usual environment. He is sitting with a secular person, speaking modern Hebrew, using terms that are not meaningful to the man opposite him.

 / Just Say, ‘‘How Are You?’’

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And all the psychiatrist was trying to do was say, ‘‘How are you?’’ Thus far, we have been considering only the difficulties that the words themselves have created. But every phrase we use reflects a way of thought and a mode of living as well, and these can make the divide of misunderstanding far greater than we originally imagined. Studies in several countries have shown that psychiatrists and psychologists tend to be less religious—in fact, are more likely to be atheists—than the general population they treat (Neeleman and King, ; Henry, Sims, and Spray, ). Israel is no exception, as is shown by a study of  mental health workers and students (Rubinstein, ), which found that well over  percent defined themselves as secular, fewer than  percent as orthodox, and fewer than  percent as ultra-orthodox (these distinctions are discussed more thoroughly in Chapter ). Our hypothetical therapist is likely to be a secular Jew who has received a secular education, with minimal Bible study. As a mental health worker, he may view psychological disturbances as precipitated by genetic, biological, social, or intrapsychic influences, depending on his professional orientation. He sees himself as an expert, and he expects patients to be open about their feelings so that he can help them understand and overcome their emotional difficulties. The religious patient, on the other hand, may view his position differently. That he is suffering is in itself a sign from God. As an observant, God-fearing Jew, he has been brought up to be wary of committing sins. When he attended yeshiva, he spent every day reading cautionary texts that encouraged him to carefully review his actions in order to improve them. But now God has apparently selected him for suffering. This would seem to

Just Say, ‘‘How Are You?’’ / 

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mean either that he has sinned and not repented or that God is testing him. As a result, he has spent hours scrutinizing his behavior, probably discovering many ways he might have sinned— having occasional sexual thoughts, not always concentrating in prayer, not eliminating ‘‘the evil tongue’’ from his conversation. He knows what is written about these weakness, these sicknesses of the soul, and he has spoken to his rabbi about them. Every text he ever read on how to improve his middos (moral qualities) made it clear that the rabbi is the person he should turn to for advice. But his rabbi advised him to study with greater concentration, and he finds it almost impossible to do so at the moment. God is testing him; his rabbi has pointed him in the right direction; yet he can’t escape his black mood. The patient is afraid. It is clear that he is being punished. He must be of weak faith, like the brother of our forefather Abraham in the Torah, who died in a furnace. He looks up at the neatly dressed psychiatrist, with his colored shirt and brown pants, no yarmulke, no beard, no sidecurls. How can he begin to tell his thoughts to a man who does not even appreciate that by saying ‘‘Boruch Hashem’’ he is fulfilling a mitzvah? Why, the psychiatrist probably doesn’t even know what a mitzvah is.1

 / Just Say, ‘‘How Are You?’’

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P I       -                                        

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 The Initiation of Mental Health Care for the Ultra-Orthodox Community psychiatry in Jerusalem began about three decades ago. In  the Ministry of Health divided the Jewish section of the city into four zones, and mental health clinics were opened in each, administered by the city’s four psychiatric hospitals. The northern quarter, home of the ultra-orthodox community of Mea Shearim, was assigned to Ezrat Nashim Hospital. Ezrat Nashim is the oldest psychiatric hospital in Israel, founded at the close of the nineteenth century by an enlightened group of women who wished to provide care for the mentally ill, untreated in Ottoman Palestine. The hospital was situated at the edge of the new part of the city, now the site of the central bus station. Just as the term Bedlam (for England’s ‘‘Bethlem Royal Hospital’’) became synonymous with madness for the English, so did Ezrat Nashim come to signify madness for Israelis. Its benign name—ezrat nashim means ‘‘women’s enclosure,’’ after the section in the Temple and later the synagogue designated for women—is misleading; Ezrat Nashim is a psychiatric hospital for both men and women. Always regarded as an orthodox Jewish establishment, the hospital seemed the appropriate choice to administer to the northern part of the city. Meanwhile, the newly established mental health center began to make contacts with family doctors and to sponsor public lectures at community centers. Slowly the trickle of referrals became a stream. Nevertheless, the scarcity of ultra-orthodox referrals was striking. The founding director of the center, Haim 

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Dasberg, described the typical presentation—bowed over, silent, frozen—of the few referrals who appeared from the ultraorthodox community as the ‘‘Mea Shearim syndrome.’’ The term was considered synonymous with catatonia, which describes patients who fluctuate between periods of being frozen in movement and mute of speech and periods of hyperactivity. Catatonia is usually associated with serious mental illness. Since then, the ultra-orthodox community has grown substantially. Today more than half the population of the catchment area of the hospital is ultra-orthodox, and the proportion of ultra-orthodox among the children is even higher. Further, ultra-orthodox parties have gained increasing political power in the Israeli parliament, particularly in the government of Jerusalem. This increase in ultra-orthodox visibility and influence may change the character of the country’s capital. It is twenty years since the two of us began to work in the clinic. We were both reared and educated in essentially Western societies, and neither of us was prepared for the reality of working with the ultra-orthodox community. Eliezer Witztum is a third-generation Israeli and a second-generation secular Jew, with ultra-orthodox grandparents.1 He studied at the Hebrew University and Hadassa medical school. Like most longestablished Israelis, Witztum has some knowledge of Judaism. He studied the Bible in school and was aware of the nonreligious aspects of the festivals, such as their use of special foods. David Greenberg, a modern orthodox Jew, was born in England. His parents and grandparents came from hasidic stock in Russia and Poland. He received his medical training at Cambridge and Westminster. When we began practice at Ezrat Nashim, ultra-orthodox Judaism meant different things to us. For Witztum the ultraorthodox were a separate sector of society who did not participate in the daily life of the country’s capital. For Greenberg, they  / Introduction

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were almost exclusively associated with Mea Shearim, a place for tourists to visit, where they might buy books and other articles of religious life. Neither of us had received any training in how to approach patients from a religious or cultural minority, nor were we aware of the need to do so. We had not even considered the fact that the ultra-orthodox speak Yiddish rather than Hebrew to be a possible deterrent to the community’s seeking help or being understood. We did not realize that patients who described their emotional difficulties using terms from their religious practices and beliefs were saying something worth listening to rather than displaying their ignorance or their ‘‘primitive’’ ideology. Neither of us had considered for a moment that the skills he had acquired in professional training might be ineffective with or unsuitable for such patients—or even threatening to them. Initially, we were proud to note how tolerant we were, how nonjudgmental of another society. Further, we made efforts to learn something about the values and practices of our patients. This, however, was not enough for effective therapy. Healing exists within a structure, and this book describes our development of structures of healing that were effective for ultra-orthodox patients. By a process of trial and error, we found that we needed to enter the world of our patients and their families, not just by visiting their homes and meeting their religious leaders but by joining them via their narrative accounts of their religious lives and experiences and trying to understand the meaning of these experiences for them. We learned that any intervention had to be consistent with the authorities and practices of their society. In other Western societies, treatment of minority populations has sometimes led to the training of indigenous therapists who speak the language of their society and are at one with its symbols and idioms of distress. The situation is more complicated Mental Health Care for the Ultra-Orthodox / 

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with the ultra-orthodox community, whose members do not go to university. Further, the community has traditionally had ambivalent attitudes toward medicine, and even more suspicion of psychiatry. The Mishnah states, ‘‘The best of doctors go to Hell’’—which is a compliment compared to the prevailing views of the ultra-orthodox community regarding psychiatry. The two societies that we describe here, the society of mental health experts and the ultra-orthodox world, are not naturally compatible, even though both are ultimately concerned with healing the soul. The mental health community has traditionally viewed the religious world as plagued by primitive beliefs, while the ultra-orthodox community has perceived psychiatry as morally and spiritually bankrupt. This book describes our difficulties in understanding our patients, our own contributions to this misunderstanding, and our attempts to develop meaningful and acceptable interventions for the ultra-orthodox Jewish community of Jerusalem. Our emphasis is on what is known as cultural psychiatry, an approach in which the influence of cultural factors in mental health work is investigated. Cultural factors are, of course, present in any interaction and may be crucial for the outcome of patient evaluation and management. Even when doctor and patient come from the same background, physicians frequently ignore the importance of such factors, a practice referred to as the ‘‘culture blind-spot syndrome.’’ We hope that this account of our work with the ultraorthodox community will make therapists more aware of similar issues with their own patients, whether from their own or another cultural, particularly religious, background. Majority cultures tend to regard minority cultures in a patronizing and devaluating way, considering their members peculiar, primitive, or superficial (Good and DelVecchio Good, ). Events in the Israeli ultra-orthodox community have always  / Introduction

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been regarded as newsworthy by the secular press, perhaps in part because of a wish to gather information that confirms these prejudices.2 In writing for a general public about a minority, we must be aware that our statements may be used to feed these prejudices. Whenever we speak publicly on mental health care for the ultra-orthodox, the first question secular audiences ask is, Is there more mental illness in the ultra-orthodox community than in the general population? while ultra-orthodox audiences ask, Is there less mental illness in our community? The only effective way to answer these questions is to carry out epidemiological studies of psychopathology in the ultra-orthodox community. One such study, conducted in Jerusalem in , found higher rates of in-patient admissions among the ultra-orthodox (Rahav et al., ). In fact, the rate of in-patient admissions from the ultra-orthodox neighborhood for men aged – was nearly three times higher than the overall rate for the city. This difference appears to correlate most strikingly to the lower socioeconomic status of the ultra-orthodox. There are many possible explanations for this distinction, in addition to any real difference in psychopathology: greater social cohesion and support, the ability to buy private care, and attitudes toward hospitalization all influence the use of in-patient facilities. An epidemiological study of , young adults was carried out in the s but did not report the effects of religiosity (Levav et al., ). On the basis of referrals to the northern Jerusalem community mental health center, we shall draw certain conclusions about the use of services by the community, particularly about the association between becoming ultra-orthodox and developing mental illness. In the absence of systematic community studies, however, these generalizations must be interpreted with caution. By presenting the social and cultural context as well as clinical Mental Health Care for the Ultra-Orthodox / 

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details, we hope to demonstrate the distinction between bias and data. Suspicious of secular publications in general, the community is understandably especially leery of books about ultraorthodoxy written by outsiders who have limited knowledge and understanding of the subject. We do not claim to be exceptions. We have tried to present the community as neither ‘‘quaint’’ nor ‘‘primitive,’’ to be neither overly sympathetic nor hypercritical. We are also aware that our wish to preserve a working relationship established over many years risks blurring our vision and calling our observations into question. Suffice it to say that we recognize these competing pressures. Readers must reach their own conclusions. Our descriptions of beliefs and practices in ultra-orthodox life may seem bizarre to outsiders. Because we are psychiatrists who treat presentations of disturbance rather than anthropologists describing everyday life, our emphasis is on the facets of ultra-orthodox life that appear to explain psychiatric and behavioral disorder rather than on the many aspects that encourage health and provide support. Readers should consider this onesidedness carefully before drawing any general conclusions. Initially the ultra-orthodox community attempted to live physically in the state of Israel while ignoring its existence. In recent years, however, the ultra-orthodox have learned to exploit their numbers for political pressure, primarily in gaining financial support for ultra-orthodox schools and yeshivas. This practice of simultaneously rejecting secular society and exploiting it has intensified hostile feelings in the secular community. For many years, the majority secular culture was content in the belief that the ultra-orthodox community was disappearing. In fact, the ultra-orthodox community in Jerusalem is flourishing; in Israel today there are more than , ultra-orthodox Jews: ‘‘The haredim, regarded only a few decades ago as a dying  / Introduction

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breed, have confounded forecasts of their demise. In their resurgence, they have proved that the dismissal of haredism as anachronistic may itself be an anachronism in the modern world’’ (Landau, , p. ). This resurgence is due primarily to the high birthrate in the ultra-orthodox community but also to the fact that few members seem to be leaving. The society is supportive of its members, and its institutions aim to cover as many facets of life as possible, so that dependence on and exposure to the outside world are minimized. The narrow focus of ultraorthodox education also means that members of the community are poorly equipped to join secular society if they ever consider doing so. The impression we have gained from contact with many ultraorthodox families is that their members are no more discontented with their lot than others. They know what is expected of them: to study the Torah and perform its commandments. This singularity of purpose does not mean that intellectual aspirations and innovative thought are shunned but that these are appreciated within the context of the values of the society. In this respect the ultra-orthodox community is no different from any other society.

 Changing Attitudes in Cultural Psychiatry

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Cultural psychiatry is a combination of anthropology and psychiatry. Whereas anthropology studies the unique aspects of Attitudes in Cultural Psychiatry / 

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cultures around the world, and psychiatry treats disturbances of mental health, cultural psychiatry attempts to understand the influence of culture on the presentation and management of psychiatric disorders. The attitudes and underlying theories of anthropology and cultural psychiatry toward the disorders of society and their management have changed radically in the past decades.1 The early anthropologists and psychiatrists came from the Western world, and they tended to view their own culture as civilized and mature, the cultures they were studying as uncivilized or primitive. This attitude influenced their perceptions of disorder: psychiatric conditions that were commonly seen in the West were, in the view of these theorists, universal, while disorders that were seen ‘‘only’’ in other societies were ‘‘culture-bound.’’ A similar attitude pervaded their views on treatment: methods developed in the West were presumed to be effective in all settings, as their efficacy had been demonstrated in ‘‘scientific’’ trials, while the treatments in ‘‘primitive’’ cultures were based on magic and were unscientific. If such treatments appeared to be effective, this was described as a result of suggestion or the ‘‘placebo effect,’’ in which the medication or therapy has no active ingredient other than the patient’s expectation of feeling better. Similarly, Western theories of psychopathology, whether biological, cognitive, or psychodynamic, were viewed by their adherents as applicable to all societies. Indigenous theories of the cause of psychiatric disturbance in a culture were considered on a par with the pre-Copernican belief that the world is flat—except that this belief was at least consistent with immediate sensory evidence, whereas theories of the cause of mental disorder were apparently drawn from thin air. In short, Western society was perceived as the embodiment of evolutionary advancement, the standard for all others.2 The changes that have taken place in anthropology may be  / Introduction

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seen to parallel the change in status of the colonial powers and the demand for equal status and respect by the former colonies. Gone is the judgmental concept that any one culture is more or less civilized than another. Cultures are now construed as different in values, idioms, and behaviors, rather than as more or less developed.3 A similar metamorphosis has affected cultural psychiatry (Littlewood, ). It has long been accepted that culture influences the content of a disorder, while the overall form of the disorder was believed to be a constant. For example, a paranoid person might claim that he was being trailed by the FBI if he was a New Yorker, by the MI if he was a Londoner, or by the Mossad if he was a Jerusalemite. All three are suffering from paranoid thoughts (the form), but the content of the delusion varies with their culture. Psychiatrists now recognize, however, that both form and content are culture-specific. For example, a condition known as neurasthenia is more common in China, while anorexia nervosa is found predominantly in Western or Westernized cultures.4 Neither condition is more authentic or universal than the other. The notion that Western forms of psychopathology are authentic and other conditions in localized areas simply masked versions of the Western forms has been disqualified: for example, patients with neurasthenia have only a partial response to antidepressant medication. Further, as historians and philosophers of science examine the development of Western theories of psychiatry, they increasingly appreciate that both theories and therapies in all cultures are deeply influenced by the prevailing political structures, social values, and religious beliefs (Kleinman, b). These changes in anthropology and cultural psychiatry have brought about a more humble attitude in the observing scientist. The growing awareness of our own limitations has, paradoxiAttitudes in Cultural Psychiatry / 

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cally, led to an increasing preoccupation with the impact of the observer’s biases on the behavior of those he or she is observing (see Hammersley and Atkinson, ). Each of us brings to our work an identity, codes of behavior, and perceptions of outsiders. The task of researchers in cultural psychiatry has extended beyond the description and understanding of the interaction between a culture and its expressions of disorder. Appreciating that they, too, are part of a culture, as residents of a particular city, adherents of a particular religion, members of a particular profession, researchers must seek to develop insight into the cultural features peculiar to their own identity. An observer of psychopathology in Japan, for example, will discover the syndrome known as taijin-kyofu-sho (literally, interpersonal fear), which is characterized by phobic avoidance of interpersonal relations. The syndrome superficially resembles the Western condition known as social phobia, yet the underlying fear of the sufferer from taijin-kyofu-sho is that his or her behavior may cause offense or hurt to others, whereas the Western phobic fears being personally shamed. The researcher needs to consider not only what in Japanese culture gives prominence to a concern for embarrassing others but also why this feature is nearly absent from Western society, where the social phobic fears the criticism or rejection of others.5 Finally, psychiatry is a branch of medicine and psychology. The ultimate purpose of all its endeavors is the alleviation of suffering. Cultural differences create barriers of misunderstanding that significantly diminish the efficacy of the therapist, as is evidenced by the repeated findings that people from cultural minorities are less likely to seek mental health care, or to remain in care, than are members of the cultural majority. They are also more likely to be offered biological treatments instead of psychotherapy—medication rather than a sympathetic ear

 / Introduction

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(S. Sue, ; Hough et al., ; Littlewood and Cross, ). Overcoming this situation requires more than a psychiatrist who has read about aspects of the way of life and beliefs of another culture. The therapist must understand and accept the language, idioms of distress, and underlying beliefs of that culture and must be aware of the role and status given to therapists there. In addition, the therapist must be aware of his own attitudes and responses toward all aspects of a culture not his own. The ultimate goal of cross-cultural psychiatry, as a combination of anthropology and psychiatry, is to provide effective health care in a wide range of settings and cultures, enabling the trained therapist to work effectively with her patient.

 A Match Is Arranged Between Cultural Psychiatry and Ultra-Orthodox Judaism

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Armed with an awareness of his or her own cultural biases, the therapist can proceed to evaluate the unique components of another society and its psychopathology. Through an understanding of both self and other, it should be possible to approach the matter of therapy. Culture-bound issues are particularly poignant in Jerusalem, given the historic, social, political, and religious intricacies of life in that city. Psychiatry and Ultra-Orthodoxy / 

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We have structured this chapter around the concept of shidduch, the arranged matrimonial match.1 The groom is a composite of two male Israeli psychiatrists who work closely with the ultra-orthodox Jewish population. Both are part of a medical tradition which takes for granted that everything the therapist observes in or is told by patients can be subsumed within its omniscient structure. Yet providing clinical care to the ultraorthodox community—the bride—is a matter of considerable complexity, as will become evident. The ultra-orthodox community lives within but apart from the rest of the Jewish population. Members are aware of many facets of secular society but choose to avoid them. This creates the paradox of a society brought up in cultural isolation that is nonetheless accessible. This isolation results in a psychopathology that is unique to Israeli ultra-orthodox culture, one that will be presented to illuminate the influences of social structure and beliefs on mental illness. The secularization of Jewish society has proceeded in waves over the past two hundred years. In most cases, the parents, grandparents, or great-grandparents of today’s secular Jews were ultra-orthodox. This means that the values of the ultra-orthodox community are part of the cultural heritage and background of virtually all members of the Jewish population in Israel. Although these beliefs and behaviors may seem foreign to most secular Jews, including most workers in the mental health establishment, they are historically familiar and near. As will be discussed later, the yichus (distinguished lineage) of the groom in the match we have created between ourselves and the ultra-orthodox community may be irrelevant.2 The ultraorthodox community needs to have access to mental health care, and this means that the match is one of convenience. The marriage could therefore be carried out without any semblance of enthusiasm. We believe, however, that real progress will be made  / Introduction

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only if the bride and groom not only respect but appreciate each other. It is this appreciation that can lead to further selfunderstanding and, we hope, professional maturity. In the nineteenth century, Jewish historians like Heinrich Graetz, presumably in a wish to accentuate their newly granted European citizenship and escape their roots, assigned insignificant historical status to such religious social movements as hasidism and denied the central role of mysticism in Judaism. Twentieth-century scholars like Gershom Scholem ( []) and Joshua Trachtenberg ( []) have demonstrated the prevalence of mysticism and its enormous influence in the past and present. We shall observe the overriding importance of mystic imagery in the fears of those born ultraorthodox, despite its fringe role in the community’s curriculum of studies; this attests to the continuing preeminence of mysticism and suggests that fears of devils and a leaning toward magic practices may lurk in all of us, barely beneath the surface.3 The self-imposed isolation of the ultra-orthodox community includes a rejection of many of the values of the secular world. Secular therapists may not be aware of the Western values inherent in their mental health work that might conflict with tenets of ultra-orthodox life. Examples of such values are the emphasis on the individual in contrast to the community and on selffulfillment in contrast to responsibility and the search for relief from frustration. Even encouraging a patient to ventilate his anger at parents or teachers—the most respected figures in a religious person’s life—can be seen as counter to the values of ultra-orthodox life. The whole purpose of the ultra-orthodox way is to give the individual a sense of completeness in the service of God. So how are we to understand depression in an ultra-orthodox person? If it is a sign that the sufferer has sinned or is of weak faith, then how can secular methods of healing help? Psychiatry and Ultra-Orthodoxy / 

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The feelings and opinions of the therapist must also be considered against the backdrop of the political and religious reality of modern Israel. In Jerusalem more than  percent of the Jewish population is ultra-orthodox, as are  percent of the children entering first grade, a consequence of the typically large ultra-orthodox families. In areas of the city that are becoming ultra-orthodox, the main roads are closed to traffic on the Sabbath, shops selling fashions or literature unacceptable to ultraorthodox values are forced to close, and pubs, clubs, and cinemas become concentrated in more secular areas of the city (Shilhav and Friedman, ; Landau, ). Awareness of these changes may create alarm in the secular therapist. In addition, the fact that ultra-orthodox Jewish men generally do not serve in the Israeli army while secular Jews are obliged to do so may create an underlying resentment in the therapist that does not make it easy for him to be empathic. In addition, whereas the secular Jew may consider his tolerant attitude toward the ultra-orthodox way of life a virtue, this attitude is not reciprocated by the ultra-orthodox Jew, who regards the secular way of life as profane (Landau, ). These fundamentalist attitudes are not, of course, unique to Israel (LazarusYafeh, ). So is this union a marriage of convenience or a love match? Such a question can be asked in the form of either/or only in a society where couples can meet spontaneously and explore the strength of their mutual attraction before they marry. In an arranged marriage, premarital meetings are few, and the bride and groom must each decide whether to marry before the two have a chance to develop a relationship. But their marriage is not therefore considered a union of convenience. The ultra-orthodox couple is expected to become ‘‘one flesh’’ (Genesis :). Similarly, the union of Western psychiatry and the ultraorthodox community cannot just be one of convenience. Trying  / Introduction

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to create facilities to carry out therapy that is, on the one hand, genuinely helpful and, on the other hand, neither foreign nor disturbing to the patient’s religious and communal values will affect the therapist’s sense of self, hitherto molded over many years in the mental health culture. Modifying this identity is no simple process, but it can lead to a true marriage with the ultraorthodox community.

 Varieties of Religious Identification

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Like all long-standing religious groups, Judaism is composed of many different strands, for divisions are inevitable within any organization that has withstood the stress of time. Three thousand years ago, in biblical times, Jews were categorized as priests, levites, and common folk; two thousand years ago they were Pharisees, Saduccees, and Essenes. (Their later reputation among Christians notwithstanding, the Pharisees believed in the potential development of the oral law and in the ultimate value of scrupulous religious observance.) The journey into ‘‘exile’’ led to separate ethnic communities, including Ashkenazi and Sephardi, and two hundred years ago the emancipation of European Jews into secular society brought further subdivisions.1 Each historical period was shaped by sociopolitical influences that determined the features of the differences between the groups. Religious Identification / 

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The modern Jewish world is no exception, with several major divisions, principally along a spectrum of ‘‘orthodoxy.’’ Religious orthodoxy in Judaism is measured by two yardsticks: the extent to which adherents view traditional religious laws and practices as God-given and holy, unchangeable and inherent, and the degree of their immersion in the values and activities of the nonreligious world. The spectrum of orthodoxy ranges from the secular to the ultra-orthodox. The range of definitions included below is especially appropriate to Israel. Further subdivisions are possible, especially outside Israel, and clear boundaries between each type of belief exist only on paper. Nevertheless, for the purposes of this book, the following four subgroups should suffice. Secular Jews consider themselves Jewish by birth alone; they may assign no religious significance to their Jewishness. A secular Jew may believe in God but does not equate belief with a duty to perform traditional Jewish practices. Secular Jews do not regard Jewish laws as binding, nor do they belong to a synagogue. However, they may maintain strong social ties with other Jews, including membership in Jewish clubs and social circles. Traditional Jews (especially in Israel) retain certain religious practices, usually those with a strong social or family component, such as the traditional family meal on the first night of Passover, fasting and attending synagogue services on Yom Kippur, and perhaps saying the blessing over the wine at the Friday night meal to start the Sabbath. These customs are preserved out of fondness for the ritual or a wish to continue the practices of their parents. Traditional Jews are immersed in the nonreligious world, study and work alongside nonreligious people, and dress according to accepted secular styles. Modern orthodox Jews balance a commitment to two sets of values. They retain the range of religious practices while being active in the secular world, accepting all work and study as long as they do not overtly contravene religious law. Modern ortho / Introduction

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dox men wear a hat or a yarmulke at all times, and married women may cover their hair with a wig or scarf. Commitment to both secular and religious ideals often requires modern orthodox Jews to take stands that can affect both standards of religious practice and involvement in secular life. Such juggling can cause both secular and ultra-orthodox Jews to consider modern orthodox Jews inauthentic. Like their secular counterparts, ultra-orthodox Jews are clearly definable. They believe that Jewish law is holy and that religious observance is the first responsibility of Jews. Even their behavior toward their fellows is guided by religious rather than humanistic motives. This is demonstrated in the interpretation of the verse in Leviticus :: ‘‘And you shall love your neighbor as yourself, for I am God.’’ The basis of the command to love one’s fellow human may appear social, but the motivation is religious: to perform the commandments of God.2 As important as performing the law is studying it: ‘‘The study of the Torah is the greatest of all commandments,’’ states the Talmud (Shabbat a), although this is a duty for men only. The greatest rewards await the ultra-orthodox man who spends his days (and nights) studying the Talmud. Any other pastime, even social banter, is defined as ‘‘bitul zeman Torah’’ (a waste of Torah-studying time). Many features of the secular world are perceived as detracting from God’s sanctity, deflecting religious Jews away from the right path. Movies, television, and all nonreligious books are forbidden; participating in sports is not encouraged; and study of nonreligious subjects is actively discouraged. The primacy of Torah values and the importance of studying the Torah, particularly the Talmud, influence the course and content of life. As a result of the ultra-orthodox belief that secular values are profane and corrupting, secular studies, restricted to a modicum of mathematics, end at the age of thirteen, when ultra-orthodox Religious Identification / 

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adolescent boys are sent to yeshiva. No ultra-orthodox boy in Israel applies to university, for men are expected to engage in full-time talmudic study. The stipend for study is low, so that ultra-orthodox women often have to take jobs to help support the family. As a result of this financial imperative and the lack of emphasis on Torah study for women, ultra-orthodox women have a broader curriculum of studies available to them than to men. Even so, the courses are pragmatic: domestic sciences, typing, computer programing, and decorative work are possible sources of income or important for running a ‘‘bayis ne‘emon be‘Yisroel,’’ a faithful Jewish household. Subjects imbued with values of the surrounding society, such as history and geography, physics, biology, and chemistry—even Hebrew grammar—are not taught. The average ultra-orthodox home in Jerusalem reflects these values. A unique feature is its relative lack of decoration. The living room will contain a large collection of books, which cover the walls. The Talmud and later commentaries on the Talmud predominate, accompanied by earlier and later versions of the Code of Jewish Law. The Torah and its commentaries will be present, but few studies of the rest of the Old Testament. There will be no secular books, maps, encyclopedias, novels, magazines, or newspapers. Even the telephone directory—the only secular book likely to appear—has recently been supplanted in many homes by a directory of addresses and numbers in the ultra-orthodox areas, with advertisements for companies that are religiously observant. What few pictures hang on the walls will either be country scenes, without human figures, or portraits of famous rabbis. There will be no pictures of women. The only other decorations will be functional religious objects: Sabbath candlesticks, a Hanukkah menorah and a Havdala spice box. Throughout the home, the message is clear: the study of the Torah and the per / Introduction

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formance of its commandments are the only important things in life. Ultra-orthodox men and women wear distinctive clothing: men wear long black coats and black hats, white shirts, and black trousers and shoes. All adult males have beards and long sidecurls (Levy, ). Ultra-orthodox women wear dresses in subdued colors and patterns with long sleeves approaching the wrists and hems well below the knees. Most women wear stockings, and cosmetics are discouraged. Married women cover their hair with scarves (ultra-orthodox rabbis disapprove of overly attractive wigs). Their guiding principle is modesty, supported by the verse in Psalms :: ‘‘All the glory of the princess is within her.’’ Bearing children is the first commandment mentioned in the Torah, and contraception is forbidden unless it is sanctioned by a rabbi, usually for medical reasons; ultra-orthodox families thus commonly have ten or more children. Their way of life and rejection of secular values have led ultra-orthodox groups to live together in areas where the facilities they need are available: schools for their children, shops carrying kosher food, and academies (kollel) where married men continue their Talmudic studies. The distinctions described here are not uniformly applicable to all communities within Israel or in the Diaspora. Secular Jews in the United States may live in an area where there are few or no Jews, so that being Jewish may have no bearing on their dayto-day lives. Those same Jews, were they to live in Israel, would necessarily learn a limited amount about Judaism in school as part of their historical heritage; the Sabbath and festivals would be holidays; their friends will be Jewish; and men would have to serve in the Israeli army. Ultra-orthodox Jews in the United States usually attend an ultra-orthodox school, but they receive education in a number Religious Identification / 

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of secular subjects, in the expectation that they will eventually have to find a job and earn a living. American ultra-orthodox Jews may view the external non-Jewish culture as alien but not antagonistic. The relationship of ultra-orthodox Jews in Israel to the surrounding society is less ambiguous: the secular Jewish state is viewed with disapproval. If Israel is indeed a Jewish state, argue the ultra-orthodox Jews, then it should be run according to Jewish law, and the rabbis should be its leaders. The ultraorthodox disapproval of a society in which they nevertheless see themselves as pivotal has led to a greater isolation in Israel than they find elsewhere in the world.

 The Parable of the Turkey Parables are a central means for teaching moral values in many cultures. Jewish religious literature is no exception. The Bible stories may be seen as the basic model, in which the parable is used to engage the listener and make a difficult message palatable. One of the most powerful examples is the parable told by the prophet Nathan to King David following the king’s affair with Bathsheba, whose husband he had had killed:

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There were two men living in a city, one rich, the other poor. The rich man had an abundance of flocks and herds, while the poor man had but one  / Introduction

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small ewe lamb, which he had bought and reared. It grew up together with him and his children; it ate of his bread, drank of his cup, lay in his bosom, and was like a daughter to him. Once there came a traveler to the rich man. Wishing to spare his own flocks and herds when he fed the traveler, he took the poor man’s lamb and prepared it for his guest. David became very angry at the man’s behavior and said to Nathan, ‘‘As God lives, the man who has done this deserves to die; the lamb shall be repaid four times over because he did this thing and had no pity.’’ And Nathan said to David, ‘‘You are the man.’’ (II Samuel :–) The use of parables became particularly common in the time of the Talmud and Midrash. Parables are also used frequently in the New Testament, which arose from the same culture in about the same period. The most recent revival of the use of parables in Jewish religious teaching has been in the hasidic movement. One of its most eloquent proponents was Rabbi Nahman of Bratslav (–). We have decided to present several aspects of what we intend to discuss in the form of a parable. In this way our reader will join us in one of our first tasks as psychiatrists: beginning to understand the thoughts and practices of the community we are treating. Rabbi Nahman of Bratslav related the following tale to his followers:

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There was once a prince who became mad. He believed that he was a turkey and that he must sit naked under the table and nibble at breadcrumbs

Parable of the Turkey / 

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and bones. All the physicians were unable to cure him. His father, the king, was greatly distressed by the situation, until one day a wise man came and said, ‘‘I will undertake to cure your son.’’ The wise man undressed himself, sat under the table next to the prince, and began to nibble at crumbs and bones. The prince asked him, ‘‘Who are you? What are you doing here?’’ The wise man replied, ‘‘And what are you doing here?’’ Said the prince, ‘‘I am a turkey.’’ Said the other, ‘‘I, too, am a turkey.’’ The two sat together in this way for some time, until they had become accustomed to each other. The wise man then gave a signal, and two shirts were thrown to them. Said the wise man to the prince, ‘‘Do you think that a turkey mustn’t wear a shirt? One can wear a shirt and still be a turkey.’’ They both put on shirts. After a while and a further signal trousers were thrown to them. Again the wise man addressed the prince: ‘‘Do you think that with trousers on one cannot be a turkey?’’ And so it continued until they had put on trousers, and similarly with the rest of their clothes. After a while and another signal they were thrown proper food from the table. Said the wise man, ‘‘Do you think that if you eat good food then you cannot be a turkey? You can eat and still be a turkey.’’ They ate. After a while the wise man said, ‘‘Do you think that a turkey must only sit under a table? It is possible to be a turkey and sit next to the table.’’  / Introduction

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The wise man continued to behave with the prince in this way until he had cured him completely. (Peli, ) What was Rabbi Nahman trying to teach? Classically in Jewish parables, the king and prince would represent the relationship between God and the Jewish people. But what does the metaphor of mental illness represent? Who were the physicians? Who was the wise man? If the illness of the prince represents the suffering of the Jewish people, the parable may be seen as discussing the role of the religious leader in helping his flock. More than any other leader of the hasidic movement, Rabbi Nahman was aware of the depression and despair experienced by the seekers after closeness to God. At a more political level, he was uncompromisingly critical of the leaders of his day who were wealthy and pampered and out of touch with their impoverished and tyrannized followers. His allusion in the parable may have been to the hasidic leaderphysicians who were out of touch with their flock-prince. It was only the wise man (possibly Rabbi Nahman himself ) who lived under the same conditions as those he served who was able to understand and help them. Part of the beauty of the parable is that it is deliberately constructed to permit many levels and types of explanations and morals. For example, if the king is God, then Rabbi Nahman seems to be saying that being a prince, the son of the allpowerful, does not solve all problems in life. This alone is a central and challenging theological issue. ‘‘One does not rely on miracles’’ is a basic rabbinic formula, implying that when we are sick or in danger, we must not wait passively for God to look after us but seek help from others. To whom do we turn when we need help? Applying the parable to society in general, the physicians can be seen to represent Parable of the Turkey / 

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medical and scientific knowledge. Rabbi Nahman is depicting the failure of science to understand and reach out to a person in distress, in contrast to the success of one who was ‘‘merely’’ wise. The wise man, we presume, had no formal training, but he knew that to help someone in distress he must get close to the person, so that the sufferer will feel that he is understood. As psychotherapists were to conclude two centuries later, the main ingredients of good therapy are empathy and trust. Empathy, ‘‘how well the therapist can step into the patient’s world and see and experience life the way the patient does’’ (Beck, Rush, Shaw, and Emery, , p. ), is described in Rabbi Nahman’s parable in the most concrete terms. The wise man entered the prince’s world, crawled under the surface of the table of civilized behavior, ate crumbs, and gnawed at bones. Like today’s homeless and starving, he was no longer competing in the majority culture. He took what others rejected. Was the prince rejecting society, or was he unable to compete within it? Rather than creating theories about the cause of the prince’s disorder, the wise man simply joined him. He was not rejected. The wise man and the prince became used to each other. They established a relationship of trust. The wise man spoke to the prince as an equal and treated his values with respect. The next phase of the parable, in which the wise man set about treating the prince, reveals a truth concerning many therapeutic situations: it is often pleasant and challenging for a psychiatrist involved in evaluation and therapy to get to know a patient and try to understand her. Eventually, however, the time for change arrives, and the switch from passive listening to actively inducing that change is complicated. At this stage the wise man presumably concocts a theory that will lead to his style of intervention:

 / Introduction

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. The snap-out-of-it theory: ‘‘Stop being an ass. You are a prince. Behave like one.’’ . The just-needs-a-good-hiding theory: ‘‘If you don’t

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come out of there immediately, the guards will come and give you a thrashing.’’ This theory is related to the idea that the prince is not mad but is just pretending and will stop his performance if the cost is greater than the benefits. The underlying - fears - that - need - to - be - understood theory: ‘‘You are a prince. Much is expected of you. You may be frightened by the responsibility of your position and have therefore retreated from society and its expectations. Let us sit here and discuss the matter. You may be able to examine why the world is so threatening, come to terms with it, and emerge from your retreat.’’ The biological theory: ‘‘You’re not well. You were a perfectly functional prince until recently. Something has changed in the chemical makeup of your mind. Once we discover what it is, I’ll give you the right medication and you’ll be fine.’’

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Instead of any of these, the wise man says to the prince, ‘‘Do you think that a turkey mustn’t wear a shirt? One can wear a shirt and still be a turkey.’’ The story was so pleasant while the two were getting to know each other. Why do we now feel uncomfortable? Because we realize that the wise man had prearranged with the king’s men that at his signal they would throw him two shirts. The wise man’s first words to the prince reek of manipulation. Is all therapy manipulative? Do all theories represent an artificial and almost arbitrary explanation, where previously there was just a naked prince nibbling crumbs? Of all the diagnoses that could have been given for the prince’s Parable of the Turkey / 

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behavior, madness was the one chosen. Does this parable thus have meaning in the sphere of mental illness? In this book, we shall look again and again at the relationship between clinical psychiatrists—ourselves—and our patients, in this case members of the ultra-orthodox Jewish community of northern Jerusalem in Israel. Rabbi Nahman’s model of reaching a person in distress while respecting his values and beliefs will be explored in our presentation of the mental health problems we see in this society. The approach this tale exemplifies can be compared to the process of ‘‘joining,’’ used by family and strategic therapists, in which the therapist initially tries to form a close alliance with the patient in order to gain the patient’s trust. Only after such a phase is therapeutic cooperation possible (Haley, ). How easily can we assume the role of the wise man, joining the ultra-orthodox patient in his world? Can we empathize? Should we be trusted? After all, we intend to start manipulating our patient immediately afterward. One can remain at a distance, aloof, or to use Rabbi Nahman’s metaphor, ‘‘above the surface.’’ The alternative, going beneath the surface, has also meant going beneath our own surfaces, as physicians, as people, and particularly as Jews. No medical school prepared us for what we were to encounter. Rabbi Nahman’s parable of the turkey-prince has been cited previously in psychiatric contexts (Greenberg and Witztum, a; H. Cooper, ) and as the basis for a religious text on how to achieve spiritual growth (Greenbaum, ). We present it here to begin to analyze some of the issues that may arise in cultural psychiatry. The parable demonstrates a principle of religious study: the text is fixed, but the ways of looking at it are endless. When a religious Jew reads the Torah, his understanding can be supplemented by any number of commentators, each with a different view. Creativity is encouraged but within a framework of  / Introduction

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commitment. Similarly, there are many commentators on the Talmud, and every young yeshiva scholar is encouraged to read them. Nevertheless the height of achievement is the hiddush, innovative thought by the reader. This tension between submission to authority and originality is a basic dialectic within Judaism. It represents the problem of distinguishing between individuality and deviance, an issue we shall discuss in the next section.

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P II

       

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 Beliefs and Delusions All religions may be said to have two principal components: beliefs (creeds) and practices (cultus). A devout member of a religious society who becomes psychologically unstable is likely to express her disturbance through the creeds and cultus of her religion. Two central symptoms, or expressions of disturbance, in psychiatry, delusions and compulsions, are respectively defined as excessive beliefs and excessive practices. How a psychiatrist who is not a practitioner of a particular religion can understand what is ‘‘excessive’’ and what is not has exercised cultural psychiatrists for decades (Murphy, ; Westermeyer, ; Greenberg and Witztum, a; Post, ). At the simplest level, coreligionists are likely to know when the beliefs or practices of one of their members exceed normal limits. A key implication of such a statement is that mental health services should wait until they are asked to intervene by the religious group. However, the religious society itself may be unsure of the boundaries between culture-specific normalcy and psychological disturbance, or it may be hesitant to seek outside help, or the individual may not be a well-integrated member of the group, one with whom people are closely enough involved to notice her excesses and insist she seek help. The chapters in this section discuss the often confusing overlap between unusual group beliefs and practices and individual psychopathology. In particular, we deal with the difficulties of distinguishing between beliefs and delusions, visions and hallucinations, rituals and compulsions in ultra-orthodox Jewish patients. 

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B   F  J Belief in God as an article of Jewish faith is not discussed in the Torah, perhaps because it is taken for granted or because the Torah emphasizes practice rather than belief (Abrahams, ). Jewish philosophers in the Middle Ages were interested in such matters, but their concern may have been a response to other religions rather than to something intrinsically Jewish. The only verse in the Torah which could be seen as a demand for belief is the first of the ten commandments: ‘‘I am the Lord your God who brought you out of the land of Egypt, from the house of bondage’’ (Exodus :). But commentators have debated whether this is a commandment in its own right or a preamble to the next sentence, which is the true commandment: ‘‘You shall have no other gods before me’’ (Exodus :). This implies that Jews are not commanded to believe in God but rather are warned not to believe in many or other gods. Characteristically, the debate is presented by means of a parable in the Mekhilta, a collection of commentaries on the Book of Exodus compiled in the third century ..: There was once a king who entered a new country. His vassals said to him, ‘‘Give us laws.’’ ‘‘No,’’ he replied, ‘‘only after you have accepted my sovereignty will I give you laws. If my sovereignty is not accepted, why should you accept my laws?’’ The Mekhilta continues:

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In the same way, God said to Israel, ‘‘I am the Lord your God who brought you out of Egypt. You shall have no other gods,’’ implying: It was when you were in Egypt that I accepted the invitation to be

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your king, as you, too, accepted my sovereignty. It is on that basis that you should now accept my laws. The implication of this parable is that the Torah does not include belief among its many laws and commandments because belief is a sine qua non, without which the laws are pointless. B   P S ‘‘Since time immemorial delusion has been taken as the basic characteristic of madness’’ (Jaspers, , p. ). A delusion is a psychiatric symptom most simply defined as an abnormal belief. The human capacity to believe exists in a spectrum of normal experiences, including convictions and opinions held with more or less tenacity, superstitions, and faith. Karl Jaspers, a leading philosopher and psychiatrist of the early twentieth century, attempted to define the characteristics that distinguish delusions from normal beliefs. He defined delusions as false judgments held with ‘‘an incomparable subjective certainty,’’ impervious to counterargument. Each of these characteristics, however, existed in varying degrees in different psychotics and could also be found in many people of strong faith or tenacious political or other opinion. Further, he described a middle ground known as an ‘‘overvalued idea,’’ which is a notion held with great conviction that is understandable in terms of the believer’s personality and history, and is not a psychotic symptom. Any therapist who has interviewed a patient who describes what is commonly termed ‘‘pathological jealousy’’ will be aware of the absence of cast-iron criteria for delusions. A patient is convinced that his wife is having an affair. If the patient interprets every stain on the living-room carpet as sperm left by his wife’s lovers, or every creak of the bed that wakens him at night

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as the sound of a departing paramour, these unlikely interpretations appear to be part of a delusion. Nevertheless, the delusions may have followed suspicions which were in fact justified. However one tries to define delusions, the overlap with normal beliefs is striking. Henry Murphy, an early cultural psychiatrist, observed that whereas it is relatively easy to diagnose ‘‘private delusions’’ because they differ notably from the beliefs of a group, there is a gray area that he termed ‘‘delusory cultural beliefs’’ (). These are beliefs that are accepted within a culture but that appear to outsiders to be improbable or even objectively disprovable. Murphy concluded that the bizarreness of the belief often does not serve to discriminate between belief and delusion; the difference may be a matter of degree of conviction. In such cases the task of discriminating between the two becomes problematic. If, for example, a patient tells the psychiatrist of the imminent arrival of the Messiah, how is the psychiatrist to distinguish between a fervent believer and a deluded psychotic? If the patient used to hold such beliefs with quiet conviction and now asserts them strongly, is this change a sign of deterioration from belief to delusion? Alternatively, she may have experienced a strengthening of her religious convictions that created messianic fervor (see Chapter ). If the psychiatrist is himself newly orthodox, will he share the fervor, nod his head encouragingly, and add, ‘‘May it come speedily in our days, Amen’’? M B V D

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In attempting to distinguish between normal religious beliefs and psychotic delusions in the context of ultra-orthodox Jewish beliefs, let us compare three statements. The first comes from the twelfth-century physician-philosopher Moses Maimonides:

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I believe with a perfect faith in the coming of the Messiah; even though he may be delayed, nevertheless I shall wait for his coming every day. (Daily Prayer Book) This statement constituted the twelfth of Maimonides’ ‘‘thirteen principles of faith,’’ which he defined as the basic beliefs of committed Jews. Faith in the imminent arrival of the Messiah is a basic tenet of Judaism, and the thirteen principles are repeated by religious Jews in their daily prayers. Although Maimonides declared that the believer should be in a state of constant readiness, the attitude he suggested was one of passive yearning. In  Moses Nachmanides, another physician-philosopher who was also a mystic, was compelled to participate in a public religious disputation in the presence of King James I of Aragon. Repudiating the Christian claim that the Messiah is both human and divine, he announced to his monarch, ‘‘The essence of our judgment, truth, and statute does not depend upon the Messiah. [For the purpose of fulfilling the commandments of the Torah,] you are more beneficial to me than the Messiah. You are king and he is king. You are a gentile king, and he is a Jewish king, for the Messiah is but a king of flesh and blood like you’’ (Nachmanides, , pp. –). The emphasis is again on passive yearning. As Maimonides (a) noted in conjunction with our first statement: ‘‘One must believe fervently that [the Messiah] will come, and not think that he may be delayed, but one must not set a fixed time for his arrival nor carry out calculations on Biblical verses to work out the date of his arrival’’ (p. ). The second statement is:

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Prepare for the coming of the Messiah.

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The essential difference between these words and the first statement concerns the timing of the event and its relation to a particular person. According to Maimonides and Nachmanides, Jews are expected to yearn for the Messiah, who could be anyone. The proponents of the statement, the Lubavitch hasidim, believe that they know who the Messiah is and that in a short time he will declare himself. Observers have interpreted the recent preoccupation of the Lubavitch hasidim with the imminent appearance of the Messiah with the insecurity they felt following the illness and subsequent death in  of Rabbi Menachem Mendel Schneerson, their leader for four decades. The movement became divided, many claiming that the nonagenarian Schneerson had not died: there was no body in the coffin; therefore no prayers for the dead need be said for him, and no new leader need be appointed. More than six years after his death, a new leader has still not been appointed, and posters go up announcing each subsequent birthday of ‘‘Our master, teacher and rabbi Melech Hamashiach’’ (Hebrew for ‘‘the Messianic king’’). No one doubts the sincerity of these hasidim. They would not be accused of having a folie-àplusieurs, a group delusional illness. Rather, they are said to share a ‘‘delusory cultural belief.’’ For this large segment of the ultraorthodox population, a general yearning became an immediate and focused concern (Littlewood and Dein, ). These two statements demonstrate the extent to which a belief in the coming of the Messiah, while alien and possibly even ridiculous to members of secular society, is a central credo of religious Jewish society. The third statement is a quote from a psychotic patient, and it is distinctive for several reasons: it suggests a grandiose role that the person thinks he must play; the speaker is secretive, with a hint that he has been directly instructed by a ‘‘higher authority’’;

 / Belief and Ritual

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the statement reflects a personal, rather than a communal attitude. I have a special job. I will help the Messiah to come. I may even be the Messiah son of Joseph, but I can tell you no more details, I am not allowed. Let us consider whether these features may be pathognomonic (distinctly characteristic) of delusions as distinct from delusory cultural beliefs. A personal grandiose role: The three statements display a spectrum of attitudes toward one’s personal involvement in the coming of the Messiah. Although Maimonides declared that every Jew should expect the Messiah, he did not claim to have a special personal role in the Messiah’s coming. And Nachmanides clearly stated that it was more important for him to be busy serving his earthly king.1 In contrast, many Lubavitch hasidim believe that their leader, Rabbi Schneerson, the ‘‘Rebbe,’’ is the Messiah. The Rebbe himself made no such claim, although he never denied it. One could argue that for his followers to believe not that they themselves but that their Rebbe—undoubtedly one of the major Jewish communal leaders of the twentieth century—was the Messiah was an acceptable possibility within normative religious beliefs. Further, they seemed to see no special individual roles for themselves in his coming. Our patient, however, suggested that he himself was either the Messiah or an important figure in his arrival. The Messiah son of Joseph is a figure mentioned in Jewish mystic texts; his task is to unite the Jewish people and then die in battle against its enemies as a prelude to the arrival of the Messiah son of David. Secretiveness: To our knowledge our patient has no particular credentials for the role of Messiah: he is neither a major scholar nor, it appears, a zaddik, a righteous man. We cannot be certain

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whether he is a zaddik, however, because according to Jewish tradition, the lamed-vav zaddikim, the most righteous thirty-six people of each generation, stay out of the public eye, and this avoidance of notice is one of their basic characteristics. One of these zaddikim may be the Messiah, and his messianic role will become known when it is revealed that he was one of the lamedvav (Scholem, ). On the basis of this tradition, our patient’s refusal to divulge the details of his mission are also consistent with the ‘‘delusory cultural beliefs’’ of ultra-orthodox Judaism. A personal rather than communal attitude: Neither twentiethcentury Lubavitch hasidim nor our patient are the first to hear the footsteps of the Messiah. Jewish history is strewn with accounts of messianic fervor and would-be Messiahs. In attempting to discriminate between the second and third statements, we should consider whether the belief usually emanated from a group or from an individual and, if the latter, the extent to which the individual was out of synchrony with his contemporaries. In  the leaders of the Jewish community of Yemen consulted Maimonides about how to handle the social turmoil created when a man declared that the Messiah was about to arrive and then announced that he himself was the Messiah. The ‘‘diagnosis’’ made by Maimonides in his written reply is particularly significant because he was both an experienced physician (at the time he was physician to the vizier of Egypt) and the world’s leading rabbinic authority. We quote Maimonides’ ‘‘Yemenite letter’’ here to demonstrate his understanding of the case and also to help us determine the extent to which the man’s claims paralleled those of the community: ‘‘You must know that the man who says he is the messiah in the cities of Yemen is undoubtedly insane, and is therefore not guilty of his acts.’’ Maimonides then proceeds to explain why the man was clearly not genuine: The Messiah should be the greatest of prophets in wisdom and prophecy,  / Belief and Ritual

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but when a man not known for his wisdom gets up and says he is the Messiah—we do not believe him. There is another proof that he is even a fool, for he decreed that everyone should give all their wealth to the poor. The Torah forbids giving away all one’s wealth; instead one may give away only a portion of it. It is clearly the same grandiosity of spirit that led him to say that he is the Messiah and to tell people to give away all their wealth. For then the rich would become poor and the poor would become rich, and the poor, now being rich, would then have to give the money back again to the rich, now being poor, and this is total stupidity. . . . Further the Messiah will first appear in Israel (not Yemen), and he will appear with such miracles that the world’s leaders will be astounded by him. Finally, if this man were to say he was a trickster, then he would be punishable by death, but instead what I am sure is the truth is that he is insane, and I will give you good advice what to do: put him in a mental asylum until it is public knowledge that he is insane. Then you can release him, thereby saving him from death from the non-Jews, as they will now insult him and treat him as mad, and you will also save yourselves. (Maimonides, c, Yemenite letter, , p. ) The young man’s messianic beliefs continued unabated for at least a year. Maimonides wrote of the outcome in a later letter:

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One year later, the man was captured and all his followers deserted him. One of the local Arabian kings who had captured him said to him, ‘‘What have you done?’’ Beliefs and Delusions / 

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The man replied, ‘‘My master the king, I am speaking the truth, for it is the word of God I am carrying out.’’ The king said to him, ‘‘And what is your miracle (that proves your messianic status)?’’ He replied, ‘‘My master the king, cut off my head, and after that I will live. I will get up and carry on as before.’’ The king said to him, ‘‘There is certainly no greater miracle than that! If it is so, then certainly I and all the world will believe that your words are true.’’ The king immediately gave an order, saying, ‘‘Bring me a sword!’’ And they brought a sword, and on his order they cut off the man’s head and killed that poor man.

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Maimonides added, ‘‘Let his death be an atonement for him and all Israel. Jews were punished by losing their wealth through him, and even now there are foolish people who say that he will still live and arise from his grave’’ (ibid., introduction, p. ) This document is valuable in showing that Maimonides’ main criteria for evaluation are religious. He implies that the man has a personal delusion, not in keeping with Jewish law. The man’s other grandiose and foolish statements are further proofs of his delusion, as is his lack of appreciation of the dangerous situation he is creating for himself and his followers. Despite Maimonides’ unhesitating diagnosis, many common folk followed the false Messiah and continued to believe in him after his death. In fact, the situation is still more complex, for Maimonides’ rationalist position toward the Messiah is in sharp contrast to the view of many other authorities (Scholem, ).  / Belief and Ritual

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The best-known example of a messiah declared by communal consent and with the blessing of the leading rabbi of the generation was Bar Kochba, who led the people of Israel in an unsuccessful war against the Romans in – .. There is no evidence that Bar Kochba viewed himself as the Messiah; coins minted during his brief rule refer to him as Nasi, meaning prince, an ambiguous term. What is generally accepted and relevant to our discussion is a statement in the Jerusalem Talmud (Taanit , halakhah ) that Rabbi Akiva, the leading rabbinic authority of his time, recognized Bar Kochba as the Messiah. That a man of Akiva’s high status should make such a declaration is unusual, yet Akiva’s opinion was not accepted by everyone, as the talmudic text makes clear: ‘‘When Rabbi Akiva would see Bar Koziva [Bar Kochba], he would say, ‘This is the Messianic king.’ Rabbi Yochanan ben Torta said to him, ‘Akiva, grass will grow in your cheeks and the [Messiah] son of David will still not have come’ ’’ (Taanit , halakhah ). The most famous and widely accepted Jewish messiah was Shabbetai Zevi (–). Zevi told a close friend that God had said to him, ‘‘You are the savior of Israel, the Messiah, the son of David, the anointed of the God of Jacob, and you are destined to redeem Israel’’ (Scholem, ). Nevertheless, when he first declared himself Messiah, Zevi was viewed as foolish, ill, or possessed. Indeed, Scholem suggests that Zevi’s reported episodes of seclusion followed by times of elation, when he would speak of his divine role, are consistent with a diagnosis of manic depression. It was only when his youthful follower Nathan of Gaza publicized his master’s achievements that the movement began to gain momentum, and many Jewish leaders around the world accepted Zevi’s claims.2 Are the religious criteria for messianic status sacrosanct? Maimonides’ Yemenite letter makes it clear that contenders for messianic status often failed to satisfy critical criteria without being Beliefs and Delusions / 

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deserted by their followers. The two most famous cases of Jewish messiahs who flouted traditions and even converted to other religions are Zevi and Jacob Frank (–). Frank, possibly the most corrupt and antinomian messiah ever, was notoriously licentious and encouraged a ‘‘free’’ life despite Jewish laws. His followers converted to Islam and eventually to Christianity. Despite his lack of learning, clearly tyrannical ambitions, and departures from traditional Judaism, which contradicted the criteria of Maimonides and fulfilled the biblical definition of a false prophet punishable by death, Frank had thousands of followers, including many deeply religious and seriously committed people; these followers were faithful for more than thirty years after his death. It is clear from this account that messiahs may be selfappointed, so that the personal nature of our patient’s messianic claims do not make them delusions rather than beliefs. It is further clear that the criteria established by leaders, with the authority of Maimonides, did not prevent generations of people, including learned and sophisticated members of the community, from accepting the legitimacy of various messiahs. Neither analysis of the content of these men’s claims nor the strength of their conviction in their messianic status moved those around them to reject them as insane. E   L  R

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We have examined religious belief, using the example of a belief in the coming of the Messiah, without discovering reliable criteria for distinguishing a religious belief from a delusion. We shall now consider religious fervor in the life of one patient to try to pinpoint the distinction between righteousness and psychotic restlessness and irritability.

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Eli’s parents first consulted us a year before he himself was interviewed. At the time, he was twenty-five years old, single, and living with his parents. He had always been a reserved, isolated person who found it hard to talk to others and adapt to their needs. He had also been uncompromising, demanding high standards of himself and those around him. He had completed his army service, where his skills as a mechanic were appreciated but fellow soldiers found him difficult to tolerate. In the previous year he had become increasingly isolated and critical. He spent hours every day alone in religious study; he refused to study with a teacher because he could not find one holy enough. He had even tried to force his father to leave their synagogue because the members of the community were too insincere by his standards. Although he was isolated and silent, if an opportunity arose to help someone he would do so without hesitation and without caution—to the point where his intensity disturbed rather than helped. During the year following his parents’ consultation he had begun to pray alone and had stopped speaking unless it concerned holy matters. He had become increasingly irritable and critical of the religious standards of others. Shortly before he was interviewed, he had nearly knocked down a pedestrian because he was driving too fast on his way to perform a good deed. He continued to refuse help and had to be brought for examination by an official order. He was very angry at being interviewed against his will and argued with every comment made by the examining psychiatrist. ‘‘I understand people in your neighborhood are concerned about you.’’ ‘‘No,’’ he barked in reply, ‘‘not everyone is against me. That is a lie! It is forbidden to tell lies against others. I act in accordance with God. There are pressures on me. My father is not a good

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driver so I insist that everyone who travels in the car with him should say the prayer for traveling.’’ When asked why he had refused to come for help, he answered with a sneer, ‘‘I am having a conversation with a man with the crown of authority. Your documents mean you can direct people by force. You received this documentation from the state. You do not live for the commandments of the Torah.’’ At no stage did he claim to be a special person; rather, he accused the examiner of being irreligious, asking him if he was wearing tzitzit and complaining angrily that many parents encourage their children to serve the establishment but do not teach them to serve God. When the possibility of forced treatment was raised, he accused the psychiatrist of being a homosexual and said he would complain about him to the area psychiatrist and take him to court. Eli then declared that there must be something wrong with the mezuzah in the room, went up to the doorpost and tried to pull the mezuzah off by force, and then ran out. It is likely that the delay in Eli’s receiving help for his paranoid psychosis was due both to his lack of cooperation and to the close relation between normative religious concerns and his paranoid thoughts. At first his isolation and refusal to join small talk were understood as avoiding ‘‘wasting Torah time,’’ and his uncompromising insistence on helping others and saying prayers for travel were regarded as correct and virtuous. Similarly, during our conversation, he perceptively pinpointed the problematic ethical issue of one person being given power over another, stating that he rejected the authority that delegates such power and accepted only the authority of God and His Torah. Such claims could find support from other ultra-orthodox people, who prefer religious courts to the regular judiciary and who do not accept the authority of a secular state. Although Eli is not a member of

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such a group, many who are would accept and identify with his views as those of a principled Jew. His increasing rigidity eventually led his parents to insist that he receive help. His beliefs were normative, but his unmitigating insistence was pathological, consistent with Murphy’s observation that the line between belief and delusion may be only a matter of conviction.3 In this chapter, we have identified some of the features that characterize delusions, compared with the accepted beliefs of ultra-orthodox Judaism: the ideas are private; they give a special role to the individual in contrast to others; and they are out of step with current religious thinking. Nevertheless, private messianic beliefs have been reported over the past two millennia by people who have been seriously accepted by the general public and even by religious leaders as the Messiah. Thus the followers of Shabbetai Zevi and particularly of Jacob Frank justified their conversion to Islam and Christianity and their antinomian practices as the chaos that must precede the messianic era. This argument is declared explicitly in the ‘‘Red epistle’’ published by the disciples of Jacob Frank in , eight years after his death, a text remarkable for its unbridled declaration of Frankist beliefs: ‘‘The Rabbis of blessed memory have said (Talmud Sanhedrin a) that the Messiah will not come ‘until the kingdom is given over to heresy’ ’’ (Scholem, ).4

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 Visions and Hallucinations             ’     

J  J Jacob, a patient with chronic schizophrenia, was becoming increasingly disturbed. His mother reported that he would stand looking out the window conversing with an angel and with the biblical patriarch Isaac. When his psychiatrist asked Jacob whether this was true, he smiled and said, ‘‘If I told you that an angel and Isaac and Moses had been speaking to me, you would say that I had one of your illnesses and you would send me to a mental hospital. You would have sent our teacher Moses himself to a mental hospital.’’

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And it came to pass, when Joshua was near Jericho, that he lifted up his eyes and saw, and behold a man was standing opposite him with his sword drawn in his hand. And Joshua went up to him and said, ‘‘Are you on our side or our enemies’?’’ And he (the man) replied, ‘‘I am the captain of the host of God, I have now come.’’ And Joshua fell on his face to the ground, and . . . said to him, ‘‘What does my lord say to his servant?’’ And the captain of the host of God said to Joshua, ‘‘Take your shoe off your foot, for the place where you stand is holy.’’ And Joshua did so. ( Joshua :– )

 / Belief and Ritual

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In the biblical account, Joshua was not praying, dreaming, or psychotic; he was preparing to attack Jericho when he met the holy apparition which he mistook for a soldier. This experience fulfills Karl Jasper’s () criterion for a hallucination: ‘‘Hallucinations proper are actual false perceptions which are not in any way distortions of real perceptions but spring up on their own as something quite new and occur simultaneously with and alongside real perceptions.’’ Hallucinations may occur under a wide range of circumstances. For example, it is common for a grieving person to see or hear the deceased. Hallucinations can occur in states of confusion, in posttraumatic stress disorder—when a person can experience vivid flashbacks of the past traumatic event—and in psychosis, most commonly schizophrenia (Berrios and Brook, ; Asaad, ). They can also be induced by stimulant drugs. In a study of baalei teshuva, young people in Israel who were brought up in nonreligious families and later become religious, nearly half reported having had revelations, some in the form of visions (Aviad, ). Hearing voices and seeing visions are neither rare nor necessarily signs of mental illness. How, then, do we distinguish between the biblical Joshua and our patient Jacob, who quietly reminds us of our secular skepticism, implying that we, the therapists, have the disorder: a lack of spirituality. D M H I?

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Psychiatrists use the term ‘‘insight’’ to refer to a patient’s attitude toward his illness. A characteristic of psychotic patients is that they often do not consider themselves ill (this is called ‘‘lack of insight’’; David et al., ). And although psychotic patients may be terrified by their hallucinatory experiences and may even try to conceal them from others, they understand these

Visions and Hallucinations / 

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hallucinations as real events, indistinguishable from other sensory perceptions, even though other people did not share them. The ‘‘normal’’ hallucinator, by contrast, is aware that his or her experience is unusual. That the presence or absence of insight can help us distinguish Joshua’s religious hallucination from Jacob’s psychotic hallucination is demonstrated by the case of Moses. After he sees and hears God at the burning bush (visual and auditory hallucinations), Moses is instructed, ‘‘Now go to Pharaoh and take the children of Israel out of Egypt.’’ Moses replies, ‘‘Look, I’ll go to the children of Israel and say, ‘The God of your fathers has sent me to you.’ They’ll say, ‘What is his name?’ What am I to say in reply?’’ (Exodus :, :). Despite the visual and auditory revelations, Moses is well aware of the skeptical response he will receive from those who have not shared the experience. God proceeds to supply Moses with a detailed prophecy of the imminent redemption, intended to convince the people of Moses’ legitimacy. Answers Moses, ‘‘They will not believe me. They will not listen to me. They will say: ‘God did not appear to you.’ ’’ (:) God’s response is pragmatic. Miracles carried out by Pharaoh’s magicians were the accepted proof of divinity in Egypt, so God accepts the need to conform to current expectations and gives Moses miracles to perform. Unlike psychotic patients, Moses has striking insight, awareness of the bizarreness of his own experiences. Although he has had a revelatory experience, he knows that it is personal and that others might not believe either in the experience or in its importance in their lives.

 / Belief and Ritual

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L  F  H: K’ M Another important distinction between a religious and a psychotic experience concerns general functioning—how the visionary deals with day-to-day life. At the time of the revelation at the burning bush, Moses was working as a shepherd. Subsequently, in the ensuing books of the Torah, he goes on to become a national leader. Psychosis, by contrast, is often associated with a significant decline in general functioning. Lenz () compared the experiences of psychotic patients who exhibit religious symptoms with the experiences of Ignatius of Loyola, founder of the Jesuits, while Prince () describes the hallucinatory experiences of a Korean woman who eventually understood these prolonged episodes as indications that she must become a shaman, a ritual healer. In both cases the symptoms, taken in isolation, and even the subject’s behavior during the episodes, could be identified as psychotic (even by accepted local definitions). It was the visionary’s subsequent ability to function extremely competently, with no recurrence of the attacks, that led the theorists to diagnose these episodes as religiously meaningful rather than psychotic. An outstanding example in Judaism of a man who combined the highest level of intellectual functioning with regular auditory and visual hallucinations is the mystic Rabbi Joseph Karo (– ), the undisputed leader of the Jewish world in the sixteenth century and the author of the classic, voluminous compilation of Jewish lore, the Code of Jewish Law. For more than forty years Karo kept a diary recording his meetings with a Maggid (Dan, b). The Maggid was a voice that spoke to him, often via the movements of Karo’s own mouth. The Maggid visited Karo when he was alone, by day and by night, though he generally appeared in the late hours after Karo had been studying Visions and Hallucinations / 

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Mishnah. The Maggid taught Karo mystic secrets, rebuked him for aspects of his personal behavior, and promised him ultimate martyrdom. The diary of these encounters is a remarkable account of a phenomenon that was frequently noted among Jewish mystics in the sixteenth to eighteenth centuries. It is salutary to realize that the Maggid was experienced by a man who is an accepted authority on all aspects of religious practice (Werblowsky, ). A  J: J  J R

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Thus far, we have considered two aspects of hallucinations: the person’s insight into his experience and condition, and his general level of functioning. Let us turn now to the content of the experiences themselves. A twenty-first-century visitor to an art gallery may enjoy standing before a painting of a group of angels by the seventeenth-century artist Peter Paul Rubens. Rubens was a worldly courtier, but he was also a deeply religious person. He treated stories of angels as real events, while the secular observer ignores the question of the validity of the content and admires the overall aesthetic effect of the work of art. She does not for a moment think that Rubens was psychotic. Similarly, depending on her commitment and beliefs, the reader may see the stories in the Bible as a series of myths or allegories, or as descriptions of real events. Understanding how an ultra-orthodox patient relates to angels involves understanding how he relates to biblical events and subsequent religious texts. The Bible presents a world visited by angels: an angel guarded the Tree of Life in the Garden of Eden, three visited Abraham after his circumcision, another helped Hagar, yet another stopped Abraham from killing his son, Isaac, as a sacrifice, angels walked up and down a ladder in Jacob’s dream, an angel  / Belief and Ritual

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wrestled with Jacob, one spoke from the burning bush, and another stopped Balaam’s ass. These are the angels that appear in the Torah. Angels are part of the Bible furniture, yet they are not described physically until later books: Isaiah saw six-winged angels, ‘‘with two wings each one covered its face, with two wings it covered its feet, and with two wings it flew’’ (Isaiah :). Ezekiel’s vision of the chariot of God contains the most physical description in the Bible: the angels were in ‘‘the likeness of a man; every one had four faces and four wings; their feet were straight, the soles of their feet were like a calf ’s foot. They had the hands of a man under their wings. Their wings were joined together. They had the face of a man, a lion, an ox and an eagle. Two wings of each were joined to each other, and two wings covered their body. Their appearance was like coals of fire’’ (Ezekiel :–). Angels are named only once in the Old Testament, when Gabriel and Michael appear in the Book of Daniel (:–:). Daniel describes a vision: ‘‘I saw a man clothed in linen, his loins were girded with fine gold, his body was like the beryl, his face was like lightning, his eyes like torches of fire, his arms and feet like burnished brass, the sound of his voice like the voice of a multitude.’’ Demonstrating his insight into the unusualness of his experience, Daniel adds, ‘‘And I alone saw the vision. The men who were with me did not see the vision.’’ (Daniel :–) The first book of Enoch, although not included in the Old Testament, was written in the Second Temple period and was very influential. Enoch describes a vision in chapter : ‘‘I saw two holy angels, and they were walking on flames of fire, their clothes were white, their cloaks and their faces shining as snow . . . and I saw innumerable angels, and Michael and Gabriel and Raphael and Pnuel.’’ The Book of Secrets, a Jewish mystical work thought to have been compiled in the fourth to sixth centuries .., names more Visions and Hallucinations / 

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than seven hundred angels and their functions, including Raziel, who stood on the seventh step of the second (out of seven) heaven (Margalioth, ). Even the rationalist philosopher Maimonides listed ten types of angels, agents between God and humans. Angels, then, are an ever-present feature of the Old Testament. They are commonplace in Jewish literature and are emphasized and carefully classified in Jewish mystical writings. Many everyday Jewish customs are filled with meanings deriving from a belief in demons and angels. Although not all contemporary Jews are comfortable with this feature, angels are part of Jewish prayer and practice. All the religious texts listed above are sacrosanct for the ultra-orthodox Jew. To doubt the existence of angels would be to doubt the veracity of the texts, a rejection of three of the thirteen principles of faith defined by Maimonides: I believe with a perfect faith that all the words of the prophets are true. I believe with a perfect faith that the prophecy of Moses our teacher was true . . . and that all the Torah that is now in our possession was given to Moses our teacher.

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Nevertheless, most ultra-orthodox Jews have no experience of angels in their everyday life. Furthermore, when a member of the family describes such an experience, the first response of an ultra-orthodox Jew is likely to be concern that something is wrong. There is a religious rationalization for these contradictory views: the Talmud teaches that ever since Moses the level of revelation has decreased; we no longer experience revelations in our time. Throughout Jewish history, however, stories abound of religious visionary experiences of particularly holy Jewish leaders. For example, Martin Buber () writes:

 / Belief and Ritual

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The story is told: The Yehudi [literally, ‘‘the Jew,’’ a title used to refer to the hasidic leader Rabbi Yaacov Yitzhak of Pzhysha, who died in ] used to put on a peasant’s smock and a cap with a visor such as peasants wear, and ride to market with his servant, who had also donned this kind of dress, to look for [the biblical prophet] Elijah wandering through the world in the guise of a peasant. On one such occasion he met a villager leading a mare by the rein. The Yehudi took his servant by the arm and cried: ‘‘There he is!’’ The stranger flashed his anger full in the Yehudi’s face. ‘‘Jew!’’ he cried. ‘‘If you know, why let your tongue wag!’’ And he vanished on the instant. Some say that it was from this time on that people called the Rabbi of Pzhysha just Yehudi, the ‘‘Jew,’’ and nothing else.

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Followers of today’s religious leaders and wonder-working mystics continue to tell such stories. We have noted that it is appropriate for an ultra-orthodox person in the twenty-first century to believe in the existence of angels, even though he does not expect to see them. He will believe that many of the great leaders of his generation have had such encounters but are prohibited from discussing them. From this perspective, our patient Jacob may be an observant diagnostician: our inability to appreciate that someone can see angels shows our lack of faith. For us, seeing is believing. For him and many other ultra-orthodox people, the converse is true.

Visions and Hallucinations / 

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 Nocturnal Hallucinations Throughout this book we have claimed that just as no two cultures are identical, so the presentation of psychological difficulties varies from culture to culture, reflecting the preoccupations, fears, rules, and values of a society and the idioms of distress peculiar to it. The presentations of psychopathology that are unique to a particular setting are known as culture-bound syndromes, a concept first defined by Pow Meng Yap ().1 A list of culture-bound syndromes published in  contains descriptions of  clusters of patterns of behavior peculiar to certain societies, including voodoo death, amok, susto, koro, and latah (Hughes, ). Koro, for example, is a term used in South China and Malaysia to refer to a sudden fear that the penis will recede into the body: the sufferer may hold his penis out by force. True to the concept of culture-bound syndromes, the patients complaining of the collection of symptoms known as koro live in certain areas of the world (Bernstein and Gaw, ). Another culture-bound syndrome, known as zar, is found in Egypt, Somalia, Ethiopia, and other countries near Israel. Although the specifics vary, the common feature of the syndrome is that the sufferer is possessed by a spirit, known as a zar, which makes him or her perform certain behaviors, such as head-jerking and speaking in tongues. Cases have been described in mental health centers in Israel among Ethiopian immigrants (Arieli and Aycheh, ; Witztum et al., ), and although the cultural origins and presentation of the condition discussed in this chapter are very different, there are two similar features: according to zar beliefs, the original children of Eve  / Belief and Ritual

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who gave birth to zar spirits were active only at night; and one of the common presentations of zar is as a catatonic state (Kahana, ). In this chapter we shall describe a symptom that, to our knowledge, is unique to the ultra-orthodox Jewish population of Israel. The main external behaviors are extreme social withdrawal, especially from strangers, neglect of personal hygiene, a near-catatonic immobility, and monosyllabic replies in conversation. These symptoms were well-known to Karl Kahlbaum ( []) and other psychiatrists in Europe during the late nineteenth century and are familiar to mental health workers in developing countries today (Peralta et al., ). What appears to us to be culture-bound about these symptoms is that in Israel, hallucinations associated with these behaviors are experienced by young men only or predominantly at night. In this chapter we shall focus on the unique details of this phenomenon, which we call nocturnal hallucinations. In the next chapter, we shall attempt to understand why this particular symptom predominantly affects ultra-orthodox teenage boys with a history of learning difficulties, and we shall consider the predisposing societal pressures unique to this segment of the ultra-orthodox community. In Chapter , we shall consider the possible diagnosis of this culture-bound phenomenon and the general presentations of which it is part. P   G W: S  N

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There was a knock at the door, and an elderly ultra-orthodox man walked in followed closely by a tall, thin teenager. The older man smiled pleasantly at the interviewing psychiatrist. The young man stood quietly inside the door, looking at the older man, who told him to sit down, speaking to him in simple Yiddish. The youngster sat down without looking around the Nocturnal Hallucinations / 

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room. His head was bowed, and once seated he barely moved except to continuously twist the sidecurls on one side of his head around the fingers of his right hand. In the first part of the interview the young man was asked very simple questions, which he answered with difficulty. He did not understand modern Hebrew, so the older man, who was his grandfather, had to translate the questions from Hebrew to Yiddish. The replies, which were in Yiddish, tended to be childish, very brief, and couched in simple vocabulary. Often the question had to be repeated before the boy would rouse himself to answer. He told us his name, Yaacov, and his age, seventeen; when asked where he lived he answered, ‘‘With my grandpa.’’ On further questioning he was able to add that their home was in Mea Shearim, but he did not know an exact address. Asked whether he studied in a yeshiva, he answered, ‘‘No . . . Don’t want to go . . . They all hit me . . . They say I’m not a good person . . . They say I’m mad.’’ ‘‘Why do they hit you?’’ Yaacov replied, ‘‘I don’t do anything . . . lots of men (hit me) . . . all of them.’’ ‘‘I don’t sleep well at night,’’ he answered to another question, ‘‘because they want to suffocate me.’’ ‘‘Who wants to suffocate you?’’ ‘‘Arabs.’’ ‘‘Why?’’ ‘‘Because I am a Jew.’’ ‘‘When do they come?’’ ‘‘They come every night, and they want to suffocate me.’’ Yaacov said that he hears them talking but does not see them. He does not hear them at all during the day. Questions on general Jewish knowledge also brought simple answers: he could not remember what he was learning; he knew the name of the weekly Torah reading but could not tell us any / Belief and Ritual

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thing about it.2 More-verbal interviewees may produce details from Bible stories, often based not on the text itself but on wellknown stories from the Midrash. From the type of knowledge it is clear that their method of ‘‘study’’ is to listen to stories rather than to read and understand a written text. Yaacov knew what month it was, but he identified it by the name of the festival in it—‘‘Pesach’’ (Passover)—not by its proper name. One of his longer answers was revealing: ‘‘Who was our Rabbi Moses?’’ (a term used to refer to the biblical Moses). ‘‘A great zaddik,’’ came the reply. ‘‘What did he do?’’ I pursued. ‘‘He saved us from the Arabs,’’ Yaacov replied. A simple answer, in which he rolled nearly all his potential enemies into one. His grandfather described Yaacov as a good and quiet boy. He was the second of thirteen children. His sisters were well, but there were problems with Yaacov and some of his brothers, who also had learning difficulties. Neither parent had a history of mental illness. As a baby Yaacov had taken longer to learn to walk and talk than other children. He had always had difficulties with his studies and had been kept behind several times, so that each year he ended up in a class of still-younger children. By the time of his bar mitzvah, the gap between Yaacov and his classmates was obvious. He had no friends, although children occasionally sat with him to help him work. Some of the boys were unkind to him, and in recent years he had become increasingly fearful about going to yeshiva and had finally refused to continue. His mother could not keep him at home, so his grandparents agreed to look after him. His grandfather would sit and tell him stories for an hour every day; the rest of the time Yaacov would listen to music or play with blocks. Yaacov’s grandfather brought him to see us in the months preceding the Gulf War. This was a time of tension, when every Nocturnal Hallucinations / 

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Israeli was given a personal gas mask and taught how to wear it. Yaacov had become increasingly restless after being introduced to his gas mask, especially after his grandfather had told him about what the Iraqis wanted to do with the gas. The grandfather had been trying to encourage the boy to wear the mask, but the effect was disastrous. Yaacov became convinced that Arabs were trying to harm him. For the past two months he had woken up at night crying that they were running after him trying to suffocate him with gas. Yaacov’s grandfather brought him to us only once. Although he had become increasingly agitated, Yaacov was not troublesome, and his grandfather was sure he would get better once the tension of the national situation diminished. He had brought Yaacov to be examined because, since the boy had stopped going to yeshiva, the army had called him for a first interview as part of the process leading to compulsory army service. He said that the call-up office had recommended that the family bring a professional report to help in the process of evaluation. Yaacov’s grandfather explained all this at the initial (and only) interview, received a brief written report, thanked the interviewer, and left. He expressed polite interest when the interviewer discussed local rehabilitation units for ultra-orthodox teenagers with subnormality and the role of medication but did not request a follow-up appointment. A S  U-O Y M

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The narrative and clinical picture presented by Yaacov does not differ greatly from that presented by many young ultra-orthodox Jewish teenagers in Israel. To understand the cultural factors that led these young men to construct a narrative in which nocturnal hallucinations were chosen forms of expression, we undertook a retrospective evaluation of the case notes of   / Belief and Ritual

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consecutive referrals of ultra-orthodox young men to one psychiatrist (David Greenberg) over a ten-year period. The young men were systematically assessed using a semistandardized clinical screening interview. If hallucinations were not spontaneously mentioned by the patient or accompanying informant, the interviewer explicitly inquired about them. The interviewing psychiatrist avoided asking leading questions, such as, ‘‘Do you see the men mainly at night?’’; but he did ask clarifying questions: ‘‘Do you have fears? What do you fear? Do you see/hear the men? When do they appear? When do they mainly appear? Do they also appear by night/day?’’ The psychiatrist made detailed notes, using a standardized outline, at the time of the interview. Because many of the interviewees were withdrawn, reticent, and monosyllabic, verbatim accounts of the clinical interviews were generally available, with a detailed history from the accompanying informant. For the purposes of this study, a research assistant, blind to the topic and hypotheses of the study, extracted data directly from the clinician’s notes using a form to record the following variables:

. demographics: age, marital status, and ethnic background; . personal history: level of intellectual functioning, family history of mental illness, religious repentance; . clinical information: duration of problems, nature and content of delusions and hallucinations, number of sessions, and request for an army letter.

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Owing to the retrospective nature of the investigation, as well as the withdrawn state of many of the interviewees, there are missing data in some clinical variables. In addition to the data we shall therefore draw upon the clinical impressions of the interviewer in order to describe the phenomena in more depth. Nocturnal Hallucinations / 

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Out of  consecutive ultra-orthodox male referrals,  reported hallucinations, of whom  reported experiencing hallucinations solely or predominantly at night. In table  we present an overview of the characteristics of the  interviewees. Of the present sample  percent reported hallucinations at the interview. Although this may seem overly common among psychiatric referrals, we must remember that the ultra-orthodox community is generally reluctant to seek psychiatric care (see Chapter , and Greenberg and Witztum, a); individuals do so only when a member of their family experiences extreme distress, or when a yeshiva no longer allows a young man to stay because of his disturbed behavior. Of the  patients reporting hallucinations,  reported that the visions were solely or predominantly nocturnal and  experienced them equally by night and day. The remaining  did not report hallucinations. As demonstrated in table , the three groups differed in several aspects. The  men who reported predominantly nocturnal hallucinations were significantly younger than the others, more likely to visit the psychiatrist only once, and more likely to request a report of the psychiatric evaluation to receive an exemption from compulsory army service. Further, they were more likely to have a history of learning difficulties. Clinical data: The hallucinations were associated with nighttime rather than with sleep, and they were not usually associated with the moments immediately preceding or at the end of sleep. The images were simple, often bizarre, but not part of a complex delusional system of beliefs. In table  we list the images that appeared in the visual hallucinations. A chi-square test on these data shows that the distribution in the two groups cannot be considered different (Chi-square = ., d.f. , p. = .). The majority of the hallucinatory images were frightening. Of a total of  images, only eleven were comforting. Thirty / Belief and Ritual

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Table : Demographic and Clinical Features of a Sample of Ultra-Orthodox Male Psychiatric Referrals with Nocturnal Hallucinations, Nonnocturnal hallucinations, and No Hallucinations (N = )

   Sample size Age Standard deviation Marital status: Single Married Divorced Number of visits Standard deviation

 . .

 . .

 . .

F = . **

   . .

   . .

   . .

Chi square = . *

Report requested Report not requested Presence of delusions Absence of delusions Delusions at night only Delusions mainly night Delusions day and night Delusions by day only Visual hallucinations Auditory hallucinations History of subnormality History of normal development

          

          

       







* p < .

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    - - -      

** p < .

F = . not significant Chi square = . ** Chi square = . **

Chi square = . ** Chi square = . *

 Chi square = . **

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Table : Hallucinations of Nocturnal Hallucinators and Nonnocturnal Hallucinators

Feared stereotypes (Arabs, nonJews, robbers, policemen, soldiers, Sephardi men, terrorists) Feared neutral figures (relatives, men, faces, friends from yeshiva, neighbors) Feared mystical figures (demons, bad spirits) Dogs Deceased relatives or friends Comforting mystical figures Other images Total

 

 













    

    

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four images were figures from daily life of the sort that may frighten any small child (for example, robbers), or specifically children in Israel (Arabs, terrorists), or even more specifically, children in the ultra-orthodox community (policemen, soldiers, Sephardi men). In thirty-four cases, the young men were able to identify the figures as biblical or mystical, whether demons and black dogs (which combine both a common childhood fear and a sinister mystical symbol), or positive figures (for example, the prophet Elijah or Rabbi Nahman of Bratslav), who encouraged them in their studies. In fourteen cases the onset of symptoms followed the death of a close relative or friend, who would visit them from beyond the grave. Owing to the inaccessibility of many of the interviewees, a test of inter-rater reliability was carried out by selecting thirtyfive files at random and letting another judge, with a similar  / Belief and Ritual

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professional status to the first research assistant, evaluate them. Inter-rater reliability on these categorical data was done by calculating the kappa-coefficient. The evaluations of the prevalence and the nature of diurnal and nocturnal hallucinations were found to be reliable (kappa-values . and .), but the nature of the images and the state of wakefulness of the patients were evaluated in a less reliable way (kappa-values . and .). Associated clinical features: In all three groups, although particularly among those with nocturnal hallucination, the young men were reluctant participants in the evaluation. They would be led in to the meeting; often they had to be actively brought in. They would sit curled over, making no eye contact. They often seemed frightened and would react with anxiety if a dog barked in the distance. The young men would not initiate conversation and would reply only to simple, concrete questions, in monosyllables or a few words. Often they would not reply. When the parent or person who accompanied them was being questioned, the young men would appear to pay no further attention to the interview. Presenting complaints: The two main complaints that parents presented were that the young men did not study properly and so did not fit into yeshiva life and that they had ‘‘fears’’ or ‘‘imaginings,’’ which disturbed them in the evenings. The terms ‘‘fears’’ and ‘‘imaginings’’ are general terms that do not necessarily imply a concern that the young men were actually imagining things. Indeed, it was unusual for parents to focus on the patient’s hallucinatory images as a central issue, and they were often unaware that these even occurred. Developmental history: The characteristic history of those with nocturnal hallucination included developmental delays (for example, walking and talking or learning to groom themselves at a late age), difficulty in learning to read and write, inability to read fluently, and refusal to play with contemporaries, preferring Nocturnal Hallucinations / 

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instead younger children and simpler games. The withdrawn state of many of the subjects precluded using the examination as evidence of learning difficulties. A history of such delay and difficulties was significantly more common among those with nocturnal hallucination (. percent of the group). Insight to the phenomenon was usually absent. Patients believed that the images they saw were real, and they did not believe that medication could help. The parents, however, did not view their sons’ experience as culturally normative.

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In our sample of  ultra-orthodox male referrals for a psychiatric evaluation, then,  experienced hallucinations that were predominantly or exclusively nocturnal. These hallucinations were mainly visual, they were all crude and simple, and they never appeared to be part of an organized delusional system. Hallucinations were mostly found associated with those who also reported delusions. The referrals with nocturnal hallucinations were younger than the other ultra-orthodox referrals. The boys were in their late teens and single, and the majority came only once and requested a letter of recommendation for an exemption from army service. They were also more likely to have a past history of subnormality. The two most interesting aspects of these findings are the presentation of nocturnal hallucinations specifically among young men in the Jewish ultra-orthodox community, and the absence of such phenomena in referrals of young women from the same culture. In the event of an unusual symptom, the question of the authenticity of the complaints must be considered: might these men have been malingering in order to receive a certification of abnormality to avoid army service? (Turner, ). Although we cannot exclude this possibility from all the cases, we noted  / Belief and Ritual

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that more than half the sample made no request for a letter— percent of those with nocturnal hallucination did not request a letter—and a further group continued in care after the receipt of the report, suggesting that the presentation of nocturnal hallucinations was genuine. A consistent clinical picture, unusual in most other settings of psychiatric referrals, has been described here: male teenagers from the ultra-orthodox community who drop out of yeshiva studies and become withdrawn, paranoid, and prone to nocturnal hallucinations of a fearful quality, including commonly feared figures, neutral figures from the surrounding world, mystical figures, and deceased relatives, rabbis, and friends. This is a narrative with symbols selected by a particular subgroup at a certain time in their lives. We shall attempt to understand the influences that bring this about and the associated clinical conditions in the next two chapters.

 ‘‘A Big Man Dressed in Black Is Hitting Me’’                         

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By day, fellow students are found to be aggressive and shaming, while the night is populated with frightening figures who hit, rebuke, and threaten death. Why do young men with longDeconstructing the Narrative / 

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standing learning difficulties who drop out of yeshiva select this particular narrative to express their distress? 1 Their personal inner world and external actions, their family life and history, their immediate circle, the overall ultra-orthodox community, and Israeli society in general are all factors that lead certain young men to select these particular idioms of distress. In this chapter we shall deconstruct their narrative to examine its social and cultural influences. The following unique aspects of ultraorthodox life will be analyzed for their influence:

. growing up with learning difficulties in an environment . . . .

where academic achievement is the pinnacle of success and no alternative is countenanced; the challenges presented by such important milestones in life as bar mitzvah, adolescence, and leaving home to live in a yeshiva; the impact of loss; the meaning of night in ultra-orthodox Judaism; the differences between the sexes. A S  S

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The distinguishing feature of ultra-orthodox life is the expectation that each male will devote his life to the study of the Talmud. The Talmud, compiled in the third to fifth century .. in Babylon, is a multivolume commentary on the Mishnah, itself compiled in the second century. The Talmud is mainly written in Aramaic, an ancient Semitic language used by the Jewish community in Babylon until around the year . The Aramaic text uses the Hebrew alphabet but without vowels or punctuation, demanding of the reader a significant knowledge of and fluency in the language. The actual talmudic text occupies half or less of the page of a standard volume of Talmud and is situ / Belief and Ritual

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ated in the middle of the page. At one side of the text is a commentary, explaining unusual words and phrases and anticipating difficult logical problems; this was written by the greatest Jewish commentator, Rashi, in the eleventh century. On the other side is another collection of commentaries, compiled by Rashi’s grandchildren and others, known as the baalei tosafot (literally, the ‘‘masters of the additions’’). This second commentary deals with difficulties that have arisen concerning the discussions in the Talmud or Rashi’s understanding of the text. Both commentaries are printed in a special alphabet known as Rashi script.2 As a young scholar progresses through his teens, he is expected to start exploring the later generations of commentators and even, if he is a truly outstanding scholar, to formulate his own questions about the text. If he also comes up with his own answers, these are known as hiddushim, or innovations. The challenge represented by talmudic study is profound. The average youngster is expected to master three languages (Hebrew, Aramaic, and Yiddish, the language of most of the yeshivas) and two Hebrew alphabets, with no vowels or punctuation, and to study a text that demands the sharpest of intellectual skills. This is the world in which a young man with learning difficulties finds himself. The blow to the self-esteem of the youngster failing to master the intricacies of talmudic dispute is not just in the intellectual realm. Excellence in talmudic study is one of the most conspicuous measures of worth in ultra-orthodox society. This value is personified in the concept of the talmid hacham. ‘‘A scholar born out of wedlock is better than an ignorant high priest.’’ These words from the Mishnah Horayot (:) embody the greatest achievement for an ultra-orthodox man. The aim of every adolescent is to be a talmid hacham (a scholar; literally, a wise pupil). The talmid hacham was not only the aristocrat of talmudic times, he is considered one today. Given an honored Deconstructing the Narrative / 

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seat in the synagogue, he is asked to speak at all major religious events, for the telling of a dvar Torah, a word of Torah, is the centerpiece of a wedding, bar mitzvah, or Sabbath meal. If the talmid hacham is present, he will be asked to say some words from the Torah. If he is a teacher, his pupils will afford him the same respect due to their parents. Rabbi [ Judah the prince, compiler of the Mishnah] said, [It says in the Torah, Deuteronomy :]: ‘‘And you who cleave to the Lord your God are all alive today.’’ How is it possible to cleave to the divine presence? [a term used to refer to God] for is it not written that ‘‘The Lord your God is a consuming fire’’ (Deuteronomy :)? Rabbi points out that that these two statements in the Torah are mutually exclusive; one encourages closeness to God, while the other implies that to get too close is destructive. He resolves the contradiction by explaining the first quotation in the following way: Whoever marries his daughter to a talmid hacham or does business for a talmid hacham [Rashi explains the phrase ‘‘does business for’’ to mean putting lucrative business deals the way of the scholar, thus freeing him of financial worries and allowing him to dedicate himself to Torah study] or enables a talmid hacham to derive benefit from his wealth, the Torah compares such a person to one who cleaves to the divine presence. (Talmud Ketubot b)

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This talmudic passage clarifies three points. First, we notice how much of the text is unwritten yet understood, enabling us to appreciate in a concrete form what a young man with learning difficulties has to face. This basic text requires an ability to see  / Belief and Ritual

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contradictions between statements and to resolve them by the use of euphemistic parallels—for example, dealing with scholars as a concrete representation of closeness to God. Second, the talmid hacham is an earthly representation of God’s presence. Finally, there is no greater shidduch (matrimonial match) for an ultra-orthodox girl than a talmid hacham, a scholar. For the young man with learning difficulties, not only is his failure to master the Talmud a source of sorrow and shame for him and his parents, but it makes him a second-rate match in the ultraorthodox world.

Denial

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In interviewing young men with long-term learning difficulties and their parents we frequently noted that the parents gave evasive answers to questions concerning their son’s level of study during his childhood. Typically, parents were vague in their descriptions: the boy did ‘‘all right’’; he was ‘‘an unremarkable student,’’ ‘‘not brilliant but held his own in the class.’’ Detailed questioning, however, revealed evidence of delayed psychomotor development: the boy had never learned to read fluently. Most of the young men had received additional private tuition but could not grasp the content of what they read. While other boys their age had been studying the Talmud for years, these patients were either told stories from the Bible or were still being taught to read from the prayer book, appropriate for ages four to six. Even worse, they would sit quietly in the classroom, neither comprehending nor participating in the proceedings. One reason for the parents’ evasive answers could be that in a very large family, it is difficult for a parent to notice anything but the most outlandish deviation from the norm. Further, a parent who has neglected a child with learning difficulties, allowing Deconstructing the Narrative / 

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those difficulties and an accompanying sense of failure and distress to worsen with the years, could have feelings of guilt, which he or she manages by insisting that there were no problems in childhood and therefore no link between the current problem and the boy’s being ‘‘not brilliant’’ as a child. The parents’ vague descriptions of the child’s early symptoms are a consequence of the values declared by Rabbi in the Talmud: most parents’ first response to learning difficulties in a son is denial; they tend to ignore the difficulties or to hope that these will improve spontaneously. If the difficulties are noticed and discussed with a teacher or headmaster, individual coaching is commonly suggested to help the boy ‘‘catch up,’’ implying that he may yet turn out to be a talmid hacham, given the right teaching. But special educational facilities are rare and unpopular among this population in Israel. The high status attached to study, and the stigma of special education, encourages parents to let children with learning difficulties remain within the mainstream. But being left in a regular class for years will be a continual reinforcement of the young man’s sense of incapacity. In addition to formal lessons given by the teacher, students spend large portions of the day in dyadic study: two students study together, reading the text out loud, exploring the commentaries, and trying to understand the difficulties in the text and the solutions the different commentators provide. The best student will always be the most sought-after study partner. Those who can barely read will be considered a burden that none willingly shoulders. While the others sit down in their fixed pairs, the learning-disabled boy will be left alone, unwanted and unvalued. His low self-esteem is often compounded by the jibes of other children, and he correctly observes that he is the object of ridicule and contempt. In the sample presented,  out of  young men with a history of learning difficulties reported delusions, which were usually para-

 / Belief and Ritual

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noid exaggerations of the way their fellow students laughed at and mistreated them.

The Value of Nonstudy There may be many reasons for an ultra-orthodox youngster to have difficulty studying. At the simplest level, he may be unable to read, concentrate, or sit still, while at more sophisticated levels, he may have problems using and comparing concepts or arguing theoretical issues that may have no contemporary application. For such a youngster one could envisage a variety of options: concentrating on more concrete practical issues or training for a less sedentary or studious occupation. But work, and even exercise, are complicated issues in ultra-orthodox life. The rabbis in the Talmud often debated the contradiction between two biblical injunctions: first, that men should work: ‘‘And you shall gather in your corn’’ (Deuteronomy :), and second, that ‘‘the book of the Torah shall not leave your mouth, and you shall meditate on it day and night’’ ( Joshua :). As in many talmudic disputes, what is superficially a discussion of a textual discrepancy is in reality a debate that deals with an entire philosophy of life, an attitude about priorities and the extent to which we can or should place our reliance in God. The most extreme position was taken by Rabbi Shimon bar Yohai.

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Rabbi Shimon ben [bar] Yohai said, ‘‘Is it possible that a man plows in the plowing season, sows seeds in the sowing season, reaps in the reaping season, treads in the treading season, and winnows in the windy season, for what then would become of his Torah study? But [the apparent contradiction beDeconstructing the Narrative / 

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tween the two statements is to be settled in the following way:] when it is a season in which the Jewish people are performing God’s will [i.e., studying Torah], then their [occupational] work will be done by others.’’ . . . Abaye said, ‘‘Many lived their lives according to Rabbi Ishmael [who argued in favor of combining work and study in one’s daily life], and it worked out; while many lived their lives according to Rabbi Shimon ben Yohai, and it did not work out.’’ (Talmud Brachot b)

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The conclusion of the debate is that whenever ‘‘the study of Torah was the main occupation and one’s work was treated as temporary, then both succeeded, while if one’s work was the main occupation and one’s Torah study treated as temporary, then neither succeeded.’’ This statement accurately reflects the attitude of the ultraorthodox community regarding the primacy of Torah study and the view that non-Torah work is a necessary evil. Ultra-orthodox young men are rarely trained in alternative forms of employment. Only in the past few years have courses in computers, bookkeeping, and other practical subjects even been offered in the community, a change that reflects the realization that not everyone is suited for a life of study. The formal attitude in the community is that economic necessity requires a man to have a job, but ideally he should work in the evening, after a day of study.3 The needs of young men with learning difficulties are still far from being answered by these developments. Not only does religious study predominate, but leisure pursuits are viewed as ‘‘time that could have been used for Torah study but has been wasted.’’ As a consequence, a child who has difficulty intellectually has no alternative avenue for excellence, to do work that will be valued.  / Belief and Ritual

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Further, in ultra-orthodox society physical exercise is not encouraged, and army service, which involves physical training, is deferred by continuing religious study. Thus ultra-orthodox teenagers may see themselves as ill-equipped for physical danger and more exposed to it than their secular counterparts. This physical vulnerability may contribute to the fears expressed by many of the young men concerning attacks from terrorists and robbers. L C Bar Mitzvah

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Several important issues combine to make early adolescence a time of particular difficulty for a boy with social and learning difficulties. The ceremony of bar mitzvah, which takes place when he reaches the age of thirteen, marks his transition to adulthood.4 It usually involves learning a speech in Yiddish on a complicated question from the Talmud. Even if the speech is prepared by a teacher, and even if the boy does not understand what he’s talking about, he is expected to stand up before invited guests and recite the speech by rote. Failure to do so out of extreme shyness or because he has difficulty committing the material to memory would make the boy, his family, and the guests very aware of his deficiencies. Bar mitzvah also signifies the assumption of responsibility for one’s actions. Although parents may have tolerated and even enjoyed dependence in a young child, the bar mitzvah of a boy with learning difficulties reminds them that he remains a child, unable to study or to care for himself. The boy himself may understand enough to realize that from the time of his bar mitzvah he will carry the burden of his own sins. Even if he has difficulty

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understanding concepts, he will understand reward and punishment in a concrete way. Indeed, salutary statements in religious texts are often written in a concrete form: ‘‘Whoever talks too much with women brings evil on himself, wastes Torah study time and in the end inherits Hell’’ (Mishnah Avot :). Adults learn to understand the rhetoric as a means of emphasis. A young man with a difficulty in grasping concepts and a tendency to see things concretely may interpret such statements as warnings that sin leads to fearful consequences. An interesting external change takes place at bar mitzvah. Throughout childhood, the clothes worn by ultra-orthodox boys are conservative but varied in color or pattern. At their bar mitzvah, as an expression of their incipient manhood, they will don the uniform they wear for the rest of their lives: black hat, white shirt, black jacket and trousers. Externally, the boy now resembles a man. If he is not able to mix with his peers and tends to spend his time playing with younger siblings, then the bar mitzvah, ordinarily a joyous celebration, becomes a rite of passage for which he is unprepared and uncomprehending.

Adolescence

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Adolescence brings general physical growth and sexual development. In ultra-orthodox society, these matters are discussed only when such knowledge is considered necessary: immediately before marriage. Ultra-orthodox adolescents with normal socialization skills may discuss the changes in their physique and their awareness of their sexuality with friends. The socially isolated boy with learning difficulties is left with disturbing drives and changes that no one explains to him. Ultra-orthodox patients sometimes mentioned problems with sexual drive and masturbation to the psychiatrist, but none of the withdrawn young men  / Belief and Ritual

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with learning difficulties explicitly mentioned these concerns. It may be that the fact that they spoke in the presence of a parent or rabbi inhibited their discussion of such topics. It is tempting but speculative to link their adolescent development with their nocturnal hallucinations as these may be accompanied by nocturnal emissions or wet dreams. Typically, adolescence includes a phase of undifferentiated sexuality, when young men form close friendships with friends of the same sex. The development of such attachments is even more likely in a dormitory setting, where the boys have suddenly lost the support of their home life and their relationships with parents and siblings. In the ultra-orthodox world, close friendships with learning partners often persist throughout life. Active homosexuality is proscribed in Jewish law; and if a young man is discovered soliciting sex in a yeshiva, he is usually asked to leave. It could be posited that an isolated, unpopular, gullible teenager with learning difficulties can become the sexual prey of more dominating peers, and such encounters or associated threats could explain some of their fears of black men with sticks, Arabs, and other enemies. But neither the young men nor their parents or teachers ever mentioned such exploitation, so these considerations also remain speculative in explanations of the emergence of nocturnal hallucinations at this phase in life.

Leaving Home

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The normal process of development involves an auspicious event during the fourteenth year of the ultra-orthodox teenager. After years of studying in heder, the junior school, during the year following bar mitzvah the young teenager leaves home and goes to yeshiva ketana, ‘‘little yeshiva.’’ Most of these institutions require that students live in the yeshiva dormitory. Deconstructing the Narrative / 

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For a young man who is socially isolated, has difficulty studying, and needs the help of his mother or brothers and sisters to wash, dress, and eat, this move is frightening and traumatic, especially if he occasionally suffers from nocturnal enuresis (bedwetting). Other boys may be repelled by the smell and are unlikely to be kind or understanding; they may insist that he sleep in a different dormitory room. Nor is this the only reason for nighttime to be frightening. The boy is away from the familiar bedroom he shares with his brothers and no longer next to his parents’ bedroom. It is possible that his fear of the dark was previously dealt with tolerantly by allowing a nightlight. Now, he must sleep in the dark, and his childhood fears return. He is with strangers who are concerned with their own needs, developing social groupings of which he is no part. L  G

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Most children growing up in ultra-orthodox society have a large number of siblings. Their mothers are able to cope only if the children attend school from an early age. If a child does not attend school, stays home all day, and gets into fights with the younger children, his mother may be obliged to send him to live with grandparents, who have more time and patience. This is the case for many children with learning and behavioral difficulties. Often, as with Yaacov, it was the grandfather who brought the child to be examined and who was able to describe his development and current achievements. The grandfather would study with the child, while his grandmother found simple tasks for him to do. The death of such a grandparent would be a major blow: first the death itself, then the teenager’s sense of loss, the lack of understanding or explanation of what death is, the loss of attention and occupation, and the return to the parental home, where he has no role and is regarded as a nuisance,  / Belief and Ritual

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would all combine to make this loss devastating.5 In twenty-six of our cases, deterioration followed such a loss, and it is possible to understand the nocturnal hallucinations as expressions of grief. The patient may have been taught that the spirits of the dead are active at night. Following a death, hallucinations of ‘‘grandfather in a shroud,’’ the frightening sight the patient saw at his grandfather’s funeral, may return when he is alone at night. Sometimes his grandfather tells him what to do, just as he had done during their life together, but usually he tells the boy to join him in heaven, where he is needed as a tenth man for prayer (communal prayer, including the recital of the prayer for the dead requires ten men). This hallucination reflects the patient’s sorrow and wish for death, as well as the loss of companionship and a sense of purpose. J   N

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To understand why these teenagers hallucinated predominantly or exclusively at night, we need to examine the significance of nighttime for the ultra-orthodox community. ‘‘You shall not be afraid of the terror by night,’’ says Psalms :. Traditional medieval Jewish commentaries explain this phrase as referring to ‘‘the terror that befalls a person at night; or from evil mishaps such as thieves and highway men, who usually attack at night; or from the demons that roam at night.’’ The Mishnah warns that ‘‘one who is awake at night, and walks out alone, and thinks about trivia will forfeit his life.’’ The leading commentary adds, ‘‘This is because night is the time of the demons, and one who walks out alone is at risk of robbers and other mishaps.’’ The Code of Jewish Law states that a person who sleeps alone in a house or room will be trapped by Lilith, queen of the demons, a spirit of the night who attacks men who Deconstructing the Narrative / 

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sleep alone, seducing them and causing them to have nocturnal emissions. The dangers of the night are alluded to in daily life in the custom of washing one’s hands immediately upon getting up in the morning ‘‘to remove the evil spirit’’ that settles on every person during sleep (Code of Jewish Law, Orakh Hayyim, :). Similarly, the Talmud warns against contact in the morning with someone who has not washed his hands because of ‘‘the danger of demons’’ (Talmud Brachot a). The main mystical text, the kabbala, describes the night in a sinister fashion, as a time when one is especially susceptible to contamination by evil spirits. Its demonic nature is apparent in the word for night, laila (plural, lailoth), source of the name Lilith. Finally, nighttime is associated with death. The Talmud (Brachot, b) says that sleep is one-sixtieth death. The final blessing recited before sleep captures the fears expressed by our patients: ‘‘May it be Your will that You will lay me down in peace and raise me up in peace. Let not my thoughts, my nightmares and my evil meditations frighten me, and then open my eyes lest I sleep death.’’ Similarly, the first sentence spoken immediately upon waking is, ‘‘I give thanks to You . . . for restoring my soul to me in Your great mercy.’’ Although it is unlikely that our young men knew the details of these laws and concepts, they did appear to understand the concrete terms of punishment, death, and demons. They may have been told that night is a time of demons, robbers, and thieves, and that the spirits of the dead prowl at night. These images appeared prominently in their nocturnal hallucinations. A M P,  M C

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The absence of even one case of nocturnal hallucination among our female referrals also requires explanation. In the ultra-ortho / Belief and Ritual

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dox community, Torah study for girls is considered of little importance, and in-depth study is discouraged. Girls are forbidden to study the Talmud; they are provided instead with special texts that do not systematically cover basic sources, thereby preventing them from gaining the necessary skills for independent study. There are four main differences between the way the sexes are treated in the ultra-orthodox community that may explain why we have only noted nocturnal hallucinations among male ultra-orthodox psychiatric referrals. The overriding importance of study of the Talmud for men creates a continuing and painful sense of failure in a young man with learning difficulties. Girls have no duty to study, and no value is placed on excellence in Torah study, so that if they are poor students they will not be upset in the same way. A young man whose thinking tends to be concrete and who views himself as a failure will react dramatically to knowledge about frightening wanderers at night. Girls hear fewer of these stories, and they have less reason to feel they have failed. The expectation that he will live away from home means that there will be no warmth and support for a young man who has difficulty looking after himself and relies on his mother or siblings to help him in the simple tasks of daily life. Teenage girls do not leave home. They continue at the local girls’ school and help their mothers look after their younger siblings— a gradual preparation for their future role as mothers—until they leave home on their wedding day. Finally, if the yeshiva is no longer willing to tolerate the presence of a frightened, withdrawn young man who does not participate in regular studies, he will be subject to army call-up. If not for this fact, more than half of the sample would never have been sent for examination, for among those who did not want letters were many whose par-

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ents hoped that treatment would enable their son to keep his place at the yeshiva. Ultra-orthodox women are not required to serve in the army. It is possible, therefore, that similar fears may be present among some ultra-orthodox young women, but the circumstances do not demand that they be brought for examination. We consider this unlikely, however, because we saw a sample of women, albeit fewer, during the same period, and none suffered from nocturnal hallucinations.

 Phenomenology and Differential Diagnoses of Nocturnal Hallucinations

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What type of phenomena are nocturnal hallucinations? In trying to understand the nature of phenomena that only occur at night, we need to remember that the patients who suffer them are not symptom-free by day; more than half are habitually withdrawn, fearful of going out unaccompanied, and incapable of independent, in-depth study at a yeshiva. They think that the other boys are laughing at them or calling them mad—and their belief may be based on actual experience. As night descends they become extremely anxious and withdrawn, reluctant to go out at all. Most refuse to sleep alone; some demand to sleep with  / Belief and Ritual

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their parents. Most experience their visual hallucinations before they sleep. Others fall asleep and then wake up and disturb the household describing their visions. In most cases it was clear that the visitations were neither a feature of the dreams nor the hallucinations commonly associated with the state of falling asleep and waking up (hypnagogic and hypnopompic hallucinations).1 Furthermore, the patients lacked insight into the unreality of the experiences and did not consider themselves as having a problem or being in need of a doctor. ‘‘How can pills stop the men from hitting me?’’ asked one indignantly. ‘‘Tell them to stop pursuing me!’’ pleaded another. These were typical responses, and despite attempts to explain that pills would give them strength against the men, the patients were often unwilling to take treatment. These visual experiences, occurring in a waking state and in the absence of insight, would appear to be hallucinations, most of them of a paranoid nature. In many non-Western cultures voices and visions are usually considered nonpsychotic and may be of a hysterical nature.2 Hysterical hallucinations typically come on suddenly, occurring at a time of emotional stress; and they are understandable in their context. All of these features are consistent with our cases. What is inconsistent, however, is the fact that hysterical hallucinations typically last only a few hours, the content constantly changes, and the patient may fail to recall it; none of these features characterized our sample (Hirsch and Hollender, ). Perhaps these young men were reacting to the shadows of the night, misinterpreting and clothing them in the images of their past frightening experiences and cultural imagery. These misinterpretations are known as illusions and are usually associated with organic states. Although most of the patients with nocturnal hallucinations also exhibit mental subnormality, suggestive

Phenomenology and Differential Diagnoses / 

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of brain damage, there was no evidence of acute disorder, such as delirium, associated with a disturbed state of consciousness. We must consider whether these nocturnal hallucinations are indeed visions or whether they are normative experiences in a society that encourages belief in angels and demons (Asaad, ).3 As we have seen, adults in ultra-orthodox society believe in angels and demons. Both are mentioned regularly in the Talmud. Yet the average adult does not expect to meet these apparitions in daily life. Furthermore, most ultra-orthodox adults have no difficulty labeling our patients’ descriptions pathological. This sophisticated distinction is comparable in certain ways to belief in a God who is omnipresent and controlling, yet never seen. Some ultra-orthodox children of normal intelligence have told us that they not only believe in demons but are afraid at night that they will be attacked. They told us that they discuss these subjects openly with their peers and are convinced that Arabs and demons have a particular interest in the ultraorthodox, God’s chosen. It is even more likely, therefore, that a subnormal ultra-orthodox boy would be unable to move from this phase of belief and expectation to an adult attitude of belief without concrete expectation. Such beliefs and fears appear to be normal for ultra-orthodox children, and the subnormal are incapable intellectually of outgrowing them.4 The hallucination of being beaten by large black men seems to represent evil and aggression. This could be an externalized representation of the boys’ sense of failure as poor students in a society whose prince is a scholar. Alternatively, this fear could be a projection of their own aggressive impulses toward friends and particularly teachers (large men in black with sticks) who see them as failures. Parents often described how other children taunted and even hit their sons; occasionally they related that a particular teacher  / Belief and Ritual

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had been unduly hard on the failing student. Corporal punishment is not unknown among ultra-orthodox teachers—and having a child with undiagnosed severe learning difficulties in a large class may frustrate the most sanguine teacher. It is difficult to know just how often a traumatic event actually occurred in the classroom; it seems more likely that the symptoms are symbolic of repeated experiences of academic failure. If many of these young men have adopted hallucinations as a form of defense for their failure, some, blessed with less insight into their own limitations, have instead adopted the more successful defense of grandiose delusions. These young men may believe that they are righteous (zaddikim), and that others persecute them out of envy. They may relate that they study with great rabbis (typically dead mystics like Shimon bar Yohai and Nahman of Bratslav), who teach them secrets that they are not permitted to divulge. Such delusions protect the failed student in a world of study. Most of our cases, however, were young men with paranoid rather than grandiose thoughts, who gave the impression that their overall feeling was one of sorrow. Being beaten by a large man with a stick appears to be a poorly differentiated representation of sexual and even homosexual energy— hardly surprising in an adolescent who thinks concretely and lives in an all-male world. As we have seen, most of the cases of nocturnal hallucinations were teenagers with a history of serious learning difficulties, consistent with a degree of mental subnormality. A normal feature of childhood is the fear that strangers, devils, robbers, and murderers will attack at night.5 For a teenager with intellectual limitations, these fears remain concrete and real. The persistence of the fears of childhood and their embodiment in the nocturnal, quasi-psychotic symptoms of our sample are presumably a consequence of these unique social pressures. In psychiatry it is rare for a symptom to be associated with Phenomenology and Differential Diagnoses / 

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only one condition. For example, anxiety can occur in many conditions (psychosis, depression, phobias, panic, and other disorders). Similarly, hallucinations can occur in schizophrenia, in manic and depressive psychoses, and in grief and posttraumatic stress disorders. It is unlikely that all eighty of our cases with nocturnal hallucinations can be explained by one diagnosis.6 Fifty-nine of the eighty young men gave clear histories of social withdrawal and learning difficulties. Many had been oversensitive from childhood, maintaining that other children were cruel to them; at night, they would not sleep alone or go out unaccompanied. This description is consistent with a diagnosis of schizotypal personality disorder, characterized by a gradual onset from early adulthood of excessive social anxiety, particularly with unfamiliar people, strange beliefs, unusual perceptions (illusions, even hallucinations, although the young men usually describe their experiences as ‘‘as if ’’), eccentric behavior and speech, lack of close friends, and paranoid thinking (Millon and Davis, ). There are also features in these fifty-nine cases that resemble autistic disorder: very early symptoms of social isolation, an inability to form personal friendships. In some cases, the young men would play with a piece of string, sniff repeatedly, or play with their sidecurls throughout the interview, actions that are similar to the way an autistic person relates to parts of objects. Further, persons with autistic disorder become upset by changes in the environment, in surrounding objects, or by unfamiliar people. The young men in our sample experienced distress predominantly in the presence of strangers; but they did not relate to people as objects. Similarly, psychotic symptoms are not a feature of autistic disorder, although they may be part of an accompanying psychosis (Volkmar et al., ). The nineteen young men who did not have signs of social and learning difficulties in childhood had probably developed a  / Belief and Ritual

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psychotic disorder, either schizophrenia or depression with psychotic features. After years of interviewing large numbers of ultra-orthodox patients, we would expect to find patients with schizophrenic and depressive psychosis in similar, if not equal numbers. However, we continue to be impressed by the bizarre nature of the psychotic experiences described by our patients and by their lack of emotional communication, a problem that led us to label them schizophrenic rather than depressed. Although many of our patients showed symptoms of depression— they were desperately unhappy and had difficulty sleeping at night—these symptoms were also understandable consequences of their frightening nocturnal hallucinations. It is likely that in many cases a variety of factors and diagnoses should be combined. Schizophrenia is more likely to occur in someone with learning difficulties, an observation made by Emil Kraeplin in  and confirmed by Doody and her colleagues (). Alternatively, a boy with mental subnormality and schizotypal personality disorder may have suffered the loss of his grandfather. At the death and burial, he would have seen traumatic, incomprehensible, and unexplained sights, suffered a grief response, and then become depressed by the major change in his circumstances. Drug and alcohol abuse are rarely encountered in the ultraorthodox community in Israel, so the experiences are highly unlikely to be the result of substance abuse.7 Like Yaacov, most of the young men were withdrawn and uncommunicative, and that it was difficult to elicit in detail their understanding of concepts such as nighttime and demons. Much of what we have said in the last two chapters has consequently been speculative. Nevertheless, one young man, Moshe, who was more communicative and better able to function than most (and did not suffer hallucinations), admitted, ‘‘At night I cannot sleep. I think about the things I learnt in yeshiva. We learned Phenomenology and Differential Diagnoses / 

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in the Talmud that there are forces, demons, so I get frightened every time I hear something move. I think they are snakes or scorpions. It is dreadful all night. During the day I am completely fine. I look in the Talmud, and I know the night is the time for forces, mazikim [destructive spirits, a type of demon]. My teacher said not to go out alone at night. You do agree with me that there is such a thing as demons. If a person is wicked, then a snake bites him.’’ As a child Moshe was slow in his studies, ‘‘but not the worst.’’ Today, at age twenty-three, he reads slowly and writes even more slowly, with a childlike hand. As a child he was afraid of robbers, animals, and the dark. At age fourteen he was sent away from home to a yeshiva; he found the studies very hard and was especially frightened at night. Some of the boys laughed at him and he heard them saying that he was ‘‘sick.’’ His parents always urged him not to talk about his fears. At age twenty-one he married. All his wife knows is that he cannot sleep and suffers cramps at night and diarrhea.

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The content of nocturnal hallucinations can be understood as a combination of childhood fears, based on culturally consistent spirits and the souls of the departed. The diagnoses are likely to be varied, including psychotic states, grief reactions, depression and anxiety, and chronic adjustment difficulties; these are in many cases secondary to lifelong learning difficulties. Followup of the cases is necessary to allow us to differentiate among them and to gain understanding of the course of nocturnal hallucinations. We have speculated that the average yeshiva is not an easy place for a boy with learning difficulties. Being a failing member of the class has cumulative damaging effects, and this may explain the severe withdrawal and bizarre fantasies that have been described. With the enormous increase in the number of  / Belief and Ritual

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yeshiva students in Israel,8 leaders, teachers, and parents are becoming more aware of the need for special-education facilities within the ultra-orthodox community. The major drawback to the development of these facilities is the fear of the effects of stigma on the youngster and his siblings. Parents are sure that the teenager wishes to see himself as a normal student and are aware that if he becomes a ‘‘second-rate match’’ the entire family will be tarred by the same brush. A compromise must be found that acknowledges the need for the student with learning difficulties to appear normal without leaving him in a chronically demeaning situation. The formal Jewish attitude is consistent with the need for special facilities. The verse in Proverbs (:), ‘‘Educate a child according to his way,’’ is usually interpreted to reflect the need to find content and methods that are suited to the individual and not to provide a single model for all. At present, however, the community is grappling with the need to resolve the clash between societal expectations and individual needs.

 Normative Rituals

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In this chapter we shall describe normal ritual in ultra-orthodox Jewish life from several vantage points: its development, its pervasive presence in religious rather than secular daily life, and the range of roles it fulfills. Normative Rituals / 

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As Freud wrote ( []): ‘‘I am certainly not the first person to have been struck by the resemblance between what are called obsessive actions in sufferers from nervous affections and the observances by means of which believers give expression to their piety’’ (p. ). Like belief, a central feature of religion, ritual—a particular way of performing a behavior, usually in accordance with certain rules—can be a symptom of psychiatric disorder. All religions and cultural groups have distinctive rituals that are central to their group identity. This is particularly true of Judaism. The canonized Code of Jewish Law describes in meticulous detail the laws concerning the behavior of Jews under all circumstances. Rituals are also present in behavioral disorders, especially in the condition known as obsessive compulsive disorder (OCD). The striking similarity between religious ritual and OCD will be apparent from this description of a typical case. Jack is afraid of becoming unclean because of germs. Never a particularly fastidious person, he first became concerned after an attack of gastroenteritis when he was twenty-six. He became aware of how few people washed their hands after going to the toilet and began avoiding public lavatories. He then became concerned about becoming contaminated after he had touched door handles, telephones, and other public property. He was especially worried about contracting an illness transmitted from feces. He avoided walking over grass and tried to avoid contact with others who may have walked across grass because of the feces left there by dogs. Jack has developed a series of cleansing rituals that he carries out on entering his apartment. He places his shoes in a ‘‘contaminated’’ area by the front door, removes his pants, and places them in the washing machine (they may have touched other people). He then begins an elaborate handwashing ritual, resembling that of a surgeon before an operation. He rinses the  / Belief and Ritual

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soap before he begins and drops it back into its original position when he is finished; he washes every finger with minute precision, careful to wash beyond the wrists, and uses a brush to clean under his fingernails with hot water and soap. Jack washes his hands in this way many times a day, each wash taking up to twenty minutes. He washes with special care on arriving home, after defecation, and before eating. He buys only packaged foods and cleans the wrapping when he brings them into the house. Throughout the day, wherever he goes outside his apartment, he perceives people and objects as potential sources of contamination and disease. Jack’s washing behaviors are known as compulsive rituals in that they are repetitive behaviors that he feels he must perform. Unlike the sufferer from delusions, Jack has insight: he is aware that others do not go to such extremes and that his behavior is excessive. But he nonetheless feels the need to perform the rituals; if he does not do them, he will experience severe anxiety. There is a rationale behind Jack’s practices—the fear of fecal contamination—and his rituals have developed a fixed pattern. If he does not perform the ritual completely, he feels distressed and unclean and usually starts the ritual over again. Although Jack is a nonreligious person from a secular background, many aspects of his behavior resemble religious rituals: the fixed format, the need to repeat the ritual if it is not carried out to the letter, and the need to be clean before certain procedures are all features of religious rituals. Even the motivation, doing what one must do rather than what one wants to do, is a feature common to both situations, as the following midrash states clearly: ‘‘Rabbi Elazar ben Azariah says, ‘A man should not say, ‘‘I don’t want to eat pig’s meat, I don’t want to be immoral.’’ Instead, he should say, ‘‘I do want these things, but what can I do if my heavenly Father has decreed otherwise, as it is written, ‘And you will differentiate between Normative Rituals / 

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the pure and the impure animal, and the pure and impure bird, . . . and I have differentiated you from the nations’ (Leviticus :–)’’ ’ ’’ (Midrash Sifra, Kedoshim, chap. ). Note that the midrash is rejecting reasons of health or preference as a basis for following the commandments. The dietary laws differentiate between kosher and nonkosher species simply to separate the Jewish nation from other nations. The rationale for performing religious acts is that ‘‘my heavenly Father has decreed’’: in other words, one’s motivation is one’s sense of obligation alone. In this respect Jack’s personal compulsion and Jewish ritual are similar. Another interesting and psychologically healthy facet of this midrash is its acknowledgment of human drives. Do not deny your attraction to forbidden impulses, says the midrash, just control them. R  E L The performance of the commandments is central to Jewish life, particularly ultra-orthodox Jewish life. There are  commandments in the Torah, of which  are positive (‘‘Thou shalt’’ as opposed to ‘‘Thou shalt not’’). These are the foundation for the performance of specific activities as evidence of religious commitment. Among the most common phrases in the Torah are the following (emphasis ours):

. ‘‘And you will keep and do what God commands you; .

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.

You shall not diverge to the right or the left’’ (Deuteronomy :). ‘‘Beware lest you forget God, and no longer keep (perform) his commandments’’ . ‘‘If you forget. . . . you will surely be destroyed’’ (Deuteronomy :, :). ‘‘And now Israel, what does God want of you? . . . To  / Belief and Ritual

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keep His commandments, that it may be well with you’’ (Deuteronomy :–). These phrases show not only that ritual observance is a central, obligatory feature of Jewish religious life but that the consequences of nonperformance are fearful. The similarities between religious ritual and OCD, however, far exceed these general conditions. The overt behaviors and underlying concerns are remarkably similar. The ubiquitous nature of OCD-like behaviors in ultra-orthodox Jewish life can be demonstrated by comparing two scenes from daily life in Jerusalem.

Scene  (Somewhere in Jerusalem, Summer) : .. Uri is asleep. The radio–alarm clock goes off, and the radio starts to play a popular song. Uri rubs his eyes, pulls back the covers, and gets out of bed. Barefoot, he goes to the bathroom, brushes his teeth, washes his face, and shaves. He goes to the toilet, then rinses and dries his hands. He slips off his pajamas, puts on his underwear, and chooses a shirt from a selection of shirts of varied colors and puts it on. He puts on a pair of jeans and his sandals, then walks into the kitchen to prepare breakfast.

Scene  (Elsewhere in Jerusalem, Same Day)

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: .. Ezekiel is asleep. The alarm goes off. As Ezekiel opens his eyes he starts to recite the phrase ‘‘I give thanks to You, the everlasting King, for restoring my soul to me in Your great mercy.’’ He reaches out for his vest lying next to the bed and pulls it under the sheet. He is careful not to let the blanket unNormative Rituals / 

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cover him while he takes off his pajama top and slips his head and arms through the vest. He is also careful not to put it on inside out, for as Rabbi Yossi said in the Talmud, ‘‘The walls of my house never beheld the seam of my vest.’’ Next to his bed is a towel, a bowl, and a mug filled with water, prepared the night before. Ezekiel takes the mug in his right hand and passes it to his left hand. He pours some water onto his right hand, transfers the mug to his right hand, and pours water onto his left hand into the bowl. He passes the mug back to his left hand and repeats the sequence, washing each hand up to the wrists three times. (This practice is based on the kabbalistic belief that the soul leaves the body during the night, and a bad spirit takes its place. In the morning the bad spirit leaves the body but lingers in the fingers ‘‘and does not leave until water has been poured on them three times.’’) Ezekiel is careful that ‘‘before washing he does not touch his mouth, nose, ears and eyes because of the bad spirit still residing on his hands.’’ He dries his hands. Ezekiel then reaches for his yarmulka and puts it on his head, for ‘‘a man should not walk four cubits [two meters] with his head uncovered.’’ Ezekiel stands up and picks up his fourcornered fringed garment from the chair next to his bed. He takes each fringe (tzitzit) in his hand, checking that it has eight long threads, and then puts it over his head and over his vest, so that he is ‘‘surrounded by commandments.’’ He recites the blessing on his ritual garment and then puts on a shirt from a pile of white shirts, a pair of black trousers, and socks. The uniformity of his wardrobe is consistent with the ruling ‘‘not to walk in the customs of the nations,’’ taken to mean that the clothing of Ezekiel and other ultra-orthodox Jews should make them dissimilar from those around them. He reaches for his shoes. First ‘‘he takes his right shoe, puts

 / Belief and Ritual

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it on but does not tie the lace, next takes his left shoe, puts it on, ties it up, and then ties his right shoe.’’ He picks up the washing bowl and because the water is unclean from the unclean spirit, he pours it away. He goes to the toilet, as Rabbi Yochanan said of the correct way to start the day: ‘‘Whoever wishes to accept the yoke of the kingdom of heaven fully should go to the toilet, wash his hands, put on tefillin, say the Shema and pray.’’ In the toilet he sits, uncovers himself minimally, and does not hold his penis. He wipes himself with his left, not his right, hand. He pours water over his hands again, repeating the previous sequence, and after drying them, says the benediction that blesses God for creating man with a series of systems that enable him to exist. Ezekiel will repeat this washing sequence during the day whenever he goes to the toilet, touches his shoes with his hands, touches areas of his body that are usually covered, or has sexual intercourse. He brushes his teeth and combs his hair and beard. Ezekiel does not shave, in keeping with the commandment ‘‘And you shall not destroy the corner of your beard’’ (Leviticus :). Occasionally he trims his beard, being careful not to cut the hair of his sidecurls. He combs both sidecurls out carefully and then curls them so that they hang neatly. Ezekiel picks up the bag containing his tefillin and prayer shawl and leaves the apartment on his way to the synagogue for morning prayers. In this way do two ordinary people, Uri and Ezekiel, one a secular Jew, the other ultra-orthodox, start their day. Since childhood, both were taught a series of behaviors for getting up in the morning. Uri’s mother taught him to wash and brush his teeth, and how to dress and behave in the toilet. So too Ezekiel’s mother. Uri’s behavior is guided by current habits and atti-

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tudes toward cleanliness, health, and fashion. Ezekiel’s behavior is guided by the Code of Jewish Law. Although Ezekiel’s system contains a series of precautions against immodesty and uncleanliness, he carries it out in the same mechanical way as Uri, with no apparent anxiety. The two hardly spare a thought for their actions. Even in Ezekiel’s case, despite the fact that these actions are precepts and not just habits, and despite the value given to the performance of precepts with devotion, it is accepted that ‘‘people’s precepts are performed mechanically’’ (Isaiah :). Only spiritual leaders or those who are newly orthodox tend to have an awareness of every action: the former are striving for higher levels of devotion and example, while the latter have rejected their old system, replacing it consciously with a new one. Unlike Uri, Ezekiel is guided by a book with a fixed system. Most of the details in scene  and all the quotations are taken from the codes of Jewish law. Encoded into actions that are performed automatically daily, these laws and warnings enter every facet of his existence. Many aspects of the early-morning religious rituals—the concern for cleanliness, repeated washing, and avoidance of immodesty and uncleanliness—are remarkably similar to Jack’s concerns and rituals. Although Uri’s morning begins with many behaviors that have a particular format, the concerns and repetitions and avoidances are much more apparent in Ezekiel’s case. Yet Jack’s secular way of life and background match Uri’s, not Ezekiel’s. If Ezekiel’s normative rituals are so similar to Jack’s OCD, was Freud right in viewing a society immersed in ritual practice as having a ‘‘universal obsessional neurosis’’ ( [], pp. –)?

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T D  R  U-O A What is the impact of teaching a child so many precautions about sexuality and cleanliness? Does it sensitize him so that he is overconcerned and frightened by these subjects, fearing heavenly retribution if he errs? Conversely, does it help him control his urges? Or as a cultural norm, does it have no impact on his individual development? The impressionistic nature of the following account of the development of normal religiosity within ultra-orthodox society must be borne in mind; it is based on the personal observations of two psychiatrists who are not members of the ultra-orthodox community. The overriding importance of childhood education as a guarantee of the continuation of the Jewish heritage is clearly stated in the following talmudic passage: ‘‘The Resh Lakish (Rabbi Shimon ben Lakish) said in the name of Rabbi Judah the Prince, ‘The world only continues to exist because of the chatterings of children studying Torah. . . . One must not stop children from studying Torah even at the expense of building the Temple.’ And Resh Lakish said to Rabbi Judah the Prince, ‘Any city in which the children do not study Torah should be destroyed’ ’’ (Talmud Shabbat b). In a similar vein, the rabbis teach that the first words to be said to a baby are, ‘‘Moses commanded us to keep the Torah’’ (Deuteronomy :). Early ultra-orthodox education focuses exclusively on the study of the Torah, the performance of prayer, and the practice of daily religious rituals. The aim is to make religious rituals a natural, unquestioned component of life. Secular education is minimal, including only basic mathematics. When they reach the age of fourteen and move away from home to the intense atmosphere of yeshiva life, many boys ‘‘discover’’ the religion that has been automatic during childhood Normative Rituals / 

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and, within the dictates of ultra-orthodoxy, seek their own religious identity. Here the ideals that are stressed are to excel in the study of the Talmud (to be a talmid hacham) and to be righteous in moral and religious behavior. The praying in the yeshivas is known for its intensity. The teachers set an example of praying slowly, taking far longer than the average ultra-orthodox person for each prayer, and the students follow suit, praying with their eyes closed, their faces expressing intense concentration, their bodies moving rhythmically, often shaking their fists or clapping their hands to increase their devotion. A psychologist observing this behavior could be forgiven for explaining this enthusiasm and outburst of energy as a displacement of the emerging yet forbidden sexual energy of adolescence. In addition, the students study texts on moral conduct and may receive lessons of general admonishment, in which their failings are described and they are encouraged to change. A typical statement from one of the most popular texts on moral conduct, Mesilat Yesharim (Pathway of the Just), reads, ‘‘A person should be careful in his deeds and other matters, contemplating and evaluating his actions and ways, whether they are good or not, so that he should not let himself get lost, God forbid, or follow his habits as a blind man at dusk.’’ Serious students may become very watchful of their behavior with their fellow students, careful to ‘‘guard their tongues from evil’’ (not gossiping) and not to talk or perform ‘‘nonholy’’ activities, thus wasting Torah time. Let us consider Jacob. At the age of thirteen, he is bar mitzvah, considered responsible for his own actions, and he takes those responsibilities seriously. At age fourteen, he leaves home to live in a yeshiva, returning for only one day a month. His parents notice that his prayers and recital of blessings are taking longer and that he is very careful in his speech and actions, trying to be patient and correct with his younger brothers. Remem / Belief and Ritual

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bering what a naughty boy he used to be, particularly how he taunted and bullied his brothers, his parents are pleasantly surprised by the change and wonder whether it will last. A year later, Jacob is still very careful and polite and has gained a reputation for studying the Talmud many hours a day, always ready to help others. Although he rebels against the mechanical practices of his father (often unconsciously, for honoring his parents is also a precept), Jacob has become an exemplary young man, and his parents refer to him with a mixture of bemusement and pride as the family ‘‘zaddik.’’ This is one possible avenue of the adolescent search for identity as expressed in the ultra-orthodox community. It is similar to the phase of scrupulosity that has been noted in some Roman Catholic adolescents, who become concerned at having sinned against God and spend prolonged periods in confession, relating their sins in devout detail (Weisner and Riffel, ). It can also be conceived as the equivalent of the searching by a secular adolescent of the Western world who studies extreme political and religious ideologies and experiments with mind-expanding drugs.1 U-O A   R  P

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Anthropologists are fascinated by the distinctive ritual practices of different societies and attempt to understand their common and unique features. A consideration of the possible inner motivations of ritual behaviors in ultra-orthodox life can also shed light on religious ritual and its link to OCD. Anthropologist Mary Douglas () published an analysis of the laws of purity in the Book of Leviticus that would have done credit to any young man in a yeshiva. Rejecting the rationale that kosher animals are healthy while nonkosher animals Normative Rituals / 

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are not healthy, she showed that the concept of holiness in the text concerned the unity and perfection of the individual and the social group, and that the function of the rituals of separating pure from impure was to bring order into society and reduce anxiety. In both of these functions, religious rituals can be said to be identical to OCD rituals. Many studies of ritual focus on ‘‘rites of passage,’’ in which the individual leaves one state of existence, moves into a transitory marginal phase, and ultimately rejoins society in a new, changed state (van Gennep, ). Another influential anthropologist, Victor Turner (), emphasized the repetitive feature of ritual in his early work, but later he viewed rituals in a wider social context. He observed that group ritual involves setting aside the daily structure of existence and focusing on the meaning of a restricted set of details. He referred to this state as ‘‘communitas’’ and considered its disruption of structure to be a challenge to society. Jacob’s adolescence, between childhood and manhood, can be seen as just such an unstable and challenging phase. His increased interest in rituals at the beginning of adolescence may be understandable, occurring as it does at a time of physiological and emotional turmoil and change in status. On the one hand, the sameness of ritual brings familiarity, order, control, and calm; on the other, the change in fervor and performance signifies an altered state, a challenge to previous values. It is not unknown for adolescents to embrace different hasidic leaders at this time or to increase or decrease their level of observance. Some of these explanations emphasize the role of ritual as a guard against instinctual drives, an attitude expressed by Freud in ‘‘The Future of an Illusion’’ ( []), in which he reduced the role of religion to the control of destructive impulses and claimed that civilized persons should ultimately be able to

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live without belief in an illusory overseeing god. This perception ignores the positive aspects of ritual observance: the exhilaration experienced during prayer, the sense of sharing in a communal activity, the feeling of closeness to God (devekut, literally, ‘‘clinging,’’ the Jewish equivalent of unio mystica). The anthropologist Bronislaw Malinowski could have been discussing the impact of yeshiva life on Jacob when he described the ‘‘creative element in the rites of religious nature’’ and its ‘‘vast conception of the entry into manhood with its duties, privileges, responsibilities, above all with its knowledge of tradition and the communion with sacred things and beings’’ ( [], p. ). Another feature of commitment to ritual observance is that it can be an endless quest. The outsider may see ritual life as a unified set of restrictive activities, but the attachment of an individual to normative ritual is a dynamic process. For a particular member of a cultural group, one aspect of ritual may be more attractive, meaningful, demanding, or stimulating than others. It could be prayer and devotion during prayer or especially high standards in observing the dietary laws. The observer will not neglect any area; rather, he will commit himself to excellence in a particular precept. Further, as our developmental account has shown, the immersion in ritual inevitably varies according to different phases of one’s life. T P  S-D, B T

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Rabbi Abahu said: ‘‘At the level where religious penitents stand, even the completely righteous cannot stand’’ (Talmud Brachot b). An extreme version of normal religiosity, in which the person is actively concerned to carry out precepts exactly and with devotion, is often seen in baalei teshuva. Unlike someone born and reared in an ultra-orthodox home, for whom religious

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performance may be automatic, a baal teshuva, new to religious ritual, may be intensely concerned about getting everything right and showing adequate devotion. Invariably, this is a transitory phase, for the intensity mellows after the novelty of becoming religious fades into the daily routine of ultra-orthodox ritual life. The description that follows is drawn from the tragicomic writings of Shalom Aleichem, the master storyteller of Eastern European Jewish village life. One by one, he describes the miserable, lonely lives of several members of the village who, once a year, at the festival of Purim, become the local klezmer band, the personification of joy and kinship. The praying of Shaya-Dovid, the religious penitent, was indeed wonderful, unlike the praying of any other creature. Shaya-Dovid does not pray in a whisper, but raises his voice, shouts and moves worlds with his praying. It would seem he is of weak faith. He suspects that the Holy One Blessed Be He hears not a poor man’s prayer be it said softly. But more than that, he is unsure of himself and hesitates as he may have erred in his prayer and left out one word, so that he is in the habit of repeating every word and every line twice over. He gives up of his own time and adds to the Almighty (and says his prayers as follows): ‘‘Blessed . . . Blessed, is He who spoke . . . is He who spoke, and there was . . . and there was; Blessed is He who spoke and there was . . . Blessed is He who spoke and there was . . . the world . . . the world.’’ (Aleichem, , p. )

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Aleichem wished to portray the spectrum of village life, not psychopathology. Indeed, this passage depicts the heightened awareness, devotion, and anxiety over error often found among

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religious penitents. It is likely that Shaya-Dovid experiences his thoughts of exactness and repeating rituals as ego-syntonic and does not resist them. Not so his fellow worshipers, who ‘‘sit near him in the synagogue, get angry with him, and say that his prayer is foolish and makes it hard for them; he confuses them with his shouting, and his repetitions jumble up their prayers and lead them astray from their correct path.’’ The irritation that Shaya-Dovid evokes in those around him can be understood as a response to the aggressive feelings he is sublimating through these rituals. Another, equally psychological explanation for the energy of the religious penitent is offered by Maimonides, discussing the talmudic passage quoted above: ‘‘The level of religious penitents is above that of the completely righteous because the latter have never known sin, while the former have had to master their former passions’’ (Laws of Repentance :). Similarly, Jacob’s rituals might be regarded as an expression of the pent-up energy of adolescence. Whereas his secular contemporary can hop on a motorbike and ride at a hundred miles an hour, Jacob prays at sixty shakes a minute. At the end of their respective trips, both feel tired and exhilarated. Both perform with great control and skill, and both have an enormous sense of release. Amid the normal expressions of adolescence, the differences between the ‘‘easy rider’’ and the fervent pray-er may be more apparent than real.

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 Ritual as Psychopathology, or Is the Code of Jewish Law a Compulsive’s Natural Habitat? Rabbi Israel Salanter (–) was scrupulous in his observance of all  commandments of the Torah. It was his custom when Passover approached to personally supervise the baking of matzos in his town, to make sure it was done according to the timehonored ritual regulations. On one such occasion, when Rabbi Salanter was laid low by illness, his followers volunteered to supervise the baking of the matzos. ‘‘Instruct us, Rabbi,’’ they said. ‘‘Tell us all the important things we have to watch for.’’ ‘‘My sons, see that the women who bake the matzos are well paid,’’ was Rabbi Israel’s brief reply (Ausubel, ). During the cholera epidemic that swept Vilna, Lithuania, in , Rabbi Israel Salanter was in the forefront of the most dangerous relief activities. He gave instructions that in this circumstance Jews were to work every day, even the Sabbath. On Yom Kippur, the Day of Atonement and the most important fast day of the Jewish calendar, he ordered the congregation to partake of food and set a personal example by mounting the pulpit and publicly eating (Alfasi, ). These stories illustrate the understanding that there is a limit to ritual piety. When religious restrictions endanger life, it is our religious duty to ignore them. The average ultra-orthodox Jew sees no contradiction between this position and the demand for  / Belief and Ritual

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meticulous religious observance: our relationship to God is expressed as much by giving charity as by prayer. The interpersonal is an important area of life, and the term zaddik is reserved most of all for the person who does good deeds and is considerate of other people, not for someone who prays with especial concentration. Nevertheless, granted these human and humane attitudes, strict adherence to religious observance is one of the two most valued features of ultra-orthodox life; the other is the study of the Torah. There is an interesting contradiction in the formal attitude toward the limits of observance. On the one hand, the Torah states, ‘‘You shall not add one word to that which I have commanded you, nor subtract from it; instead you must keep the commandments of the Lord your God which I have commanded you’’ (Deuteronomy :). This sentence contains two of the  commandments: one must neither add to nor subtract from the Torah. On the other hand, ‘‘The men of the Great Assembly said, ‘Make a fence around the Torah’ ’’ (Mishnah Avot :). Maimonides explained that this refers to the rabbinic decrees that are intended to keep a person far from sin. The basis for these decrees is the phrase ‘‘And you shall guard my guarding’’ (Leviticus :), meaning ‘‘put a guard around my guard.’’ As an example, the laws proscribing immoral conduct have layers of laws around the original injunctions to protect people from their own evil inclinations. It is apparent that Jewish law contains many paradoxes. Most ultra-orthodox Jews cope with these contradictions; indeed, they are at the root of many of the debates recorded in the pages of the Talmud and continue to be debated in yeshivas today. The authority of the additional decrees has been a source of tension between groups within Judaism throughout its history. The general attitude of the ultra-orthodox community toward these

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additions is uncompromising acceptance; they are seen as an integral part of Jewish law, inseparable from the laws of the Torah. In this chapter, we shall examine the religious rituals that most commonly become OCD symptoms in ultra-orthodox patients to ascertain whether there are limits to the expectations of religious ritual and, consequently, whether it is possible to define compulsive behaviors as excessive and pathological. If these behaviors emerge from a body of law that encourages care and order and that even, as it will be shown, condones checking and repetition—all of which are cardinal aspects of compulsive behaviors—and if the rabbis over the generations have tended to add ‘‘fences’’ of further restrictions around the law, then it may be that the law never limits the lengths to which adherents should go to avoid slipping into error. Such an attitude is likely to make diagnosis difficult. It can dissuade the patient from viewing himself as unwell and could make any attempt at a therapy that limited these precautionary measures religiously indefensible. R S  OCD In interviews with ultra-orthodox sufferers from OCD, four areas of religious observance have dominated the clinical presentation of religious symptoms: devotion in prayer, meticulous observance of the dietary laws, the menstrual purity laws, and the laws of cleanliness before prayer.

Concentrated Devotion in Prayer (Kavvanah)

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The Code of Jewish Law defines kavvanah as follows: ‘‘When praying, one should concentrate on the meaning of the words, and think that the Divine Presence is in front of him. He should  / Belief and Ritual

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banish all preoccupying thoughts, until his thoughts and devotion are purely of prayer. He should behave as though in conversation with a king of flesh and blood, preparing his thoughts and concentrating carefully lest he stumbles in his words. For how much more careful should one be in the presence of the King, king of kings, the Holy one, blessed be he’’ (Code of Jewish Law, Orakh Hayyim, :). In the next section, however, the Code adds the following qualifying statement: ‘‘Nowadays, we are no longer so particular over all these limitations, since we do not have so much concentrated devotion during prayer.’’ In Judaism, prayers are said three times daily. Certain prayers are more important than others and require extra devotion. The most important prayer in the Jewish liturgy, the Shema, features prominently in OCD, as patients tend to have doubts about their level of kavvanah relative to the importance of the prayer. The Code says, ‘‘One should say the Shema with concentrated devotion, awe, fear, shaking and trembling’’ (:). The practice is to say the first and most important sentence aloud: ‘‘Hear, O Israel, the Lord is our God, the Lord is one’’ (Deuteronomy :), and at the same time to cover one’s eyes to increase one’s devotion. Having added these ‘‘fences’’ to increase devotion, the Code states explicitly that the words of the Shema must not be said more than once, as this would imply that there is more than one God, defeating the purpose of the sentence (:). Furthermore, in principle the Code states that laws, including reciting the Shema, do not have to be performed with kavvanah. Kavvanah is desirable but not a sine qua non of prayer. The second-most-important prayer is the collection of blessings known as the Amidah (literally, ‘‘standing prayer,’’ for it is said while standing). The first of the blessings, referred to as Avot (literally, ‘‘fathers,’’ for it deals with God’s covenant with the biblical forefathers) is the most important. The Code states, ‘‘If one did not have concentrated devotion for Avot, even if Ritual as Psychopathology / 

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one did for the rest, one must go back and repeat the entire prayer.’’ An Ashkenazi authority, Rabbi Moses Isserles (– ), noted in response to Karo’s ruling that one should repeat the Avot prayer, that ‘‘one does not go back over one’s prayers owing to lack of concentrated devotion, as even if one repeats it one is again unlikely to concentrate; in which case why repeat?’’ (:). Another important prayer is called Ashrei (literally ‘‘Happy are they,’’ the opening words of the text, Psalm ), which is said three times daily. The Code states, ‘‘One should say the verse ‘You open your hands’ with concentrated devotion, and if one did not do so, one should go back and repeat it’’ (:). Repetition owing to lack of concentration is permitted in this case because only one sentence is involved, and the person praying is likely to succeed in concentrating the second time. Another aspect of prayer that has attracted some OCD sufferers is the care taken on wearing one’s phylacteries, or tefillin. The Code states, ‘‘Nothing should be interposed between one’s tefillin and one’s skin’’ (Code of Jewish Law, Orakh Hayyim, :). A recent authority adds, ‘‘even the smallest interposition, and one should beware even of live lice, and should certainly beware of dead lice or dust; for this reason some have the custom of washing the area of skin before laying the tefillin.’’ Baruch, aged nineteen, lives at home with his parents. He is friendly, in fact excessively so, and self-negating, apologizing for taking up my time and excusing himself if he closes the door too noisily or speaks too loudly. He speaks softly, with a lisp, and has no conversation other than the problem that consumes him. Baruch has difficulty saying his prayers. He thinks that he does not pray with enough devotion, and while praying he finds that thoughts of blasphemy or religious doubts assail him. He becomes distressed at having such thoughts and decides that his prayers are invalid. As a result, he constantly repeats his prayers,  / Belief and Ritual

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so that they can take several hours, particularly the Shema. He always completes his prayers with the feeling that his level of devotion is poor. He is particularly concerned that he does not say Psalm  properly. Baruch takes twenty minutes over this psalm, repeating many sentences, and particularly verse : ‘‘You open your hands and satisfy the needs of all living.’’ Several months before his referral, Baruch saw a notice in the ultra-orthodox area near his home warning that great care must be taken in wearing tefillin, for ‘‘he who is not careful will inherit hell.’’ Since then he has become intent on making sure that his tefillin are lying directly on the skin of his arm and forehead, that they are positioned in exactly the correct spot, and that the leather of the tefillin is completely black, with no stains or marks. In addition, he checks his tefillin, their position, and his skin throughout prayers, and finds himself thinking of them when he is meant to be studying in the yeshiva, so that his level of studying has deteriorated. Contrasting our review of the Code with Baruch’s OCD reveals certain inconsistencies. Baruch’s concerns are normative for the ultra-orthodox community in that devotion in prayer is indeed a virtue in the Code, and the hierarchy of importance Baruch gives to prayers is identical to that in the Code. The Code, however, takes a pragmatic attitude: repeating a prayer to achieve increased devotion is recommended only for single verses of especial sanctity. The overall position is that concentrated devotion is not essential to acceptable prayer and that prayers should not be repeated. The Shema, the most important of all sentences of prayer, must not be repeated. Baruch’s behaviors, therefore, are excessive and inconsistent with the Code, which discourages repetition for a reason that is equally applicable to repetition in OCD: if you don’t think you got it right the first time, why are you likely to be satisfied the second? Note that the prohibition is on repeating; slowness is not criticized. Ritual as Psychopathology / 

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The Battle of Milk and Meat In addition to the types of animals that the Torah lists as kosher, the main feature of the Jewish dietary laws is the separation between dairy foods and meat. The following instructions appear in a modern guide to the dietary laws: On changing from working with milky to meaty food or dishes or vice versa, one has to wash one’s hands. . . . The main ‘‘battle’’ between milky and meaty foods and utensils takes place on the cooking range, where the boiling pots are ready to shoot out steam or to overflow at any time. The need for caution is imperative, since even a single drop of milk splashing onto the outside of a hot meaty pot would render the latter unusable! It is up to the busy housewife to ‘‘keep the peace’’ by preventing the slightest contact of the two. . . . Salt and sugar in an open container that has been used at a milky meal cannot be used at a meaty meal, and vice versa. . . . Bread which has been used for a milky meal may be used for a meaty meal, and vice versa, provided that it is certain that it was touched by clean hands which had not come into contact with milky or meaty foods. . . . Bread which has been within the reach of young children during a meaty or milky meal cannot be used for an opposite meal, as the children may have touched it with unclean hands, unnoticed by adults. . . . Since milky and meaty foods may not be eaten at the same time, a person wishing to eat milky food must make sure that his mouth is clear of any meaty food, and vice versa. (Wagschal, , pp. –)

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Another area of the Jewish dietary laws that features prominently in OCD is the special provision for Passover. All bread must be removed from every Jewish home before the festival of Passover. The guide to the dietary laws states, ‘‘In order to ascertain that one should have no bread in one’s possession during Passover, an extensive house-cleaning is carried out before Passover. All rooms and parts of the house into which bread may have been brought at any time during the year, must be thoroughly cleaned. This applies to attics, pantries, cellars, offices, shops, garages, cars, wardrobes, drawers, pockets, handbags, shopping bags and travelling-cases. The cleaning operation naturally requires time and effort, and most housewives find it expedient to commence it as early as possible, usually one month before Passover’’ (p. ). The Code of Jewish Law (Orakh Hayyim, :) states, ‘‘It is customary to scrape walls and chairs that have been touched by bread.’’ One commentator adds, ‘‘One should not scoff at this custom, saying it is . . . foolish . . . and overly stringent.’’ Nevertheless, an awareness of the possibility of overmeticulous observance of Passover laws is apparent in the Mishnah: ‘‘One is not to be concerned that, having completed the pre-Passover cleaning in one room of the house, a rat from another [as yet uncleaned] room may drag a crumb into the cleaned room. Why not? because if such a thought could be entertained, then why not the additional possibility that the crumb may be brought from one house to another, or from one town to another—and there would be no end to the matter!’’ (Mishnah Pesachim :). John, aged forty-five, married with five children, is neatly dressed, friendly if slightly formal, and a little shy. He refers to a list on an envelope throughout our discussions. He often telephones between visits to describe a minor infringement of the dietary laws and to speculate as to how he should proceed:

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‘‘Should I throw it away, ignore the whole matter, or go and do the infringement again on purpose as in behavior therapy? What do you think I should do?’’ John is excessively concerned over the dietary laws, worrying particularly that milk and meat might be mixed together, making the food nonkosher and the utensils unusable. For John and his family, mealtimes have always been a nightmare. John sits at the table like a coiled spring, anxiously watching his children lest they touch the ketchup and other bottles with greasy hands. Every few minutes he insists that the children wipe their hands on a napkin or gets up himself to wipe their hands. If he thinks a bottle or utensil has been touched by a milk food, he will either put a label on it that says ‘‘milk’’ or hide it until he can decide what to do with it; in this way the kitchen cupboards have become full of collections of ‘‘touched’’ bottles over the years. He wipes his own hands more than thirty times during a meal and washes his mouth, teeth, face, hands, and particularly his fingernails after every meal for fear that they may have collected food. The more crowded the dinner table, the more tense he is, so the family has not invited guests over for years. He avoids helping in the kitchen for fear that the water washing the milk dishes will splash onto meat dishes and foods.1 The weeks before Passover are particularly tense. John insists that the children not leave the table before wiping their hands and not take food out of the kitchen. The towels used to wipe their hands are put in plastic bags at the table to ensure that no crumbs drop out on the way to the washing machine. He tries to check all his books to see whether any bread has fallen inside them, and then worries that he has not done the job adequately, has not opened the pages wide enough to inspect the binding. The ceremony of searching for bread on the night before Passover is particularly stressful, for he cannot decide whether a room has been adequately cleaned. He fears he  / Belief and Ritual

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may have forgotten a particular area and often begins the search again. John’s problems began eighteen years ago, when he became a baal teshuva. The Mishnah injunction about following reasonable standards of cleanliness appears to be in contrast to the general stringency of the codes. In the codes, the dietary laws demand care and cleanliness, and precautions are encouraged. The arena is viewed as a battlefield between the clean and unclean; the weapons are vigilance, separation of foods and utensils, and the washing of hands and mouth. In these respects, the codes and John’s OCD are compatible. Nevertheless, there are inconsistencies. Although staples such as salt, sugar, and bread must be separately designated either milky or meaty, for example, closed food containers are not included. John’s fear that one of the children may have touched the top of the ketchup bottle with greasy hands may be understandable, but it is excessive. Further, the cupboards full of stale loaves of bread, old bottles of mayonnaise, and utensils whose status has not been decided are evidence of compulsive hoarding and indecision; they are not a feature of Jewish law. The codes therefore are stringent, yet, unlike John, they set clearly defined limits between what has happened and what may have happened.

Menstrual Purity

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The Torah states, ‘‘If a woman has a discharge of [menstrual] blood, she shall be in a state of separation for seven days’’ (Leviticus :). Whoever touches a menstruating woman or touches the place where she has been lying during this time becomes unclean. The Mishnah and the Talmud proscribe a menstruating woman from having sexual (or any physical) contact Ritual as Psychopathology / 

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with her husband for the period of her menstruation and the seven days following (known as the seven days of purity or cleanness). During this time she is expected to examine herself for signs of continuing menstrual discharge. At the end of the seven days, she immerses herself in a ritual bath (mikve). A modern guide to menstrual purity states, On each of the seven days of cleanness, the woman must examine herself twice. All examinations must be performed by daylight. . . . When the woman performs her immersion, she must be completely clean, entirely free of any substances which might prevent the water from reaching her body. . . . Since all foreign substances must be removed from her body, and all hairs must be neither knotted nor matted, nor may they be dirty, the woman must wash her entire body with warm water prior to the immersion. She must cut her finger- and toenails. She must wash and comb her hair so that not a single hair is entangled. Before immersion, the woman should examine her entire body to make sure she is completely clean. If she did not examine her body prior to the immersion, she must perform the immersion over again. If a limb or even a single hair protrudes above the surface the immersion is not valid. If she at all suspects that her hair might have protruded above the surface of the water, she must perform the immersion over again’’ (Kahana, , pp. , , , , , , ).

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Sara, aged thirty-one, began to feel accountable to God after her marriage. Previously she had been a combination of the funloving and the serious. Unlike Baruch and John, she exhibited neither the indecisiveness nor the excessive politeness which are  / Belief and Ritual

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often described as obsessive-compulsive personality characteristics and which are often features of the personality of a person who will develop OCD. Her problems fall in two main areas: the dietary laws and the menstrual purity laws. Sara is undisturbed during menstruation itself: she knows she is not ‘‘clean,’’ and her mind is untroubled. But once the bleeding seems to have ceased and she begins counting the days of cleanness, she becomes tense, preoccupied with every sensation in her abdomen, wondering whether she is losing blood. During the seven days after the end of menstruation, Sara inserts a pad to check whether there is vaginal bleeding. She measures the pad carefully before use to be sure it is the prescribed size, and after removing it she checks it minutely for any sign of a stain. If she finds anything, she will either consult her rabbi about whether the stain is considered blood or decide that she must recommence her count of the seven-day period before she can immerse herself. As a result, she usually delays her immersion for one to two weeks, until only a few days are left before her next period. Once she is ready for the ritual immersion, she takes up to three hours to prepare herself, checking her body for cuts, calluses, loose skin, and dirt, especially under her nails and cuticles. She combs her hair for ten minutes, until she is convinced that none is loose before the immersion. Sara repeats the immersion process many times, until she is sure that it has been performed properly. The attitude of the Jewish religion is unmistakable: ‘‘There is no stronger ritual uncleanness in the world than the uncleanness of the menstruating woman’’ (Zohar Exodus ). In spite of our awareness that many women with OCD exhibit symptoms of excessive concern for menstrual purity, we have found no formal evidence of leniency in rabbinic attitudes toward these rituals. In this case, the symptom creates a clear conflict between Ritual as Psychopathology / 

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the quest for religiousness in one commandment and the demand for procreation in another commandment; a woman who keeps delaying her date of immersion also defers the possibility of having sex and thereby becoming pregnant. Procreation is the first commandment in the Torah and large families are one of the pride of ultra-orthodox life. A childless marriage is not just a source of sorrow, it is ground for divorce. The distinction between religiousness and OCD may be reflected in the extent to which the problem intrudes into daily life. The codes encourage Jewish women to be as careful and stringent as possible. Nevertheless, they must have a clear reason for deferring immersion. If a woman has a discharge of a dubious color, she should turn to her rabbi. If he says it is not blood, she must listen to him. An OCD sufferer will find this difficult and may demand a second (or third) opinion; a conscientious wife will accept the rabbi’s decision. Although the texts may appear inflexible, day-to-day problems are dealt with by rabbis, who are able to be lenient when necessary. Most rabbis (and all ritual bath attendants) know women with these problems and try to help them by making lenient rulings, such as ordering patients not to check twice daily throughout the seven days of cleanness as the codes suggest but instead to check once on the first and once on the last. Rabbis can also help in cases involving a subjective feature of the laws that OCD sufferers tend to discover. The Code defines the ‘‘onset’’ of menses as the moment when menstrual blood first appears. However, a woman who experiences the sort of feeling she associates with the onset of menses can be considered unclean even if no blood is visible. From the moment of immersion, many OCD sufferers wonder: ‘‘Did I just have a feeling? Was it exactly the same? Should I do a test?’’ Rabbis have often advised patients that this law does not apply to them, and that they should rely only on clear, objective evidence.  / Belief and Ritual

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A Clean Body Before Prayers Cleanliness and purity in daily life are mentioned frequently in the Torah. In contrast, feces are referred to only once, but they are frequently discussed in the Mishnah and Talmud, for their presence prevents practitioners from carrying out religious duties. This preoccupation persists in the Code of Jewish Law; for example, of the thirty-one chapters dealing with the laws of saying the Shema, seven are devoted to the need to urinate or defecate, or to the presence of urine, feces, or a toilet while one is praying. This preoccupation with cleanliness has been noted by Mary Douglas and other anthropologists and has a special significance for OCD, a condition Freud described as a way of diverting anal-erotic impulses. The laws that are most relevant, which tend to be well-known to OCD patients with the symptoms mentioned below, are the following (emphasis ours):

. ‘‘One should not pray if one needs to go to the toilet, .

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.

and if one does pray, that prayer is an abomination, and one must repeat the prayers. . . . In the first instance one should not pray until he has checked himself thoroughly first’’ (Code of Jewish Law, Orakh Hayyim :). ‘‘It is generally agreed that one must not say the Shema if there is any fecal matter around the anal orifice, even if covered (by clothing), whether visible or not, whether the person is standing or seated’’ (Orakh Hayyim :). A modern authority adds, ‘‘One should be very careful to wipe well, as the smallest amount of fecal matter is significant. . . . It is good to wash the anal orifice with water or spittle’’ (Mishnah Brura :). ‘‘One should not pray near refuse that has a bad smell’’ (Orakh Hayyim :). Ritual as Psychopathology / 

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Isaac, aged thirty, continually fears that he is not clean in the anal region, resulting in meticulous cleaning for half an hour whenever he uses the toilet. He was embarrassed to relate that he keeps taking fresh toilet paper, wiping himself, and then inspecting the paper carefully to see whether it is clean. After he has used twenty or so sheets he starts splashing himself with water until he is convinced that he is clean. At other times in the day he may bend over ‘‘to feel if something is there’’ and check whether he needs to go the toilet. He is continually thinking, ‘‘Am I clean? Am I damp? Is something there?’’ This anxiety increases before and during prayer, Talmud study, benediction, and eating, for which cleanliness is necessary. In addition, he will not say benedictions at home unless he has made certain that there are no rags or garbage to be seen and that the baby’s diaper has been changed. Isaac has consulted many rabbis, all of whom exempted him from taking such precautions, but after leaving each rabbi, he would worry that he hadn’t told the rabbi everything, or that he hadn’t understood him properly.2 The Code is clear and stringent: before prayer, one should check oneself for the slightest amount of feces. The distinction between the Code and the OCD sufferer has to do with flexibility. Isaac usually misses prayers because he is still in the toilet cleaning himself. But the very length of the section in the Code on this subject reflects its recognition of the many mitigating circumstances. For example, despite the statement that a person should not pray if he needs to go to the toilet, the Code says, ‘‘If one needs to go in the middle of the Shema, whether to defecate or urinate, one should continue praying’’ (:). The Code itself does not mention individuals who may be excessive in these practices, but the whole tone of Jewish law is that it should be health-giving, not pathogenic. If there is a hint that strict ob-

 / Belief and Ritual

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servance of the law may be harmful, the law must be modified. This is expressed clearly in the following story from the Talmud. If one goes to the toilet during prayers, one removes one’s tefillin and leaves them on a ledge facing the street [not facing the toilet]. On one occasion a young man left his tefillin on a ledge facing the street and a prostitute came and removed them. She went to the yeshiva and announced, ‘‘Just look what so-and-so paid me for services rendered!’’ When the young man heard of this, he went up to the roof and fell to his death. It was immediately decreed that one can put one’s tefillin in one’s pocket and go in with them into the toilet. (Talmud Berachot a) R  C: D

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Our survey of the religious symptoms of OCD shows that they emerge from within the body of Jewish law and that the written codes are as stringent in their expectations as are the consciences of our patients. With rare exceptions, justifications can be found in the religious literature for performing the compulsive behaviors. Only one component of the compulsive behavior itself stood out as abnormal, and that is the repetition of ritual behaviors. In the cases of OCD with religious content, the fear was religiously consistent—for example, the fear of being in contact with feces before prayer. The underlying logic was also religiously consistent: the understanding that if there is a speck of feces in the anal region, prayer is forbidden. Even the performance of the compulsive behavior—wiping before prayer—was religiously justified. However, Isaac would clean himself repeatedly for more Ritual as Psychopathology / 

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than half an hour before every prayer. The Code of Jewish Law does not describe repetitive cleaning, and Isaac knew that he cleaned himself more often than other ultra-orthodox Jews. Similarly, all religious Jews would agree that tefillin must lie directly on the skin. A careful person would check to be sure his skin was clean before putting on his tefillin. A very careful person would inspect the spot minutely or even wipe it once. Only a patient with OCD would wash or wipe it repeatedly. If we compare the clinical vignettes of OCD described above with the experience of normal religiousness, we can distinguish between the sufferer from OCD and the religiously fastidious person in several other ways (Greenberg, ). First, the religious behavior that is the source of concern is often of trivial religious importance, for example, cleaning the anal region before prayer. Second, the OCD sufferer is usually preoccupied with one particular type of observance, whereas fastidious observers, although they may ‘‘specialize’’ in one particular virtue, are careful in all areas of observance. In addition, OCD sufferers can become so preoccupied with their particular concern that they neglect the main purpose of the action. For example, a man may take so long to clean before prayers that he is too late to perform them; he may repeat prayers over and over at the start of the service, leaving himself time to say only an abbreviated version of the more important parts of the service; or a woman may delay ritual immersion following menses so long that there is no time left that month for intercourse. The OCD sufferer becomes so caught up in the preparations that the religious act that these rituals honor and protect is lost. Students of psychodynamic theory would see in this behavior an expression of aggression against God,3 symbolizing aggressive feelings against the patient’s own father. Such feelings are unacceptable for the sufferer from OCD or for the ultra-orthodox.  / Belief and Ritual

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As a development of the preceding observation, we have found that in some cases our patients actually transgress other and more important laws in order to relieve the discomfort arising from their symptoms; thus John would wash his hands on the Sabbath in a manner that is strictly forbidden. Finally, as the condition worsens, other features of religious life are neglected. Baruch spends his entire day praying and has stopped all talmudic study, even though the latter is the most important activity for an ultra-orthodox male. This feature is comparable to what we discovered in our examination of those with religious delusions: the patient may appear to be observing the religious codes with remarkable precision and ‘‘orthodoxy,’’ but the ultimate discontinuity is that the proper religion of an ultra-orthodox person covers a range of religious activities and social interactions. The most noticeable symptom of disorder may well be the breakdown in the variety of that life, in which only a single, exaggerated aspect remains.

 Religious Ritual and OCD     ‘‘ ’’                ?

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Let us consider two opposing views of the function of the Torah commandments. The first is from the Talmud: Religious Ritual and OCD / 

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The Rabbis teach, ‘‘It is written, ‘And you shall put the words of my Torah in your hearts’ (Deuteronomy :) and the word ‘you shall put’ [Hebrew: Samtem] can also mean ‘a perfect medicine’ [Hebrew: Sam Tam], for the Torah can be compared to a life-giving medicine. ‘‘This may be expressed as the following parable: A man once hit his son and gave him a serious wound. He put a bandage on the wound and said, ‘My son, as long as the bandage is covering the wound, you may eat, drink and bathe however you wish, and you need not fear. If, however, you remove the bandage, the wound will spread.’ ‘‘This parable may be applied to God, who says to his people, Israel, ‘My son, I have created the evil inclination, and I have created the Torah as a medicine for it. If you occupy yourselves in matters of Torah, you will not be overcome by the influence of the evil inclination. But if you do not occupy yourselves in matters of Torah, you will indeed be overcome by the influence of the evil inclination.’ ’’ (Talmud Kiddushin b) The second is that of Sigmund Freud:

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In view of these similarities and analogies one might venture to regard obsessional neurosis as a pathological counterpart of the formation of a religion, and to describe that neurosis as an individual religiosity and religion as a universal obsessional neurosis. The most essential similarity would reside in the underlying renunciation of the instincts that are constitutionally present; and the chief difference would lie in the nature of those instincts, which  / Belief and Ritual

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in the neurosis are sexual in origin, while in religion they spring from egoistic sources. (Freud,  [], pp. –) The attitudes presented above are well known. The talmudic passage describes the Torah and its commandments as a healthgiving elixir that helps people overcome their impulse to evil. Freud, on the other hand, views religious precepts as stunting mature development and independence. Religious thinkers do not view religion primarily as a form of therapy. Its function is to serve God. Nevertheless, few adherents would disagree with the claim that ritual observance is a positive influence in their lives, giving them a sense of purpose, a structure, and a set of values. Agnostics or atheists can equally enthusiastically propose the opposite: religious ritual is a negative component in society, justifying rigidity, conformity, and lack of originality. If, as these thinkers claim, Halakhah, for instance, trains by indoctrination and fear, an inevitable consequence of Jewish law would be a greater prevalence of OCD among ultra-orthodox Jews than in the general population. In this chapter, we shall analyze data from our clinical work with ultra-orthodox OCD sufferers and from epidemiological studies in several countries to evaluate the claims of the two sides in this perennial debate: Does religious ritual induce OCD? We shall focus on three issues: the selectivity of religious compulsions among religious practices, the presence of religious and nonreligious symptoms among OCD sufferers, and the distribution of OCD in different cultures. The  commandments of the Torah cover most areas of life, from the observance of the Sabbath and seasonal festivals to acts of charity and honesty, from warnings against varieties of idol worship to details of types of sacrifice. The Code of Jewish Law comprises four large volumes: the first deals with prayer Religious Ritual and OCD / 

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and Sabbath and festival observance; the second with dietary laws, financial matters, purity, and mourning; the third with marriage and divorce; and the fourth with civil and criminal law. In contrast to this wide range of subjects, OCD sufferers in the ultra-orthodox community describe symptoms in only four main areas: prayer, dietary laws, menstrual purity, and cleanliness before prayer. These four areas are by no means the most important in Jewish law: as we noted in Chapter , kavvanah is not obligatory, and most people do not think about cleanliness before prayer. Of the Ten Commandments, two—concerning Sabbath observance and honoring one’s parents—have a prominent place in the Jewish tradition. Observing the Sabbath is considered as important as obeying the entire Torah (Maimonides, d, Sabbath Laws, :), while the command to honor one’s parents is reinforced by repeated references in the Torah to punishments for striking or even cursing them (Exodus :,; Leviticus :; Deuteronomy :). It is not difficult to invent an obsessive-compulsive symptom in which the sufferer repeatedly checked to see whether she profaned the Sabbath or worried that in brushing past her parents, she might have ‘‘struck’’ them, or that she might have cursed them during a conversation—or merely while she was thinking about them. Further, the Talmud (Kiddushin b) compares honoring one’s parents to honoring God, so developing such a symptom could be understandable psychodynamically as equivalent to blasphemous or aggressive thoughts against God. Nevertheless, these laws, despite their importance, are not to our knowledge the focus of obsessivecompulsive symptoms among ultra-orthodox Jews. If the religious cultus of Judaism were pathogenic—if it induced OCD—we might expect all areas of Jewish practice to be involved in the disorder. That these symptoms are selective suggests that ultra-orthodox practices are the setting rather  / Belief and Ritual

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than the catalyst for the disorder. On the other hand, can it be argued that the existence of these quasi-obsessive-compulsive areas of concern within Jewish law encourages the development of OCD? Over a period of five years, we evaluated thirty-four consecutive referrals of OCD in the north Jerusalem mental health center. As we have noted, more than  percent of the inhabitants of the catchment area are ultra-orthodox Jews. Of the thirtyfour cases, nineteen were ultra-orthodox. The remainder were modern orthodox, traditional, or secular. Thirteen of the nineteen ultra-orthodox patients exhibited the religious symptoms described in the previous chapter, of whom five had only religious symptoms,1 and the remaining eight had both religious and nonreligious symptoms. Only one of the fifteen nonultraorthodox cases had religious symptoms. Of the thirteen ultra-orthodox cases with religious symptoms, prayer was the obsessive-compulsive topic in seven cases, dietary laws in two cases, menstrual laws in two cases, and cleanliness before prayer in five cases. There were no other religious topics in this sample, although we have encountered cases elsewhere of a compulsion for a ceremony to counteract dreams and for a ceremony to annul vows (Rapoport, ). In a lecture to the Royal Society of Medicine in , one of the first evaluations of a series of cases of OCD, Aubrey Lewis noted that the concerns of patients tend to be restricted to five main topics: dirt, orderliness, aggression, sex, and religion. If we apply these topics to our thirteen ultra-orthodox patients with religious symptoms and ignore the religious context of the symptoms, we can reclassify the topics as dirt (eight cases), orderliness (six cases), aggression (two cases), and sex (one case). Examples of dirt include blemishes on the body and menstrual blood before ritual purification, milk and meat mixed during eating, feces in the anal orifice before prayer, and open rubbish bins during Religious Ritual and OCD / 

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prayer. Saying prayers correctly and concentrating during prayer are examples of orderliness, while blasphemous thoughts would be subsumed as a form of aggression. So although certain areas of religious practice are the idioms of distress chosen by ultraorthodox sufferers of OCD, the same topics are to be found in OCD in other cultures (Greenberg and Witztum, b).2 Similarly, the compulsive behaviors noted in the thirteen cases were cleaning (seven cases), repeating (six cases), checking (one case), and slowness (two cases). These behaviors and their distribution among our cases of OCD are identical to the findings of studies of OCD in other populations (Rasmussen and Eisen, ). The data show that religious symptoms of OCD are generally found only in patients whose religious beliefs and practices have a dominant role in their lives. They concern selected religious topics, such as cleanliness before prayer and concentrated devotion in prayer; they are often accompanied by typical nonreligious symptoms of OCD; they involve topics in a religious context that also concern nonreligious OCD sufferers (dirt, order, aggression, and sex); and they are associated with the same ritual behaviors found in nonreligious samples of OCD. These findings emphasize the similarities between ultra-orthodox and nonultra-orthodox populations in the presentation of OCD and suggest that religion is the context for the presentation of OCD rather than the reason.3 Careful study of ultra-orthodox cases of OCD suggests that despite the religious form and content of many of the symptoms, the underlying subject and accompanying rituals are typical of OCD in all cultures. These findings, however, do not preclude the possibility that an upbringing under the influence of the Code of Jewish Law predisposes members of the ultra-orthodox community to develop OCD. There are, unfortunately, no data on the prevalence of OCD among ultra-orthodox compared  / Belief and Ritual

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with nonultra-orthodox Jews in the general population. Findings of epidemiological studies carried out in a broad range of cultures can now be compared, and additional differences between subcultures can be noted so that we can approach the question of the effect of an ultra-orthodox upbringing on the prevalence of OCD.4 Early psychiatric anthropologists, influenced by Freud’s observations on the link between toilet training and obsessionality, were interested in the possible link between cultural influences in upbringing and the subsequent development of psychopathology. For example, Weston LaBarre () observed, ‘‘The Chinese are as free from compulsiveness about time and performance as they are unobsessive in all the other spheres of life.’’ He concluded that OCD is far less common in China than in the West, where toilet training is more rigid. These speculations are not supported by the Taiwan Psychiatric Epidemiological Project, which found a lifetime prevalence of OCD in Taipei and local towns and villages of between . and . percent. A more recent study by Char-Nie Chen and colleagues () in Shatin, Hong Kong, found a lifetime prevalence rate of .–. percent for OCD. At the other extreme, Owen Berkeley-Hill () described what he termed ‘‘the anal-erotic factor in the religion, philosophy and character of the Hindus,’’ and A. Chackraborty () described Suchi-bai, a normative Indian ritual based on the fear of contamination and the desire to remain clean. Both authors noted the central role of washing and purity in Indian life and believed that normative states such as Suchi-bai include many sufferers from OCD. Since the s, there have been three studies that describe large samples of OCD in India (Akhtar et al., ; Dutta Ray, ; Khanna et al., ), and none suggests that the preoccupation with cleanliness and purity in Indian religious life is associated with a high rate of OCD. A reReligious Ritual and OCD / 

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cent epidemiological study in Bangalore found twelve cases with current OCD, giving a lifetime prevalence rate of . percent (Khanna et al., ). The findings in all these studies are remarkably similar, demonstrating that two societies, Chinese and Indian, considered to be at the opposite poles of obsessionality in their everyday lives, do not differ in the prevalence of OCD. To date, researchers have used an identical diagnostic instrument, known as the Diagnostic Interview Schedule, Version III, for studies in the United States, Canada, Puerto Rico, Germany, Taiwan, Korea, and New Zealand. The researchers collaborated on a joint study in which all the data on OCD were collected, and minor differences in age ranges were excluded to enable comparison of the rates of OCD in the seven locations (Weissman et al., ). The rates in Taiwan, . percent in the recalculation, were lower than in all the other centers, and the authors observed that the Taiwan study was conspicuous in having lower rates in most diagnoses. The lifetime prevalence rates in the remaining six locations were remarkably similar: . percent in the United States, . percent in Canada, . percent in Puerto Rico, . percent in Germany, . percent in Korea, and . percent in New Zealand. The Shatin study quoted above used the same instrument but only at a later phase of the research, after cases had been identified by a self-reporting screening questionnaire. An earlier study of two Ugandan villages by John Orley and John Wing () found obsessions in  percent of the women and . percent of the men. Using a structured interview based on DSM-III-R criteria, an epidemiological study in Israel of sixteen-to-seventeen-year-olds evaluated for army service found a point-prevalence rate of . percent for OCD (Zohar et al., ). The study was carried out in the center of Israel, where the proportion of ultra-orthodox Jews is smaller than in Jerusalem, and the variable of religious affiliation was not reported. In all these studies OCD emerges as a common disorder, with  / Belief and Ritual

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similar results in most centers. The Taiwan study found that the lifetime prevalence of OCD was . percent in the villages, . percent in the towns, and . percent in the city. The authors’ explanation of the urban-rural difference was that city life demands accuracy and punctuality, while village life is traditional, rural, and family-oriented (Hwu et al., , p. ). This explanation is reminiscent of the speculations of LaBarre, and it is not supported by the studies in Puerto Rico and Uganda, where a lifetime prevalence rate of . percent was noted in nonurban societies. The population of Taipei is likely to be more secular and the village population more religious; therefore, although religious commitment was not measured directly in the Taipei study, we can conclude that it was not associated with an increased prevalence of OCD. Studies in societies as different in their ritualistic practices as the Chinese and Indians suggest that religion may not be an influential variable, but the issue has not been specifically investigated (Greenberg and Witztum, a). In the data from our Jerusalem clinic, religious symptoms are prominent in OCD sufferers for whom religion is the dominant theme in their lives, although these patients also commonly have other, ‘‘secular’’ obsessive-compulsive symptoms as well. It is possible that patients with OCD who exhibit only religious symptoms would be less willing to recognize the pathological nature of their problem and to seek help from a psychiatric clinic, perceived as secular, and more likely to turn to a rabbi for such a purely religious problem. Although no research has specifically examined this factor, a review of the prevalence of OCD in a range of cultural settings does not implicate religious background as a causative factor in the development of OCD. We conclude, therefore, that religious symptoms of OCD are not a separate or unique presentation of OCD but merely the form OCD typically takes in patients for whom religious beliefs and practices predominate. Religious Ritual and OCD / 

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There is no evidence that religious settings encourage the development of these symptoms. The Talmud summarizes some of the conclusions of the last three chapters: It once happened in the presence of Rabbi Eliezer that a pupil who was leading the prayers was taking too long. The pupils complained, ‘‘Rabbi! How long he takes!’’ Rabbi Eliezer replied, ‘‘Is he taking longer than our teacher Moses, of whom it is written, ‘And I fell down before God for forty days and forty nights’?’’ (Deuteronomy :). On another occasion, in the presence of Rabbi Eliezer, a pupil who was leading the prayers was too fast. The pupils complained, ‘‘How fast he is!’’ Rabbi Eliezer replied, ‘‘Is he faster than our teacher Moses, of whom it is written [that he prayed for the well-being of his leprous sister, Miriam, with five words], ‘Please God, heal her now’?’’ (Numbers :). (Talmud Brachot a)

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Religion has no single message, no single influence. For some, it is a source of revelation and discovery, for others a body of law. For some, prayer is a fleeting moment in the day; for others it is a lengthy struggle to be correct and proper. Religion, said Rabbi Eliezer to his complaining pupils, is whatever we make of it, and we should beware of ascribing failings to it that may be our own.5

 / Belief and Ritual

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P III

     

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 The Baal Teshuva and Mental Health, or Why the Camel Changed His Burden, and How He Felt About It Shortly after the founding of the state of Israel in , Prime Minister David Ben-Gurion visited the religious authority of the ultra-orthodox community in Israel, Rabbi Avraham Yeshayahu Karelitz, known as the Hazon Ish.1 The Hazon Ish asked Ben-Gurion to exempt ultra-orthodox yeshiva students from army service. Ben-Gurion understood that the request stemmed not only from the ultra-orthodox credo that men were to immerse their lives in Torah study alone but also from an antagonistic attitude toward the values of the modern secular state. The Hazon Ish began with a parable: ‘‘There is a halakhah that if two camels meet in a narrow passageway, and one is carrying a load while the other is not, the camel without the load should give way to the loaded camel. We are carrying the burden of keeping the Torah and its commands, and you should give way to us.’’ ‘‘Is this camel carrying no burden?’’ protested Ben-Gurion, referring to himself and the secular population. ‘‘Is settling the land no burden? Security, protecting the land, and the heavy price of wars, these are no burdens?’’ The Hazon Ish replied, ‘‘It is only thanks to our study of the Torah that you can achieve all these things.’’ ‘‘Were it not for the Israel Defense Force,’’ retorted the prime minister, ‘‘the Arabs would have killed us all, both those studying the Torah, and those protecting them.’’ 

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Neither of these two highly intelligent communal leaders really thought that he could persuade the other. Ben-Gurion, founder of the Israel Defense Force, did not believe that Torah study protected the nation physically. The Hazon Ish did not believe that the army could protect the nation spiritually. Nonetheless, the Hazon Ish did not believe that the best thing to do when confronted by an armed gunman was study the Talmud, and similarly Ben-Gurion, a secular Jew but a serious Bible scholar, was concerned about what would happen to Jewish values and tradition in a secular state of Israel. In the middle of the twentieth century, the sociohistorical forces and trends in Israel and more generally in the West were leading to the erosion of the ultra-orthodox community. Many of those who had survived the Holocaust had abandoned religious tradition, encouraged by the socialist ethos of the Western world and the secular state of Israel. Within a few decades, however, the tide turned. Whereas in the s many young people rejected their religious upbringing, by the s large numbers of young people were returning to the religious practices of their parents and grandparents, becoming religious or even ultra-orthodox, and far fewer were leaving ultra-orthodoxy. A person who turns to ultra-orthodoxy after a secular upbringing is known as a baal teshuva, literally a ‘‘master of repentance.’’ This process of returning to traditional values is part of a worldwide phenomenon, including ‘‘born-again’’ Christianity and Islamic fundamentalism. Similarly, the new religious movements and cults that have emerged at the same time do not involve a reclamation of an earlier identity, but they all share a rejection of modern materialistic values, achievement, and personal pleasure–oriented goals, and an adoption of a more collectivistic life style (Schwartz, ). In the preceding chapters we looked at the psychiatric problems of the ultra-orthodox community to find evidence of a link  / Psychopathology and Religious Return

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between the community’s unique cultural features and the development of psychopathology among those who were born into an ultra-orthodox household, for whom religious values were normative from childhood. We shall now discuss the link between ultra-orthodox baalei teshuva and psychiatric disorder. As in the previous section, we shall first consider the normative aspects of the baal teshuva movement, particularly the underlying historical and sociological factors and the internal influences that can lead individuals to such a drastic change in position, from being the camel who protects the state and develops its economy to being the camel that bears ‘‘the yoke of the kingdom of heaven.’’ S I  R C

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The baal teshuva movement is considered to have undergone three main ‘‘waves,’’ each with a distinctive target population and social and historical influences (Aviad, ; Eisenstadt, ). The first followed the Arab-Israeli war of  (the SixDay War). During the weeks before the war, when military forces were gathering on Israel’s borders, Jewish youth around the world, but primarily in the United States, who had previously been indifferent to their Jewish identity and often minimally educated in Judaism, found their Jewishness awakened by their fears for the country’s future. This was followed by exhilaration at the success of the Six-Day War and Israel’s acquisition of traditional holy sites, such as the Temple Mount and the Western Wall. The combination of these events released a euphoria over the fulfillment of a two-thousand-year-old dream (since the destruction of the Temple by the Romans in  ..), mixed with messianic fervor. The second wave followed the Yom Kippur War of . Both wars were destabilizing: they threatened the existence of The Baal Teshuva and Mental Health / 

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the state of Israel, undermining its inhabitants’ sense of security. Unlike the  war, however, the  war was plagued by a serious failure in intelligence at the onset and subsequent heavy loss of life, catastrophes that precipitated a crisis in Israeli society, shattering the dream of absolute security and raising the possibility that armed conflicts would continue for the foreseeable future. If the  war encouraged the myth of the invincible Israeli soldier, the  war destroyed that myth. In , , Israeli soldiers died and , were wounded in a country whose total Jewish population was  million, losses that were a source of deep personal and national grief. Another casualty among the myths of modern Israel was that the genocide of the Holocaust and the pogroms would never happen again. Well-educated Israelis of East European origin, including wellknown figures from the world of entertainment, not only experienced dissatisfaction with the new Israel but sought an internal, more permanent security in the world of ultra-orthodox Judaism (Beit-Hallahmi, ).2 The third wave, beginning in the s, consisted of young Jews of Asian and African origin who lived in the disadvantaged neighborhoods of Israeli cities. Their own parents had been orthodox Jews but discarded their religious values in the s during their traumatic dislocation from their countries of origin. The religious change in the children of this generation can be interpreted as a reaction of disillusionment with the state of Israel as it was founded and developed by Jews of East European origin. All three waves challenged facets of Jewish identity, the first of the Jew in the Diaspora, the second of secular Israelis, and the third of disadvantaged ethnic Sephardim in Israel (Ben-Rafael, ). Despite some ebb and flow, the baal teshuva movement has maintained its momentum. In  there were approximately  / Psychopathology and Religious Return

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 baalei teshuva in Israel; by , according to the Ministry for Religious Affairs, there were ,. In  there were , men and women enrolled in special baal teshuva yeshivas; by  the number had risen to ,, and by  to ,. These figures represent the first year of study alone. There are no known data on the number who remain within the orthodox or ultra-orthodox community after becoming baalei teshuva and how many revert to their former secular existence, but it appears from the data that the movement continues to thrive. P F L  R C

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In his classic analysis of religious experience, William James ( []) observed that change is an integral part of daily life: ‘‘The President of the United States when, with paddle, gun, and fishing rod, he goes camping in the wilderness for a vacation, changes his system of ideas from top to bottom. The presidential anxieties have lapsed into the background entirely; the official habits are replaced by the habits of a son of nature, and those who knew the man only as the strenuous magistrate would not ‘know him for the same person’ if they saw him as the camper’’ (p. ). As described by James, the president moves between different identities; in one he may be decisive and active, in the other pensive and passive. Usually we can deal easily with our varied identities, appreciating each as an aspect of a single person. The president appreciates the tranquillity, isolation, and informality of the fisherman, while the fisherman admires the president’s hectic procession of planning and decision making. For some people, however, filling different roles can cause tension. The president may decide that fishing is too trivial a pastime for a man with such an important official role and resolve to schedule more staff meetings instead. Certain values and roles are rejected while others are allowed to dominate. ‘‘If now he The Baal Teshuva and Mental Health / 

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should never go back, and never again suffer political interests to gain dominion over him, he would be . . . a permanently transformed being. . . . Whenever one aim grows so stable as to expel definitively its previous rivals from the individual’s life, we tend to speak of the phenomenon, and perhaps to wonder at it, as a ‘transformation’ ’’ (pp. –). An individual who undergoes major changes in his life invariably relinquishes many of his former tastes, opinions, and pleasures. There are many paths that lead to change. Rising politically can lead to the presidency, progressing professionally may lead to managerial responsibility. Religious change can also be a progression and involves acts of choice and rejection, but it is motivated by a search for direction that can only be described as spiritual. The other features of life are viewed as nonspiritual, and the person undergoing change may find them increasingly uninvolving, unsatisfying, and, ultimately, unacceptable. Although the change can involve losing cherished aspects of one’s previous existence, James and later researchers have been impressed by the overall good feeling experienced by persons undergoing religious change: ‘‘Happiness! happiness! religion is only one of the ways in which men gain that gift. Easily, permanently, and successfully, it often transforms the most intolerable misery into the profoundest and most enduring happiness’’ (p. ). Seeking out a religious group can provide answers for many stressful dilemmas. Before conversion, baalei teshuva are often unhappy with the values of their society and with their own state of virtue and purpose (Beit-Hallahmi and Argyle, ). Religious groups bring communal membership and emphasize the overriding importance of the group over the individual. There is often a leader to whom followers are subservient. There is a code of spiritual values that is clear, authoritative, and divinely inspired.  / Psychopathology and Religious Return

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The abrupt change that baalei teshuva undergo may be at the expense of areas of their lives that were formerly sources of happiness, purpose, and support. The durability of the change can be influenced by a kind of cost-benefit analysis of these two factors: the loss of features of life that once were gratifying versus the alternative sources of happiness the change provides. Many of the issues presented here are analogous to the process of change among those who join new religious movements like the Church of Scientology, the Divine Light Mission, est, , and the Unification Church (Barker, ). What distinguishes the baal teshuva movement from these is that people are returning to a tradition that was their ancestors’, and they are joining a long-established society. The change is discontinuous with their previous life, but it reconnects them with a tradition that stretches back for millennia. The age of the tradition means that there is much for the initiate to learn, but the presence of a vital, close-knit community is an attractive and important part of the appeal to persons who experience themselves as outsiders.3 T B T Y: T   S S

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What began as a response to ‘‘religious outreach’’ by a few isolated individuals who returned to religious Judaism has become a movement with many institutions, styles of working, and types of appeal. As the numbers of would-be baalei teshuva increased, yeshivas were established to cater specifically to the needs of young people wishing to return to Jewish tradition. ‘‘For Reb Noah [one of the founders of the baal teshuva movement, and head of a leading baal teshuva yeshiva in Jerusalem], the baal teshuva yeshiva is where refugees from the folly, evil, and insanity of the Western world can be taught to transform them-

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selves, to return to truth, and thereby be restored to sanity’’ (Aviad, ). Set within an ultra-orthodox neighborhood, the baal teshuva yeshiva is always open to newcomers; in fact they are actively sought out at the Western Wall, at rallies or concerts, and at special weekends organized for seekers. The yeshiva is what sociologist Erving Goffman () called a ‘‘total institution,’’ providing lessons and facilities for study from early morning until late at night, as well as a dormitory where young arrivals are given a bed and meals. Students are not asked to pay; the only condition is that they wish to study. The courses are strictly religious: an introduction to the Talmud, Jewish moral values, and the Torah. The teachers stress the lack of morality in the secular world as seen in family life, individual values, and public practice. They encourage students to visit them in their homes to witness ultra-orthodox family life. Prayers are times for extra closeness to God, and the Sabbath and festivals are experiences of joy, celebrated with song and dance. In many respects, the baal teshuva yeshiva seems an idyllic retreat from the world, a place to heal the scars of civilization.4 However, it can also be seen as a no-man’s-land between the secular and ultra-orthodox worlds. Baalei teshuva differ from students at regular ultra-orthodox yeshivas in several ways: . Baalei teshuva are novices in religious study. In contrast to their contemporaries, who were reared ultra-orthodox from birth, baalei teshuva must be introduced to the texts and commentaries of Judaism, and they must be taught the basics of how to pray, keep the dietary laws, and observe the Sabbath. A baal teshuva from outside Israel may even need to be taught Hebrew. One-to-one teaching is often provided to help students. . The baalei teshuva’s secular educational background and the fact that their turn to ultra-orthodoxy followed a quest for religious values may lead the teacher to refer to features of secu / Psychopathology and Religious Return

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lar life and values and to try to deal with philosophical questions not normally raised within a regular yeshiva. . Those reared ultra-orthodox tend to be suspicious of baalei teshuva. They wonder whether the newcomers are stable. If they were secular yesterday and are religious today, what will they be tomorrow? Do they retain some of their old ways, have they resolved their questions? If I study with a baal teshuva, will I be exposed to dangerous influences? . That baalei teshuva remain as outsiders within the ultraorthodox community is particularly apparent when we consider their marriage prospects. These are poor, not only because parents fear the baal teshuva’s potential instability. An important value of ultra-orthodox life is yichus, genealogy. A candidate for marriage who is the son or grandson or even great-grandson of a revered rabbi is considered a good match. Baalei teshuva are at the bottom of the yichus ladder. A man may be referred to as ‘‘ben-niddah,’’ the son of a mother who did not keep the laws of menstrual purity. A woman may be considered ‘‘used goods.’’ For these reasons, baalei teshuva not only study together but often marry one another. The Rosh Yeshiva at a male yeshiva or his wife often maintains close contacts with similar institutions for female baalei teshuva in order to arrange matches between the students. They may see this as a sealing of the process of change, in which the couple will now settle down to a life in which the husband studies the Talmud and the wife works and looks after their growing family. The baal teshuva yeshiva, then, is a world between worlds.5 It caters to the needs of the seeker and is also more evangelical than a regular yeshiva, deliberately making itself more visible for these purposes. Its members have undergone a change in order to join a society that nevertheless regards them as outsiders to a certain extent.

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B T V Z: T C  E Ultra-orthodox Jews believe that their ‘‘camel’’ has the right of way because its load, the Torah, is of absolute and permanent value. Nevertheless, most ultra-orthodox Jews consider their task to be to strengthen their own community, not to teach baalei teshuva or convince and convert the uncommitted. Further, as we have noted, those born ultra-orthodox tend to be suspicious of baalei teshuva. The seeds of this suspicion are apparent in a debate on the relative status of the baal teshuva and the zaddik in the Talmud: ‘‘Rabbi Abahu said, ‘At the level where stand baalei teshuva, even the completely righteous cannot stand.’ This is supported by the verse, ‘Peace, peace to far and near’ (Isaiah :).’’ According to Rabbi Abahu, ‘‘far’’ and ‘‘near’’ are to be measured by the distance one has traveled to become close to God and thereby merit peace. The baal teshuva has come a long way, but the zaddik grew up in religious and moral surroundings. Thus the baal teshuva takes precedence. Maimonides also placed his authority on this side of the discussion: ‘‘The reward of the baal teshuva is great—for he has tasted sin, pushed it aside and overcome his evil inclination. His level is greater than that of the Zaddik as the latter has never sinned, while the former has succeeded in overcoming his evil inclination’’ (Laws of Repentance :). But Rabbi Yohanan disagreed: ‘‘What does the first term far mean? It means the one who was originally far from sinning (the Zaddik), while the second term near means the one who was originally near to sinning (the baal teshuva)’’ (Talmud Brachot b). The status of the baal teshuva can be viewed from these opposing vantage points. The accepted opinion is that of Rabbi Abahu and Maimonides, which holds that the baal teshuva is more rewarded by virtue of having overcome temptations that  / Psychopathology and Religious Return

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others have not experienced. To overcome recidivist tendencies is a greater achievement in baalei teshuva. They do not have the background of habit that helps those who were religious from birth, and, unless a baal teshuva is strong, the very intensity that led him to search for a new path and take it up may allow him to be overcome by moments of doubt during the process of religious change. Rabbi Adin Steinsaltz (), one of the foremost thinkers in the orthodox community in Israel offered the following observations in a sensitive guide to the baal teshuva: Spiritual crises befall every observant Jew; they are certainly not unique to the baal teshuva, but he is especially sensitive to them, and their effects are likely to be much greater on him than on one who has lived a whole life in a religious framework. The baal teshuva, more than others, is involved in an ongoing process of change that makes his life situation inherently unstable and vulnerable to shock. . . . Suddenly one falls into utter degradation and shame. This feeling of shame does not spring from piety alone, and the end result is revulsion, weariness, and despair. This is what the righteous of various generations meant when they said that even the worst transgression is not as bad as the dejection it leads to. (pp. , )

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Baalei teshuva should expect moments of doubt during their voyage of change, and their emotional reaction can at times be disproportionate. Mood swings can be marked, from elation over the sense of spiritual progress to depression over doubt and the fear of slipping back. Such tendencies could lead a therapist to predict that significant problems might arise that would require professional psychiatric intervention. The Baal Teshuva and Mental Health / 

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R C  P D Changing one’s main values and rejecting many features of one’s previous life; turning from professional studies or progress to study in a yeshiva from morning to night; no longer dating (and sleeping with) women but fraternizing only with other men until a matrimonial match is arranged; forswearing literature, newspapers, television, theater, movies, pubs, and discos, in order to study Talmud, sing at the Sabbath table, and dance at weddings—do such drastic changes not imply serious instability and psychopathology? Saul of Tarsus was a Pharisee who persecuted the followers of Jesus, until, on the road to Damascus, ‘‘at midday, I saw in the way a light from heaven. . . . And when we were fallen to earth, I heard a voice speaking to me, and saying, ‘Saul, Saul, why persecutest thou me?’ ’’ . . . ‘‘Festus said with a loud voice, ‘Paul, thou art beside thyself; much learning doth make thee mad.’ But he said, ‘I am not mad, most noble Festus; but speak forth the words of truth and soberness’ ’’ (Acts, :–, – ). Overcome by his experience, Saul converted to the new religion, renaming himself Paul, and began prosletyzing. Since the dramatic conversion of Saul of Tarsus, much has been written about the psychological aspects of religious change. The New Testament text shows the central role of revelation as Paul’s motivation for change. Paul saw a light and heard a voice that showed him the way. Festus, the outsider, suggested to Paul that he was following the voices of madness. Distinguishing religious inspiration from mental disorder is particularly difficult in Paul’s case: moments before his change, Paul had been even more of an outsider and critic than his skeptical friend Festus. Janet Aviad () questioned  baal teshuva yeshiva students in Jerusalem about their conversion experiences. Sixtythree percent reported having had a religious experience, in / Psychopathology and Religious Return

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cluding a vision, which most interpreted as divine revelation. They described a sense of dissatisfaction with the values of their society before they became religious and, in most cases, they reported a developing interest in religion. Yet despite this gradual growth in interest, most of them experienced a specific moment of teshuva (repentance), after which they felt a greater harmony between their values and their actions, a greater sense of commitment and belonging. Until the rise of cults in Western society, religious conversion was a relatively neglected subject of study. Although the psychology of religion, particularly conversion, has excited attention for more than a century (Starbuck, ; James,  []; Coe, ; Leuba, ; de Sanctis, ), the association with psychopathology was restricted to a few case reports of psychotherapeutic treatment. Whereas the researchers, respected psychiatrists, claimed to be seeking the universal psychological processes that underlay conversion, the source of their material reflected the belief of the times in which they lived that conversion was a pathological behavior. In a case involving a young doctor who underwent a religious conversion after seeing the body of an old woman on a dissecting table, Freud ( []) considered oedipal jealousy and anger to be central issues, while Leon Salzman () concluded from a study of four patients that hatred, resentment, and hostile, destructive attitudes were important prerequisites to conversion. Since the s the climate has changed. The ‘‘counterculture’’ that developed in the West included many cults (Roszak, ). Research into their methods and influence was often prompted by the clamor of parents of cult members, who believed that their children had been psychologically kidnapped and brainwashed (Shapiro, ; Clark, ). They suspected that once a person joined a cult, he or she would be unable

The Baal Teshuva and Mental Health / 

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to leave, even if he or she were unhappy with his or her new identity. Researchers sought to validate or disprove these claims. Systematic research of the members of the Unification Church (Galanter et al., ) and other cults (Levine and Salter, ; Ullmann, ) has found that – percent of the converts had sought professional psychological help before their change. As we have noted, studies of psychological well-being following conversion have generally reported beneficial effects. Thus in a study of theology students, converts were found to be more stable than students who were not (Stanley, ); Michael Ross () found no evidence of psychopathology among the members of the Hare Krishna temple in Melbourne, Australia; a survey of , respondents to a questionnaire in Redbook, a popular American women’s magazine, found that those who had undergone a religious conversion were more content than those who had not (Shaver et al., ). In a wide-ranging review of research, Bergin () concluded that conversion ‘‘significantly reduces pathological symptoms,’’ and that converts are ‘‘as functional as or better off than non-converts,’’ supporting the view of William James ( []), who described conversion as ‘‘the process, gradual or sudden, by which a self hitherto divided and consciously wrong, inferior and unhappy, becomes united and consciously right, superior and happy’’ (p. ). Thus studies of populations who had undergone religious change (rather than populations of converts in therapy) generally concur that conversion brings relief to the unhappy. The change is often sudden and accompanied by an experience of the divine. The extent to which these findings can be extrapolated to the members of baal teshuva yeshivas is not known. The next three chapters will present findings based on baalei teshuva referred to our community mental health center. The location of the study means that it will necessarily emphasize psychopathology, and the findings should not be used to support conclusions about  / Psychopathology and Religious Return

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the risks of conversion. They are not presented as typical of the process of religious change, but they do depict problems for the community and the mental health worker that should not be ignored.

 Mental Illness and Religious Change: The Chicken or the Egg Let us begin with another parable.

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One day, Rabbi Yohanan, who was renowned for his beauty, was swimming in the River Jordan. Resh Lakish, a very powerful man who at that time was a robber, dived into the Jordan after him. Rabbi Yohanan said to him, ‘‘Your strength belongs to Torah.’’ Resh Lakish said to him, ‘‘Your beauty belongs to women.’’ Said Rabbi Yohanan, ‘‘If you come back to Torah, I will give you my sister who is more beautiful than me.’’ Resh Lakish agreed, and, as he tried to jump back to the side of the river, found he was unable to jump, as he had lost his strength after accepting the yoke of Torah. Mental Illness and Religious Change / 

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Rabbi Yohanan taught him Torah and Mishnah and he became a great rabbi. One day they were disputing the following matter together in the Academy: ‘‘When can the sword, the knife, the dagger, the spear, and the scythe become capable of becoming impure? From the moment they are completely manufactured. And when are they completely manufactured and therefore fit for use? Rabbi Yohanan said, ‘‘When they have been smelted in the furnace.’’ Resh Lakish said, ‘‘When they have been polished in water.’’ Said Rabbi Yohanan, ‘‘It takes a robber to know the instruments of thieving!’’ Resh Lakish was deeply hurt by this insult, and said, ‘‘If I have not changed at all, then why did you bother bring me back to Torah? I was called Master (Rabbi) among robbers, as I am called Rabbi here.’’ Said Rabbi Yohanan, ‘‘I did it to bring you near to God.’’ Rabbi Yohanan became upset by his lack of gratitude, and they became estranged. Resh Lakish became dangerously ill. His wife, Rabbi Yohanan’s sister, came crying to her brother. She said, ‘‘Pray for him for my children’s sake.’’ He refused. ‘‘Do it so that I, your sister, won’t be a widow.’’ He refused. Resh Lakish died. Rabbi Yohanan was very distraught at the loss and at what he had caused. The Rabbis said, ‘‘Who can we send to learn with him who will settle his

 / Psychopathology and Religious Return

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mind? Let Elazar ben Parat do it, for his knowledge of Halakhah is incisive.’’ Elazar went and sat before Rabbi Yohanan, and every idea that Rabbi Yohanan expressed, Elazar told him of a source that supported it. Rabbi Yohanan said to him, ‘‘Do you think to replace Resh Lakish? For every opinion I would express, he would raise twenty-four logical objections, and I would have to find twenty-four explanations, and by this process did we arrive at the Halakhah. And you tell me there is a supporting source? As if I am not aware that it is a good idea! I don’t want support! It is his creative criticism that I miss.’’ He would walk about in torn clothes, sobbing, ‘‘Where are you, Resh Lakish, where are you, Resh Lakish?’’ He cried in this way until he lost his mind, and the Rabbis asked for him to be relieved, and he died. (Talmud Baba Metzia a)

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This astonishing story in the Talmud tells of the intensely close relationship between two great minds, one man renowned for his beauty, one for his strength. Resh Lakish was a baal teshuva. Although he became one of the leading teachers and religious thinkers of his generation, he retained the sensibility of a baal teshuva. When his teacher and friend dropped a single disparaging remark implying that he still retained traces of his former self, he felt that he had no place that was truly his home: among robbers he was a rabbi, among rabbis he was a robber. Once he lost the closeness of his friendship with his teacher, he became melancholic and died. But the story is not just about a baal teshuva, for two figures die of sorrow. In the close yet complicated relationship that developed, each was attracted by underdeveloped aspects of his Mental Illness and Religious Change / 

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own personality that he found in the other. Yet they were ambivalent about these characteristics, and ultimately denied them, resulting in their deaths. Nevertheless, our romantic imagination is stirred by the athletic robber, a powerful man and lover of beauty, who then converted all his physical energy into finding twenty-four points for discussion in every debate of Halakhah. Yet beneath that torrent was an insecure man, who felt that he was living a charade. ‘‘They said of Resh Lakish that he never again smiled with his whole face after he heard his teacher Rabbi Yohanan state that ‘It is forbidden to smile with a full face in this world’ ’’ (Talmud Brachot a). The words of his teacher guided and gave purpose to Resh Lakish’s actions and his feelings. When he felt he had lost the admiration of that teacher, he withdrew, and his beautiful wife watched helplessly as he pined away and died. Is the baal teshuva at home nowhere? Is his emotional equilibrium more fragile than that of the ultra-orthodox or secular person who follows until death the course he inherited at birth? From many years of clinical work, we formed the impression that the number of referrals who mentioned during their screening interview that they were baalei teshuva was larger than their likely proportion in the general community. We decided to test this hypothesis by analyzing referrals in the course of a single year. In spite of the serious limitations in a study carried out among psychiatric outpatients rather than in the general community, we hoped to find answers to the following questions:

. Is mental illness more common among baalei teshuva? . Is there a relationship between the process of religious change and the onset of mental illness? . Are there specific psychiatric conditions associated with

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religious change?

 / Psychopathology and Religious Return

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The catchment area of the community mental health center (CMHC) of north Jerusalem includes nearly all the major academies of study for baalei teshuva, particularly those who joined during the ‘‘third wave.’’ The study included all new patients between the ages of eighteen and sixty-five who first attended the clinic during the course of one year, –, and who specifically identified themselves as baalei teshuva. The therapists who carried out the initial interview were asked to complete a questionnaire on every new patient, including age, sex, marital status, ethnic origin, religious background, and, if appropriate, duration of religious change. In addition, patients were asked whether they had had previous psychiatric problems and treatment and if so, when. The new referrals to the clinic during the period of the study who did not describe themselves as baalei teshuva were included in a control group. Diagnosis of all the new referrals was based on the initial assessment interview and summaries of previous and subsequent treatment, if any. The diagnosis was confirmed by the authors according to the current classification manual at the time of the survey, the DSM-III. Of the  new referrals who came to the center during the year of the survey,  were identified as baalei teshuva (. percent of the total clinic sample). Fifty-seven ( percent) of the baalei teshuva were male, compared with  percent of the nonbaalei teshuva. In her study of  students at baal teshuva yeshivas, Janet Aviad () found that  percent were male. A more recent study at our center in – found that  referrals over a fifteen-month period were baalei teshuva (. percent of the total clinic sample), and  percent of these were male (Buchbinder et al., ). Ministry of Religious Affairs figures for that year, , reported that  percent of those in their first year at a yeshiva for baalei teshuva were male.

Mental Illness and Religious Change / 

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The baalei teshuva in the clinic sample averaged . years in age, with a range of  to  years; the average age of the other clinic attenders was . years and the age range – years. Thus the baalei teshuva referrals were significantly younger than other clinic attenders. Aviad’s () study of baalei teshuva attending yeshiva found an average age of  years. The marital status of the baalei teshuva was very similar to that of the control group: a little less than a third of each group were single, a little less than two-thirds were married, and the remainder were divorced or separated. This finding is in contrast with Aviad’s study of baalei teshuva, in which  percent were single. The duration of religious change in our sample ranged from  to  years (average . years). Comparison of the characteristics of the clinic sample and Aviad’s sample suggests that yeshivas for baalei teshuva house young single men who have only recently undergone religious change, whereas the baalei teshuva clinic attenders are older, having been religious for a longer time, and are more likely to be married. Table  shows the psychiatric diagnosis of the sample. Baalei teshuva differed significantly from the other clinic attenders in the distribution of diagnoses. More than  percent of the baalei teshuva presented with schizophrenia, usually with a severe clinical picture of florid symptomatology and marked social disintegration. A further  percent had affective disorders such as depression and bipolar disorder (manic depression); marked psychiatric pathology was thus present in a little under half the sample of baalei teshuva clinic attenders. Most of the remainder presented with long-standing instability in social ties and employment and fulfilled DSM-III criteria for personality disorder. In these cases, as with the schizophrenics, the problem was severe, with behavioral problems in  / Psychopathology and Religious Return

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Table  Psychiatric Diagnosis of Baalei Teshuva and Other Clinic Attenders     () 

N

Schizophrenia and paranoid disorders Bipolar affective disorder Major depressive and dysthymic disorder Anxiety, phobia, obsessive-compulsive Personality disorders Adjustment disorders Other conditions Total

-



N



 

. .

 

. .



.



.

   * 

. . . . .

    ** 

. . . . 

* Includes neurological and other disorders: ; addictive disorders: . ** Includes neurological and other disorders: ; addictive disorders: ; no diagnosis: ; inadequate information: .

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the personal and social spheres that affected their ability to stay in yeshiva. At the time of this survey, –, there were an estimated , baalei teshuva in Israel, approximately . percent of the total adult Jewish population. As noted, the concentration in our area is likely to be higher. Nonetheless, even if the majority of the entire country’s baalei teshuva population elected to live in the quarter of Jerusalem served by the center, its proportion of the local population would be only  percent. The finding that . percent of the referrals to the clinic were baalei teshuva suggests that they present to the CMHC far more commonly than would be expected. The predominance of severe psychopathology, such as schizophrenia and affective disorders, among baalei teshuva and the Mental Illness and Religious Change / 

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relatively few cases of mild conditions, such as adjustment disorders and neurotic disorders, may be explained by the likelihood that baalei teshuva with milder problems will turn to their rabbi rather than to a CMHC. This implies that only a select group, consisting of those who were more seriously ill, come for help. Reconsidering the data for schizophrenia, manic depression, and major affective disorders alone, it appears that  out of  referrals with these serious psychiatric disorders (. percent) were baalei teshuva. The data suggest that mental illness is more common among baalei teshuva than among other referrals. However, the lack of definitive data on the numbers of baalei teshuva in our area limits the conclusions that can be drawn, as does the fact that our sample was a clinical one. An example of a referral with a personality disorder is Noam, a thirty-four-year-old unmarried yeshiva student who had been a baal teshuva for one year. The fifth of twelve children of Yemenite parents, he was raised in poverty and left home at an early age after he was repeatedly caught stealing from his mother. He then passed through a series of institutions—a religious school, a kibbutz, and several boarding schools—without staying long in any one place. He described himself as an energetic youth, continually seeking fresh stimuli. When he was called up for army service at the age of eighteen, he served as a driver but was punished for repeated desertions, thefts, and breaches of discipline and was frequently imprisoned. Following army discharge, Noam roamed the Sinai Desert, spending long periods wandering near Nueba, part of the commune of drifters who frequented that area, smoking hashish and having casual sex. In an attempt to discover a purpose in life, he became a baal teshuva. Initially Noam was exhilarated by the change. The yeshiva reminded him of commune life, and the intensity and energy of the other students reminded him of drug  / Psychopathology and Religious Return

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highs, but these highs were not followed by lows, and he was deeply impressed by the inner calm of the teachers. For a period, his ennui was but a memory. Yet a year later he was again overcome by feelings of inner emptiness, associated with restlessness and anorexia. When we examined him, Noam was fully oriented, spoke voluminously, and seemed keen on impressing us with the severity of his problem. He did not appear to be depressed, nor did he exhibit psychotic features. Despite his declared wish for help in finding purpose in life, he had difficulty coming for a further assessment because he was unable to get up in the mornings, erratic in his timekeeping, and reluctant to commit himself. After keeping one appointment, he missed the next three, and his therapy was terminated. Anton Boisen () a founding father of pastoral counseling in the United States who himself underwent a deep religious experience during an episode of mental illness, observed that men of religion tend to note the healthy and anxiety-relieving effects of religious change while mental health workers emphasize the pathological nature of the process. This discrepancy reflects the viewpoints and the referral sources of both groups. Our present study, emerging as it does from a community mental health center, inevitably emphasizes pathology.1 Of the seventy-one baalei teshuva in the sample, forty-seven ( percent) were psychiatrically unwell before their religious change, and eighteen (. percent) became unwell after it; in only six patients (. percent) did the two processes appear to coincide, according to the account obtained from the patient and other informants. This distribution varied according to diagnosis. Of the twenty schizophrenics, eleven were unwell before, six became unwell after, and three became psychotic at the same time as their religious change. Of the thirteen depressives, seven were depressed before the change and six became Mental Illness and Religious Change / 

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depressed after; in no patients did religious change and the onset of depression coincide. Of the twenty-seven referrals with personality disorders, a lifelong condition usually apparent during the course of adolescence, twenty-three had significant difficulties previous to religious change. The baalei teshuva referrals came for psychiatric help an average of five years after their religious change. It would appear, therefore, that most of the sample were not seriously mentally ill at the time of, or in the first years after, their religious change. Some authors have suggested that entering a society with a ‘‘repressive religious ethic’’ induces mental illness (GoshenGottstein, ). If this were so, we could expect to find high rates of mental illness among the ultra-orthodox as a whole. Yet preliminary data suggest that ultra-orthodox Jews are underrepresented in the clinic sample, although this could be a result of their avoidance of public, nonreligious clinics. There are no data to suggest increased rates of mental illness among ultraorthodox Jews. Alternatively, although growing up ultra-orthodox may not predispose a person to psychological disturbance, it is possible that entering ultra-orthodox life at a later stage does. However, only a quarter of the sample developed their disturbance subsequent to becoming ultra-orthodox. The proportion of baalei teshuva who developed their disturbance subsequent to becoming ultra-orthodox relative to the nonbaalei teshuva referrals is :. This relation must be close to the proportion of baalei teshuva in the local general population, suggesting that the data do not support the claim that religious repentance produced psychological disorder. Another possible hypothesis is that the initial effect of religious change is to diminish preexisting psychopathology (Witztum et al., ). It is not until the exhilaration of change fades and the baal teshuva becomes affiliated with a supportive group  / Psychopathology and Religious Return

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and subsequently marries that psychological problems reemerge (Kiev and Francis, ). Although it has been reported that religious change can produce a change in sexual identification in homosexuals (Pattison and Pattison, ) and can have beneficial effects in criminal offenders with severe personality disorders (Cromer, ), the long-term benefits and recidivism rates of religious change have still to be researched. Unlike studies on religious conversion from Western countries (Roberts, ; Meadow and Kahoe, ),2 religious change in this sample in Israel was not a phenomenon of adolescence but in most cases occurred in the third decade of life, following army service. Army service is an inevitable companion to adolescence in Israel, and it undoubtedly has a significant effect on the process of teenage development. Most youngsters have to defer experimenting with their lives until after army discharge. It is possible, however, that those who undergo religious change during adolescence are enacting a normal feature of the search for identity associated with that period of life, while those who wait until their twenties are trying to resolve more pathological long-standing conflicts. As we have noted, the finding that baalei teshuva tend to present with severe and enduring pathology may be explained by the fact that affiliation to ultra-orthodox Judaism usually means skepticism and rejection of psychology; the CMHC will be avoided unless absolutely necessary. Thus the proportion of the clinic population suffering from various conditions may reflect community attitudes toward the service rather than the range of pathology present in the community. An alternative explanation is that the group of individuals who have elected to make a radical change in their beliefs and way of life contains a large number of people who have been unstable for many years and turn to ultra-orthodox Judaism in order to find tranquillity. Once the glow of conversion has Mental Illness and Religious Change / 

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abated, chronic problems reemerge. This explanation implies that religious change has the capacity to temporarily diminish or even defer the onset of severe pathology. Studies contrasting large populations of those who have and have not undergone religious change and identifying the age they experienced onset of mental illness would be needed in order to answer this intriguing question. The findings in our study appear to contradict the conclusions of the survey of Allen Bergin (): the rate of mental illness among baalei teshuva is higher than expected. Although the initial effects of a change to orthodox Judaism may have been positive, in subsequent years the sample experienced the onset or recurrence of severe mental illness. A possible explanation is that the ultra-orthodox community is concerned with helping the physically and mentally ill. Friends will find financial help for mentally ill baalei teshuva, and their institutions for religious study will often ensure they receive treatment and will continue to care for them long after they have ceased to be able to study. The psychotic baal teshuva remains within the ultra-orthodox community. In contrast, many cults may well attract unstable devotees, but the small size of the group and the high demands on participants may mean that followers whose functioning deteriorates are excluded before serious pathology emerges (Bird and Reimer, ). Similarly, studies of psychological disturbance and religious change in student populations do not include people who are currently ill and have dropped out of their studies. As James and Bergin both emphasized, religious change is a positive experience for most people. Nevertheless, the results of our survey indicate that a disproportionately large number of persons attracted to ultra-orthodox Judaism have suffered previous psychiatric disturbance. Initially, religious change brings

 / Psychopathology and Religious Return

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tranquillity and stability into their lives, but they go on to redevelop serious psychiatric disorders.

 ‘‘A Very Narrow Bridge’’                                                   

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To an outsider, the world of ultra-orthodox Judaism appears monochromatic. Every day is programmed according to a single rule book, and every ultra-orthodox Jewish man looks like every other: black hat, beard and sidecurls, long black coat. Such a perception of sameness is the view of outsiders, who inevitably think that their own way is independent and varied. For those on the inside, however, the ultra-orthodox community is not a single unit. There is, first of all, a basic ethnic division between Jews of Eastern Europe origin, who are known as Ashkenazim, and those from Africa and Asia, who are known as Sephardim. Each group has distinctive customs, prayers, and even some festive days. Ashkenazi Jewry can be divided into Lithuanian and hasidic, and hasidic Judaism is further divided into a number of groups, most of them named after the towns where they were founded, such as Ger, Belz, and Lubavitch. Each group has a rebbe (or zaddik), who is both a religious leader and an individual spiritual mentor, and each has distinctive elements Baalei Teshuva in a Fringe Hasidic Group / 

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of dress and festive ritual (Levy, ). In many cases, previous rebbes have left written works of spiritual guidance, which invest the practices and celebrations of the followers with unique qualities. Similarly, although the outsider may perceive every feature of ultra-orthodox life as separatist and extreme, the ultra-orthodox community is composed of many groups with a spectrum of attitudes and behaviors, some more and some less involved with secular life, politics, and trade. In this chapter, we focus on a number of referrals to the clinic who were members of the group known as Bratslav hasidim (Witztum et al., ). Bratslav hasidim are viewed by many ultra-orthodox as extreme, separate, and strange in their customs; it has been our experience that ultra-orthodox families tend to react with alarm if a son or daughter is attracted to this group. The Bratslav hasidim who were interviewed described practices that were unfamiliar to us, whether because of our ignorance or their eccentricity or both. It was necessary for us to become acquainted with the behavior and values of the sect in order to distinguish between culturally normal and abnormal symptomatology. This led us to a study of the life and teachings of the founder of the sect, Rabbi Nahman of Bratslav. B H  R N

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The emergence of hasidism (from hasid: literally, pious) among the Jewish communities of Eastern Europe has been linked to the pogroms of Bogdan Chmielniki (–), which killed or forcibly converted half a million Jews, to the continuing attacks of the Haidamacks throughout the eighteenth century, culminating in the massacre at Uman in , and to the unfulfilled messianic hopes ignited by Shabbetai Zevi (–)  / Psychopathology and Religious Return

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and Jacob Frank (–). Poland-Lithuania was breaking up and unable to protect its Jewish inhabitants, while the communities were struggling with rampant antisemitism, which led to killings and litigations (Dubnow, ). An alternative view of the foundations of hasidism has been proposed recently by Moshe Rosman (), whose historical studies have revealed that there were many holy men known as baalei shem during that period; the movement and its components represented no more than a moderate change. Founded by Rabbi Israel Baal Shem Tov (‘‘the Master of the Good Name,’’ –), hasidism brought a message of comfort and hope, declaring that closeness to God was not the privilege of the learned but that everyone was capable of spiritual greatness. Within a generation, thousands of Jews in Poland and the surrounding areas had joined the movement. Spiritual leaders emerged and became the founders of dynasties, many of which have retained their following to this day. One such hasidic group was founded by Rabbi Nahman of Bratslav (–), a great-grandson of Rabbi Israel Baal Shem Tov (Green, ). Followers were attracted to Rabbi Nahman during his teenage years, and he had amassed several hundred by the time of his death. Rabbi Nahman was prone to bouts of depression, struggles over faith, and sexual conflicts. Yet he urged his followers to shun despair and be joyous. Although he never considered himself the Messiah, he claimed that the Messiah would be of his stock. In contrast to many other zaddikim, he lived an ascetic life and spent periods abstaining from food and sex. He frequently visited the graves of zaddikim to communicate with the souls of Rabbi Israel Baal Shem Tov and Rabbi Shimon bar Yohai, a second-century leader who is traditionally considered the founder of Jewish mysticism. The atmosphere of his court was serious and produced many beautiful devotional melodies. Baalei Teshuva in a Fringe Hasidic Group / 

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Rabbi Nahman’s repeated condemnation of ‘‘false’’ zaddikim and his contention that he was the zaddik of his generation and the reincarnation of Moses, Rabbi Shimon bar Yohai, and Rabbi Israel Baal Shem Tov did not endear him to other hasidic leaders. He and his followers were often harassed by other Jews. At certain times Rabbi Nahman became very excited about the imminent arrival of the Messiah and hinted that his own daughter would give birth to him. Rabbi Nahman died of tuberculosis after a long and debilitating illness. His grave in Uman, Ukraine, remains the focus of pilgrimages by Bratslav hasidim. Unlike other hasidic movements, Bratslav hasidim did not choose a successor to Rabbi Nahman; thus they are sometimes called the ‘‘dead hasidim.’’ A disciple named Nathan published and disseminated his master’s writings. The principal work is Likkutei Moharan (The collected writings of our rabbi and teacher Rabbi Nahman). Today, Bratslav hasidim number several thousand and flourish particularly in New York and Israel. Their international center is located in Mea Shearim, the oldest ultra-orthodox section of Jerusalem. With the ‘‘third wave’’ of baalei teshuva since the s, there has been a reemergence of Bratslav hasidism. People who have been through adversity, with histories of prison and drug abuse, are particularly attracted to the figure of Rabbi Nahman, his writings, and the customs of his group. These converts have been welcomed in yeshivas for baalei teshuva set up by members of Bratslav hasidism, themselves often new to the group (Greenbaum, ). Rabbi Nahman stressed that the world is a gloomy, threatening place within which one strives to live by faith in the deity and in the zaddikim: ‘‘The entire world is a very narrow bridge; the main thing is to have no fear.’’ The material world and the physical nature of human beings are to be despised inasmuch as they threaten to engulf our spiritual aspirations. However, solace and encouragement are provided by niggun (melodies),  / Psychopathology and Religious Return

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dance, communion with zaddikim, and prayer. To be joyous is considered a divine obligation. The major sins inveighed against are sexual, particularly masturbation; Rabbi Nahman compiled penitential prayers (hattikkun hakkelali) specifically to rectify sexual sins. He regarded rational thought as suspect and vigorously denounced secular studies. For Rabbi Nahman prayer and repentance healed all ills; his view of doctors was low: ‘‘The angel of death cannot do all the killing himself, so he appoints agents in each locality. These agents are the physicians.’’ Rabbi Nahman took seriously the forces of darkness, sometimes clothed in the guise of mortals, that threaten to overwhelm and destroy. He himself acted as a confessor to his followers and repented on their behalf. Reflecting Rabbi Nahman’s sense of sinfulness, Bratslav hasidism is concerned with awareness of sins and repentance. Bratslav hasidism is especially known for espousing simple, direct, cathartic dialogue with the Creator, often taking place in the isolation of forests or mountains. Bratslav hasidim can spend several nights praying at the gravesites of zaddikim. They also have an unusual tolerance for bizarre behavior. They can equally enthusiastically join in exuberant dance and song and accept open displays of despair. The most unconventional behavior is not censured but is seen as an expression of the person. Until the recent upsurge in fervor among Lubavitch hasidim (see Chapter ), Bratslav hasidism was the most overt of all hasidic sects in its messianic claims. A C S

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During the year –, nineteen male Bratslav hasidim were referred to the community mental health center, comprising . percent of all new male referrals. Since it is estimated that fewer than . percent of the total adult male population of the catchBaalei Teshuva in a Fringe Hasidic Group / 

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ment area are Bratslav hasidim, this group therefore represented six times more referrals than would be expected statistically.1 Using the criteria of DSM-III, fourteen were diagnosed as having paranoid schizophrenia; one, undifferentiated schizophrenia; one, schizoaffective disorder; and two, personality disorder; in one case the diagnosis was unclear. Thus schizophrenia was diagnosed in  percent of this small sample, in contrast to  percent of all new referrals to the clinic. This is more than five times the number of other clinic referrals and thirty times greater than their proportion in the general male population. The absence of neurotic disorders in the Bratslav sample, on the other hand, is likely to be a consequence of their mistrust of the medical profession and their tendency to turn to their rabbis and the community for help. A noteworthy finding is the dominance of the paranoid subtype among our schizophrenic subjects ( percent of the sample). Cross-cultural studies of schizophrenia report that the paranoid subtype is the most common, but it does not usually exceed one-third of most samples of schizophrenics (Sartorius et al., ). Of the nineteen cases, fifteen were baalei teshuva and three were born to religious families but had only later joined Bratslav hasidism; only one was born a Bratslav hasid. Men exposed to Bratslav hasidism from birth were not overrepresented in the total clinic sample; it is thus not the effect of Bratslav hasidism per se that is being described but its appeal to non-Bratslav hasidim. Fifteen of the nineteen cases were of Sephardic origin, although, as we have mentioned, hasidism originally emerged in Ashkenazi East Europe, and the town of Bratslav is in the Ukraine. The sample averaged twenty-seven years of age (ranging from seventeen to forty). Four were single, thirteen married, and two separated or divorced. Four of the sample experienced grandi / Psychopathology and Religious Return

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osity and eleven persecution delusions; fourteen had guilt feelings or depressive moods; five sought solitude; and five demonstrated behavior that was considered bizarre even by Bratslav standards. There are many similarities between this sample and the general sample of baalei teshuva referrals discussed in Chapter , but there are also at least two unique features in the Bratslav sample: their attraction to Rabbi Nahman, and the beliefs and behaviors they demonstrated. The cases we will present can be better understood if we consider the personal appeal of Rabbi Nahman and the social position and structure of Bratslav hasidism. S,  F   M

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Simon was thirty years old, the oldest of a large traditional family of Moroccan descent with no history of psychiatric illness. In the army he had received awards for his technical skills. Also during army service, he had ceased all religious practices. Two years before his clinic referral, he became an ultra-orthodox baal teshuva and enrolled in a yeshiva. He studied Rabbi Nahman’s Likkutei Moharan and joined Bratslav hasidim in their nocturnal prayer sessions in the fields around Jerusalem. At this point, although his change had been quite rapid, he was a quiet but socialized Bratslav hasid, conversing and studying with other students. After a few months, Simon began to sleep less and wander at night, praying and studying mystical tracts at such holy sites as the Western Wall and the graves of zaddikim. He ate little, barely spoke to his wife, and no longer communicated with other Bratslav baalei teshuva. His wife became uneasy at the changes Simon was undergoing. True, his practices were appropriate to his new group. However, although it was apparent that he was Baalei Teshuva in a Fringe Hasidic Group / 

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motivated by a laudable wish to be holy, he eventually ceased all serious study. His social withdrawal became extreme, he no longer responded to even the most basic requests, he neglected his personal hygiene, and he rarely changed his clothes. At the initial interview, Simon was dressed in a long black coat and hat. He looked shabby and dirty. He did not speak to or look at the interviewing psychiatrist but swayed in his chair, whispering prayers to himself. Simon had been brought to the clinic by his uncle, who told us that Simon would become agitated at night; indeed, it was apparent from the words he muttered that he was seeing and conversing with angels and with Rabbi Shimon bar Yohai. He heard voices warning him that if he did not behave properly he would be taken to Hell and instructing him to study the Likkutei Moharan, to recite psalms, and to exhort others to repent. Rabbi Shimon bar Yohai hinted to Simon that if he were to father a son, the boy would be the Messiah. Bringing Simon to appointments involved hunting for him at the graves of local zaddikim. He refused medication, quoting Rabbi Nahman in support of his decision, until his uncle, whom Simon respected, countered with the talmudic injunction that doctors have been empowered by God with the ability to heal (Bava Kamma a). Under medication, Simon improved: he slept at night, was more alert by day, and became far more sociable. He continued his study of the Likkutei Moharan and hattikkun hakkelali and continued to travel with other Bratslav hasidim to the graves of zaddikim. He continued to believe that he could bring the Messiah but came to realize that for such a task he must have the blessing of others. He therefore actively sought and received blessings from the chief of the main Bratslav group, the aged Rabbi Levi Yitzchok, and from the greatest Jerusalem kabbalist, Rabbi Yitzchok Kadouri. As he became more sociable, he en / Psychopathology and Religious Return

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couraged his relatives to repent. Similarly, he spoke of rejoining the army in order to bring other soldiers to repentance. Finally, in contrast to his original unkempt appearance, he began to show concern about grooming and hygiene. He became quietly messianic, but organized; content with his current state, his wife asked him to stop attending the clinic while maintaining a low dose of medication. He has continued to study in a Bratslav yeshiva. L: T B B  F  L  D

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Leo, a thirty-one-year-old married Israeli-born male of Eastern European descent with three children, became religious ten years ago. He presented with complaints of uncontrollable impulsive and aggressive behavior, mood swings, bizarre behavior and gestures, and persecutory and grandiose auditory hallucinations. Based on interviews conducted over a period of two years, he was diagnosed as having schizoaffective disorder. As a teenager Leo had started smoking marijuana and spending time with young delinquents. During his mandatory army service, he had dressed and behaved bizarrely, was suspected by his officers of malingering, and had to be hospitalized. He was diagnosed as having a severe personality disorder and received early release from the army. A short time after his discharge, Leo became ultra-orthodox and began attending a baal teshuva yeshiva, which soon expelled him for bizarre and aggressive behavior. He held various jobs but was unable to maintain employment for more than a few weeks. Three years before his referral, he began frequenting a Bratslav yeshiva, where he found that his unpredictable behavior was more accepted. Only in Rabbi Nahman’s writings could he find meaning in life. Baalei Teshuva in a Fringe Hasidic Group / 

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Leo’s course of treatment has been complicated by his noncompliance and outbursts of unusual behavior. Sometimes in the clinic waiting room or in the middle of a session, Leo has sung, danced wildly, or prayed aloud, refusing to converse until he has completed the entire hattikkun hakkelali. Once he took a heavy cigarette lighter from his pocket and threw it at the therapist. He later expressed remorse but could not explain why he had attempted to hurt the therapist without provocation. Initially, his wife was opposed to treatment but following joint sessions she became a vital cotherapist. Leo continued to have labile affect and tangential thinking. He spoke of fears of persecution from unknown mortal enemies and from ‘‘forces of darkness’’ and hinted at being charged with a special cosmic mission. Antipsychotic medication was prescribed, but his compliance was poor until his wife went to his Bratslav rabbi, who ordered him to obey his doctor. He gradually improved on lithium. Leo continued to test his therapists’ endurance. He often missed sessions or arrived unkempt straight from a night out in the fields. In sessions he could be elated, depressed, or paranoid. He once arrived with a large knife. He found the therapists’ acceptance of this behavior perplexing and expressed his ambivalent feelings as follows: ‘‘Are you sent by the forces of evil? You are so good to me.’’ He also tested the therapists by changing languages, often including terminology of Bratslav hasidism and kabbala. T A  R N  S  L

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Rabbi Nahman believed that he came of messianic stock, and he may have tried to ‘‘bring’’ the Messiah by various means during the years –, which he believed were of messianic portent. The details of Simon’s messianic beliefs were similar to those of Rabbi Nahman. Eminent local rabbis did not totally reject him  / Psychopathology and Religious Return

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(according to his account); although he was encouraged to seek help, Simon’s basic ideas were accepted within his group. Rabbi Nahman was tortured by a sense of his sinfulness and saw his role toward his followers as one of saving them from the effects of their sins. For Leo, Rabbi Nahman was an endless paradox: friend and father, equal yet superior, sinner yet redeemer. Above all, for a young man unable to quell his outbursts, Rabbi Nahman was a source of comfort and hope, legitimizing his distress yet constantly challenging him. Rabbi Nahman sought to overcome his own imperfections by solitary meditative contact with the great zaddikim at gravesides. Similarly, although the isolation Simon and Leo experienced in their relations with the outside world differed—Simon withdrew into a world of saintly mystics and the Messiah, while Leo’s violent behavior strained all relationships—when they were out in the fields beyond Jerusalem late at night they were at peace. Away from their abrasive contacts, they confessed their misdemeanors to their master. Rabbi Nahman eschewed the material world and its pleasures and immersed himself in study of the kabbalistic text called the Zohar. The stories he told his followers concern kings, princes, princesses, merchants, and paupers—symbolic references to mystic concepts of God, the divine presence, the Jewish nation, and the fall and ultimate rise of humans. The central theme of his stories is tikkun, ‘‘repair’’ (Steinsaltz, ). Simon and Leo identified powerfully with this mystic concept, albeit in different ways. For Simon, tikkun referred to universal redemption, involving a total rejection of sin and the arrival of the Messiah. For Leo, tikkun had strong personal undertones, turning the flawed sinful individual into a participant in the process of redemption. The appeal of Rabbi Nahman and his teachings for Simon, Leo, and the other referrals can be understood in light of these issues. The referrals had grandiose thoughts with messianic conBaalei Teshuva in a Fringe Hasidic Group / 

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tent, yet tended to be isolated and paranoid, similar to the isolated and persecuted position of Bratslav hasidism. They identified with Rabbi Nahman’s self-doubts and were consumed by the need for repentance. Their psychotic isolation found a socially acceptable form in nocturnal meditation in the fields and at the graves of zaddikim, and their bizarre behavior could be explained as acceptable expressions of distress while battling with their impulses. The absence of a living leader also provided a basic framework with no single authority figure, so that their erratic behavior went unadmonished and was tolerated. They withdrew into a psychotic world populated by zaddikim, demons and angels, and other characters in the Zohar. It is likely that the central role of the Zohar in Rabbi Nahman’s thinking explains its appeal to baalei teshuva of Sephardic extraction, as will be discussed in the next chapter. Roland Littlewood (), a psychiatric anthropologist, has noted that many cultures accord a status of sanctity to the mentally ill; he calls this process ‘‘symbolic inversion.’’ As an example, he describes the case of a young hasid who transgressed the sexual and dietary laws when in a disturbed state (Littlewood, ); Littlewood claims that other hasidim viewed this behavior as messianic, drawing support for their position from the fact that antinomian acts were carried out by Shabbetai Zevi and his followers as well as by Jacob Frank (Littlewood, ). Rabbi Nahman was sharply criticized by leaders of his time, and his followers were often persecuted. Despite the sect’s position at the margins of religious Judaism, Bratslav hasidism can hardly be described as antinomian. Nevertheless, the flight from secular values to a fringe hasidic sect may be a process similar to symbolic inversion, in which our referrals have found a framework that accommodates and values many of the symptoms of their mental illness. The Bratslav way of life is indeed unusual by ultra-orthodox  / Psychopathology and Religious Return

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standards. At night the men go out to meditate in isolation and pray near the graves of zaddikim. They arrive home in the middle of the night and leave for morning prayers on waking, assigning the running of the house entirely to their wives. Male and female roles are clear: he studies and prays, she runs the home. In such an arrangement, the sanctioned isolation in which the patient lives may make diagnosing abnormality problematic. We have noted Henry Murphy’s () observation that the only distinction between hallucinations or delusions and culturally held beliefs may be the intensity with which the belief is held. Baalei teshuva who seek spiritual elevation together may be unaware of deviance in a colleague. (For example, a psychotic young man intermittently responded to the interviewer’s questions with brief accounts of hallucinations of angels talking to zaddikim. A fellow student who accompanied him to the interview sat silently reading a Bratslav text, ignoring the interview. When asked by the interviewer whether his friend had any problems, the student unwillingly looked up from his book, glared at the interviewer, said ‘‘We speak with God,’’ and returned to his text.) Eventually, however, teachers become aware that a student has become wholly preoccupied with his ‘‘mystical experiences’’ and has ceased to relate to other aspects of religious life. In addition, whereas those who turn to Bratslav hasidism pursue spirituality, our psychotics differ in that spirituality pursues them. Frightened by their experiences, terrified of the angels, they refuse to go out alone. There were also certain features that clearly demarcated the psychotic Bratslav referrals: a process of change had occurred. Where previously they had studied and conversed with others, now they became isolated and did not study. They emphasized such fringe religious practices as the incessant recitation of psalms, especially hattikkun hakkelali, while neglecting the Baalei Teshuva in a Fringe Hasidic Group / 

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main routine of religious life, such as the thrice-daily prayer. All ultra-orthodox Jews shun fashionable dress as immodest, but our patients’ neglect of clothing and personal cleanliness, which they justified in terms of concentrating on matters of holiness, was in excess of anything acceptable to their spouses or peers; it actually transgressed the religious requirement of cleanliness before prayer and before the Sabbath. The ultimate arbiters of the pathological nature of the beliefs and behaviors of these young men are their rabbis, who are becoming increasingly sensitive to the distinction between religious and pathological spirituality and willing to refer their students for help. E: L   N

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Efraim, a thirty-year-old man, a Bratslav hasid since he was fifteen, was led into the room by his brother. His eyes were closed tight, his thumbs were firmly placed in his ears, and his little fingers blocked his nostrils. He refused to answer any questions of a nonspiritual nature (age, address) and angrily rebuked us for immodesty when we inquired about his marriage. His strange pose appeared to be an attempt to escape all temptations of the senses. This was confirmed when he was asked to explain why he blocked his nose. He answered with five words: ‘‘Lo tin’af; lo tehene af.’’ The first two words are the Hebrew for the Seventh Commandment—‘‘Thou shalt not commit adultery’’ —to which he added, as commentary and explanation, ‘‘One’s nose must have no pleasure.’’ His reply was a play on the Hebrew words n’af (adultery) and af (nose). He blocked his nose because the sense of smell, like all the senses, can lead a person astray, especially to sexual sins. His rabbi, whose referral letter was particularly descriptive and perceptive, wrote that this young man was estranged so / Psychopathology and Religious Return

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cially even from Bratslav hasidim because of his complete unwillingness to speak of anything other than the Torah. His wife was contemplating divorce, for he never spoke to her or helped her. The letter went on to describe how for years whenever the young man walked in the streets, he would do so in a state of self-imposed blindness, deafness, and anosmia, making him a nuisance to others—he had even been hit by cars. Efraim had no overt psychotic symptoms. His standard of talmudic study was high; he prayed daily and carried out all the ‘‘commandments between man and God.’’ Yet not only did he neglect the ‘‘commandments between man and man,’’ but he saw the world as a place of uncontrollable urges, aggressive and sexual. His role in the marginal society of Bratslav was itself marginal; his coreligionists admired his knowledge but not his interpersonal behavior. Rabbi Nahman visited Israel only once in his life, in –. On the way, he stopped in Istanbul, where his behavior became both strange and childish. He would run about barefoot, without his hasidic belt or hat, sometimes only in his underwear, and play children’s games. In Istanbul he met a representative of the hasidim of Israel. Rabbi Nahman continued his pranks with this man: each time he was asked his name, he would give a different answer and deny the previous answers; Once he wakened the man in the middle of the night. Rabbi Nahman later explained that his strange behavior had been intentional. He wished to be belittled by others, to feel foolish and childlike, as a preparation for his spiritual journey to Israel. To Bratslav hasidim, Rabbi Nahman was pretending to be mad in order to make a particular impression on those around him. For every hasid, the Rebbe is not just a spiritual leader and mentor; his every behavior is a guide, a standard. We have been informed that his followers see this episode as justification for feigning mental illness when necessary. Although such feignBaalei Teshuva in a Fringe Hasidic Group / 

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ing could have been the case in some of the more colorful presentations, such as Efraim’s, we conclude that in most of the cases presented in this chapter, it could not have been so. Unlike Efraim, who was seen only once, most of the patients were seen on several occasions over a period of months and would have had a hard time—and little reason for—sustaining the pretense.

 Mysticism and Psychosis              

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Four eminent rabbis entered the garden of mystical speculation. Ben Azzai glimpsed and died. Ben Zoma glimpsed and was damaged (lost his sanity). Elisha ben Avuyah lost his faith. Rabbi Akiva departed in peace. In this story from the Talmud (Hagiga b), mystical speculation is seen as dangerous for our physical and psychological welfare: only one of the four rabbis was unhurt, and Ben Zoma became mentally ill (Ostow, ; Scholem, ; see A. Goshen Gottstein [] for an analysis of alternative interpretations of the text). Elsewhere the Zohar tells of three students who died while experiencing mystical ecstatic states. Maimonides concluded from the episode described above that ‘‘it is not safe to wander through the garden of mystical speculation unless one  / Psychopathology and Religious Return

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has a belly full of bread and meat.’’ He explains his remarkably concrete choice of imagery thus: ‘‘Bread and meat is to know what is forbidden and permitted in all the other commandments. The four Rabbis viewed such issues as ‘minor’ in contrast to the study of Ezekiel’s vision of God’s chariot (Ezekiel ), which they viewed as a ‘major matter’; nevertheless these [minor matters] should come first, for they settle a person’s mind ’’ (Laws of the Foundations of Torah :). The relation between mysticism and religion is complex— the mystical experience is perceived as a deepening of normal religious life, yet it is also destabilizing. Awareness of the dangers of mystical study led Jewish religious authorities to decree that only people who were stable in all areas of their lives— more than forty years old, married, and conversant with the basic Jewish texts from years of study—could engage with mystical texts. Mystical studies and experiences are dangerous for both the individual and the community. For individuals, the risks arise from absorption in the unseeable and unprovable, the entry into ecstatic states, which include seeing visions and the loss of boundaries, and which test their link with reality (Ariel, ; Schneiderman, ). The structure of authority within the community is also threatened because the mystic achieves a closeness to God that may not be experienced by the religious leaders. Furthermore, the veracity of any claimed revelation is unprovable, a problem that faced religious leaders at the time of Shabbetai Zevi (Scholem, ). The challenge to their authority led the rabbis to rule that rabbinic authority always overrides the claims of mystical experience (Scholem, ). In this chapter, we present the cases of two young men who left secular lives to become baalei teshuva (Greenberg et al., ). In the course of their change, they immersed themselves in mystical study and eventually became psychotic. These cases Mysticism and Psychosis / 

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were selected from a number of similar cases and are explored here in order to examine the following issues:

. Does mystical study precipitate illness, or does it appeal to those who are already mentally unstable (or both)? . Do local religious attitudes toward mysticism affect the development of psychopathology? . How do religions distinguish between the mystic and the psychotic?

M  P

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It has often been noted that the more central the role of certain beliefs and behaviors in a society, the less likely they are to be associated with severe psychopathology (Leff, ). If having visions is normative, then it is unlikely to be a feature of psychotic illness (Kroll and Bachrach, ), and the converse is also true. So too with mysticism. Mystical experience is a central feature of Buddhism—the term Buddha means ‘‘enlightened one’’ and refers to the mystical experience of the religion’s founder, Siddhartha Gautama. Similarly, the seminal text of Hinduism, the Bhagavadgita, contains a mystical vision. In both religions meditation is a part of everyday life, and the mystic is an unremarkable member of society. Not so the modern Near Eastern religions. Although mystical experiences are valued in Christianity, Judaism, and Islam, they are treated with caution. None of these religions includes meditation as part of its rituals or encourages the attainment of mystical experiences. Their founders described mystical revelatory experiences, but the religious authorities emphasize rituals and social codes. Muslim authorities were concerned that novice mystics would suffer excessive elation and despair arising out of the mystical states of ‘‘expansion’’ and ‘‘contraction’’  / Psychopathology and Religious Return

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(Zaehner, ). The sixteenth-century Christian mystic John of the Cross described the intense depression experienced by the mystic yearning for union with God, a state he termed ‘‘the dark night of the soul’’ ( John of the Cross, ). The parallels between mystical and psychotic states—social withdrawal, delusions, hallucinations, and strange behavior are common to both—have received attention among mental health workers (Buckley, ; Sedman and Hopkinson, a, b). William James ( []) noted that mystical states have two characteristic features: they cannot be adequately described or appreciated (ineffability), and they contain a sense of the revelation of knowledge hitherto unknown (noesis). These features emphasize the divide between the mystic and the onlooker, who is skeptical of the veracity and significance of mystic experiences and unsure whether to view the mystic as normal or abnormal. Yet noesis can be experienced at the onset of psychosis (Bowers and Freedman, ; Buckley, ), as can unio mystica, the sense of mystical union with God (Dupré, ; Fenichel, ). The following features have been thought to differentiate between mystic and psychotic states.

. Hallucinations are common to both, but psychotic hallu-

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.

cinations are predominantly auditory, while mystical hallucinations are usually visual. Psychotic hallucinations are generally peopled by critical and aggressive enemies, while mystical visions are filled with benevolent elderly counselors (Arieti, ). Nevertheless, a figure in a psychotic hallucination will often tell a person what to do and what to think. Glossolalia, or speaking in tongues, noted in mystical states in Christian revivalist groups, is distinguishable from psychotic thought disorder in that the words of the mystic are incomprehensible, representing a language Mysticism and Psychosis / 

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. .

. . .

unknown to the speaker (Littlewood and Lipsedge, ). Delusions of personal grandeur and omnipotence may be features of paranoid psychosis. They are unusual in mystics, who view themselves as privileged vessels who must deny their own importance and avoid self-flattery. The affective responses can also differentiate the two: mystics experience ‘‘joy and sweetness,’’ or ecstasy, while psychotics can be terrified by or indifferent to their psychotic experience (Underhill, ; Buckley and Galanter, ; Wulff, ). Ecstasy is often present initially in psychosis but is then replaced by dread (Bowers and Freedman, ). The mystical experience is transient (usually lasting for a few hours) and resolves completely, while psychotic states may last months or years and will often leave residual delusions, flattening of affect, or reduced social functioning. The withdrawal of the mystic has been described as ‘‘facultative rather than obligatory’’ (Group for the Advancement of Psychiatry, , p. ). Entering a mystical state is a facility, induced by choice or under certain situations, while psychosis is thrust upon one. Unlike the isolated psychotic, the mystic desires to share her experience with others (Group for the Advancement of Psychiatry, ).

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‘‘The mystic’s inner life has some apparent similarities to the inner lives of some psychotics. But while the psychotic is unable to observe the distinction between the inner and outer world, the well-adjusted mystic lives happily and productively in both’’ (Heehs, , p. ). Although brief duration and absence of deterioration can  / Psychopathology and Religious Return

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distinguish mystical states from schizophrenia, this distinction does not apply to brief psychotic disorders, which may last hours or days. Peter Buckley () has speculated that both mystics and those suffering from brief psychotic disorders may be responding to ecstatic affective changes. David Lukoff () has claimed that some psychotics are undergoing a religious experience and should not be medicated but helped to grow spiritually through their experience, a view consistent with those of R. D. Laing () and Anton Boisen (). M  J

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Although the mystical tradition was widespread among Jewish communities between  and  (Scholem, b), it has been most consistently accepted among Sephardic communities, in which the Zohar is read daily in communal services and at celebrations, and groups of young men are encouraged to study it regularly (Chouraqui, ; Stahl, ). In contrast, as we have noted, the Ashkenazi communities hold restrictive attitudes toward students of mysticism. Jewish mysticism can be divided into two strands: theosophy and theurgy (Idel, ). Theosophy is the Jewish mystical lore known as kabbala, and epitomized by the books of the Zohar. It concerns such concepts as how and why God created the world, the principles and means for God’s ongoing maintenance and control of the creation, and the deeper meanings of religious rituals. Theurgy comprises attempts to influence God’s actions in the world through prayer and practice, bringing on the redemption, and overcoming evil. It also flourishes on the personal level in cursing enemies, healing ills, and wearing goodluck charms. Amulets containing parchment with written texts including the names of God and guardian angels have been used since medieval times as protection against the forces of evil. Mysticism and Psychosis / 

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They are commonly requested at times of danger, when ‘‘Satan accuses,’’ such as birth, circumcision, illness, a long journey, or the death and burial of a close relative (Hillel, ; Trachtenberg,  []). There is a body of practices known as folk kabbala, which at a sophisticated level is concerned with theurgy. Although amulets are commonly worn in Israel, the active use of magic is expressly forbidden by rabbis: ‘‘Demons start up only with those who start up with them, such as by writing amulets, practicing sorcery or asking dream questions. Therefore one should not engage in these practices’’ (Rabbi Judah Hasid in Sefer Hasidim , in Hillel, , p. ). F C  M  P E

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Demons and evil spirits are unquestioned denizens of the Talmud. Subsequent mystical works, particularly the Zohar, accord demons a role in the cosmic design on the left side of creation, known as ‘‘the other side’’ (sitra ahra in Aramaic Hebrew). These represent the forces of evil, in opposition to the right side, the side of holiness. The Zohar states that demons are created by improper sexual relations: demons arousing a man’s passions at night cause nocturnal emissions, in which more demons are created from the spilt seed (Trachtenberg,  []).1 In our clinical work we have noted that masturbation and other forms of sexual activity that occurred before religious repentance trouble our baal teshuva patients greatly; they are particularly frightened by the demonological consequences. The term for masturbation used in Jewish mystical literature and repeated by our patients is an interesting example of the fusion of physical and spiritual concerns: pegam ba-brit, literally ‘‘defect in the covenant.’’ The Hebrew word for covenant, brit, refers simulta / Psychopathology and Religious Return

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neously to the brit mila, the circumcision, and what it symbolizes, the covenant between God and the Jewish people to keep the Torah. Masturbation is considered equivalent to defiling our relationship with God. Visiting graves: One of the reasons for the custom of visiting the graves of deceased relatives several times a year is to ask them to intercede with God on behalf of the living. The souls of the dead live on and may help or harm the living. The graves of famous rabbis, particularly mystics, are visited on the anniversary of their death. Rabbi Nahman, for example, visited the graves of mystics to invoke their prayers on behalf of the Jewish people. His followers continue the practice and also gather in the thousands at his tomb in Uman on Rosh Hashanna, the time when Rabbi Nahman held court (Green, ). Birth of boys: Jewish custom has long favored the male sex. As Rabbi Judah the Prince stated unequivocally, ‘‘There cannot be a world without males and females, but happy is he whose children are sons, and woe is he whose children are daughters’’ (Talmud Pesachim :). A Sephardic custom is for pregnant women to say the name of their intended son every Friday to ensure a boy is born. Names: The practice of naming children after their grandparents was mentioned in the Talmud. Naming a child after a deceased relative transfers to the newborn the qualities of the dead person and of other bearers of that name in history. Among kabbalistic writers, the act of assigning the name of a forebear to a newborn was considered so potent that Rabbi Judah the Hasid, the thirteenth-century German mystic, insisted in his will that neither his name nor his father’s was to be given to descendants for fear that this would oblige the two to leave heaven. Repairing the world (tikkun): The transmigration of souls from one body to another is an ancient concept, known in Sanskrit as samsara and in kabbala as gilgul. The concept was originally Mysticism and Psychosis / 

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limited to the transfer of the soul of a dead body to a live one as a punishment or in order to make retribution for sins, mainly sexual. The sixteenth-century mystic Isaac Luria broadened the concept to include the opportunity for all souls to go back and complete their tasks on earth. He described tikkun (repair) as ‘‘the process of cosmic restoration and reintegration’’ (Scholem, ). Later it was related that the souls of the dead who were suspended, able neither to enter paradise nor to transmigrate, would come in droves to Rabbi Israel Baal Shem Tov, the founder of hasidism, begging him to repair them so that they could find their eternal rest in paradise. He succeeded in doing so, presumably through prayer or magical means (Dov Baer ben Samuel, ). The battle against evil (theurgy): In Judaism, God is perceived as an absolute unity with dominion over supernatural forces and creatures of evil (Sharot, ). In Jewish mystical writings evil is regarded as a necessity without which there would be no free will for choosing the good path. In kabbala, the realm of evil is distinct from that of holiness, yet both are produced by God. Mystics, particularly hasidic leaders, are described as calling on God to destroy the forces of evil (Buber, ), although the practice is discouraged in the general population by religious authorities (Hillel, ).

Avi and Hallucinations, or Demons

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A twenty-eight-year-old of North African origin, Avi is married with two children and is unemployed. He began compulsory army service as an electrician and rose to the rank of staff sergeant. During Avi’s childhood, his brother, David, went missing during military action. After completing his own army ser-

 / Psychopathology and Religious Return

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vice, the twenty-five-year-old Avi became a baal teshuva and began visiting cemeteries throughout Israel in search of David’s lost burial site. David would appear to him as an apparition and tell him where to look. Whenever Avi would locate a possible site, he would light candles and remain there for the night, conversing with David’s apparition in order to ‘‘repair and elevate his brother’s soul.’’ He became a Bratslav hasid, and a few months later he married. When his wife became pregnant, David told him that the son about to be born should receive his name. When, instead, a daughter was born, Avi refused to see her or refer to her, and left home. He believed that the birth of a daughter was a punishment for his sexual activities, particularly masturbation, during the years before he became religious. A demon appeared to him, threatening to break his bones. He believed his situation to be ‘‘beyond repair.’’ When he came in for examination, Avi was unkempt, bowed over, with his eyes fixed on the ground. He appeared depressed, barely replied to questions, and mumbled his brief, rare responses. He reported auditory and visual hallucinations of both his brother and a group of demons. After he visited the tomb of Rabbi Shimon bar Yohai, on the advice of his own rabbi, he became slightly calmer. He was then taken to the tomb of Rabbi Nahman in the Ukraine. Avi has not returned for treatment, and his rabbi has informed us that he is largely unimproved two years later. In our diagnosis, Avi’s depressed mood, concern with guilt and punishment, and mood-congruent hallucinations are indicative of major affective disorder with psychotic features, while the paranoid content of his psychosis, the predominance of his withdrawal into psychosis, and his chronic deterioration are consistent with paranoid schizophrenia.

Mysticism and Psychosis / 

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Eli and Delusions of Grandeur, or Tikkun Eli is a twenty-six-year-old unemployed man of Bulgarian Sephardic decent. He had recently married, and became ultraorthodox the previous year. His wife reported that Eli had been behaving strangely over the past four months, had ceased studying, and rarely spoke. He became depressed and introverted and withdrew from all social contact. Eli had completed school and army service without problems but then immersed himself in the study of cults, such as Emin,2 and in the philosophy of the occult, including the writings of G. I. Gurdjieff. After he became a baal teshuva, his behavior changed: he would sit on the floor and cry over trifling matters, visit cemeteries around Jerusalem with invisible companions in order to study kabbala, and complain that the soul of a dead friend had transmigrated into his body, saying: ‘‘I have been impregnated by a spirit.’’ He undertook the ‘‘repair of spirits of the sinful who had died’’ and to this end he pronounced the ineffable names of God and recited prayers of unification with God, which he had collected from books on folk kabbala. In his bed at night he heard voices crying out to him to repair their dead souls. When he arrived for examination he was unkempt, avoided eye contact, stared at the floor, and sighed despairingly. His answers were brief and sporadic. He said that the sorrow he could express was but a part of what he felt over his failure to repair souls. He stated that he studied kabbala with the prophet Elijah. We gave him a low dose of neuroleptic medication, and his rabbi advised him to stop studying kabbala. Eli became calmer and tidier, and noted that the cries had become softer; he could no longer make out what they were saying. He was less perturbed by the demons created by the sexual excesses of others, although he still worried about the masturbatory errors of his own  / Psychopathology and Religious Return

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earlier ways. His relationship with his wife improved. Nonetheless, he refused to increase his medication and dropped out of treatment. His wife understood his change thus: he was neither strong spiritually nor knew kabbala sufficiently, so he had failed in his mission. Like Avi, Eli suffered from depressed mood, concern with sin and failure, mood-congruent delusions, and hallucinations, all suggestive of major affective disorder with psychotic features. His chronic psychotic withdrawal and persecutory delusions and the partial effect of medication are indicative of paranoid schizophrenia. The cases we have presented are typical of young men who began to study Jewish mysticism and became severely psychiatrically disordered. All the cases we have seen were males in their twenties with nonreligious parents. There was no apparent family psychiatric history, although collateral information was sometimes scant because the patient was brought by a fellow penitent or a rabbi who had not known him before his conversion to ultra-orthodoxy. With the exception of drug abuse in one case, the patients’ teenage years had apparently been uneventful, and they had successfully completed army service. It is not uncommon for psychiatric disorders to emerge during the stresses of military service, so it is noteworthy that this did not occur. The clinical picture in all cases was severe: vivid visual and auditory hallucinations, paranoid delusions, social withdrawal, marked deterioration of habits with neglect of hygiene and clothing, and a cessation of basic practices of Judaism and religious study. Those who received low doses of neuroleptic medication showed improvement in the interest they took in their surroundings, in their hygiene, and in their religious practices. Hallucinations persisted, perhaps because the doses were so mild. It is possible that these patients refused to increase their medication Mysticism and Psychosis / 

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because they were deeply drawn to their hallucinatory experiences and reluctant to relinquish them. This position was sometimes supported by their wives, fellow students, and rabbis, who often continued to ascribe a special sanctity to them. In our experience, however, although rabbis may initially have related to the experiences as mystical, once they perceived the prolonged duration of the patients’ withdrawal and the cessation of regular religious practice, they became convinced that the state was pathological. At this point, rabbis would agree to the need for psychiatric treatment. A Q  P

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In considering the question of whether mystical study precipitates illness or appeals to the mentally unstable (or both), we noted that several patients reported the deaths of close friends or family members. The Jewish mystical explanations for these losses appealed strongly to their tortured consciences: their past sins had created demons, and their present behavior and repentance could alter the course of events. They changed concepts into concrete forms, and the guilt they felt as part of their pathological grief was symbolized by demons who tried to kill them and drove them to the graves of mystics. Their recent religious repentance could have been an attempt to atone. In Avi’s case, the birth of a daughter instead of a son was experienced as a lost opportunity for further repentance and proof of his unworthiness. David Aberbach () has noted many similarities between grief and mystical states: depression, searching for the hidden one, withdrawal and detachment, visions of union, and identification with the dead (or God). Learning that most mystics suffered early losses of their parents, he suggested that ‘‘loss may be an important, even crucial, factor inclining an individual to  / Psychopathology and Religious Return

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mystical withdrawal’’ (p. ) and that ‘‘mystical union is a transcendent expression of grief ’’ (p. ). Most of the men in our cases became orthodox gradually, and their mystical study was a late component of this religious development. It appears that the process was simultaneous with their incipient psychosis and that their mystical state reflected their increasingly spiritual and decreasingly pragmatic concerns. Considering their problem-free army service, it seems that our patients had unresolved grief responses, which were reactivated by the kabbalic message that the souls of the dead not only live on but can be repaired by our intervention. In this way, an interest in kabbala may precipitate or aggravate psychosis. Increasing interest in the occult in recent decades has led many young men to study kabbala in yeshivas. But only a few are referred for help. Premorbid testing could establish whether unstable people are particularly attracted to the occult. Only the unlikely design of random allocation to mystical or nonmystical studies would demonstrate whether mystical study encourages the development of psychiatric problems. L R A

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All the cases in our sample came from Sephardic homes. As we have mentioned, Ashkenazi communities discourage and restrict mystical study, but Sephardic communities do not, and the major mystical texts have a respected role in everyday life. Similarly, the practice of folk kabbala, such as wearing amulets and turning to folk healers at times of illness, is more accepted in both the religious and the secular Sephardic communities. Superstitious beliefs about tempting the devil, transmigration of souls, possession, fortune-telling, the evil eye, amulets, lucky numbers, and walking under ladders are more commonly held by Sephardic than by Ashkenazi adolescents, and the strength and Mysticism and Psychosis / 

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prevalence of these beliefs increase during adolescence (Zeidner and Beit-Hallahmi, ). We can conclude that the attraction that mystical study and practices hold for Sephardic referrals reflects the familiar place of the Zohar and mystical beliefs in Sephardic society. Is a Sephardic baal teshuva more drawn to the study and practice of kabbala than his counterpart who was born to a religious family, or is he more disturbed by his learning, for lack of ‘‘a belly full of bread and meat’’? The yearning of the spiritual seeker who discovers religion as an adult is different from the more habituated study of those brought up religious. In addition, motivated by unresolved losses, the intense mystical pursuit of the baal teshuva may reflect a new avenue for a person suffering from a long-standing psychopathological process. T M   P  J

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Mystical texts are an integral part of the Jewish religion, seen as a means for committed Jews to gain greater understanding of the essence of God as He appears to us through creation and revelation. The great Jewish mystics have included eminent rabbis famed for their knowledge and observance of the ritual aspects of Judaism (Werblowsky, ). It is clear, therefore, that an absorption in mystical study can be acceptable and respected within the Jewish community. By contrast, the deterioration of habits, particularly the neglect of religious ritual in our patients, was an indicator of disturbance. The two cases we have presented demonstrate that the terminology and behaviors of our patients were products of their studies—so much so that teachers of mysticism continued to prescribe religious rituals (for example, fasting and visits to graves) as appropriate responses to patients’ sorrows until their conditions reached advanced stages. The symbols and language  / Psychopathology and Religious Return

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these patients used were typical of mystics and were expressed in the same terms used by their fellow students of kabbala. Reflecting their integrated social status in Sephardic society, mystical texts are taught by a sage in groups. The provision of guidance and the practice of learning in groups and pairs establish such study as normative, support its members, and control the content. The isolation and independent study of our patients were early signs of disturbance. This study again supports Henry Murphy’s () observations that delusions and hallucinations may not differ from cultural norms in their content. All our cases developed delusions and hallucinations that were apparently bizarre and pathological. Perusal of the concepts and practices of Jewish mysticism reveals that the patients’ thoughts of demons, angels, and the like were acceptable within the society they had joined (delusory cultural beliefs). The pathognomic features were the accessory details: neglect of other studies and practices, study in isolation and without guidance, and the suspect practice of folk kabbala. These were what distinguished our cases from true mystics.

 ‘‘Jerusalem Syndrome’’                      

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In this chapter, we shall examine the appeal and impact of a visit to Jerusalem from the perspective of psychiatric disorder. Our ‘‘Jerusalem Syndrome’’ / 

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inquiry leads to two separate topics: tourism and Jerusalem. The motivation for tourism has been conceptualized along a spectrum that includes escaping one’s daily life, seeking relaxation, and searching for a new direction for existence. The facilities of the holiday resort reflect these motives, from the seaside hotel to the ashram: the former lack intellectual stimulation, the latter beach and bar. Jerusalem is not only closer to an ashram as a tourist site, but it has a long history as the center of pilgrimage for three world religions. Every night, Jerusalem hosts at least three thousand tourists. For many, the visit is an exhilarating experience. Christian pilgrims come to see the Church of the Redeemer, the Via Dolorosa, and Gethsemane; Muslems visit the Mosque of El Aqsa and the Dome of the Rock; and Jews pray at the Western Wall, view the recently discovered relics of the Old City, and visit the new city of Jerusalem. For many it is a dull city: there is no beach, no golf, and no gambling. But for some, the emotions evoked are deeply disturbing, and the term ‘‘Jerusalem syndrome’’ was popularized to describe how people could became mentally ill during a visit there (Bar-El et al., ). The phenomenon most similar to ‘‘Jerusalem syndrome’’ is the condition designated ‘‘Stendhal syndrome’’ by the psychiatrists at the Santa Maria Nuova hospital in Florence (Magherini and Zanobini, ). Stendhal, whose passionate novels include Le Rouge et le noir, visited Florence in  and experienced a painfully intense sense of excitement as he toured the works of art. His heart pounded and his thoughts raced. Graciella Magherini and A. Zanobini described  foreign patients admitted to their hospital in Florence over a ten-year period starting in the mid-s; Most were Europeans aged twenty to forty who were traveling alone and were not part of a tour. More than half had previously received psychiatric help. Their hospitaliza-

 / Psychopathology and Religious Return

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tion tended to be brief; the patients improved quickly but were usually unable to resume their holiday. According to Magherini and Zanobini, the art of Florence offers not only the height of ecstasy and fulfillment for most art lovers but can radically disturb some viewers. Jerusalem is a magnet for tourists who are searching. Some of these tourists require urgent psychiatric hospitalization during their holiday, and we present here an evaluation of a two-year sample of eighty-nine hospitalized tourists (Bar-El et al., ). The data suggest that, like the appeal of Bratslav hasidism and of mystical study to baalei teshuva, the sanctity of Jerusalem has an effect on its guests that, for a few of them, has very unsettling consequences. T P  P  T

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Motives for tourism vary. Some people travel out of curiosity, others for adventure; for some having ‘‘been there, seen that’’ confers status. Erik Cohen () has described five types of tourist experience. Particularly interesting for our study of the links between religion and psychiatric disorder, the paradigm he used was based on Mircea Eliade’s () concept that every religious cosmos has a center, a sacred area of absolute reality. Cohen conceives of tourists as on a quest for that spiritual center. Their motivation is a combination of disenchantment with their own culture and a desire to immerse themselves in the culture they are visiting. Cohen’s five types of tourists include recreational tourists, the most common today: for them the trip and the contact with a foreign culture are a form of passive entertainment, comparable to watching television or seeing a movie. Travel as a diversionary experience involves an escape from the tedium of routine

‘‘Jerusalem Syndrome’’ / 

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life. The traveler seeks to alleviate boredom, to ‘‘have a good time.’’ Unlike recreational tourists, diversionary tourists find the return to routine difficult, for the experience has not been restful and restorative. Experiential tourists actively seek a vicarious experience of the authentic life of other peoples or cultures. Experimental tourists try out many alternative ways of life, seeking a new one to adopt. These tourists travel to ‘‘find’’ themselves. Finally, existential tourists, like the premodern pilgrim, are committed to experiencing a sense of arrival and fulfillment at their elected spiritual center. Today’s pilgrims may seem indistinguishable from other tourists. It is only when their motivations are analyzed that pilgrimtourists, whose travels are a search for the religious or cultural center of their life, and recreational tourists, who move away from the center to the periphery of their world for a rest or a change, can be distinguished. Tourism, therefore, is not a single phenomenon. It ranges from the a lone adventurer with little baggage and money setting out to explore exotic and distant places to a large group on a carefully preplanned and prepaid trip to familiar spots. Nevertheless, however well packaged (and protected) it is, a tour represents a change, and change is unsettling. Conversely, those who are unsettled may be more likely to opt for change and travel. For both reasons, we might expect to find a significant number of disturbed people among tourists. We shall discuss two studies that describe severe psychiatric disorders among holiday-makers. The reason that severe disorders predominate in these studies is that tourists who are mildly unwell tend to defer psychiatric treatment until they get home, while those who are moderately disturbed will get on the next plane home. Only tourists who are not only disturbed but also disturbing will have their itinerary punctuated by a visit to

 / Psychopathology and Religious Return

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a psychiatric facility in the host country. This bias in the selections of the samples must be borne in mind in any interpretation of the data. The first and largest study was of  psychiatric admissions from John F. Kennedy Airport, in New York City (S. Shapiro, ). Of these admissions,  percent exhibited symptoms of schizophrenia, and most had a preexisting disorder. A study of  psychiatric admissions from Heathrow Airport, London, in – ( Jauhar and Weller, ) revealed the unexpected finding that those traveling from East to West were more likely to be depressed while travelers from West to East were more likely to be hypomanic; the authors thought this implicated the impact of time-zone changes on mood. Thirteen percent of their sample were ‘‘airport wanderers,’’ with neither plans nor funds for travel;  percent were at the airport for a reason other than travel;  percent were departing; while the largest group,  percent of the sample, were arriving, usually at their final destination. About half the sample were diagnosed schizophrenic, and another  percent had affective psychosis. Although schizophrenia was far more common in this sample than in admissions from the local population, compulsory hospitalization was also far more common in the airport sample, reflecting the dramatic nature of the psychotic behavior, which must attract sufficient attention at an airport to lead to admission to hospital. T P  J

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The meaning of Jerusalem for Jewish pilgrims has evolved over the millennia. Before the destruction of the Temple in  .. the city was a center of sacrifice; since the destruction it has become the apotheosis of yearning.

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It is because of this that our heart is faint, It is because of these that our eyes have dimmed. It is because Mount Zion has become desolate, jackals prowl around it. . . . . . . . . . . . . . . . . . . Bring us back to you, O Lord, and we shall repent. Renew our days as of old. (Lamentations, :,,) We all began our existence as tourists, nomads, wandering from one area to another in search of food and shelter. Only later did humans gather in fixed settlements, where they cultivated crops. In a similar vein, Jewish history began with wandering forefathers: Abraham left Ur of the Chaldees and crossed the desert to Israel, Isaac moved from one waterhole to another, and Jacob left Israel and traveled to Egypt during a period of famine. After the oppression of the Egyptian slavery, Moses led the descendants of Abraham, now a nation called the Children of Israel, back to the land of Israel in a forty-year trek through the desert. An early use of the Hebrew word tour is in Numbers :, which describes the spy mission of the twelve leaders sent by Moses into the land of Israel. Thus, the first experience of the land of Israel by representatives of the Jewish nation was an act of ‘‘touring.’’ Once the Jews were settled in Israel, regular trips to Jerusalem became a central feature of religious life: throughout the year each family sent its sacrifices to the Temple, and every year the people visited the Holy City on the feasts of Passover, Weeks, and Tabernacles, known as the three pilgrim festivals. These cross-country visits were a symbol of the earlier desert wanderings of the Jews; all three festivals commemorate phases of the journey of the Children of Israel from Egypt. The focus of  / Psychopathology and Religious Return

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the pilgrimage, however, became more specific: the aim of the Exodus had been to reach Israel, while the purpose of the pilgrim festivals was to reach the Temple in Jerusalem. This ended with the destruction of the Second Temple by the Romans. And to Jerusalem, Your city, may You (God) return in mercy And dwell there as You spoke And rebuild it, an everlasting building, quickly in our lifetime. . . . . . . . . . . . . . . . . . . . . And may our eyes behold Your return to Zion. (daily prayers) For nearly two thousand years religious Jews have repeated these sentiments in their thrice-daily prayers, awaiting the rebuilding of the Temple and the reinstitution of its services. This yearning not only occupies their daily thoughts but has found physical expression in the direction they face during the most important daily prayer, the Amidah: If one is praying [the Amidah] outside of the land of Israel, one should face [literally: direct one’s heart] to the land of Israel. If one is praying in the land of Israel, one should face Jerusalem. If one is praying in Jerusalem, one should face the Temple. If one is praying in the Temple, one should face the Holy of Holies. . . . . . . . . . . . . . . . . . . . . So it is that all Israel are directing their hearts to one place. (Talmud Brachot a)

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Every day, spiritually and physically, religious Jews direct their thoughts to Jerusalem and the site of the Temple. Every ultraorthodox home has a section of the eastern wall left undecorated

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as a sign of mourning for the destroyed Temple, while at every wedding a glass is broken by the groom as a sign that in the midst of the greatest joy one should remember that the Temple is in ruins, in keeping with the words of the Psalmist: If I forget thee, O Jerusalem, let my right hand forget its cunning. Let my tongue stick to the roof of my mouth if I do not remember thee; If I do not set Jerusalem above my highest joy. (Psalms :–) Grief for this lost center and the wish to sit among the ashes where once there was holiness found expression in the poetry of the twelfth-century Spanish philosopher Judah Ha-Levi: My heart is in the East, and I in the depths of the West. My food has no taste. How can it be sweet? How can I fulfill my pledges and my vows, When Zion is in the power of Edom, and I in the fetters of Arabia? It will be nothing to me to leave all the goodness of Spain. So rich will it be to see the dust of the ruined sanctuary. (Ha-Levi , p. )

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(Legend relates that in , at the age of sixty-five, Ha-Levi set out for the Holy City in fulfillment of his dreams and yearnings. After an arduous journey, he arrived in Jerusalem. As he bowed down in prayer at the Western Wall, he was trampled to death by a horseman.)

 / Psychopathology and Religious Return

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Throughout Jewish history, all countries outside Israel have been referred to as ‘‘exile’’; for two thousand years Jerusalem has represented both the loss of a spiritual and physical center and past glory. This was not a loss to be ‘‘worked through’’ and overcome but a tragedy to be kept simmering over the generations. For some people, returning to Jerusalem was expressed by a sentence in the daily prayers, for others it was a dream, while for a minority of pilgrims, it was translated into action. For the past thousand years a steady stream of Jewish pilgrims has visited Jerusalem’s holy sites. Nachmanides, the Spanish Bible scholar and physician who arrived in Jerusalem in , wrote to his son: ‘‘Many men and women from Damascus, Babylon and their vicinities come to Jerusalem to see the site of the Holy Temple and to lament its destruction’’ (‘‘Pilgrimage,’’ , :). This was a voyage fulfilling the dreams of a lifetime. Rabbi Hayyim Ben-Attar wrote of his decision to leave North Africa for Jerusalem: ‘‘God enlightened my eyes and mind to get up and go up to the exalted place of the divine presence, to the city beloved by the eternal God. I girded my loins like a strong man, wandered from city to city, placed myself in great dangers, until God brought me to the land of my delight . . . a land where the only true joy is to live in it.’’ He arrived in Jerusalem in , established the Or HaHayyim Synagogue and the Knesset Yisrael Yeshiva next door, where he ‘‘would sit wrapped in his prayer shawl and Tefilin, and those who saw his beaming face thought he was an angel of the Lord of Hosts, and the Divine Presence (Shekhina) was hovering over him all day’’ (Vilnay, , p. ). Most of the pilgrims traveled in groups: Judah Hasid had hundreds of followers and Hayyim Ben-Attar came with thirty. They came to establish communities; although they were dreamers, they were also pragmatists.

‘‘Jerusalem Syndrome’’ / 

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‘‘J S’’: T P   L-D P In Chapter  we considered the risks of kabbala study. Pilgrimage, too, involves dangers: Judah Ha-Levi and Judah Hasid both died within days of arrival in Jerusalem, and Hayyim Ben Attar died within the year. Since  all tourists who need psychiatric hospitalization in Jerusalem—about fifty a year—have been admitted to Kfar Shaul Hospital. In – systematic data were collected on the eighty-nine tourists (fifty-seven men and thirty-two women) who were hospitalized over the two-year period (Bar-El et al., ). More than  percent of the sample came to Jerusalem in response to a mystical experience. Seventy-four ( percent) were diagnosed as psychotic, thirty-five ( percent) had the delusion that they themselves were mystical or biblical figures, and more than half believed themselves to be the Messiah. Forty-five of the tourists ( percent of the sample) were Jewish, but only  percent were strictly practicing members of their religion. Although the majority had long-standing psychiatric illnesses, for  percent of the sample, this was their first episode of psychiatric disorder. The majority of the sample was aged twenty to forty, averaging . years. Consistent with the findings of other studies, sixty-six ( percent of the sample) were single, thirteen ( percent) divorced, and only ten ( percent) were married. Thirtysix ( percent) were from North America, thirty-nine ( percent) were from West Europe, and the remaining fourteen were from East Europe, South America, South Africa, or elsewhere. Using Cohen’s typology, thirty-four of the sample ( percent) were recreational, diversionary, or experiential tourists and sixteen ( percent) were experimental tourists, of whom ten ( percent) had come to study, usually at a religious institution, and  / Psychopathology and Religious Return

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six ( percent) had come to do volunteer work (on a kibbutz, for instance). Twenty-three ( percent) could be described as existential tourists, since they had come for mystical religious reasons. Thirteen ( percent) were visiting relatives. In considering the types of behavior that led to hospitalization, it must be remembered that the tourists’ condition had to be so disabling that they were incapable of continuing their journey or returning home. Of the eighty-nine admissions, ten had attacked other people, twelve had attempted suicide, ten were found walking around naked, and twenty-nine were preaching or wandering the streets. In twenty-eight cases the nature of the deviant behavior was not recorded. These data are difficult to analyze in the absence of equivalent information on unhospitalized tourists. Nevertheless, it is noteworthy that strictly religious tourists comprised only  percent of the total sample. If religious feelings were an important factor in the deterioration, then they mainly affected those for whom religion had not previously been a central feature of their lives. All eighty-nine cases were diagnosed retrospectively from the case notes according to ICD-: forty-nine were suffering from schizophrenia, fourteen from acute psychosis, eleven from affective psychosis, seven from personality disorder, and two from dementia. In six cases the diagnosis was unclear. There was no relation between the diagnosis and the religious background, sex, or age of the patients, although of course both tourists suffering from dementia were much older than the other patients. All were asked whether they had experienced a mystical event preceding their admission, and thirty-six ( percent of the sample) believed that they had. Twenty-four patients ( percent) believed themselves to be the Messiah, four thought that they were God, three identified with Satan, and another seven patients identified with various biblical figures. It is noteworthy that mystical experiences were more frequent in patients with ‘‘Jerusalem Syndrome’’ / 

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a Roman Catholic background than in Jewish or Protestant patients. The two earlier studies found that people who require psychiatric help during their holiday tend to have received previous psychiatric treatment. The Jerusalem sample was no different: seventy-three of the patients ( percent) had received psychiatric treatment before their hospitalization. The remaining sixteen first became acutely psychiatrically ill during their trip to Jerusalem. This subgroup did not differ from the rest of the sample in demographic variables, purpose of journey, religious involvement, or nature of religious delusions. E,  E T

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Eric, a fifty-year-old bachelor from the United States, had never visited Israel before. He had studied accountancy but then gone on to work in a variety of jobs, never lasting more than a few months. Eric was reluctant to talk about his psychiatric history, and his account was hard to piece together: ‘‘I sought help when I was twenty-three, I saw a psychologist for three months; all the other times it was forced, I was captive.’’ When he was twentyfive he was hospitalized involuntarily. At that time he first became religious, ‘‘but I got signals that religion would not pay off for me, so I lapsed. Then, at the age of thirty-seven, I started getting signals, sensations in different parts of my body that had specific meaning, like bells rang in me, they said consult Samson. These sensations have been with me ever since. A sensation in my neck means ‘I’ll bless your neck,’ a sensation in my arms means ‘I’ll bless your arms.’ People’s noises cue me into different features. ‘‘Over the next six months I had sensations in my hand and body which told me not to eat, or that eating would be good for me. I realized that there is reward and punishment and subsisted  / Psychopathology and Religious Return

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on one meal a day. That Yom Kippur I had sensations [urging me] to commit suicide, sensations from parts of my body told me different things. It’s bizarre. I believe I am somewhat unique in the world; I think I am a first-time-round, not a transmigrate, the way people study me. . . . I was writhing in immense pain, and I slashed my wrists six times. ‘‘I was in the hospital for two weeks. After that, I did occasional accounting jobs, but I always left. I lived with my mother in Queens. My brother lives in Jersey. Last year my mother died. I was living alone. ‘‘Eight weeks ago I changed my name to Samuel. I thought it would give me more spiritual leverage. Then I heard of an incursion by Arabs at Akaba. . . . I thought a war was in the offing, I didn’t want to stand by, so I came here. I thought I would help on a farm. ‘‘I feel I am on an endangered-species list because of my theology. Situations have been created not at random, with a motive. My fortunes have been low of late, it’s not paranoia, it’s real. The fact that I got on a plane that is L, the Judge’s name was Zal [the numerical value of the Hebrew letters in Zal is thirtyseven], the Judge said, ‘Exactly,’ the psychiatrist’s registration number is , he gave me injections, I think it is a conspiracy. They took my personal effects, I believe I am a marked man. It’s been that way all my life. ‘‘I came here with a one-way ticket. I spent the first night at a hotel. Friday I was looking for hotels, nothing suited me. I left my cases with a taxi driver. I bought food at the supermarket and went to the Kotel (Western Wall) for the night. I got up in the morning and davened Shacharis [said the morning prayers]. I was resting near the police station. A gentile was smoking at the Wall; he was in a teeshirt and gym shoes. I was upset. I pictured myself as some sort of Kotel cop, thought this was insulting to God and the sanctity of the place. ‘‘Jerusalem Syndrome’’ / 

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‘‘I confronted him. I told him he was dressed improperly. I said, ‘You have five seconds to leave.’ Then I assaulted him, punched him. There were no police around. There was someone else dressed improperly with a baby on his back in a knapsack. We had words. The police came over. ‘‘The cops said to go over to the police station. My back was to the scene of the Sanhedrin [the rabbinic assembly, held in Jerusalem during the Temple period]. I said, ‘I don’t recognize your authority, this is a holy place, we can talk here.’ I refused to move. Other cops came over. They pulled me off. I told them they weren’t bigger than Moses at Sinai and God. People had been killed for looking at holy vessels when they weren’t supposed to. The fate of the world is balanced on the keeping of one commandment. I don’t know if this is grandiose. ‘‘The emphasis is on holiness and the holy ark, which is buried under the Temple courtyard; they gave me the impetus to act. ‘‘Well, they dragged me off to a prison cell, where I was held for four days. In the cell, they were all priests and one rabbi; I don’t know who is writing this scenario. ‘‘The priests knew karate, I thought they were trying to attack me, so I tried to stab them with a ballpoint pen. ‘‘They moved me to a wing with pseudo-religious people; the whole thing is very strange. It could be that this is a trick to get me into trouble because I am a hard-liner with Halakhah.’’ Everything about Eric was incongruous. He was dressed in the black jacket of the ultra-orthodox, yet his yarmulka was hippie in style. Similarly, his manner was very open and unrestrained, and he appeared unaffected by the presence of female patients and staff. Most incongruous and arresting was his conversation: his language was rich, at times literary, reminiscent of Damon Runyon, and full of terminology of the s. Eric was initially very friendly but became irritable when I explained that he might not be allowed to remain in the country. He per / Psychopathology and Religious Return

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ceived this as a plot against him and complained that his unusual qualities were not appreciated. In fact, after Eric had been hospitalized for two weeks, a court decided he should be returned to his family in the United States. Eric had lived with his mother until her death, the year before he came to Jerusalem. Since then, he was largely left to his own devices. This could mean that he was not taking his medication regularly. Eric has been sick for at least thirteen years, possibly more than twenty-seven. He grew up in a nonreligious home, and it appears that whenever he becomes unwell, his delusions urge him to become more religious. It is not clear whether he suffers from tactile hallucinations, but his explanations for his sensations are clearly delusional. He accepts these as commands, and they led to an earlier suicide attempt. The symbols that occur during Eric’s illness are to some extent inconsistent. Notwithstanding that Yom Kippur is a day of fasting and atonement, suffering and self-injury are not basic tenets of Judaism. Indeed, the messages from the parts of his body leading to his attempted suicide are more reminiscent of when Christ’s stigmata appear on Christian mystics. Eric was educated in a secular Jewish-American home, and it is likely that he knew far more about Christianity than Judaism. His psychosis was overtly an expression of Jewishness, yet the symbols were Christian. The worsening of his mental state after his mother’s death again expressed itself in religious terms: he changed his name and saw international and personal meaning in the news. His motivation for the trip was to participate in the coming holy war. On his way, he saw mystical signs in the plane, his judge, and his psychiatrist (suggesting that he foresaw a conclusion of paranoid defeat rather than glory and salvation). If indeed he was coming to work on a farm, as he claimed, the metropolis of Jerusalem would not have been his first stop. But ‘‘Jerusalem Syndrome’’ / 

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the truth for Eric was that he was coming to protect the holy sites from the heathens and the secular, so he set out for Jerusalem. Far from being part of a package tour, Eric’s trip was an individual’s crusade. He made no plans during his stay, spent the night at the Temple site, and then picked a fight in the name of righteousness, which led to his hospitalization and deportation. J   M I The data we have presented do not permit us to draw conclusions about whether and how Jerusalem’s religious ambience induces psychiatric disturbance. Nevertheless, over a quarter of the sample were attracted to Jerusalem for overtly mystical religious motives, and  percent had had mystical religious experiences before their admission. Further, Eric’s story describes a man whose motive for becoming religious was based on somatic hallucinations and delusions. Later, his decision to visit Israel was also founded on psychotic thinking. The religious importance of the Western Wall combined with his delusional sense of grandeur to produce the event that led to his hospitalization and deportation. Eric is an example of someone whose preexisting psychotic thinking was fanned into flame by the spiritual atmosphere in which he had placed himself. The data on the eighty-nine hospitalized tourists and Eric’s account clearly rule out the possibility that these tourists came to Jerusalem to be healed. Forty percent of the sample believed that they were important religious figures with a mission to help others. Jerusalem, center of the world for three world religions, appealed to their grandiose ideas, and they traveled either with clear eschatological motivation or with vague spiritual ideas that clarified themselves in Jerusalem. Only a small proportion had never undergone treatment. It is not known how many of the  / Psychopathology and Religious Return

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patients were unwell before travel and how many succumbed to the atmosphere of the Holy City.1 Eric and his fellow travelers have shown us that we, the inhabitants of Zion, are dealing not with a source of psychosis but with the attraction a religious symbol has for the emotionally unstable.

‘‘Jerusalem Syndrome’’ / 

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P IV

                           

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 Ultra-Orthodox Attitudes Toward Mental Health Care In the next two chapters, we shall consider the difficulties of establishing a structural and ideological framework for the provision of mental health care to the ultra-orthodox community. We have referred several times to the antipsychotherapy attitudes of ultra-orthodox religious leaders. In this chapter we shall try to understand these in the context of the history of psychotherapy and its attitudes toward religion and religious leaders, as well as of the structure and hierarchy of the ultra-orthodox community. The guidelines for behavior and opinion in the ultra-orthodox world were established by the writings of the leading rabbis of earlier generations and are updated by public statements and personal advice given by today’s authorities. Public statements often appear in the form of halakhic responsa, the replies written by leading rabbis to questions on Jewish law posed by members of the community. While one might expect responsa to deal with narrow religious issues such as Sabbath observance and dietary laws, in practice most rabbis will be called upon to pasken (declare the law) on problems of faith, political issues, and matters of health, both physical and psychological; their advice may be sought on business ventures and the suitability of candidates for marriage. In evaluating the difficulties of providing mental health care for the ultra-orthodox community, it is therefore appropriate to begin with the written opinions of the religious leaders, for these are the guidelines to the community’s behavior. 

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R O  P S Possibly the foremost rabbinical authority of this generation was the late Rabbi Moshe Feinstein (–).1 His collected responsa contain the following: It is forbidden for a psychiatric patient to go to a psychologist or psychiatrist who is a heretic or an atheist. These specialists inquire about a person’s thoughts, and tell him how he should behave, so that one ought to suspect that occasionally this advice will be against the laws of the Torah, even against the principles of religion, and against matters of modesty. All the healing of psychologists and psychiatrists lies in their words; therefore one should take care, for they may speak words of heresy and profanity. If they are specialists, and promise the parents that they will not speak against the faith and the law of Torah, one may perhaps rely on them, for they are specialists and should not lie. Therefore, one must seek out a psychologist or psychiatrist who keeps the Torah, but if this is not possible, one can even go to a heretic or atheist, yet it must be stipulated and he must promise not to discuss matters of belief and the Torah with the patient.’’ (Igrot Moshe, Yore Deah, :)

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Although Rabbi Feinstein was leery of the secular advice of mental health professionals, he was aware that their services are sometimes needed and should be used. His responsum implies that their methods may well be useful—it is the content that needs to be controlled. They must be asked to remain within the confines of issues that do not contravene the Torah. Rabbi Moshe Sternbuch is a contemporary ultra-orthodox  / Provision of Mental Health Care

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authority living in South Africa and Israel. It is clear from his many responsa on psychiatric matters that he takes care to inform himself before writing his replies. For example, in discussing whether two people who are introduced to each other with a view to marriage must disclose a history of personal or family psychiatric problems, he distinguishes such features as whether a past episode was brief, whether there was a return to full functioning, and whether the person is still on medication. He adds that while a young man who has totally recovered from a brief episode need not reveal its occurrence, a young woman should tell her prospective husband of such an episode because of the risk of a postpartum recurrence. We quote in full one of Rabbi Sternbuch’s several responsa on the subject of psychotherapy, for it contains four matters of interest: a clear ruling on the use of psychotherapy, the suggested therapeutic alternative, the view of sin in the etiology of depression, and the values implied in each therapeutic approach:

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Question: Is it right to go to psychologists and psychiatrists for healing? I have spoken publicly on many occasions against going to psychologists and psychiatrists, for their way is the opposite to Torah. They consider that the way to heal psychologically is to permit the person to fulfill his strong desires and not to limit them as is fitting. Fulfilling a desire, however, only leads to desiring more, and there is no end. This does not heal but leads to deterioration. Even the best therapists have nothing to offer those whose sins have brought them to depression or sadness, for the help they need is from those knowledgeable in Torah, who are the real healers of souls. Here [in South Africa] many go for counseling Attitudes Toward Mental Health Care / 

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to those who lead them astray, for their way is the exact opposite of the Torah way, which explains that sorrows and trials are for one’s benefit and atonement. These trials breathe into one the spirit of faith that the outcome will be beneficial and that one must take courage that God will help. This realization will give the person courage and he will become joyous. This is the essence of his healing. He should completely forget the past, and the essence is the future, serving God and rejoicing in the performance of God’s commandments. Psychologists and psychiatrists, on the other hand, require, God forbid, that one should not make demands of the person, but instead grant his every desire and wish. They imagine they are calming him transiently by allowing everything. In this way they steal from him a lot of money and imagine he will be healed. (Sternbuch, , p. ) Rabbi Sternbuch’s attitude is clear: Turn to mental health professionals only if told to do so by your rabbi, and avoid psychotherapy. He makes no distinctions between types of therapy, although indirect references to patients on medication in other responsa imply that he does not frown on pharmacotherapy. A D   P

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At a level below books of halakhic responsa are the newspapers of the ultra-orthodox community. Each paper is affiliated with a particular rabbi or religious authority, and each is widely read within the community. As in all other areas of life, the press is carefully monitored. Not only are no immodest pictures or

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articles published, there are no pictures of women. Many articles are intended to offer spiritual uplift. In – a debate developed in the ultra-orthodox press in England on the subject of psychology and psychiatry. In October , the front page of the Jewish Tribune reported a speech by Rabbi Moshe Deutsch, head of the Katamon religious court in London: The Hatam Sofer had fought hard against psychologists and others who are Apikorsim [a derogatory term, from the Greek Epicurus, meaning a heretic], and he [Rabbi Deutsch] warned that one should have no dealings with them.2 He quoted the Hatam Sofer [as] having said in a Shabbat Shuva drasha [a speech encouraging repentance, spoken by rabbis to their communities on the Sabbath before Yom Kippur] that it is forbidden to go to psychologists or to accept their advice. Most of their advice is heresy against the holy Tora, in the opinion of the Rabbis, especially when dealing with marital problems. The greatest rabbis of Israel, America and Canada condemn going to psychiatrists for marital difficulties. They are unanimous in their opinion that it is forbidden to consult psychiatrists because they are unprincipled and give advice that is against the Tora and transgresses Jewish law. The Hazon Ish of blessed memory was also opposed to consulting psychiatrists.

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Early in , advertisements offering telephone counseling services for the ultra-orthodox community appeared in the same English newspaper. Rabbi Deutsch wrote a letter to the paper, published as two separate special announcements in Hebrew and English: Attitudes Toward Mental Health Care / 

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A strong warning against seeking the advice of counsellors or psychologists, signed by prominent Rabbis and headed by the Hazon Ish, has already been published. The vast majority of psychologists’ ideas are based on sources foreign to fundamental principles of our Holy Tora, and derive from authors who themselves do not believe in our Tora. No good can ever come from such ideas, and witness to this is the fact that many Jewish homes have been destroyed through following the advice of these people. In fact, in a recent letter, the famous Posek [authority on Jewish law], Rabbi Wosner of Bnei Brak[,] states categorically that ‘‘their advice is the counsel of the wicked and it usually results in evil.’’ Recently, advertisements have been published— unfortunately even by Orthodox newspapers—from various organizations which offer a telephone helpline for various problems. I have been requested by several Rabbis to make it clear that this is also included in the above-mentioned warning, as these counsellors also take their instruction from nonJewish sources, and the Orthodox community should beware of the potential pitfalls. Our holy Tora contains solutions for every problem, and one has only to consult a qualified and God-fearing Rabbi who has not dabbled in non-Jewish methods of counselling. The next week, a letter was published from Rabbi Shlesinger, head of a leading London yeshiva:

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I wish to support my friend in his stand against the idol-worship of psychologists, and the many  / Provision of Mental Health Care

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cults with their laws and titles, under the heading of counsellors and supervisors. They are the counsel of sinners, derived from impure sources, and false opinions, foreign to the spirit of Israel. It is public knowledge just how many have fallen prey to it. The matter is simple and clear to anyone educated and raised in Tora and the treasure of fearing God unalloyed by secular study and non-Jewish wisdom, that the holy feeling flees from such people, for the very basis of their outlook on the essence of life, and particularly on the life of a Godfearing woman, is in total opposition to the Tora attitude. Even though their humble opinion is that they intend to help, they have no idea about a life of purity and holiness, and the fear of sin, so that they only cause destruction.

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The same issue of the Jewish Tribune published three letters in English that responded with polite attacks on Rabbi Deutsch’s announcement: ‘‘To deprive a patient of treatment and therapy that could be essential to their well being, must surely not have been the intention of the notice.’’ More aggressive: ‘‘Amateur dabbling in this area causes negative outcomes and may, God forbid, lead to suicide.’’ This writer tartly suggests that before telling people with phobias, depression, and OCD to consult rabbis rather than a psychologist, ‘‘success rates for Rabbis for particular conditions ought to be objectively assessed and published.’’ One is struck by the two separate worlds of terminology even in this brief encounter: wicked-evil-sinners-purity-holinessdestruction versus negative outcomes–success rates–objective assessments. The ultra-orthodox reader will feel at home with

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the first group and ill at ease with if not mistrustful of the latter, while the clinician’s reactions will be the reverse. In May  an Israeli authority, Rabbi Shmuel Wosner, head of the Bnei Brak religious court, wrote to the same paper concerning the study of psychology by women: ‘‘It is as clear as the sun, and so I have learnt from experience, that occupations such as these change the pure thoughts of Jewish women, and also can cause such things as are difficult to write about.’’ Subsequent to this debate, the following advertisement appeared in the paper:   The Aneini Confidential Listening-Line In view of the recent correspondence concerning the danger of consulting secular-trained psychiatrists, we wish to make it known that ‘‘Aneini’’ 3 is merely a ‘‘listening-line’’ and gives no medical or psychiatric advice whatsoever. It is manned by strictly orthodox personnel and as such has the       . T  C: A B C C

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The attitude of rabbinic authorities within the ultra-orthodox community is clearly stated in these responsa and announcements. The reasons for the rejection of psychiatry in general and psychotherapy in particular are various. Change: A community that exists to perpetuate traditional commandments, values, and even styles of clothing will invariably react with suspicion to changes that are incorporated with alacrity by the rest of society. Ultra-orthodox leaders will initially respond by considering whether the new development  / Provision of Mental Health Care

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threatens existing values. To date, movies and television are forbidden but computers and cars have been deemed not to be active purveyors of immorality, although they imply a more materialistic outlook on life. This attitude is epitomized in a statement by the Hatam Sofer which was adopted as a slogan by the reactionary members of the ultra-orthodox toward modernity: ‘‘That which is new is forbidden by the Torah.’’ Psychotherapy, a child of the twentieth century, is therefore suspect just because it is new. The godless product of godless people: The founders and first generations of psychotherapists were known for their atheistic attitudes, which they often incorporated into their theories. They viewed belief in God as primitive and illusory and saw religious practice as a defense against forbidden impulses. Although ultra-orthodox rabbis have not read this literature, they are aware of the position and have clearly been told sorry tales by anguished parents and spouses. As Abraham Amsel (), a rabbi and a psychiatric social worker, related, ‘‘At the meeting with one of these [Orthodox] Rabbinic authorities, we learned, much to our dismay, that nearly all of the Orthodox Jews referred for psychiatric treatment, if treated for a significantly lengthy period, turned away from Orthodox Judaism.’’ 4 A challenge to religious authority: For ultra-orthodox Jews, the ultimate authority is their rabbi. Therapists may consider their treatments to be problem-oriented and value-free and may insist that they do not tell their patients what to do.5 Patients, along with their spouses, families, and friends, however, are only too aware of the powerful influence exerted by the therapist. The experiences of transference, dependence, and idealization of the therapist, and above all the sharing of one’s most private thoughts and fantasies in a regular and intimate setting unquestionably challenge the patient’s other affiliations. The therapist is experienced as an authority figure, problems are laid before Attitudes Toward Mental Health Care / 

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her, and important life decisions are often reached in the course of the therapy. In the more traditional psychodynamic therapies, the therapist is intended to be a facilitator rather than an adviser. In the cognitive-behavioral therapies, however, with an emphasis on applying problem solving to current issues (Hawton and Kirk, ), the patient will be encouraged to define problems, present a range of solutions, evaluate their advantages and disadvantages, make a decision, test it out in the real world, and report the outcome to the therapist. In a society in which problems are usually presented to the spiritual leader in the form of a she’ela and teshuva (a question and rabbinic responsum), this type of therapy is a challenge to the social order. With the passing years and the development of many alternative theories and practices of psychotherapy, the omnipotence previously accorded psychotherapy has abated. Recent demands by insurance companies for proof of the effectiveness of a psychotherapy have damaged the practice’s image. Further, recent generations of psychotherapists have included priests and rabbis. Today there are religious psychodynamic psychotherapists who treat orthodox and even ultra-orthodox patients.6 Freedom from restraint: A view that recurs in the responsa quoted above is that psychotherapy is permissive, working to release the overinhibited patient from her pathological defenses, so that she becomes free of restraint. This is equated by the therapist, or so the responsa assume, with being free of anxiety and misery, but it is seen by the ultra-orthodox as contrary to their quest for righteousness and closeness to God. Rabbi Yehoshua ben Levi was aware of a basic contradiction when he stated the Jewish attitude toward freedom and restraint: ‘‘There is no one so free as he who studies Torah’’ (Mishnah Ethics of the Fathers :). The acme of religious expression is involvement and commitment. These are concepts diametrically opposed to  / Provision of Mental Health Care

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the release from a paralyzing conscience that is seen as the root of neurotic suffering. Sex, sex, and more sex: Freud’s presentation of the central role of sexual development in everyday life and in the development of neuroses produced shock, revulsion, and rejection among many of his contemporaries (Kiell, ). The subsequent proliferation of alternative theories has reduced the sting, but the underlying theories remain unacceptable to ultra-orthodoxy. The attitudes toward sexuality that have become associated with psychodynamic theories recur in many of the above responsa. Sexual behavior is a subject saturated with possibilities for sin. Two of the Ten Commandments relate to sexuality, one overtly (‘‘Thou shalt not commit adultery’’) and one covertly (‘‘Thou shalt not covet thy neighbor’s wife’’), and sexual prohibitions abound in the Torah and the Talmud. For Freud the strength of sexual taboo was fuel to his claims, but in a society with strict sexual mores, theoretical formulations and open discussions on these subjects are forbidden. The community or the individual: Perhaps the most telling distinction between psychotherapy and ultra-orthodoxy lies in the emphasis of the former on the individual’s search for happiness and fulfillment, and the latter’s emphasis on the individual as a person bound to God and the community. The extent of the difference in social attitudes is clear in the following statements by two ultra-orthodox leaders. In a responsum on the status of suicide, Rabbi Sternbuch () states, ‘‘The prohibition on suicide is based on the verse: ‘And surely your blood of your lives will I [God] require’ (Genesis :). In such cases, suicide may be an act of murder. Just as when one person has killed another and is guilty, so too in the case of killing oneself is one guilty, for a person is not master of his own body’’ (p. ). In the introduction to a text by another rabbi on how to overAttitudes Toward Mental Health Care / 

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come depression, the highly respected Rabbi Hayyim Sheinberg of Jerusalem wrote the following definition, illuminating a community’s attitude: ‘‘Depression prevents a person from performing God’s commandments, stops him from studying Tora and praying with devotion, and nullifies good thoughts in the service of God’’ (Pliskin, ). For Rabbi Sheinberg, the suffering caused by depression is not central. The seriousness of depression lies in its impact on one’s ability to live as a God-fearing Jew. According to the Torah, the Ten Commandments handed to Moses on Mount Sinai were carved on two tablets. The first five deal with our relationship with God, the second with our relationship with our fellow humans. An individual is principally the sum of his relationship with God and his relationship with his fellows. This self-definition of the committed member of the ultra-orthodox Jewish community underlies the attitudes toward therapies quoted in this chapter. Anyone attempting to provide mental health care for the community must accept this underlying attitude.

 Improving Mental Health Care for the Ultra-Orthodox

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The factors that prevent a working relationship between patient and therapist exist within the psyche of the therapy-providing  / Provision of Mental Health Care

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community as much as within ultra-orthodox society. In this chapter, we shall suggest ways of surmounting these difficulties to improve the quality of care for the ultra-orthodox community. As a consequence of the relatively large size of ultra-orthodox families, more than  percent of all Jewish primary school children in Jerusalem are ultra-orthodox.1 Within a single generation, the ultra-orthodox may become the largest group in the Jewish community in the nation’s capital. The issue of provision of mental health care is therefore of immediate practical importance. How service providers facilitate the meeting of two cultures is relevant wherever such an encounter occurs, be it in Israel, with its new Soviet and Ethiopian immigrants, or in any country whose community mental health services attempt to reach out to minorities. W  M P M H C   M

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Most societies are composed of a majority culture and a few or many minority cultures. The services in such a society are generally provided by majority group members and express the values of the majority culture. Members of a cultural group will inevitably feel more comfortable with people who share their values and perform and understand the same religious rituals or social practices. Members of a minority group who seek help from services provided by majority members will inevitably feel like strangers, and the accepted values will differ from and may clash with their own. This general impression has been supported by many studies: an epidemiological study in Los Angeles in the s found that whites see a mental health specialist three times as often as Mexican Americans (Hough et al., ). Stanley Sue ()

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studied , referrals to seventeen community mental health centers in Seattle from  to  and found that both African Americans and whites were overrepresented among the referrals while Asian Americans and Hispanics were underrepresented. Following his reports, CMHCs were set up in minority areas, and staff were employed from among the minority populations. When the study was repeated a decade later, researchers found that most minority groups were now turning to CMHCs for help as much as the majority group (O’Sullivan et al., ). Sue also found that referrals from the majority culture usually attended more therapy sessions, whereas minority referrals were more likely to attend only one. O’Sullivan’s follow-up study found that the dropout rate was the same for the different ethnic groups and that all groups attended a similar number of sessions. Overall, patients were attending four times more sessions than had done so a decade before. A more complex picture emerged in the study of all patients in treatment in CMHCs in Los Angeles County from  to . Patients from ethnic minorities (Asian Americans and Latin Americans) were underrepresented in the CMHC, while African Americans were overrepresented. Nevertheless, once in treatment, ethnic minority patients did not tend to terminate treatment prematurely nor did they attend fewer sessions. African Americans were more likely to drop out early and do less well. Both length of treatment and outcome were related to ethnic matching between the patient and the therapist, a finding that supports the need for therapists who speak the language and come from the culture of the patient (Sue et al., ). An evaluation of interventions in a psychiatric unit in East London showed that minority group referrals had a far greater chance of receiving medication or electroshock therapy and a lower chance of receiving psychotherapy (Littlewood and Cross,

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). Further, studies in the United States (Snowden and Cheung, ; Flaskerhud and Hu, ) and the United Kingdom (Lloyd and Moodley, ) have found that blacks are more likely to be hospitalized than whites. A similar pattern of service utilization is found among ultraorthodox referrals to our CMHC in north Jerusalem:  percent of the referrals are ultra-orthodox, although they constitute more than  percent of the community; this implies that the nonultra-orthodox are three times more likely to seek public psychiatric help than the ultra-orthodox. Furthermore, among the referrals from the ultra-orthodox community to the mental health services, the more serious psychiatric diagnoses of schizophrenia and major depressive disorder with psychotic features are far more common, while milder diagnoses such as anxietyrelated and adjustment disorders are more common among the nonultra-orthodox referrals. From these diagnoses it appears that the ultra-orthodox referrals are more likely to be viewed as mentally ill, requiring physical treatment, while the nonultraorthodox are more likely to be viewed as simply in distress and in need of the more personal contact of a talking therapy.2 We can conclude that, consistent with other studies of the use of CMHCs by minority cultures, the ultra-orthodox are underrepresented among new referrals, are more likely to drop out of treatment, are more likely to be diagnosed as having severe psychopathology, and are offered a narrower and more biological spectrum of treatment possibilities. Uncomfortable though it may be for service providers, the inevitable conclusion is that a significant proportion of the ultra-orthodox community prefers not to use the available CMHC facilities. Some of the reasons will be evaluated from the vantage point of the therapeutic setting, the patient, the therapist, the therapeutic alliance, and the therapeutic options.

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P   T S Stigma A series of epidemiological studies in the United States, Puerto Rico, Taiwan, Hong Kong, India, and Canada have estimated that the prevalence rate of diagnosable psychiatric disorders in the general population is about  percent (Regier et al., ). It is estimated that in the United States more than  percent of the general population will seek some sort of help for psychological distress every year; only about  percent will see a mental health specialist in a public clinic (excluding those with addictions). Every year more than  percent of the population of north Jerusalem visits our CMHC, so the local figures are not dissimilar from those in other countries with organized mental health services. The reason for the fourteenfold disparity between the number of sufferers and the number treated in CMHCs throughout the world is that everyone hesitates before seeking psychiatric help, as it involves first acknowledging the existence of a psychiatric problem and second taking the risk of being seen entering a psychiatric establishment and thus being labeled mentally disturbed by others. The fear of stigma is a powerful social force, active in every society. We noted earlier that nonultra-orthodox referrals are three times more common than ultra-orthodox referrals to our CMHC. This means that only about one in fifty ultra-orthodox sufferers seeks such help. This figure does not include those who turn to their family doctors or to private-sector psychiatrists. Our impression is that the ultra-orthodox are proportionately high users of the private sector and that stigma is a real deterrent to the use of public services. A history of mental illness is a major blot on any family pedigree. One family member with a psychiatric record affects the  / Provision of Mental Health Care

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marriage prospects of everyone else in the family. For this reason, families will try to hide a psychiatric problem by sending the ill member abroad or seeking help from a private practitioner. Everything is done to avoid making the existence of mental disorder public knowledge. In providing a community psychiatric service for the ultraorthodox community, we have tried several methods of overcoming the fear of stigma. We decided that changing the name of the clinic and removing the identifying plaque on the wall of the building were too transparent. The community labels an institution on the basis of its function, not by the title on the wall of the building. In a more sophisticated attempt, we expanded our liaison work with the local general medical centers, actually treating patients there so that psychiatric referrals were lost within the anonymity of all those waiting to see a family physician. Within a short time, however, it became known that on Tuesday mornings a psychiatrist sat in Room , which destroyed the confidentiality of those observed in the waiting room outside. We who provide private care for the ultra-orthodox are aware of the importance of preventing patients from meeting one another. We have managed this by establishing our offices in a nonultra-orthodox neighborhood, providing separate entrances and exits, and trying not to schedule ultra-orthodox patients in consecutive hours. It is not unusual for a patient to call before an appointment to confirm these details.

The Clinic as a Feature of a Godless Society

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Ultra-orthodox society perceives the clinic as a component of secular Israeli society, and this impression is confirmed by many small details. The sign in Hebrew outside the building anImproving Mental Health Care / 

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nounces it to be a community mental health center. The term used for mental is nefesh, which means ‘‘soul’’; the literal meaning of the Hebrew words for mental health is ‘‘health of the soul.’’ This implies that the psychiatrist is a healer of souls. The word nefesh was first used in Genesis : to describe the vital force in animals. In this sense, the term ‘‘health of the soul’’ would refer to veterinary medicine. Later mystical writings, however, refer to the godly soul. Moralistic religious writings of the past two centuries deal extensively with how to improve one’s spirituality, and this is expressed as refining the godly soul. Soul has an undoubtedly religious and spiritual meaning in religious Judaism.3 Ultra-orthodox Jews may well be offended by the secularization of a term that has distinctly religious connotations. They may question whether a nonreligious therapist with secular knowledge can possibly understand the godly soul. The basic mental health terminology used by the rest of society may be experienced as presumptuous and offensive by the ultra-orthodox. In addition, as we enter the building of our mental health center, we see posters on the walls, some of which depict the human form. Most ultra-orthodox homes have few or no pictures. What pictures there are will be portraits of rabbinic leaders or pictures of the countryside, in fulfillment of the ban on artworks showing the human form: ‘‘And you should be very careful . . . lest you make a carved idol, the likeness of male or female’’ (Deuteronomy :). Are the pictures modest? The strength of feeling behind this issue is apparent when we recall the campaign in Israel in  against immodest advertising posters. Activists within the ultraorthodox community set fire to shelters at bus stops until the posters were withdrawn. Do the scenes in the pictures represent secular or Zionist values?

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After the patient arrives, he or she may now be asked to sit in a room with a therapist of the opposite sex, creating the problem of yihud, being alone with a person of the opposite sex, which is forbidden by religious law. In response, he or she may ask to be interviewed by a therapist of the same sex or bring a companion to the session or leave the door of the interview room ajar, to avoid infringing the laws of modest behavior. Further, since few if any of the staff are even modern orthodox, the women may be wearing trousers and sleeveless blouses, and married women may have uncovered hair, all of which are forbidden and considered immodest by the ultra-orthodox. Patients may respond by averting their eyes throughout conversations with female secretaries or therapists, increasing the sense of strangeness and separateness, usually important components of the initial contact. All these problems arise before the therapist and patient have even said hello. P   P: W D H A G I W?

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The system of health care in any society is a construct of the interactions between the people involved: therapists and patients (Kleinman, b). Every culture has its own illness behaviors, beliefs, and expectations. Arthur Kleinman calls the importance of understanding these features of health care the ‘‘clinical reality.’’ The various aspects of health care are all being researched in individual cultures, particularly when therapists and patients come from different cultures. Failing to appreciate these differences is as important in diabetes (Greenhalgh et al., ) as in psychological disturbance (Bilu and Witztum, ) and can lead to serious misunderstanding (Heilman and Witztum, ). Before we discuss the expectations of ultra-orthodox

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patients, pause a moment to ponder the expectations of the average therapist in the average interaction. The ‘‘problem’’ with most patients is that they don’t perceive things ‘‘correctly’’—that is, in accordance with the therapist’s worldview. Patients whose problems are psychological may complain of physical pain instead of realizing its psychological basis and may blame others as the cause of their unhappiness rather than recognize their own role in their situation and misery. Furthermore, patients usually misunderstand the role of the therapist. They expect the therapist to tell them what is wrong with them or their situation and what they should do about it. Therapists, perceiving this ‘‘error’’ again and again, give a weary sigh and an indulgent smile of superiority, and they once more set out to teach the patient that it is she who must discover what her real underlying problems are and she who must discover the solutions. (When the patient then fails to keep her second appointment, the therapist declares that she lacks insight and motivation for change.) Most patients have different expectations, and it is hardly surprising that only the elite, the ‘‘psychologically minded,’’ enter psychotherapy. If we observe the ultra-orthodox community, we find that when its members have a problem in everyday life, they approach their rabbi or teacher, irrespective of whether the problem is religious, ethical, or personal. The rabbi is asked a she’ela, a question, and responds with a teshuva, an answer. Although the process of dealing with problems requires a wide-ranging understanding of the principles and practice of Jewish law, each problem is posed as a question, the solution as a series of clear instructions. The contrast between these two perspectives is striking. There is a marked gap between the nondirective expectations of the mental health therapist and the pragmatic teshuva expected by the ultra-orthodox person.  / Provision of Mental Health Care

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And if you do not listen to the voice of the Lord your God, and keep and do all his commandments, then all these curses shall come and overtake you. . . . . . . . . . . . . . . . . . He will smite you with madness and blindness and astonishment of heart. . . . . . . . . . . . . . . . . . And the Lord will give you there a trembling heart, and failing eyes, and despair of soul.’’ (Deuteronomy :,,) According to the Torah, depression and madness are not random events. They are God’s means of punishing sinners, and their purpose is to lead the sinful nation back to repentance. And when all these things happen to you, the blessing and the curse. . . . . . . . . . . . . . . . . . . . . . . . You shall return to the Lord your God, and you will listen to his voice. (:,) For the individual, despair of the soul has one solution: The Lord is near to the broken-hearted, and he saves those with a depressed spirit. (Psalms :)

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Knowing this background, and remembering the guidance Rabbi Nahman gave to those suffering from despair, we can understand why the ultra-orthodox community has been reluctant to seek help from a mental health professional rather than a rabbi. Are the ultra-orthodox, as a consequence, sentencing themselves to unnecessary suffering? The response of

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the ultra-orthodox to distress will be considered further in the next chapter. P   T Living in the cultural and political reality of Israel, the therapist is likely to be affected by prejudice. Consider the following encounter: An ultra-orthodox man asks the receptionist whether he can speak to the clinic director. He takes out a religious text that deals with religious problems in medical treatment and shows the director a statement (a teshuva) that religious persons in need of psychological help must go only to a God-fearing therapist. The man asks to be seen by such a person. The director replies curtly, ‘‘If you wish to be seen by a religious therapist, I suggest you encourage your children to go to university and complete a training in medicine and psychiatry, so that we can employ them in our clinic. Until this happens, there can be no ultra-orthodox therapists.’’ This interaction exemplifies one of the central patient-therapist tensions: does either person in this encounter have the right to impose his values and rules on the other? For the visitor the opinions of the religious leaders have absolute authority. He shows the director the text. The director, aware of religious law yet not religious himself, recoils from the outstretched book, thinking, ‘‘I do not recognize the authority of this text. Why are you coercing me into looking at it? Do I force you to go into a movie house or art gallery, which I love and you reject?’’ The ultra-orthodox visitor repeats simply what the authority in the book states. The director’s mind starts to wander farther: ‘‘I have no need of you or your books, yet you need me and my kind to build your houses, heal your sick, grow your food. You are leeches. And if that is not enough, you even think you are holier than  / Provision of Mental Health Care

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I am because you sit all day reading your antiquated Talmud.’’ Since he knows that most ultra-orthodox do not serve in the Israeli army, especially the fighting battalions, the director may feel even more antagonistic toward the patient: ‘‘I risk my life, my children risk theirs, and we protect you!’’ Although religion and the values attached to religious practice undoubtedly increase the tension of such encounters, the underlying issue concerns the prejudiced attitudes held by most therapists encountering minority patients, be they whites treating blacks, Israelis treating Arabs, or secular Jews treating ultraorthodox Jews. Gorkin () has noted several typical reactions of therapists with minority patients: the therapist can show an exaggerated interest in the cultural aspects of the patient’s situation, losing sight of the patient’s personal problems; he can behave as though therapy is a haven from prejudice, from which he, the therapist, is totally free; or he can be aggressive, viewing the patient’s culture as inferior (Greenberg and Witztum, a). If the patient is newly religious, thrilled by his discoveries of a life of belief, the therapist may even feel envious of the confidence and enthusiasm he sees (Spero, ). T T A

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The initial contact between the patient and the therapist is of vital importance. When a patient first comes for help, the therapist commonly asks the accompanying family member or friend to wait outside while he speaks alone with the patient in order to encourage the patient to speak openly, in this way helping to establish a close personal contact. Often ultra-orthodox patients are accompanied by their rabbi or teacher. Not only does the teacher come in with the patient, but he often places his seat between the patient and the therapist. Does the therapist ask him to leave? Improving Mental Health Care / 

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From the outset, the patient has been feeling suspicious, uncomfortable, and ashamed. In fact, it was his teacher’s idea and exertion of authority that brought him to the clinic. Consequently, the teacher perceives himself as responsible for the patient’s welfare in this alien environment. For the therapist to insist on sitting alone with the patient would be to challenge the teacher’s authority and thereby immediately clash with a basic feature of religious life, the social hierarchy. In our experience, the therapist should allow himself to be the minority in the room.4 The person being interviewed is the therapist. The object of the interview involves the therapist’s assessment of the patient and—no less important—the teacher’s assessment of the therapist. Other issues in the patient-therapist interaction can arise. Patient and therapist will have different communication styles. For example, different cultures may maintain different interpersonal distances. If the ultra-orthodox patient comes close to the therapist, too close for the therapist’s comfort, the therapist may involuntarily withdraw to a further distance, and the patient may sense this as rejection. These impressions are also immediately conveyed to the patient by the distances between the chairs in the interviewing room ( Jensen, ). Body movements and facial expressions also vary between cultures. Western psychiatrists are usually aware of the value of eye contact, and many ultra-orthodox referrals appear with their heads down, eyes on the floor. Until they know how the average ultra-orthodox community member relates to strangers and to strange situations, therapists should be wary of reaching conclusions and should not feel excluded when greeted in this way (D. W. Sue, ). Language is also a barrier. The official language of modern Israel is Hebrew, while that of the ultra-orthodox world is Yiddish. Today, few nonultra-orthodox people speak Yiddish, while  / Provision of Mental Health Care

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most ultra-orthodox speak Hebrew, so that communication is possible but not on the patient’s home ground. This language change has a further significance. A century ago, the leaders of the ultra-orthodox community were aghast at the secularization of Hebrew. At that time, Hebrew was a written rather than a spoken language; it was the language of prayer and religious study, the holy language. It was inconceivable that someone should go to the bathroom and call from there in the ‘‘the holy language’’ or that newspapers and novels should be written in words from the Torah. Worse, the use of ancient words for new concepts represented an erosion or even an active attack on religious life. A term used to describe the most ineffable of biblical accounts, the vision of Ezekiel, was now used to describe electricity, while the term previously reserved for wondrous stories of miracles in the Talmud was used to refer to fairy tales. This was reductionism, and the ultra-orthodox community considered itself under attack. These issues have long been supplanted by more immediate concerns, but the ultra-orthodox world continues to teach and converse in Yiddish and refers to Hebrew as the holy language. It is likely that when an ultra-orthodox patient converses in Hebrew, he feels that it expresses the views of the dominant majority, not those of his world. For many reasons, then, the therapist should converse with the ultra-orthodox patient in Yiddish if possible. Every community has its own vocabulary. Western patients will often describe themselves as depressed or sad while the ultra-orthodox speak either of ‘‘fears,’’ a term with a variety of meanings, or of mara shchora, literally, black bile, or melancholy. If the therapist does not understand these terms, he may feel mystified or irritated. Stanley Sue and Nolan Zane () analyzed the therapeutic alliance in the cross-cultural patient-therapist interaction and Improving Mental Health Care / 

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concluded that there are two main factors with which the therapist must be concerned: his credibility in the eyes of the patient, and his ability to ‘‘give’’ something to the patient early on in their contact. Credibility is a universal factor in creating a therapeutic alliance. If you are told that you must see a specialist, your first thought is, ‘‘Whom do people I trust recommend?’’ This factor is even more critical when the patient comes from a minority culture, uneasy in its contacts with the majority culture. It becomes a greater problem in the ultra-orthodox community, in which the medical profession has dubious credibility.5 Often patients will be sent by their rabbi to ‘‘see Doctor X’’; to ignore the source of this recommendation is to undermine the success of the contact. If Doctor X cannot see the patient, it is vital that he at least assure the patient that he will hear all the details and be involved in the decision. The concept Sue and Zane call giving something to the patient includes such factors as reassurance, normalization (‘‘Many go through what you are going through’’), clarification, skills acquisition, goal setting, and anxiety relief. Attention to giving during the first contact with the patient increases the therapist’s credibility and discourages dropout. Achieving these goals with someone from another culture is far from simple and, as will be discussed, may well require working with the person accompanying the patient. We conclude this chapter with ten suggestions for how to make the mental health profession better serve the ultra-orthodox community. . The ultra-orthodox society is highly structured. Community mental health services must respect that structure and work within it. Jacob Buchbinder (), himself an ultra-orthodox psychologist, explains: ‘‘In general, the ultra-orthodox therapist is not likely to be among the elite in the hierarchical ultra / Provision of Mental Health Care

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orthodox society. This is because the elite in a religious culture is comprised of religious scholars and theologians. The therapist is aware of the relatively humble status and understands the necessity of having the legitimacy, support and advice of religious leaders of stature’’ (p. –). . Community care of the ultra-orthodox should include regular contact with religious leaders so that they get to know individual mental health workers and each side comes to respect the other’s opinions. In this way, the professionals will gain credibility within the ultra-orthodox community. . Therapists involved in work with the ultra-orthodox require regular supervision, including discussion of their attitudes and feelings toward the religious group. It is important to know something about the ultra-orthodox way of life, but knowledge alone will not produce good therapy. . Therapists who work in this area should, if possible, speak Yiddish and have a basic religious knowledge. Ideally, members of the community should be employed as therapists. In this instance, such people would generally be paraprofessionals, as the ultra-orthodox object in principle to the study of psychology. They have recently started training social workers from within the community. . The results of formal testing of intelligence, personality traits, and concepts such as self-esteem have been found to vary between majority and minority cultures and among different ethnic groups. In most cases the tests contain values and norms established in Western white societies (Jones and Thorne, ). The interpretation of findings from such instruments should be cautious if used with members of the ultra-orthodox community. Testing of intelligence and orientation of ultra-orthodox patients should focus on blessings, religious festivals, and the weekly Torah reading. Asking the name of the prime minister or the names of football stars will merely increase the patient’s susImproving Mental Health Care / 

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picions and disapproval of the therapist, leaving aside the effect that having to say ‘‘I don’t know’’ will have. . Specific knowledge of the characteristic behaviors of subgroups is necessary. For Bratslav hasidim, for example, nocturnal visits to the fields and tearful prayers at the graves of the righteous are normative behaviors. . The therapist should continue working with the patient’s teachers or rabbis throughout the therapy, deferring any religious questions to them. These intermediaries, described as ‘‘culture-brokers’’ (Westermeyer, ), not only protect the patient but may also be the therapist’s advocate. If cognitive or behavioral therapy is offered, the teacher may be a valuable cotherapist. . It may be best to discuss the findings and treatment options with the patient and her teacher following the assessment, with attention to giving some relief or guidance at the first contact. . It is not a particular therapy but the therapist whose credibility is in question. All forms of therapy have been used with the ultra-orthodox community (Margolese, ), for example, cognitive therapy and behavior therapy.6 . Therapists should be wary of offering an ‘‘ultra-orthodox treatment package.’’ Sue and Zane () warn that acquiring knowledge of a culture and even developing culture-specific techniques run the risk of evolving into a cookbook approach. They compare this to a Taiwan therapist evaluating an AngloAmerican, and embarking on insight-oriented psychotherapy on the premise that, compared with the Chinese, Anglo-Americans are more self-disclosing and expressive and tend to prefer insight-oriented therapies. Individualized assessment and suggestions for appropriate treatment, with a full description and explanation, are necessary in each case. The teacher or rabbi can then decide with the patient whether to continue therapy or not.7  / Provision of Mental Health Care

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 Treating Depression in the Community by the Community ‘‘Several disciples of Rabbi Nahum of Tchernobil came to him and wept and complained that they had fallen prey to darkness and depression and could not lift up their heads either in the teachings or in prayer. The zaddik saw the state of their hearts and that they sincerely yearned for the nearness of the living God. He said to them, ‘My dear sons, do not be distressed at this seeming death which has come upon you. For everything that is in the world, is also in man. And just as on New Year’s Day life ceases on all the stars and they sink into a deep sleep, in which they are strengthened, and from which they awake with a new power of shining, so those men who truly desire to come close to God, must pass through the state of cessation of spiritual life, and ‘‘the falling is for the sake of the rising.’’ As it is written that the Lord God caused a deep sleep to fall upon Adam, and he slept and from his sleep he arose, a whole man’ ’’ (Buber, , p. ). As is clear from this story, among the ultra-orthodox crises and depression are perceived as spiritual challenges, the domain of rabbis and zaddikim. In this chapter, we shall seek to understand how the community manages such problems. We have noted that referrals are often accompanied by a ‘‘culture broker.’’ These persons are not policy makers or leaders themselves, but usually rabbis or communal members who are involved with people who have problems in their everyday lives and who cooperate with mental health workers and centers. Depression / 

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Here we present the attitudes of two such ultra-orthodox rabbis. We selected them because they deal with young men with psychiatric problems and have extensive contact with CMHCs. The structure of ultra-orthodox society is such that each leader has many followers and therefore can give only a limited amount of time to any individual. A person with a continuing mental health problem that requires long-term management will turn to such a figure to discuss his difficulties and decide whether to seek professional help. It was clear that our two rabbis had different opinions on certain topics, reflecting their personal approaches and the subgroup of ultra-orthodoxy to which they belonged. We have structured their opinions in the form of question and answer. What do you offer people at a time of crisis? Both rabbis stressed similar themes in their responses to this question: ‘‘We treat such problems within the community. We give the person with difficulties a boost, talking about belief and trust in God, saying that we must not despair, and at the same time encouraging him to discuss the situation. We tell him to strengthen his faith, for everything is from Heaven, that no man moves a finger on Earth unless guided by G-d. We tell him that the world is a very narrow bridge not just for him, and that he should cry to G-d. We remind him of the privilege of being a Jew and keeping the Torah. We encourage him to listen to soothing niggunim [tunes sung by hasidic leaders and their followers], to read stories of miracles from the lives of the great rabbis, and to learn Aggadah [stories from the Talmud)], rather than the more academic sections of the Talmud.’’ 1 Ultra-orthodox cases of depression are relatively rare at the CMHCs. How does the community handle depression? Both rabbis distinguished between what have been called exogenous (reactive) depression and endogenous (biological) de-

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pression. They readily supplied examples of situations that produced depression in young yeshiva students: the boys often find it hard to keep up with their learning and become despairing before examinations; they may become envious when their fellow students marry while they remain single. Both rabbis stated that such cases need spiritual encouragement and a change of environment, less pressure on studies, encouragement to go on outings. Their explanatory model was that if a depression was a reaction to a situation, the solution was to manipulate that situation, for example, reducing stress and encouraging distraction. In contrast, patients experiencing depression with no apparent external cause are brought to the clinic for medication, which ‘‘gets them out of it and they get better.’’ These rabbis take most of their ideas on how to manage distress from leaders in their community, although much of their work reflects an accumulation of common sense and experience. In the past few decades, leading rabbis who see many people in distress have written down their ideas. Many of these suggestions were followed by our referrals. We present them here as insight into the ‘‘folk’’ management of depression by a community. Every generation has leaders to whom people turn at times of crisis and sorrow. The Jewish people during two thousand years of exile have seen too much carnage and sorrow not to be aware of personal distress. The Book of Job is dedicated to this topic, while Psalms vacillates between praising God and thanking Him for offering comfort during times of sorrow. As we have noted, the hasidic movement can be seen as a response to the despair that followed a series of massacres. It should thus come as no surprise that the role of the rebbe or zaddik is so prominently to support, comfort, and guide, and that stories of achieving closeness to God after experiencing doubts or poverty or sor-

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row abound in hasidic literature. As Rabbi Menahem Mendel of Kotsk (–) noted, ‘‘There is nothing so whole as a broken heart’’ (Meizlish, ). Maimonides is generally viewed as the foremost codifier of Jewish law and philosopher of Judaism. His thinking continues to dominate today, and the guidelines he offered for treating depression undoubtedly influenced contemporary opinions: ‘‘Whoever has developed melancholy should get rid of it by listening to songs and musical instruments, and by walking in gardens and beautiful buildings, and being in the presence of attractive scenes that enlarge (give pleasure) to the soul’’ (Maimonides, b, chap. , p. ). Rabbi Sternbuch () explains the Torah method of healing depression in detail:

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The correct advice is to go to those healers of souls, the righteous ones [zaddikim] or leaders of Israel [the rabbis], who will show them the way and teach them to trust in God. They will explain that God’s will is always for the best, and that a little suffering replaces much suffering in the after-life, be that physical suffering, God forbid, or even more so if in the form of psychological suffering. With this help they will both come to trust in God and also rejoice in their suffering when they realize that without it one cannot inherit the after-life, as the Vilna Gaon said: ‘‘Without suffering it is very difficult to merit the after-life.’’ In the end he will be happy, for ‘‘he who trusts in God shall be surrounded by kindness’’ [Psalms :]. Many have done this and have become healed and happy. But those who have chosen the way of darkness and have unnecessarily gone to psychologists when  / Provision of Mental Health Care

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they were not counselled to do so by rabbis, they have found no blessing in it. Only Torah is the way of life, and one should not move away from it. (p. ) Rabbi Yaacov Kanievski (–), a contemporary figure to whom many turned for help with psychological difficulties, wrote the following on the management of a yeshiva student who has lost his will to live. If he is capable of holding a job as a Talmud teacher, then giving him such a responsibility would increase his interest, encourage him to study in depth, and in this way his feelings would be developed towards everything. If he is exceptionally gifted, he should be advised to edit a religious text, not of his own ideas, as he is unlikely to be capable of this, but rather a collection of the statements of others that appeal to him intellectually and emotionally. He should not write this in a snatched fashion, but weigh them carefully and be sure they are clear to him, gather them slowly, and over time he will find interest and pleasure in this task. The awakening of his emotions in this one area will lead to general improvement. If he is an outstanding student, then he should start studying with a fellow student the texts on dietary laws requisite for becoming a rabbi, so that while studying he will have an ambition to become a rabbi. If this happens, then his other feelings will follow suit. (Kanievski, , pp. –)

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The following account was written by Rabbi Yaacov Meir Shechter (), a contemporary leader who lives in great simplicity in Mea Shearim and whose door is crowded by those who Depression / 

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suffer. His understanding of the text of the Talmud that follows seems to have come straight out of a textbook on cognitivebehavioral therapy. The foundation of mental disorders and their treatment is to be found in Proverbs (:): ‘‘Anxiety in a man’s heart, he should suppress it.’’ The word used for suppress literally means decrease. The Talmud says, ‘‘Rabbi Ami and Rabbi Assi debated the meaning of this verse. One said, ‘It means: He should distract himself.’ 2 The other said, ‘It means: He should turn to others for advice’ ’’ (Talmud Yoma a). Here are two ways of bringing relief to an anxious person, but they are interdependent, and the common factor is distraction. The Baal HaTanya 3 explained this talmudic passage to mean that all emotions are products of one’s thoughts; to the extent that one succeeds in distracting oneself, the emotional state will improve. Struggling directly with a bad feeling is not only ineffective, it prolongs the disorder, increases it, deepens it, and weakens and damages the place in the brain where the sickness is located, on the same principle as the idea that ‘‘touching a wound makes it worse.’’ It is well known that a bruise or an external bodily wound heals itself through the natural processes God implanted in man’s body. The function of the doctor is to remove the external impediments and infections that keep the natural healing process from performing its wondrous function. Exactly the same principles apply to mental disorders; one must allow the body and its powers to do their own healing,  / Provision of Mental Health Care

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using the methods of distraction mentioned by the rabbis rather than struggling or touching the wound. As Rabbi Nahman said, ‘‘He who is attracted to sorrow, his sorrow will be even more attracted to him.’’ The difficulty the sufferer faces, of course, is how to achieve distraction. In a severe case of anxiety, this cannot be done, for however much one may wish to be distracted from distress, it floats to the top like oil on water. The sufferer should try to diminish the severity of the anxiety as much as he can, for when it bothers him less, he will find it easier to divert his thoughts to other things. Rabbi Nahman commented on the verse ‘‘When I was in distress, you gave me breadth’’ (Psalms :) by noting that it is within distress itself that there is a broadening. The Baal Shem Tov stated that the key to sweetening and canceling out distress lies in finding a broadening within distress.4 This is akin to the general observation that depressives tend to feel better at times of national crisis, such as war, because they are so absorbed in the events going on around them so that they pay less attention to themselves. (pp. –)

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When do you bring a person in distress to a clinic for medication or talking therapy? Psychiatrists are viewed mainly as people who prescribe medication, as one of the rabbis explained: ‘‘We don’t know what outlook on life the patient will hear from a psychologist. It can harm a boy. It is a different outlook on life. I don’t know what sort of epikores I’ll find. He [the therapist] will have no belief in God, and will say that everything is due to nature; tell the boy Depression / 

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to be more free, encourage him to eat more, go to the seaside, meet girls, in short, enjoy life. But our outlook on life is based on faith.’’ The other rabbi said simply, ‘‘We very very rarely involve psychologists. A psychiatrist can be like a physician, treating an infection, while a psychologist may interfere on matters of basic communal values.’’ How do you decide who needs psychiatric help? ‘‘Everyone is a member of certain systems: family, yeshiva, synagogue, hasidic group. The main definition of disorder in community members is that they do not fit into their system. The leaders of that system, the rebbe, rosh yeshiva, or father discuss the problem at first. If, for example, the suggested solutions are unsuccessful in the yeshiva, then the family will become involved. Only if no advances are made, will professional advice then be sought.’’ At this stage, the rabbi or teacher prefers to consult the professional alone, in the absence of the patient, describing the case and asking for advice. Only if the professional considers the case to be complicated and an interview necessary does the teacher bring the patient. The teacher, however, still thinks, ‘‘He’s not out of my hands. We will go for counseling, and the professional may then suggest medication or some other direction that I haven’t thought of, such as sport, work, or a vacation from study.’’ The three-way interview and the ‘‘intrusive’’ position taken by the teacher will be recalled at this point. The intention of the teacher is to be the go-between for the professional and the patient, who is still ‘‘in his hands.’’ What are the features you seek in a nonultra-orthodox therapist? Although one rabbi sought a ‘‘God-fearing man,’’ the other stated clearly that the therapist need not be religious: ‘‘What matters is that he understands the religious way of life and respects each person with their outlook.’’ He went on to tell of  / Provision of Mental Health Care

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a rabbi-cum-psychologist, very popular in some circles, whose advice to a young student so appalled him that he took counsel from a rabbinic leader of the community, who described the advice as ‘‘the counsel of Ahitophel’’ 5 and told him to avoid referring students to the therapist. The other rabbi commented, ‘‘Some modern orthodox therapists may be more anti-ultraorthodox than secular people, being particularly antagonistic toward the yeshiva lifestyle.’’

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P V

 

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 The Soldier of the Apocalypse In this section, we describe in detail the management of three cases. In the first, the therapists were relatively passive participants. In the other two cases, however, they undertook to join the patient’s world of concepts and performed rituals calculated to remove or improve his symptoms. The reader will have to decide whether the therapists were acting as professionals, proceeding on the basis of their training, behaving intuitively yet still as therapists, or playing games, respecting neither professional rules nor professional intentions. Each case instructed the therapists in different aspects of their work. The case of Benjamin, soldier of the apocalypse, taught us the complex, onionlike nature of every case. A brief initial evaluation would have revealed psychotic experiences in this young man. Explaining to him that he needed medication and giving him a prescription would presumably have driven him away. Instead, the therapists’ wish to understand (and help) and the patient’s wish to be understood (and helped) led to the gradual revelation of layer after layer of his narrative. The description, bizarre to the Western ear, of battles with forces of evil, was not necessarily psychotic, and the therapists’ ability to listen and react but not overreact was crucial. Ultimately, the story of Benjamin teaches us that even after we learn an enormous amount about a person, we as therapists must come to terms with how little we understand. When early maps of the world were drawn, the central point was its spiritual focus, the city of Jerusalem. Even today, three major religions direct their prayers toward it, nationalist groups 

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wish to possess it, and the world powers devote a disproportionate amount of energy trying to make it the ‘‘city of peace’’ (the literal translation of the name Jerusalem). A city so exposed to public glare, the object of such powerful religious and political yearnings, is a magnet for those seeking to make a dramatic and significant impact on the course of history. When the biblical Jacob returned to Israel and was about to be reunited with his brother, Esau, who had previously vowed to kill him, he prepared for the meeting in three ways: he prepared for battle (Genesis :), he prayed to God (v. ), and he sent Esau a generous gift (v. ). In this chapter, we shall tell the story of another man who went to meet the powers of evil. He, too, used more than one approach, but he prepared no gifts. To try to understand Benjamin is to grapple with the forces of fundamentalism and dualism, best compared to the psychological defense mechanism of splitting, in which the shadows and the gray areas are dismissed and the world is seen as black and white, good and evil. Three unrelated issues will emerge from his story: his apparently unconscious enactment of a collective myth of battling with evil, the dilemma a therapist faces when he discovers that his patient is engaged in dangerous activities, and what might be described as the sting in the tale. T B  E

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Unlike most referrals from the ultra-orthodox world, Benjamin was unaccompanied when he first came to the mental health center. Twenty-five years old and single, he was bearded, dressed in black, untidy, red-eyed, tired, anxious, and miserable. During the interview, he stared at the wall. He seemed closed in on himself and made no emotional contact. He spoke in a hushed monotone, saying no more than was necessary. He complained that he could not sleep, eat, or concentrate and that he was both / Case Studies

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ered at night by voices that gave him commands, although he would not divulge what these were. He described finding that he had done things he could not recollect—for example, he had wreaked havoc in his parent’s house—and he hinted that mysterious forces might be at work. Benjamin’s parents had come to Israel from Morocco before he was born. Although they came from orthodox homes, they brought up their three children in a traditional atmosphere. Because Benjamin was an unruly child, prone to violent outbursts of temper, he was sent to a school for special education. Over a period of three years he became more settled and completed his education at a regular school. During his mid-teens he was drawn to an extreme right-wing political group and participated in setting fire to a left-wing printing press. The extent of his educational success was demonstrated when, at the age of eighteen, he was selected for army service in an elite paratrooper commando unit; eventually he became an instructor in parachuting and sabotage. However, shortly before the completion of his service, he was involved in an incident whose repercussions continue to this day. His unit was caught in a border terrorist ambush. His closest friend became separated from the others during the action, and when the men sent up a flare they mistook him for the enemy and opened fire. Benjamin ran to his friend, holding him as he died. He was very distressed and could not clear his mind of the sight of his friend’s head covered with blood. He became depressed, irritable, and impulsive, found no interest or purpose in his army service, and was referred for psychological help. Shortly before his discharge date, he befriended a baal teshuva, who introduced him to the study of kabbala. Benjamin decided to enter a baal teshuva yeshiva and train as a scribe of religious tracts. The atmosphere of the yeshiva was exclusive and excluding. Students prayed, studied, ate, and slept together. They left the Soldier of the Apocalypse / 

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building only to pray at one of Jerusalem’s holy sites. No secular subjects were studied, and discussion of topics unrelated to the Torah was discouraged. For the next four years Benjamin found relief in this fervent atmosphere from the inner tension that accompanied him throughout life. It was only after several clinic visits that Benjamin felt he could entrust us with details of his secret life. He and a friend had started studying kabbala together, apart from the group, reading the Zohar, the Book of Visions, and the Book of Transmigrations. One day they read the Zohar’s comments on the biblical text ‘‘When you go out to war against your enemy’’ (Deuteronomy :). Benjamin’s friend became very excited, swaying in his chair, his eyes closed in concentration. He whispered to Benjamin that here was no coincidence; it was ordained that they should study this text. This was an injunction to them to go and do battle with the enemy, Samael and Lilith, the lords of the demons, to force them to intervene in the natural order of things and hasten the redemption of the world. Using his knowledge of kabbala and his skill as a scribe, Benjamin secretly wrote out God’s full name and other declarations of God’s unity on parchment in Hebrew and Aramaic. Next he wrote out the names of various angels combined with his own name and that of his friend, to create a spiritual task force to counter the forces of darkness. The parchments were to be used to call up the lords of the demons, whom they would attack, and the end of the world would ensue. To ensure success in the battle, they inscribed one of the names of God on a parchment in the shape of a sword. Once the preparations were complete, the two friends excitedly performed a ceremony declaring God’s unity. They immersed themselves in a ritual bath, put on clean clothes, and recited militant biblical verses emphasizing redemption and victory over evil. They then retired in a state of tense anticipa / Case Studies

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tion. After a brief sleep, Benjamin beheld a terrifying apparition: the shining form of a man wrapped in flames chasing him. A second apparition followed: a line of shabbily dressed men, all either blind or hairless, standing staring at him. The shining form was at the end of the line holding a sword, and it screamed, ‘‘You thought to beat me? It is I who will beat you!’’ Benjamin understood the shining form in flames to be the devil and the hairless shabby men to be demons. He added, ‘‘The sword of parchment that I had prepared for battle with the devil, it was double-edged.’’ From the moment he saw the apparitions, demons started to pursue Benjamin day and night. They told him to kill people and then commit suicide, threatening him, ‘‘We will strike you with madness. You will inherit Hell twice over.’’ Their appearance was always the same: blind, bald, beardless, hatless, and disgusting to behold. At this time, he was again preoccupied with the death of his friend in the army and used magical practices to call up his spirit, wishing to find out whether his own bullets had killed the man and seeking his forgiveness. His friend appeared, muttering incomprehensibly, and then screamed that Benjamin’s actions were defiling souls. Shortly before Benjamin’s first appointment at the clinic, he began experiencing a recurring nightmare of a file of soldiers falling one by one, including his dead friend. Benjamin also fell and felt himself being lifted onto a stretcher, whereupon he awoke. Terrified by his experiences and wishing to purify his soul, Benjamin left Jerusalem for the town of Safed in northern Israel, which had been the center of Jewish mystical study in the sixteenth century. Here he sought out rabbis knowledgeable in kabbala and at last shared the secret of his attempts to ‘‘hasten the end.’’ He told of his suffering from the demons and pleaded for help. The rabbis were astonished that he had dared to do Soldier of the Apocalypse / 

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what the greatest of them had not attempted and knew not what to advise him. One suggested that he undertake a series of eighty-four fasts, but Benjamin felt himself too weak for such an ordeal. During this period, his comrade-in-magic saw similar apparitions, became very withdrawn, and was admitted to a psychiatric hospital. As the voices of the demons continued to disturb him, Benjamin’s concentration deteriorated, and he became unable to study or write religious tracts. In an attempt to shake off the demons, he removed all the books on mysticism from his apartment, left the yeshiva and went to live with his parents, and took a job as a security guard. The demons, however, pursued him to this nonholy environment and continued to order him to commit suicide. On one occasion, when they were taunting him after a day’s work, he shot at the wall in his parents’ home in an attempt to get the demons to let him be. In the two weeks before his referral, he became very depressed and suicidal, suffering anorexia and insomnia. Benjamin perceived himself and his companion as two who ‘‘glimpsed and were damaged. The vessel was too weak to handle so much light; it cracked and was then broken to smithereens.’’ The first phrase was used in the Talmud to describe Ben Zoma’s fate (see Chapter ). The concepts of light and the breaking of vessels are derived from Isaac Luria, innovator of kabbalistic thought in sixteenth-century Safed. According to Luria, the first recipient of the divine light and peak of creation were humans. This light had to be held in vessels for the purposes of creation, but the light proved too strong and the vessels broke. Luria considered the breaking to be the origin of evil in the world. Benjamin was using the terms more concretely, to refer to the attempt he and his friend had made to achieve great heights of

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spirituality (vessels containing much light). However, neither of them was sufficiently strong spiritually (the vessel was too weak), so that they were destroyed and the powers of evil prevailed (the vessel was broken). The attempt by Benjamin and his companion to battle evil was provocative and presumptive. It was provocative in that they were actively raising the forces of evil, and it was presumptive because they knew that their teachers discouraged regular students from going beyond the written page of Zohar. Only the most sanctified of rabbis was allowed to know when and in what way he could engage in any type of activity based on the study of kabbala. Benjamin’s motivation to go so far beyond his role can be understood in his initial incentive to become ultra-orthodox: his guilt over his possible role in the death of his friend and his distress at the loss of one so close to him. At worst, his own death in this new battle might compensate for his guilt, at best, the soul of his dead friend and his own soul would find peace. The glimmer of hope in his dreams was that after he, too, fell he was raised on a stretcher: Benjamin had sought psychological help and gradually entrusted his therapists with many details; he seemed to believe that his own vessel could be reconstituted. D A

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Benjamin’s brother became involved in his care. With his encouragement, Benjamin began to take a low dose of neuroleptic medication at night to calm the effect of the demons when they were most persistent. Over the next two months, Benjamin became more trusting of his therapists and revealed less-spiritual but more-worrisome attempts to hasten the redemption. He decided that if his actions led to a decree that he must die, then better to die helping his people. He would blow up the Temple

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Mount and destroy the mosques on it. He had already made some preparatory reconnaissance visits dressed as an Arab and acquired a detailed picture of the security arrangements. He also informed us that he possessed explosives and the expertise to use them effectively. When Benjamin revealed these plans, we found ourselves in a dilemma: Should we maintain medical confidentiality or inform the security forces? Meanwhile, we debated with Benjamin about the attitude of Jewish law: Was it permissible to attempt to hasten the end, or was this meddling with God’s management of the world? Benjamin promised to consult with us before taking any further practical steps. We demanded that he hand his weapons and ammunition back to the army, and with his consent we contacted the army to ask that he be discharged from further service in order to avoid further temptation. Benjamin was due for regular army service in the next weeks, and to be absolutely sure that nothing went awry we contacted a senior mental health officer in the Israel Defense Force. Benjamin handed in his weapons, a detonator, and a large amount of dynamite. He also rejected a request from an extremist organization to train them in methods of sabotage. The interpretation we gave Benjamin that was culturally meaningful to him was that the voices telling him to blow up the mosques were demons and did not express his will. The function of his therapists was to help him withstand the counsel of the forces of evil. He received a combination of antidepressant and neuroleptic medication with good effect. His apocalyptic yearnings diminished, although they did not disappear. To our relief, they became theoretical and speculative. Shortly afterward, however, his comrade in demon fighting was discharged from the hospital, and the two renewed their activities. They went to the Knesset and marched around it seven

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times while reciting declarations of God’s unity for magical purposes. They added another three turns to include three politically disruptive government ministers in their magic. Their actions attracted the attention of the Knesset guards, who apprehended them. The two explained that like Joshua at Jericho, they were removing a source of unholiness from society. The guards smiled indulgently and released them. In the clinic, Benjamin stated confidently that these actions would bring about serious instability in the ruling party. Four weeks later, the leader of the three ministers, Ariel Sharon, resigned. Benjamin informed us that this was the first step toward toppling the ruling party, to be followed by ‘‘waste and void’’—total chaos (Genesis :)—which would be the forerunner of the Redemption. We too smiled indulgently, relieved that Benjamin’s means of ‘‘hastening the end’’ were at least more peaceful than his previous attempt. Shortly afterward, early in , the government fell. ‘‘Who has the last laugh?’’ said Benjamin at his next visit, grinning from ear to ear. Benjamin continued to improve. He became calmer and less depressed, the demons’ voices quieted, and he left his parents’ home and found work in Safed preparing the bodies of the dead for burial. This work had a high spiritual if not financial reward, and it may be that Benjamin regarded it as atonement for his previous sins, particularly his role in the death of his friend. Over the ensuing months Benjamin maintained regular contact with his therapists while continuing to live in Safed. He was now taking large doses of antipsychotic medication (chlorpromazine  mg), which diminished the ferocity of his nocturnal experiences and nightmares. The demons, however, continued to order him to kill himself. On one occasion, he took an overdose of pills, but ‘‘the hand of providence made me nauseous and I vomited it all up.’’

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After several months he stopped coming to the clinic but would phone at irregular intervals for moral support and encouragement. Then the calls ceased. We heard no word from him for a year. Calls to his parents’ home and to the Safed burial society revealed that he was alive, but he never called back. T S   T Then suddenly, a year later, Benjamin phoned to say that he was living in Jerusalem and studying to be a teacher at a religious seminary. He was calling because he wanted our help in trying to reverse his army discharge. We were intrigued to learn that he had apparently recovered from his florid and persistent paranoid psychosis. The young man who came to see us two years after his first visit bore little resemblance to the shabby, bowed-over man we had known. Benjamin was now neatly dressed in pullover and jeans and wore a knitted yarmulka, emblem of the modern orthodox. More striking, however, were his erect bearing and direct gaze. He spoke freely, tending to examine and analyze what he was telling us. His attitude toward his previous studies and actions was that the study of kabbala was foolish, a dabbling in forces more powerful than himself; the ceremonies he had performed now embarrassed him. He told us that both he and his friend had left the yeshiva. In fact, his companion had left religious practice altogether. Benjamin considered him an unstable person and a negative influence, and they spoke only occasionally. Benjamin’s attitude toward his career choice was ambiguous. Teaching was not really suited to him, and the seminary was not academically satisfying. However, he saw teaching as a mission to guide children so that they would not be drawn to the wrong

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choices. As he spoke, he looked away, and we felt the force of his feelings, aware that once again in his life, Benjamin wished to do tikkun, to affect the course of the world. Neither extensive interviewing nor projective psychological tests revealed any evidence of current mental illness or any deterioration because of a long-term mental illness. Despite these findings, we had to explain to him that in view of his previous history, the army would probably want to wait several years before considering his request for reinstatement. Benjamin was visibly disappointed. During a subsequent session of psychological testing, he told the psychologist that everything he had said two years earlier was a pack of lies. He had fabricated his story at the encouragement of his fellow yeshiva students in order to evade further army service. His therapists were stunned and called Benjamin. He confirmed that his previous account had been a fabrication. If this were so, he was asked, once you had the army discharge, why go to the trouble of acquiring and handing over actual firearms and explosives? Why continue coming from Safed for follow-up sessions? Why continue collecting prescriptions? Benjamin could not provide convincing answers. Late that evening, Benjamin called, this time retracting everything he had said earlier that day. His explanation was that he had been very disappointed when he learned that he would not be recalled to army service in the near future and thought that if he claimed his previous account had been a bluff, he might speed up his recall. After his first ‘‘confession,’’ he had spoken to an eminent religious leader, who had rebuked him for lying to his physician and insisted he ‘‘straighten the crooked’’ (Ecclesiastes :). He thanked his therapist for not being angry with him during his earlier call and insisted that this time he was telling the truth.

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A The Battle with Evil: Collective Myth and Personal Delusion The expulsion of the Jews from Spain in  was one of the most traumatic episodes for the Jewish people, terminating a golden age of culture and development and launching a period of insecurity, homelessness, and wandering. Many Jews took comfort in the belief that their exile was the forerunner of the coming of the Messiah. Stories abounded of miracles and people with mysterious powers, and there was an upsurge of interest in mystical studies. Among the legends that emerged during that period of suffering was the story of Rabbi Joseph de la Reyna, who sought to bring about the salvation of the world. Rabbi Joseph was a mystic who decided to trap the forces of evil and destroy them. He chose five of his pupils and went out into the desert, where they purified themselves in preparation for the great deed. Using mystical means, they succeeded in calling up the lords of the demons, Samael and Lilith, in the form of black dogs. Rabbi Joseph and his pupils bound the demons, but in a moment of weakness Rabbi Joseph allowed them to sniff a grain of frankincense he was holding. The demons were able to loosen their bonds and disappeared. Rabbi Joseph was punished and lost his faith.1 Benjamin had not heard about Joseph de la Reyna, although the legend is alluded to in the books he studied with his friend. The features common to both accounts are the attempt to destroy Samael and Lilith by use of kabbalistic stratagems and the outcome, in which the destructive forces turn on the mortals. Two dissimilar features are the form of the demons (black dogs in the original account and blind hairless men in Benjamin’s

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story) and the method of mortal downfall (loss of faith versus insanity). Nevertheless, Benjamin’s description of demons is consistent with accounts in the Zohar of blind hairless men in old clothes and of the lord of the demons as a figure wrapped in flames. Similarly, in the account of the four eminent rabbis who entered the garden of mystical speculation discussed in Chapter , both outcomes are mentioned: one rabbi, Elisha ben Avuya, lost his faith, and Ben Zoma became psychotic. It is clear that the story of Rabbi Joseph is a cautionary tale for students of mysticism. Novice mystics hear about various manifestations of evil, such as demons created by our daily sins, and learn that our actions have an impact in the upper spheres, mending defects and combating the forces of evil on ‘‘the other side’’ (sitra ahra). Fledgling mystics are warned not to be drawn into an attempt to do battle with evil and not to tread where their greater ancestors stumbled. It is perhaps not surprising that Benjamin was a baal teshuva, who lacked the restraints of generations of practice but felt burdened by the weight of sins committed before he became religious. This combination of factors emerged in Benjamin’s case as a personal venture in the garb of a collective myth. It is noteworthy that scholars treated the story of Rabbi Joseph de la Reyna as a fable until Gershom Scholem discovered that he was an important historical figure during the twenty years after the expulsion of the Jews from Spain.

What If a Patient Reveals That He Is About to Blow up the Temple Mount?

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The Temple Mount, in the Old City of Jerusalem, is the site of both the First Temple, built three thousand years ago by King Soldier of the Apocalypse / 

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Solomon, and the Second Temple, destroyed by the Romans in the year . The only remnant is the western or Wailing Wall, the remains of the supporting wall to the Second Temple, which has become a center for pilgrimage. Today, the Temple Mount contains two mosques and is also a holy site for Muslems. Shortly after the Temple Mount came into Israeli hands in , the Rabbi of the Wailing Wall announced that the problem of mosques being on the site would be resolved by God, although individuals ‘‘might well lend a helping hand.’’ In  a psychotic tourist set fire to the El-Aksa Mosque, and in  a baal teshuva with a past psychiatric history ran amok on the Temple site. Since then several groups of Jewish activists have been caught planning destruction, setting up ladders, or laying explosives there. Benjamin’s intention of blowing up the Temple Mount was particularly worrisome given his expertise with and apparent access to explosives. Our only justification for not informing the military or police authorities immediately was that he told us his plans only at a late stage, when he was contemplating abandoning them. We actually photographed the detonator, fusewire, and other appurtenances but declined Benjamin’s offer to bring the dynamite into the clinic so that we could hand it over to the army.

Fact or Fiction: The Sting

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Disentangling mental illness from malingering can be difficult (Palermo et al., ; Turner, ). In Benjamin’s first recantation, he claimed that he had presented himself at the clinic as mentally ill in order to get out of army service. Subsequently, his clinical presentation had completely remitted, and he reappeared

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at the clinic with the avowed purpose of seeking our help in reversing the previous recommendation, for his army discharge would adversely affect his chances of finding a teaching post. According to this second version, his every visit to the clinic had been made for a purpose, which is consistent with a diagnosis of malingering. There were many puzzling features to his story. The series of confessions and denials made us doubt the veracity of any of Benjamin’s accounts. His symptomatology seemed too florid to be true, although other chapters in this book have presented sufferers with similar symptoms; it may be that these dramatic clinical pictures reflect their cultural sources. The apocalyptic themes in Benjamin’s account were also very dramatic and seemed to come from a novel rather than real life. However, the personal variations on the collective myths suggested that he had not intentionally copied them. That Benjamin had been genuinely mentally ill was suggested by the very real nature of his armamentarium and the fact that we were the ones who suggested an army discharge—and then only after several weeks—by the lengthy period he remained in follow-up once the letter was in the mail, by the repeat prescriptions, and by the quality of his contact with us. Our continuing relationship with Benjamin leads us to believe that the only deception was his ‘‘confession’’ of malingering. In follow-up he frankly discusses the experience of being pursued by demons and his plans to blow up the Temple Mount. Additional support for the veracity of Benjamin’s initial account is the fact that his brother, an unsophisticated, simple-spoken man, was concerned about Benjamin’s condition and would never have abetted an attempt to evade army service.

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Benjamin’s Diagnosis Benjamin is a young man with a powerful fire burning within that led him to special education, extremist political organizations, a fringe ultra-orthodox yeshiva, and a desire to hasten the redemption by the use of practical mysticism and explosives. For a whole year he was withdrawn, depressed, and pursued by demons. It is possible that Benjamin was suffering from delayed posttraumatic stress disorder, a psychological condition that appears after severe trauma, such as witnessing the death of a friend. Benjamin’s recurrent nightmares of the event and his depression support this view. Hallucinations like Benjamin’s demons have been reported among Vietnam veterans. In his case they may also reflect the content of his mystical studies and the cultural beliefs of his North African background rather than the presence of a psychotic disorder. The delayed appearance of the condition may be attributed to his study of kabbala, which revealed to him that past sins create demons, thereby reviving his feelings of guilt at his friend’s death. Alternatively, the burning man who pursued Benjamin and his attempts to raise his friend from the dead can be understood as features of pathological grief. His attempts to hasten the redemption and rectify the country’s political situation can be seen as a projection of feelings of guilt and an attempt to atone for his actions. Benjamin may have suffered an episode of major depressive disorder with psychotic features (the voices telling him to kill himself, visual hallucinations of devils pursuing him, poor concentration, sleep and appetite disturbance), which is now in remission. This would explain the excellent recovery. Another possibility is that Benjamin experienced a single, albeit lengthy, episode of schizophrenic psychosis, with a surprisingly good remission. Hallucinations, delusions, a low level  / Case Studies

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of social functioning, and a good response to antipsychotic medication support this idea. An interesting alternative diagnosis is atypical dissociative disorder with psychotic features. This condition, rarely seen by Western psychiatrists but commonly reported in India, is consistent with Benjamin’s florid symptomatology, his report of having carried out actions he could not later recall, and his excellent recovery. Still another possibility is folie-à-deux, in which a weaker personality is drawn into the web of delusions of a seriously mentally ill person who has a powerful influence over him, until both share the same system of paranoid beliefs. Benjamin’s partner in magic was clearly more ill than he; Benjamin improved in his absence and returned to his apocalyptic activities on his reappearance. But if Benjamin’s friend were the cause of his illness, Benjamin’s psychopathology ought to have remitted completely in his friend’s absence. This did not occur. Finally, perhaps Benjamin’s illness was the price to be paid for trying to hasten the redemption. As Benjamin understood himself, ‘‘If the vessel [the student] is too fragile to contain the awful light that pours into it, then it is damaged. Now I have atoned and am whole again.’’ Over the years, we have become well acquainted with Benjamin, yet we cannot assign a diagnostic label with confidence. Our contact with him has always been both exciting, a reflection of his inner fire, and bewildering, reflecting his insatiable search for meaning. We have been uneasy armchair observers of the strength of fundamentalist belief and the actions of the soldier of the apocalypse.

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 The Healing Power of Ritual We have mentioned that it is critical in working with patients from a minority culture for the therapist to have credibility and be able to give the patient something meaningful at the beginning of the intervention. We here present two cases to illustrate these ideas. In the first case, neither goal was achieved; in the second both were. S’ S  E’ M

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Samuel came to see us when he was fifty years old. He was accompanied by his twenty-three-year-old son Eli, who preceded his father into the room and sat in the chair nearest to the therapist. With mild reluctance Samuel assumed the ‘‘patient’s chair,’’ but he spoke freely and articulately. For the previous five months, since Eli’s marriage, Samuel had been depressed: he had stopped eating, he hardly slept, and he could not bear being separated from his son. When Eli and his wife would get ready to leave the house, Samuel would start to feel sick and faint; once he even fell to the floor. He would become particularly excited if the young couple were alone in one of the rooms of his apartment, although he was unable to explain what he feared was going on there. Samuel’s wife had died twelve years earlier. ‘‘It was a wonderful marriage; we were the happiest of couples. . . . My only comfort after my wife’s death has been my son Eli. We have always been very close. I tell him everything, everything I have is for

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him. . . . I have married and divorced twice in the past ten years. Since Eli’s marriage, I can’t cope; I am depressed all the time; I go to work and sit crying. I want to die; I can’t bear to be away from him.’’ Eli, a well-dressed yeshiva student, sat back quietly during these remarks. When he was asked for his comments, he agreed that he and his father had indeed always been very close—so close that his brothers were envious, feeling that their father loved him more. On the other hand, he had always felt that he could not study away from home; he had never even gone on overnight trips with his school, knowing that his father was anxious when he was away. The present situation was terrible for him. His wife was furious, and they had started arguing about his father and other matters. He did not want to lose her but did not know how to handle the situation. We discussed how Samuel’s dependence on Eli had given Samuel great support after his wife’s death but was now proving destructive. Samuel said that he understood the problem but could do nothing to change his behavior. He was depressed and had no interest in living as things were. Eli became visibly angry but declined to respond. We felt the power of Samuel’s dependence, expressed by his tears, faints, and threats, and also the impotence of Eli, which was modified by his irritation. We told Samuel that we thought that he was in fact a strong person. His achievements were considerable, and his depressive response was understandable. With the aid of medication he would regain his strength. Samuel was disappointed that we did not instruct his son to be more attentive and submissive to his father. He did not like the idea of medication and took his prescription reluctantly. Samuel arrived alone for his next appointment. He explained that his son could not come; Eli was angry. He and his wife ar-

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gued continually about Samuel. She wanted the two of them to move away from Jerusalem, but Eli did not see how he could. Samuel claimed that the pills we had prescribed had not helped. He still cried a lot and could not bear to be alone, although he slept a little better. We believed that Samuel was rejecting our help, particularly our authority. We asked whether he had a rabbi with whom he consulted. No, he replied. We discussed alternative outlets for Samuel, such as taking classes in the Talmud or visiting friends, to take the pressure off Eli and his wife. ‘‘I cannot,’’ he replied, ‘‘I have no interest in these things; I would rather die.’’ At the end of the interview, we repeated our belief that he was a strong person. We asked Samuel to increase the dosage of his medication. He was not happy but agreed to do so. Samuel did not appear for his next appointment and did not call. We tried to call him several times; three months later we eventually caught up with him. ‘‘I am well,’’ he said. ‘‘I went to see a rabbi who told me to visit the graves of the righteous. So I went to Tiberias and stayed a month, visiting graves and saying Psalms. Then I visited the kabbalistic rabbis in Safed. They blessed me, gave me prayers to say, and encouraged me to stay. I returned to Jerusalem briefly, but I may give up my work here and live in Safed. The rabbis would like to introduce me to a match for marriage. I am much happier. I no longer cry. ‘‘My son? Oh, he is fine. He and his wife have left Jerusalem. No, I don’t think I need your help. Goodbye.’’ Our impression was that Samuel had a dependent personality. He had transferred his dependence on his wife onto his son. His son’s marriage had destroyed the support system he had created, and he responded with an adjustment disorder with depressive features. Psychotherapy, whether insight-oriented or supportive, did not carry sufficient authority for Samuel; only the au-

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thority and community of the society of northern Israel’s kabbalists provided the framework for him to restructure his life and release his son. We do not know how long this solution will last; presumably it will depend on the continuing ability of the community and his prospective wife, if any, to contain his need for support. We present Samuel’s course of ‘‘treatment’’ here to demonstrate the limitations of conventional psychiatric approaches in his kind of situation, as well as the capacity of the community as an institution and religious rituals in the form of prayers, visits to shrines, and sessions with rabbis to provide support and relief. Both traditional healing practices and modern psychotherapeutic approaches are based on a myth of healing that includes an explanation of illness and health, deviancy and normality. In traditional societies, the myth is compatible with the worldview, often religious, shared by the patient and therapist. The traditional healer—a shaman, for example—makes a diagnosis by performing certain acts and then offers a remedy which can involve drugs or the performance of specific symbolic acts and incantations. According to Jerome Frank (), the efficacy of these procedures lies in the patient’s expectation of help and his perception of the healer as possessing a special power. But it is not simply in traditional healing practices but in all health care systems, including modern psychotherapy, that explanatory models held by patients and practitioners guide the choice among therapies and therapists and lend personal and social meaning to the experiences of sickness. The relationship, or lack of one, that existed between Samuel and his therapists is a clear example of the conflict that can emerge when the patient belongs to a subculture or religious group whose beliefs and explanatory models differ widely from those of the mental health establishment. What we said had

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little meaning to Samuel; who we were gave him no confidence in our ability to help. We were unable to say, ‘‘Samuel, my son, our sorrows in this world are a trial for us. You must strengthen yourself (that is, strengthen your faith) by going to the graves of the righteous. Ask them to pray for you, to give you strength enough to trust only in God. You must study more Torah. Although you have encouraged your sons to learn, you have neglected your own learning. You must go to a yeshiva and sit there and learn, and ask God for strength.’’ This could be described as a cognitive-behavioral approach. Samuel’s dependence on his son is not analyzed directly, but he is told that he lacks faith, implying that he is depending on his son rather than God, a spiritual weakness for which there is tikkun, a remedy. Samuel’s difficulties are reframed in terms that tie him to God, his rabbi, the Torah, and the community. He is instructed by his rabbinic authority to pray for greater trust in God, an act of cognitive restructuring. He is then given behavioral exercises: visit graves, spend your day studying the Torah in a yeshiva. He is kept both busy and challenged, with the support of the learning community. En passant, his dependence on his son is rechanneled. Can a mental health worker reframe not only his patient’s distress but also his own perception of his patient’s difficulties by using idioms that are meaningful and acceptable for the patient? Strategic psychotherapists attempt to resolve the incompatibility described above by adjusting to the patient’s worldview. Within the context of cultural therapy, they try to help patients articulate their symptoms and solve their problems in the framework of the prevailing idiom and metaphors of their unique cultural background. We shall describe here a form of cultural therapy in which we were able to use these differences successfully (Witztum et al., ).1

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T C  E: S  P A Ezra, a twenty-four-year old married man, had been a baal teshuva for two years. He was brought to the clinic by his brother because of ‘‘bizarre behavior.’’ During the previous six months, while immersed in study of the Zohar, he had begun to hear voices and dream of his late father as a threatening black apparition. He engaged in ascetic practices such as frequent fasting, visited the graves of zaddikim, and ritually lit candles on these graves and in his house. All these behaviors became more frequent when his first child, a girl, was born, four months before he came to the clinic. Ezra had to be led into the room. We were immediately struck by the contrast between his brother, immaculately neat in a suit, with well-trimmed beard, upright stance, at once establishing a presence of concern and dignity, and Ezra, who looked like a scarecrow in clothes that were much too large for him. He sat bowed over, did not initiate any contact, and replied to our questions only if we repeated them several times. His answers were vague, never giving any details. He seemed not to know where he was or even what the name of the weekly Torah reading was. His brother told us that Ezra experienced nightmares in which he saw his father dressed in black, wearing a sad, suffering expression. This condition had worsened after his daughter was born. A native Israeli of North African origin, Ezra was the younger of the two boys. Their father had been a successful and respected man before he emigrated, but in Israel he had been unable to find regular work and became increasingly morose and withdrawn. He began to drink steadily and often slept in his own vomit. One night when Ezra was fifteen years old, his father asked him to bring him a glass of water and stay by his side, for he felt The Healing Power of Ritual / 

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ill. Ezra brought the water and remained until his father dozed off. Then, repelled by the smell of alcohol, he left his father alone for the night. The next morning his father was dead. Ezra blamed himself for having left his father to die. He cried for several days, avoided company, wandered the streets alone, and ate little. Following their father’s death, Ezra’s older brother became a baal teshuva and went on to train as a rabbi. Ezra’s course was different. Neighborhood friends offered him hashish, which softened the pain he felt over his father’s death, and he moved on to opiates. For a year he neither worked nor studied. When Ezra was seventeen, his brother persuaded him to stop taking drugs and enter military service. With support from his family, he completed three years in the army. Two years before his referral he too became a baal teshuva and began to study kabbala. He married after an introduction, and when his wife became pregnant, he began praying for a son to name after his late father. Ezra was very distressed when his wife gave birth to a daughter. He began to hear a voice which he identified, after reading some books on kabbala, as that of a personal angel. But instead of protecting him, this angel had come to punish him for the neglect that had led to the death of his father. The angel ordered Ezra to chastise himself by frequent fasting, abstaining from sexual relations, and wearing tattered old clothes. This self-affliction, the angel said, would eventually bring him forgiveness. At his own initiative, Ezra also began to visit gravesites of Jewish saints, praying there for his father’s soul and for his own forgiveness. He acquired an eight-armed candelabrum similar to one in the kabbalistic text the Book of Raziel, which he lit in his house at night.

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Phase  of Treatment: Confronting Grief While Restricting Its Expression Our first impression was that Ezra was psychotic. It was clear that the appearance of his father in his dreams and the angel’s demands for self-affliction represented a resurgence of his guilt over his father’s death, while the birth of a daughter became a lost opportunity for atonement; in effect, Ezra was continuing to grieve. At the second meeting, we prescribed a small dose of antipsychotic medication. With his brother’s help, we pointed out to Ezra that Jewish law forbids mourning a dead relative for longer than a year. Further, Jewish law perceptively states, ‘‘He who grieves for more than a year is not grieving for the deceased one.’’ In this way, we acknowledged Ezra’s grief and sense of guilt while giving his suffering a context. At our request he brought a photograph of his late father to the next session and for the first time wept openly as he gazed at the picture (Ramsay and Noorbergen, ; Witztum and Roman, ). Although he hardly spoke, we felt that his sense of trust in us and our capacity to contain his suffering were growing. From week to week we noticed that he became more open and communicative, so we asked Ezra to take an important step toward completion of his unresolved mourning by writing a letter to his father requesting forgiveness and permission to continue to live (van der Hart, ). A week later, Ezra brought his letter to the session and read it aloud, crying and trembling:

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Father, I just want to ask for your forgiveness and pardon. I know that I am to blame for your death, but I ask forgiveness. I did not know that this is how it would turn out. I want to see you alive. But only say, ‘‘I forgive you.’’ Until I see you alive, I will not The Healing Power of Ritual / 

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believe that you have forgiven me. I have an angel that helps me to afflict myself. Please appear to me. I do not want to be reincarnated as a stone,2 and therefore I cry the whole night. I wait for the angel to teach me mystical secrets of the upper spiritual worlds. Then I will know that you have forgiven me. Ezra told us that he had felt a certain relief from his suffering after he had written the letter and was sleeping a bit better. But he continued to punish himself in his habits of eating, dressing, and sexual relations and persisted in his frequent visits to gravesites of zaddikim and the ritual lighting of candles at home. We told him that he was behaving like a person suspended between death and life. In effect, we were reframing his condition in a comprehensible and less fearful form. We said that we were surprised by the instructions of his personal angel, for such an angel should be protecting instead of punishing him. We asked Ezra to change his tattered, dirty jacket because it was inappropriate for a religious student, and he complied. According to both traditional rabbinic thinking and cognitive-behavioral theory, an improvement in his outer appearance could influence his inner world for the better. From Ezra’s comment at the end of his letter to his father, we surmised that despite his suffering, Ezra was actively pursuing an ecstatic religious experience, which would signify to him that God (and his father) had forgiven him. Only then would he permit himself to resume enjoyment and involvement in everyday life. At the fourth meeting, his brother reported that Ezra had removed his dirty jacket for a day. But when his angel had warned him that he would be reincarnated as a stone, he had put it back on. Nevertheless, Ezra did show some overall improvement. He was less depressed, more alert, and less self-neglectful. With his  / Case Studies

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brother’s help, we negotiated an agreement with Ezra that he would have his coat dry-cleaned. We now asked Ezra to try and discover the angel’s name and intentions: was it a personal angel advancing his welfare or an evil spirit in disguise? At the fifth session, there was a marked deterioration in Ezra’s condition. More afraid of the angel, he had refused to change or clean his clothing. We suspected that his progress had been too rapid, his sense of guilt still too weighty; the angel had successfully halted our progress. After some discussion, Ezra agreed to remove his dirty coat after the upcoming Ninth of Av, a Jewish day of fasting commemorating several national tragedies that occurred on this day. This compromise halted his regression and even gave it cultural respectability. Ezra had been unable to ascertain the name of the angel but told us that it belonged to the inner circle of the angel Raziel. (Raziel is an important angel whose name implies that he is connected with the ‘‘mysteries of God.’’) Ezra added that he summoned his angel by lighting eight candles aligned in a specific geometric form and reading from the Book of Raziel. It was apparent at the next two sessions that Ezra was improving. He began to smile a little and even made eye contact on a few occasions. However, he still spoke only a few words. The angel responded to this symptomatic improvement by ordering harsher ascetic practices, including greater fasting. In the eighth session, Ezra reported that he planned to go on a pilgrimage to the gravesite of the Holy Ari (Isaac Luria) in Safed and to the graves of other saints in Tiberias. During the ninth session, he haltingly recounted his pilgrimage experiences: he had recited kabbalistic penitential prayers, but he still felt the angel was ‘‘deep inside.’’ The angel continued to make him believe that his father had not forgiven him, so he was forced to go on with the afflictions. These now included halting his medication. With his brother’s help, we were able to The Healing Power of Ritual / 

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persuade him to resume his medication, to which small doses of clomipramine, for depression, were added. Ezra appeared for the tenth session wearing a fashionable new hat. He reported that the angel now wanted him to mourn the destruction of the Temple in Jerusalem instead of the death of his father. We pointed out that this mourning is practiced in the Hebrew month of Av, which had just ended. Ezra began to cry. We then offered a positive interpretation of his behavior; we noted that Elul, the current Hebrew month, is the proper time for self-reflection about deficiencies in one’s spiritual condition. We considered Ezra’s response to be a sign that he was catching up with normal life: he realized that since he had been busy mourning his father, he had not paid attention to the appropriate mourning of the destruction of the Temple during Av or to soul searching during Elul in preparation for the Jewish New Year and Day of Judgment. His brother reported that Ezra was able to concentrate better and had resumed his study of the Talmud. He studied alone, however.

Phase : Active Measures to Counteract the Angel

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By the eleventh and twelfth sessions, Ezra was functioning better, but, as ordered by his angel, he was practicing more selfaffliction by eating less and he was reluctant to take any medication. We decided that we had to confront his angel directly and order it to stop punishing Ezra. Our intention was to reframe the functions of the angel so that it became an ally and friend instead of an agent of punishment. This intervention would accord with Ezra’s cultural beliefs. His brother was excited about the possibility and accepted our suggestion that the three of us serve as a lay Jewish religious court for this purpose. We planned to enact this ritual procedure during the next session.  / Case Studies

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What actually happened during the ritual deviated from our original design. Ezra’s brother regarded the angel as a mystical phenomenon with definite power; he therefore believed that it was better to get rid of the angel than to try to neutralize its effect and, in his role as head of the court (by virtue of being a rabbi) he pushed the ritual in this direction. In retrospect, we realized that he believed that any connection with the angel was deleterious for his brother. In spite of all our attempts to respect and appreciate this attitude, we viewed the angel as an inner psychic phenomenon reflecting Ezra’s depression, grief, and guilt, and therefore thought we should try to manipulate it as a means of bringing about therapeutic change. Ezra and his brother were late for the next session. We felt that this reflected their ambivalence and fear about the upcoming ceremony. Nevertheless, Ezra arrived carrying a shopping bag containing candles, book, and matches, so we decided to proceed. His brother locked the door, turned off the lights, and closed the windows and shades, in effect transforming the room into a setting foreign to its usual identity—a place where a religious event could take place. Ezra set the candles he had brought in the form of an eight-stemmed candelabrum. After he lit them, we ceremonially stated that a Jewish court of three was formally constituted. Leading the ritual, Ezra’s brother asked that one of us read the formula from the Book of Raziel that Ezra used to summon the angel, a formula originally used to neutralize the impact of Ashmedai, the king of demons. During the reading, Ezra began to sway, moving his body and head in an increasingly rhythmic, vigorous manner. He began to join in, adding his own ecstatic sing-song of a two-note phrase, with increasing volume and force. He seemed to enter a trancelike state. Suddenly he gave a shout and then fell silent. The atmosphere of the room was charged and thick. It was clear that Ezra was experiencing the angel. I spoke quietly and clearly: The Healing Power of Ritual / 

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‘‘Ezra, we would like you to talk to the angel. Tell him how much you have suffered, and ask him whether he thinks the time has come for him to forgive you. Tell him you would like to befriend him.’’ I paused momentarily. His brother now spoke to Ezra: ‘‘Tell him to get out. He is disturbing you. He is stopping your study.’’ The brother was very tense and announced abruptly that on behalf of the court he ordered the angel to cease afflicting Ezra, never to return, ‘‘neither for good or bad, nor even to teach him mystical secrets.’’ Ezra was stunned and confused. We sensed his ambivalence toward the angel: he respected his brother as a father yet was attracted to the angel. I explained to him that from then on the angel had no right to disturb him, since it belonged to another realm. His brother, tense and emotional, told Ezra to blow out the candles in one breath, thereby ending the ritual. The court of three declared that Ezra was now a free man, under his own control. His brother hurriedly opened the shades and windows and turned on the lights. He handed us the copy of the Book of Raziel, saying that Ezra no longer needed it. Ezra nodded his agreement.

Follow-Up

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Ezra was smiling, relaxed, and neatly dressed when he came to the next session, the fourteenth, and his brother reported several significant changes: Ezra now ate normally, he had resumed sexual relations with his wife, and for the first time he had played with his nine-month-old daughter. Nevertheless, the angel had appeared unsummoned on several occasions. He had instructed Ezra to study the Talmud, a nonmystical work, and to read from the kabbalistic book Tikkunei Zohar. Since Ezra still showed depressive affect, the antidepressive medication was increased.  / Case Studies

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At the fifteenth session Ezra reported that the angel had not appeared during the preceding week. His brother added that Ezra functioned better at home, was more sociable, and took much better care of himself and his appearance. At the next session, Ezra said that the angel had appeared twice, on both visits praising his Torah study. Moreover, whereas his father had previously appeared in Ezra’s dreams as a mournful old man in a black cloak, he now appeared dressed in white and bathed in light. His brother remarked that Ezra had ‘‘chosen life’’ (Deuteronomy :). He felt that Ezra was still saddened by the loss of his father, so the two brothers had decided to study the Mishnah and chapters from the Zohar together in order to elevate the soul of their father. Such studies are culturally normative for Sephardic Jews. His brother added that they would soon hold a memorial meeting in honor of their late father, where they would ritually celebrate the completion of their study of the Mishnah. This development was a clear example that Ezra was working through his guilt and grief using normative rituals. He had forsaken his idiosyncratic, pathological behavior. In addition, the memorial meeting was an apt leave-taking ritual which would further aid the working through of the unresolved mourning. Ezra’s brother was due to leave Jerusalem to become the head of a yeshiva in another city, and Ezra and his family were planning to join him there. Four months later, Ezra came back to the clinic with his wife. He was neatly dressed and cooperative but still seemed sad. He reported that the angel had stopped visiting him, and he agreed to start taking antidepressant medication again. After two weeks his mood improved. A year after the end of treatment, Ezra remains well. He dresses neatly, takes an active role in family life, and studies full-time in yeshiva alongside his brother. Every now and then his personal angel visits him and encourages him in his studies. The Healing Power of Ritual / 

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Understanding Ezra’s Condition Any formal psychiatric examination would have concluded that Ezra was suffering from major depressive disorder: depressed mood, cessation of eating with marked weight loss, diminished interest in all activities, psychomotor retardation, strong feelings of worthlessness and guilt. This depression was associated with features of psychosis: hallucinations of the angel, both visual and auditory, and delusions of worthlessness, guilt, and punishment consistent with his mood. This was Ezra’s second depressive episode; the first followed his father’s death when he was fifteen. At that time he did not seek therapy but had apparently tried to diminish his intense pain and possibly also punish himself by using drugs. The second episode followed the reactivation of his grief by the birth of a daughter instead of the son he had hoped would atone for his role in his father’s death. The diagnosis of depression with psychotic features ignores important aspects of Ezra’s symptomatology, however. The psychotic features involved not only involuntary and spontaneous hallucinations of the angel; they also concerned his deliberate summoning of and communicating with this angel. In addition, Ezra appeared to be a highly hypnotizable subject, whose trance induction and summoning procedures were inspired by traditional mystical sources. Ezra’s spontaneous and deliberately evoked hallucinations involved trance states similar to hypnotic states, so that his quasi-psychotic experiences could be understood as a feature of hysterical psychosis, a seldom-used diagnosis (Hirsch and Hollender, ; van der Hart et al., ). This condition, described by Pierre Janet, Joseph Breuer, and others in the nineteenth century, disappeared in the early twentieth century when Eugen Bleuler defined a broad new concept that he termed schizophrenia. Interest has revived recently in cases of sudden onset, in  / Case Studies

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which the ‘‘psychotic’’ content is colorful and relates to a recent trauma or revives an old trauma. The patients do not respond to regular medication but do respond to psychotherapy, particularly hypnotherapy that works through the trauma (Spiegel and Fink, ). If Ezra’s experience of his angel is placed in the context of altered states of consciousness in cultures around the world, it appears that he was experiencing nonpossession trance states. Erika Bourguignon () distinguished between possession and nonpossession trances. In possession trances, the ‘‘trancer,’’ usually a woman, takes on the role of another personality, is active throughout the event, and usually does not recall the details later. Possession trances are induced by drumming, dancing, crowd excitement, or drugs. By contrast, in nonpossession trances, the trancer, usually a man, sees, hears, feels, or interacts with one or more personalities, beings, or forces through the hallucinatory experience. Nonpossession trances are more passive experiences; the subject will receive instructions from the spirit, which he will be expected to remember and subsequently enact. Before entering a nonpossession trance, the trancer prepares for the experience by learning what to expect and how to interpret what he perceives; nonpossession trances are usually induced through hypoglycemia caused by fasting, sensory deprivation, self-mortification, or drugs. Ezra was experiencing a nonpossession trance: he was passive and receptive to the angel’s admonitions, and he remembered them afterward. In preparation for the trance, he would fast and isolate himself. Then he would use rhythmic body movement and a repetitive melody to induce the trance and an incantation formula to summon the angel. At the root of Ezra’s symptoms was pathological mourning complicated by unresolved remorse. It can be speculated that his self-blame was a result of guilt feelings based on letting his father The Healing Power of Ritual / 

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die alone and also of a repressed wish to be free of his drunken father. Much of his subsequent behavior can be seen as acts of atonement: the use of hashish and hard drugs were a punishment, becoming a baal teshuva was an attempt to be a good son, marriage and childbirth were his chance to recover his father’s name and thereby his life, and his mystical studies were intended to purify himself and find forgiveness or escape pain through ecstatic mystical experiences. When these normative means of atonement failed, his auditory and visual hallucinations of a personal angel who provided spiritual guidance and prescribed ascetic practices and dreams of his suffering father were the final representation of his unresolved mourning.

The Personal Angel as a Cultural Phenomenon

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Ezra’s personal angel is very similar to the traditional Jewish mystical phenomenon of the Maggid, and may have been inspired by it. The Maggid, literally ‘‘one who relates’’ (see II Samuel :), is an angel or supernatural spirit that in mysterious ways conveys teachings to scholars worthy of such communications. A Maggid is thought to pass secrets to the recipient both when he is sleeping and awake and may speak through his mouth or induce automatic writing. The most famous account of a Maggid is the one recorded in the diary of Rabbi Joseph Karo. There are some interesting similarities between Karo’s Maggid and the angel that appeared to our patient. For example, Karo’s Maggid had a tendency to lecture him on morality and prescribe ascetic practices. R. J. Zwi Werblowsky (), who wrote a biography of Karo, believed that the Maggid represented Karo’s strict, guilt-ridden conscience. Critical of Karo’s sinful ways, the Maggid advised him, ‘‘Take no pleasure from

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this world,’’ and ‘‘Beware of food and drink and bodily pleasures,’’ encouraging fasting and self-flagellation. From a psychodynamic point of view, the appearance of the Maggid can be explained as a culturally sanctioned projection of a harsh superego. Culturally, it embodies key fundamentalistic religious values and ideals. Through his mystical studies, Ezra found a recognizable and culturally sanctioned form for his deep remorse in the figure of the angel.

The Personal Angel as a Dissociative Phenomenon

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According to Werblowsky, the phenomenon of the Maggid is comparable to a dissociative state. Aubrey Lewis () also regarded Karo’s Maggid as a mild dissociation resembling a hypnotic state, adding that he hesitated to consider the experience pathological because Karo’s consciousness remained clear and he retained a clear memory of the experience. Of interest for our understanding of Ezra is Pierre Janet’s ( []) definition of dissociation as the splitting off, separation, and isolation of certain parts of the personality. Often caused by traumatic experiences, these dissociated parts escape the control and often also the awareness of the habitual personality. They start to lead lives of their own and either take over the patient’s behavior or exist side by side with him. Janet’s formulation would describe the Maggid’s speaking through the mouth of Rabbi Karo. In  Janet described a devil that spoke through the mouth of his patient Achille. Indeed, Janet also suggested that Achille’s dissociative disorder was based upon extreme feelings of remorse (). Current researchers link dissociative symptoms and disorders to the experience of psychological trauma (Putnam, ;

The Healing Power of Ritual / 

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Spiegel, ). Dissociative reactions after acute trauma are conceptualized as an adaptive process that protects the individual and allows him to continue functioning, albeit often in the manner of an automaton. Dissociative states may be little more than traumatic imagery—that is, the unassimilated memories of traumatic events—but can also develop a sense of self, most clearly seen in patients suffering from dissociative identity disorder (DID), formerly known as multiple-personality disorder (Putnam, ). Ezra experienced the death of his father as a psychological trauma that evoked violent emotions, particularly guilt and remorse. His angel may be seen as a kind of alter-personality, comparable to those of DID patients. However, unlike the alters in DID, the personal angel, like demonic possession, is based on normative cultural beliefs in the existence of such supernatural beings.

Religious Ritual as Therapy

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Our strategy with Ezra was an experiment in combining two different approaches. The first, traditional psychiatry, included evaluation, medication, and support; the second was a culturally sensitive mixture in which modern strategic treatment techniques joined and utilized the patient’s own belief system. From the outset, we did not question the reality of Ezra’s hallucinations or his belief in the existence of a supernatural personal angel. Supported by the religious authority of his brother, we explained that Jewish law forbids mourning a dead relative longer than one year. Our recourse to religious sources increased our credibility, while our uniting with his brother increased our authority, helping to motivate Ezra to accept our joint guidance.

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Our instructions to Ezra that he improve his outer appearance in order to change his sense of self were also based upon Jewish tradition. Further, Ezra’s brother had discovered that his outsize clothes had come from a box in the cellar, possibly belonging to their father, and thus may have been a linking object (Volkan, ). We resolved to combine Ezra’s experiences with his mystical beliefs by dealing directly with the punishing angel. We performed a religious ritual, summoning this angel to a lay court. The cultural congruence enabled the two brothers to participate in the ritual. Taking examples and courage from therapeutic approaches used in ego-state therapy (Watkins and Watkins, ) and the treatment of malevolent alters in dissociative identity disorder (DID), we had intended to invite the angel to discuss its reasons for punishing Ezra and then negotiate a more benign kind of influence. This approach was contrary to traditional Jewish law, however, which regards such entities not as dissociated ego states but rather as malevolent supernatural beings and orders their complete removal. Attempts at exorcism are considered therapeutically contraindicated (Putnam, ). Our dilemma was resolved when Ezra’s brother stepped in and ordered the destruction of the supernatural being. Ezra’s therapy was conducted in a culturally sensitive manner and offered unique treatment opportunities. It supports a policy of strategically combining culture-specific and modern psychiatric approaches. As the course of the summoning ritual indicates, potential conflicts between modern treatment techniques based upon secular therapeutic myths and traditional religious approaches are not always easily bridged.

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 Paradise Regained            

In this chapter we again delve into a world we initially found bizarre and to which we responded as professionals with such terms as ‘‘psychotic’’ and prescriptions of large doses of antipsychotic medication.1 Our inability to help the inhabitants of this world led us to try alternative avenues, including hypnosis and guided imagery. We made assumptions about the links between events and symptoms and then tested them in the natural laboratory that is our community mental health center. We relate here a story of the apparently delayed effects of loss and recurrent trauma, and how they were mitigated by a combination of traditional psychiatric methods and traditional Jewish concepts. T C: M C  A

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A familiar picture by now in our clinic. A young man is led in by his wife. Our attention was arrested by the tall, rather stately woman, simply dressed in somber colors, rather than by the rounded shoulders she coaxed into the room. Her face was thin, her lips tightly closed; her eyes examined our faces in a way that was modest yet expectant and anxious. She held her husband’s arm gently but firmly and led him to his seat in a way that indicated the respect that she was accustomed to give him. His clothes were clean but disheveled. A tall, obese bearded man in his mid-thirties, he was so bowed over we could not see  / Case Studies

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his face, and he paid no attention to us or to his new surroundings. He moaned frequently, as if in pain. ‘‘Are you in pain? Are you suffering? Are you miserable?’’ Our questions received no response. We searched our cultural lexicon for something he might respond to: ‘‘Are you melancholic?’’ we asked, using the term mara shchora, ‘‘black bile.’’ He seemed to stop in the middle of a moan and froze into attention. What had we said that made him listen so intently? We asked him whether he heard voices and tried other stock psychiatric questions, but he responded only once more during the interview, when he shook his head to deny that he wanted to die. When we turned to his wife, she spoke quietly to her husband, asking his consent to speak on his behalf and assuring him that she would not, God forbid, offend his dignity. Their rabbi had said she must seek help and be open and honest. He nodded his consent and sat quietly and immobile while she spoke. His wife told us that his name was Avraham, he was thirtyfive, and they had five children. His parents came from Yemen. Avraham’s father was a respected Sephardic orthodox rabbi and kabbalist, who had also been his first teacher of the Torah. When Avraham was eight years old, his father was killed in a car accident on the way to synagogue. The family was not informed until two days later. His mother became deeply depressed; she did not really recover from her grief for a decade. She could not cope with caring for Avraham and his eight brothers and sisters, so at the age of twelve, Avraham was placed in an orphanage and later studied in two yeshivas. He was a serious adolescent with few friends, devoted to study and to his family. As a full-time orthodox yeshiva student, he did not have to do army service, and he married at the age of twenty after an introduction to his future wife. He was an attentive husband and father and a dedicated and

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reliable student. He studied the Talmud and occasionally read kabbalistic texts, especially the Book of Transmigrations. Twice every week throughout his life, Avraham visited the Western Wall of the Temple in the Old City of Jerusalem. One evening, during a visit to the Wall, three grenades were thrown into the crowd, killing one person and injuring many others.2 Avraham was not hit, but the force of the explosions first threw him into the air and then knocked him down. He did not lose consciousness and was not sent to hospital; he simply returned home. But over the next two weeks, his wife observed marked changes in him. He became distracted, hardly noticing his family. He was startled easily and spoke only to himself, muttering single words like shooting, dying, and explosions. The third week, his appetite became uncontrolled; he would consume huge quantities and even take food from the children’s plates. He gained  pounds in one month and developed peripheral edema and cellulitis. He became still more withdrawn. He no longer had any interest in physical contact with his wife, cried for long periods, paid no attention to personal hygiene, did not shave or change his clothes and became dirty and disheveled. He could not sleep and would call out and cry when he lay in bed. The words he mumbled were largely incomprehensible, but sometimes he said, ‘‘They want to kill me.’’ He could not concentrate on his yeshiva studies and rarely attended, so that after a few weeks he was dismissed, and his wage from the yeshiva ceased. It was at this point, eight weeks after the grenade attack, that his wife brought him to the clinic. As Avraham seemed inaccessible to conversation, yet intermittently responded to his wife, we asked her to give him increasing doses of an antidepressant. After a month, however, he seemed to be worse. He was particularly agitated at night, running about and screaming that someone was after him. We prescribed a large dose of an antipsy / Case Studies

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chotic over the next three months, but this had no more effect than to sedate him slightly. We were at a loss. P   T: R  S   T We had noticed that whenever we referred to the grenade attack at the Western Wall, Avraham became agitated, jerking his arms upward and then horizontally. We presumed that he was suffering from posttraumatic stress disorder and asked him whether it was possible that the movements he made represented the sight of people being thrown in the air and others running about in panic. Avraham nodded agreement and for the first time began to talk to us haltingly, describing fragments of the attack. Our assumption was that he was having dissociative episodes during which he relived the attack. P : U G   L  F

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The severity of Avraham’s response to the grenade attack and the prominent features of regression in his rapacious eating led us to consider that the attack at the Western Wall might have reactivated a deeper traumatic event: the loss of his father when he was eight (van der Kolk and van der Hart, ). We asked him to go home, sit down in a quiet room, and compose a letter to his deceased father, describing how full of sorrow life had been without him, and saying everything he had been wanting to say to him. To our surprise, he arrived at the next session with a letter that began, ‘‘Father, father, father, why did you leave me?’’ (See Psalms : for this phrase related to God, the Father.) ‘‘Why Paradise Regained / 

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didn’t you come when I was married?’’ The handwriting in the first sentence was age-appropriate but then it degenerated into a disorganized pattern, with large letters, typical of the handwriting of a young child. By the end of the letter it had become an illegible scribble. Similarly, when we asked him to read the letter to us, he began in a composed manner but then degenerated into screaming and hitting himself vigorously, while making masticatory movements (sucking his mouth) and rocking back and forth. We were sure our theory was correct: his eating, chewing, sucking, screaming, and self-hitting represented the behavior of an infant in severe distress. He seemed to be regressing to well below the age of eight and reliving the news of his father’s death and his emotional response, which had been reawakened by the attack. He said with great intensity of feeling that he would forever be alone, that life would never be the same, and that forever there would be only a cloud of emptiness. After this session, Avraham became more disturbed. He had outbursts of tearfulness and reported, ‘‘They want to kill me, night and day.’’ His eating habits deteriorated still further, and his rapid weight gain led to medical complications, with the result that he often missed therapy sessions. We were alarmed by his deterioration. We had theorized that his grief about his father’s death was a central issue, but his collapse convinced us that he could not yet deal with it directly. We decided to try to understand the source of his immediate distress and then confront the forces that wanted to kill him. P : U  M   V

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We already knew that from time to time Avraham would study kabbalistic texts and therefore assumed that the forces that wanted to kill him were supernatural. It is common knowledge  / Case Studies

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in demonology that to identify a force is to bring it under control. We therefore set about uncovering the mystery of Avraham’s disturbing experiences. In response to quiet but assured questioning, he told us that the visions occurred two or three times a week, usually during sleep but sometimes during the transition state between sleeping and waking. He described seeing a ‘‘being,’’ but he remained vague, calling it simply ‘‘the black one’’ and providing no more details. We now felt that we understood why he had frozen during our first interview when we had mentioned ‘‘black bile’’; he associated the term with his own terrifying experience of ‘‘the black one.’’ We told him that it was possible he was being visited by a demonic agent. ‘‘One mustn’t speak of such things’’ he answered; now we also understood his unwillingness to describe his experience. Nonetheless, we explained the importance of our having an accurate description. To our surprise, discomfort, and disbelief, he began to describe an ugly animal with red eyes and legs and feet like a chicken’s, typical of traditional descriptions of demons in Jewish folk literature. We asked his wife to keep a diary recording the visits of the demon. She told us that when they occurred he would run about shouting for help and hitting his head against the wall as if to dislodge the vision. She then added quietly, almost apologetically, that Avraham was refusing to leave the house and insisted that all the windows and doors be kept shut because people were trying to kill him. We realized how hard a time she must be having and were uncomfortable in our awareness that although we kept alighting on the various mines in the veritable minefield of psychopathology, all we seemed to be doing was setting them off rather than defusing them. Avraham’s experiences could be interpreted as paranoid visual hallucinations—often found in delirium, withdrawal states, and psychotic disorders. However, they were brief, and afterward Paradise Regained / 

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he would be alert and responsive. The antipsychotic medication was having no effect. We were convinced that he was experiencing visual hallucinations in a nonpossession trance state as part of episodes of dissociation (see Chapter ) and that the content and experience could be understood only in the light of his religious and ethnic background. Considering his state of withdrawal, the distress he continued to express, his unresolved grief, and our assumption that his experiences were of a dissociative nature, we decided to use hypnosis as a form of treatment. Through an induction of breathing exercises, Avraham entered the hypnotic state with ease. His speech became less monosyllabic, and with minimal encouragement he began to describe his experiences: ‘‘It is black, always the same, black, with red eyes, I cannot make out a face clearly, but it mocks me and threatens me, it speaks to me, it says: ‘I killed your father, and now I will kill you like I killed your father.’ ‘‘My father is there. He is in the shadows. He is sad. I cry. I call to him for help. He cannot help. I try to escape from the black one.’’ Avraham started to thrash about wildly, as if trying to escape. We were now able to understand his calls for help and his chaotic behavior during the episodes. Making sucking movements with his mouth, he continued, ‘‘When I was eight, after my father’s death, I had frightening dreams. I thought that demons had killed my father, and that was why he hadn’t come home that night. Then at night I dreamt that the demons were coming for me.’’ P : F   D

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We told Avraham that we were now convinced ‘‘the black one’’ was a shed (a Hebrew term for demon). He was alarmed to hear us use this word so openly.  / Case Studies

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One of us had some knowledge of kabbala; he had already sought advice on the subject of driving away demons from one of Jerusalem’s authorities, and we had consulted some of the available texts to arrive at the formula we now presented. We continued: ‘‘It is a demon, and he frightens you and comes whenever he wants. He comes from the ‘other side’ (sitra ahra), yet this too is part of God’s world. Is it not written, ‘The earth is the Lord’s and the fullness thereof ’ [Psalms :]? Even the devil is part of God’s world, and so God has given us special prayers, psalms, and formulas to send away the devil and other forces of darkness. We are now going to teach you a formula that has been used by generations upon generations to dispatch demons. Whenever you see the black demon, you must immediately say the following words three times over: ‘Go, go, go away because you do not belong to our world.’ Repeat it to us so that we know that you will say it correctly.’’ Avraham started to sway with rapt attention and said the formula aloud, placing great emphasis on the word ‘‘Go!’’ ‘‘Now,’’ we continued, ‘‘we have a special request. We must be sure that you are using the formula properly. We want you to make an effort to bring the black demon into your mind [a technique used in clinical psychology, known as guided imagery]. Can you now see him in front of you?’’ Avraham nodded his head vigorously in assent. It was clear that he was seeing the demon. ‘‘Now,’’ we continued, ‘‘say the formula. Slowly. Three times.’’ Avraham spoke with difficulty. His voice was husky and shaky. As he started the final repetition, his facial expression lightened and his body relaxed. When he finished, he added, beaming, ‘‘It is running away.’’ We gave him a written version of the formula to carry at all times and use in homework sessions with his wife. At the next session he reported that he had lost the paper. We suspected that Paradise Regained / 

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both Avraham and his wife had been too frightened to use the formula alone. We said nothing and repeated the previous session with similar results. Armed with the confidence that comes from repeated success, he did not lose the formula a second time. Between sessions, Avraham reported that the formula was effective if his wife was present but not if he was alone. By this time Avraham was becoming calmer and a little more sociable. He no longer shouted, although he was still distressed at night. He remained overweight, but he stopped overeating. Having embarked on traditional remedies with a modicum of success, we decided on another tactic to increase their potency. According to traditional beliefs in both Jewish and non-Jewish demonology, knowing the name of a demon is vital for vanquishing it. We therefore told Avraham that he must demand to know the name of the demon when next they met. He practiced once during the session using guided imagery, but the demon refused to answer and ran away. In addition, we taught him a simple technique of self-hypnosis and asked him to practice it with his wife every day. Initially, Avraham became calmer and less frightened. He was, however, unsuccessful at uncovering the name of ‘‘the black one.’’ When he confronted it at home with his wife, it became frightened and ran away, but the next night it returned with two helpers. The three visited him when he was at the ritual bath and tried to drown him. We suspected that the two helpers were brought in to match the beneficial influences of his two therapists. We felt flattered that we were now clearly associated with the forces of good in his battle against the powers of evil. Avraham arrived at the session after the attempted drowning in some distress. He entered a hypnotic state. When he called up the demons, only the helpers appeared. One was in the form of a black dog, a well-known form of the devil. ‘‘Where is the

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black one?’’ we asked. Avraham began to look tense and fearful. His voice shook and his words came out in a stammer: ‘‘H-he is trying to s-sneak into the gutter ab-bove the room.’’ ‘‘Insist that he come out and identify himself.’’ ‘‘H-he is hes-s-sitating.’’ ‘‘Insist.’’ ‘‘H-he is still not sure. He w-won’t say anything.’’ ‘‘Avraham, be firm. Insist.’’ After a few moments, Avraham told us with surprise and relief that the demons had run away. We were elated. P : T W   L P

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Now Avraham was able to frighten away the demons if his wife or the therapists were present. Alone he was still at their mercy. We decided to concentrate on guided imagery under hypnosis. ‘‘Close your eyes and bring to your mind the picture of the last place you saw the demon and his helpers. Can you see it?’’ He nodded. ‘‘Describe it to us.’’ ‘‘The desert, nothing there, a desolate spot.’’ The term for desolation in Hebrew has overtones of destruction and despair, and we felt this scene was a metaphor for Avraham’s sense of depression and hopelessness. ‘‘Look at the spot carefully, look around you. You are looking for shade and protection. Which direction should you take?’’ ‘‘Nothing. Just desert, just desolation.’’ ‘‘Keep looking, again and again, don’t give up, you will see somewhere you can seek shelter.’’ ‘‘No . . . although there is a tiny spot of green at the horizon.’’ ‘‘Good, good, it may be an oasis, with water, food, shelter, and the company you are seeking.’’ In this phrase, we were alluding

Paradise Regained / 

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to his father, whom we felt throughout to be the missing and hitherto untouchable piece of the jigsaw. ‘‘Start walking toward the green spot in the distance. Have no fear.’’ Avraham immediately gasped, ‘‘The three of them, the black one and his helpers, they have appeared, they are trying to stop me from going on, they are pulling me to the side.’’ ‘‘Insist that they tell you who they are. Demand their names.’’ ‘‘I did, and they ran off to a distance.’’ ‘‘Good, well done, now call them over, tell them to come close, you want to talk to them.’’ Avraham was silent and then smiled, his eyes closed: ‘‘They won’t. I think they are afraid of me.’’ During the next few sessions, progress toward the green spot was slow. On the one hand, Avraham was encouraged and supported by his wife and therapists; on the other, he was hampered and frightened by recurrent attacks from the black one and his helpers. The metaphor of being in a desert and trying to reach an oasis came to represent his current despair, his sense of guilt (which maintained it), and his newfound confidence in trying to end it. The number of disturbed nights was decreasing, and Avraham was feeling increasingly confident in his dealings with the demons. One night a black dog appeared, and Avraham picked up an imaginary stone and shooed him away. We were pleased that Avraham’s image in his own dissociative states was becoming more combative. P : ‘‘T L  L’’ H A R P

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The anniversary of the death of a famous rabbi named Hayyim Ben Moses Attar (–) took place in the week between  / Case Studies

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Avraham’s seventeenth and eighteenth sessions. Popular belief holds that a pilgrimage to the grave of the righteous, especially on the day of his hillula (death anniversary) is an effective panacea, and that requests at his grave on this day will be granted. Rabbi Hayyim Ben Moses Attar was born in Morocco and settled in Jerusalem in . He was a kabbalist and author of the popular commentary on the Pentateuch Or HaHayyim (‘‘The Light of Life,’’ a metaphor for the role of the Torah and a literary allusion to his own name, Hayyim, which means ‘‘life’’). During the last year of his life, he and his students visited graves of the righteous, prostrated themselves, and prayed for the welfare of the people. They spent their nights in fasting and prayer. His grave in the cemetery on the Mount of Olives is one of Jerusalem’s most popular sites. People come there to pray for the healing of the sick, for the souls of the dead, and for blessings for individuals and for the people. On the day of the hillula, Avraham went to the grave of Rabbi Hayyim Ben Moses Attar with a large group of people. After they had recited Psalms and each had said his own private prayer, the others left. Avraham remained there alone the entire night crying and praying, asking Rabbi Hayyim for help against the black one. As he prayed, he felt the presence of Rabbi Hayyim strengthening him and became convinced that the Light of Life was lending support and authority in his struggle and that his prayers were being answered. At the previous session under hypnosis he had felt more powerful and supported. Using self-hypnosis, Avraham and his wife had continued the sessions at home, and he was gradually approaching the green spot. They deferred arriving there until the eighteenth session, preferring to do so with our support. They were no longer frightened, even though they were contending with the forces of evil. They were hesitant but felt they could trust us. We, too, were cautiously optimistic. This was Paradise Regained / 

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hardly regular clinical work, but we were encouraged by the inner strength Rabbi Hayyim bestowed on Avraham, helping him cope with whatever challenges the next phase might produce. During the next session, Avraham approached the edge of the green area. He spoke freely: ‘‘The green is a beautiful garden. It has a high wall around it. As I walk around it, I see a gate. I am approaching the gate, and I can smell a lovely odor coming from the garden.’’ At this moment a pained expression appeared. ‘‘Oh,’’ sighed Avraham, in a tone of fear and resignation, ‘‘Will they never leave me alone? They are trying to hit me and bite at me. They are holding onto me, I cannot continue, they are dragging me toward a pit.’’ ‘‘Avraham,’’ we told him, ‘‘you are not alone. You do not have to cope with them alone. Tell them, Avraham, tell them.’’ Avraham was standing in the center of the room. He began to make wrestling movements with his arms and legs, pushing aside chairs and the table, and then shouted forcibly, ‘‘In the name of Rabbi Hayyim Ben Attar, I tell you, Go away! I am not afraid of you! Go away!’’ His voice became even louder as he shouted, ‘‘He that dwells in the secret place of the Most High shall abide under the shadow of Almighty’’ (see Psalms :). The wrestling ceased, his body became calm, and he spoke quietly: ‘‘They have gone. They have lost.’’ Avraham now approached the guardian at the gate of the garden and asked to be allowed to enter. As he stood talking to the guardian, he saw that the garden contained many zaddikim with flowing white beards and shining faces. Suddenly he discovered his father among them. He called to him and asked his father to instruct the guardian to let him in. Then he was allowed to do so. When he described his entrance into the garden, his whole demeanor changed and his depressed expression completely dis / Case Studies

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appeared. He told us that he was entering the Lower Paradise (a term used in Jewish tradition), that the air smelled like perfume, a concept also consistent with traditional descriptions of Paradise, and that he saw two springs of water. According to tradition, there are four springs of water in Paradise; if you drink from them you gain strength. We encouraged him to drink and satisfy his thirst. He drank and described the water as sweet and fresh. He appeared completely refreshed. He walked among the zaddikim, searching for his father. At last he spotted him and ran up and embraced him. Avraham talked to his father with excitement and great joy. His expression was completely changed. His face shone with joy, his body was light and agile. After our own momentary pleasure, we became concerned that he would not wish to leave the garden. Then he saw his grandfather Avraham, after whom he was named. Avraham ran to him and embraced him. Next he met his own rabbi, who had died in a traffic accident when Avraham was eighteen. Avraham experienced and described all this with wonder, astonishment, and joy. It was as if all his past, previously repressed because it was so painful, was now being revived. He quoted many biblical verses to express his feelings. At the end of the session, Avraham was exhausted but elated. ‘‘From now on,’’ we told him, ‘‘you have the support not only of Rabbi Hayyim Ben Attar but also all of these zaddikim, your father, and your grandfather. With their help, you will be a Godfearing husband to your wife and father to your children.’’ With this reminder of his responsibility to the living, Avraham took his leave of the dead. ‘‘From now on,’’ said Avraham, ‘‘my sleep will be undisturbed.’’ For many months, Avraham’s wife had worked regularly with him between sessions, using self-hypnosis, guided imagery, and whatever else we suggested. She kept detailed accounts of their Paradise Regained / 

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sessions and arrived at each of ours with a diary. They arrived for the nineteenth session without a diary. ‘‘There is nothing to report,’’ she said with a huge smile and tears in her eyes; ‘‘Avraham slept peacefully every night. He had no upsetting visitors. He is tired, but he spends time with the children and tries to help.’’ In our session he described what had taken place as a miracle, which he had had the honor of experiencing. In Judaism it is the nature of miracles, however, that one should not investigate them or seek to repeat them. We honored his request, hypnosis was no longer used, and no further homework was set. Avraham then told us that that very week had been the anniversary of his father’s death. He had gone to the grave with his family and had wept there, but left the cemetery feeling relieved. Avraham and his wife repeated that they thought the hypnotic sessions, particularly the last one, were a miracle. They believed the ‘‘green place’’ to be Lower Paradise and that Avraham had had the great privilege of going there. They thanked us profusely, gave each of us a copy of the Book of Psalms as a gift, and Avraham said that he prayed daily for our well-being. ‘‘Most of all,’’ he said, ‘‘I no longer feel alone. I used to think that I would feel empty and alone forever. I now feel my dead father as a comfort in my life. He left me when I was small, and I felt alone. I now feel there is happiness again in my life.’’ F-U

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The period following the end of treatment was far from paradise. The family faced many outstanding debts from the period when Avraham had received no stipend, and just then all their creditors started clamoring for payment. They had to move to less expensive, more cramped accommodations, and they had barely

 / Case Studies

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enough money left for food. Nevertheless, apart from mild insomnia, Avraham remained calm under all these pressures. Three months after the last session, we succeeded in arranging extra financial help from the national insurance agency. At that time Avraham was also referred to begin a weight-reduction program. It is now more than eleven years since Avraham’s treatment. He has lost a lot of weight, no longer takes medication, and spends a full day studying in the yeshiva of his late father. Occasionally he is frightened by cars in the street, aware that these are reminders of his father’s death. He is attentive to his children and both caring and grateful to his devoted and respectful wife, who led him across the desert until he regained Paradise.

Paradise Regained / 

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P VI



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 Betrayal       

In our years of work in the field of mental health, we have yet to encounter a patient who claims to be a turkey, let alone behaves like one. Our knowledge of the history of psychiatry also encourages us to think that neither two hundred years ago, when Rabbi Nahman wrote his story, nor in any earlier period was mental illness portrayed in this way. Furthermore, we doubt that mental illness can be cured by the treatment described, an example of the modeling and role-playing typical of behavior therapy. The successful use of a behavioral program would imply that the prince’s madness was a behavior change that could be healed by either reteaching him the skills of daily behavior or gradually acclimatizing him to the anxieties of everyday life and responsibility. But skills training alone has not been shown to heal madness. If the condition is atypical and the treatment improbable, what is going on? Could it be that the prince was not mad but was feigning what he thought others would take for madness? Perhaps he was unable or unwilling to continue as prince and had decided to play mad so as to be relieved of a task he did not want. What, then, was the wise man doing? The prince asked him, ‘‘Who are you? What are you doing here?’’ and the wise man replied, ‘‘And what are you doing here?’’



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The prince says, ‘‘I am a turkey’’ (he thinks, Get out of here, this is my scene). The other says, ‘‘I, too, am a turkey’’ (he thinks, I know exactly what you are up to. Turkey, shmurkey). Was the wise man, too, pretending? Having caught the prince in his subterfuge, was he demonstrating his wisdom yet again: I have caught you. If I jump up from under the table and tell everyone that you are a fraud (and, therefore, what a clever fellow I am) you may refuse to break out of your role lest you be shamed. If I give you a means of ‘‘returning to life’’ that is respectable, you will avoid shame and I will achieve the same accolade. Perhaps more, as no king wishes to be told his son is malingering. This alternative explanation implies that both prince and wise man are feigning their condition: the prince his illness, the wise man his therapy. Where is the trust we have discussed as playing a crucial part in our work? This book, like so many accounts by psychiatrists about their clinical work, has emphasized our overriding care and concern for our patients (see, for example, Bowers, ; Greben, ). In response, each patient feels that the therapist is present for him, to heal him; that he can be trusted. Trust means to have faith or confidence in, to place reliance in, to confide in someone or something. Psychiatrists, however, do not just treat patients. They write letters that do or do not enable their patients to receive disability pensions. They provide reports to courts on whether someone is fit to stand trial. In the most extreme scenario, they can arrange for a patient to be compulsorily committed to a hospital if they think there is a danger to life and the patient refuses treatment. In every one of these situations, the psychiatrist may find himself doing things contrary to the wishes of the patient, thereby infringing the covenant of trust so vital for therapy. At those moments he has dual loyalties: to the patient and to the national  / Conclusion

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insurance, the law courts, the district psychiatrist, society. Is trust unidirectional? Does the onus to be trustworthy fall only on the therapist? Once again, trust takes center stage only when therapy is the heart of the contact. The moment another factor is involved, such as the patient’s safety or the writing of a report, then the patient may feel the need to present his material in a different way in order to achieve certain ends. M: ‘‘A I S  M?’’

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Malingering is the ‘‘intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty’’ (American Psychiatric Association, , p. ). By definition, it is difficult to assess just how common malingering is, for the only cases recognized are those who are ‘‘caught.’’ Malingering taking the form of psychiatric disorder has a long history. When David was fleeing from King Saul, he arrived at the Philistine city of Gath, whose giant hero Goliath he had killed years earlier. The local populace was delighted at the opportunity for revenge. ‘‘And David put their words in his heart, and he was afraid of Akhish, king of Gath. And he changed his behavior before them, and feigned himself mad in their hands, and scratched on the doors of the gate, and let spittle run down on his beard. ‘‘And Akhish said to his servants: ‘Behold, you see the man is mad. Why have you brought him to me? Am I short of madmen that you have brought him to be mad in my presence?’ ’’ (I Samuel :–). Both of us have worked for many years in the Israel Defense Force (IDF) as psychiatrists. We have met people in civilian psychiatry who told us they malingered during army service. Similarly, young men at the call-up office sometimes change their Betrayal / 

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minds, and reveal that their previous interviews were feigned to avoid service. Others say that they have faked distress to avoid combat duty; they had not intended to completely evade service, however, and wished to retract their false testimony. One of our own children, himself a combat soldier, told us that combat soldiers in the IDF derisively refer to the mental health officer as ‘‘the magician’’ because when conditions become unbearable, he is the one who can make you disappear. There is, however, another side to malingering. Physicians, especially those serving in the army or making evaluations for compensation and disability pensions, often decide that people are malingering when this may not be the case. The suspiciousness that such evaluators experience was described vividly by the eminent British physician Richard Asher (–), when one Sunday, he got his two-year-old daughter up from her rest, dressed her, and took her out for a walk. She kept stumbling to the left, with a ‘‘ridiculous scissor gate,’’ and she frequently fell to the ground. ‘‘I knew this was sheer devilment, a malignant aggressive demonstration against the father figure.’’ After they got home, his wife undressed the little girl for her bath, and commented, ‘‘Do you realize you’ve put both her legs through the same hole in her knickers?’’ Asher notes, ‘‘I can still remember, after those tortured limbs had been freed from the crippling garments, how that gay, naked figure raced unrestrictedly to the bathroom without a trace of malingering’’ (Asher, , p. ). This aspect of malingering—a physician harboring unfounded suspicions—was investigated in the cases of twentyfour ultra-orthodox young men suspected of malingering at the IDF call-up office over a period of a year (Witztum et al., ). Careful interviewing and gathering of reports from yeshivas suggested that there was severe psychopathology in all but three, and none were considered malingerers.  / Conclusion

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Before presenting the next two cases, we would like to make it clear that malingering as a phenomenon is by no means restricted to the ultra-orthodox community, and we have no way of knowing whether it is common or rare. The difference between how the ultra-orthodox community and the rest of Israel’s Jews regard malingering, however, is that the ultra-orthodox are opposed in principle to serving in the army and therefore may see themselves as justified in using any means to avoid it. As the DSM-IV puts it, ‘‘Malingering may represent adaptive behavior, for example, feigning illness while a captive of the enemy during wartime’’ (American Psychiatric Association, , p. ). In recent discussions of the possibility of the enforced call-up of yeshiva students, the venerable Rabbi Eliezer Shach has been quoted as saying that army conscription is an issue that a yeshiva student should be willing to ‘‘die for rather than transgress,’’ a phrase usually reserved for acts of idolatry, murder, or gross immorality. Given this background, it is likely that the ultra-orthodox young man views malingering in order to avoid army service as adaptive behavior. U-O   I A

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The subject that is perhaps the most difficult for us to handle as nonultra-orthodox therapists working with ultra-orthodox patients concerns military service, an issue that provokes intense feelings. In several of the cases discussed in this book, army service has played an important role. Here we will present some of the issues and then describe two cases that demonstrate the feelings of both parties involved. The majority of the ultra-orthodox community object to serving in the army for three reasons. First, the army is a component of the secular Jewish state, which the ultra-orthodox oppose in principle, just as they opposed the development of secular ZionBetrayal / 

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ism in the late nineteenth century under Theodore Herzl. Herzl and his followers were not religious people, and their motives for founding a Jewish state were to find a refuge from oppression and antisemitism. Their object was to establish a Jewish nation, but it didn’t have to be religious (indeed, it didn’t have to be in Israel; Why not Uganda? suggested Herzl to the Sixth Zionist Congress in ). Religious leaders, already alarmed by the corrosive effect of the Haskala (Enlightenment) on the Jewish community, saw the forging of a national Jewish identity in which religious and nonreligious Jews were considered equal as another nail in the coffin of religious life. Further, they believed that the reestablishment of a Jewish nation was to be brought about only by the arrival of the Messiah. In fact, during the s the ultra-orthodox Jewish movement Agudat Yisrael (Israel Association) preferred contacts with Arab nationalists in Palestine because of their opposition to secular Zionism. Second, and in part because of their objection to a secular Jewish state, the ultra-orthodox were not part of the Hashomer, Hagana, and Irgun movements, which defended the Jewish population during the decades before the establishment of the state in . Once the state of Israel was formed, a major achievement of Agudat Yisrael was to win the exemption from army service of all religious young women and any religious young men who were studying in a yeshiva. The third objection of the ultra-orthodox is that women serve in the army. Ultra-orthodox men spend most of their daily lives in single-sex settings; contact with women, particularly single women, is kept to a minimum. Further, the army uniform worn by women includes trousers, and according to Jewish law it is forbidden for a woman to wear ‘‘men’s clothing’’ (based on Deuteronomy :). Israeli law avoids confrontation on these issues by allowing students to defer call-up as long as they continue to study in a yeshiva. However, any ultra-orthodox person who leaves his  / Conclusion

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yeshiva or becomes ultra-orthodox subsequent to his initial army training can be required to serve—but he won’t wish to do so. It is common knowledge that ultra-orthodox young men in this situation sometimes pretend to be mentally ill in order to avoid call-up. R   N-O T Let us now consider the possible attitudes and feelings of nonultra-orthodox therapists asked to provide a psychiatric report for an ultra-orthodox man who wishes to stay out of the army. The greatest difficulty confronting the therapist is accepting that other men are obliged to take risks that the ultra-orthodox can avoid because of their religion. The psychiatrist’s train of thought may run as follows. ‘‘The modern history of this small country has been a series of wars with our neighbors. Each war has been fought for our continued existence. Everyone who fought and everyone who died did so to enable the Jewish population, secular and religious, to continue living in the only country that is ours. ‘‘I myself served in the Israel Defense Force, first at age eighteen, when I began my three years, and then in annual reserve duty and during call-ups in wartime. I am alive, but many of my friends are not, having died in these wars. I saw some of them killed. ‘‘My children are all going to serve in the army. They will give up critical years of their lives for it. But this loss is nothing compared with the danger that they will be injured or killed. During the months and years they spend in dangerous places I shall live in constant fear of the knock at the door that will tell me of the death of my son, the knock that will change my life forever. Yet I must live with the situation, and so must my children, because this is our country and we must protect it. Betrayal / 

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‘‘How am I meant to feel about people who consider themselves too holy for this task? They think that their time can be better spent studying the Talmud. They think they are the army of God, and that their prayers and religious practices are as effective in protecting Jews as my army service and that of my children. Those prayers didn’t prevent the largest destruction of Jews in world history fifty years ago, so they are obviously fooling themselves to think prayers will help now. ‘‘But we are the fools, for we accept the situation. We exempt the ultra-orthodox from army service. We send our sons to die and theirs to study. And now this young man is sitting before me. Sixteen years old. Why do all their young men become mentally ill at the age of sixteen, the year they get their first call-up papers? What a coincidence! They come to be examined, ask for advice, accept a prescription, and then casually mention that they just got a letter from the call-up office. ‘‘If the presentation is unusual, I think, Well, the ultra-orthodox are a different cultural group. The alternative explanation is that this is a performance, easily taught to highly motivated individuals at the School for Procurement of Army Exemption, Ultra-Orthodox Department. I have no way of knowing which hypothesis is correct. The army has no interest in hospitalizing them or putting a plainclothes detective to follow them to find out if they’re faking it. ‘‘At the end of the day, their way of life is incompatible with army service. They rarely exercise but sit all day and study. So I wouldn’t want these people protecting the state, but I do not accept that my children should risk their own lives protecting them.’’ The therapist must be careful that his resentment of this unequal treatment does not cloud his judgment. The two cases we present here were unusual in that the therapist’s suspicion was confirmed; in many this is not the case. They demonstrate the  / Conclusion

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complicated, conflicted roles that both sides, prince and wise man, patient and therapist, can find themselves playing. Regardless of the outcome, these situations are always distressing, provoking disappointment, anger, frustration, and shame (Witztum et al., ). ‘‘D, I H A C  Y’’ I have known Rabbi Lerner for many years. He is a member of an extreme group among the ultra-orthodox, yet I have always been impressed by his openness and tolerance. He is a lively man, always late and in a hurry, talkative, apologizing, complimenting. He has been bringing young students to see me for many years and always tells them not to worry, the doctor is a friend, a God-fearing man. At the end of these evaluations Rabbi Lerner asks for a letter to the army. He brings back many of the young men for continuing care; but several come only once. In recent years, Rabbi Lerner has come less often, for he has been engaged in writing religious books. He once brought me a copy of one, inscribed: ‘‘To my dear and very eminent friend, helper of broken souls.’’ Our relationship has always been one of mutual respect, verging on friendship. Not long ago he called: ‘‘My dear friend, how is your important work progressing? May God bless you in your work. I have a cousin I wish you to see. He now lives in America, he has a wife and seven children, he came back alone for a visit, and the army won’t allow him to return. He has been broken by this treatment and needs to be seen.’’ When Moshe was brought to me he was neatly dressed and kept his head in a text of the Zohar. He did not initiate conversation but provided answers to my questions. ‘‘How old are you?’’ ‘‘About thirty.’’ Betrayal / 

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‘‘Where do you live?’’ ‘‘A long, long way away. You travel in an airplane.’’ He knew the place was America, but did not know the name of the city or street. ‘‘Do you have a telephone?’’ More intelligent people tend to reply with the telephone number, while more concrete thinkers simply answer yes. Moshe’s answer was unusual. ‘‘Occasionally.’’ I understood this to be another concrete response: occasionally the telephone rings. In reply to a series of leading questions, Moshe then said that he had returned to Israel because he missed his grandfather, to whom he had been very close before he married. As we have noted, it is a common arrangement for subnormal children from large families to be brought up by their grandparents, who have more time and patience than the harried parents. When Moshe arrived in Jerusalem and asked for his grandparents he was told, ‘‘They have a room together on Mount Olives’’ (a large cemetery in Jerusalem). ‘‘Are they dead?’’ I asked. ‘‘They [people] don’t want to tell me.’’ At this stage of the interview, my initial impression was that Moshe was a young man with mental subnormality. Moshe informed me that he had gone to America to marry and has ‘‘less than eight’’ children. He earns his living by cleaning a synagogue and studies a little kabbala. Moshe went on to reveal that he studies secrets, contacting the righteous at night. ‘‘Of course I speak to Rabbi Shimon bar Yohai at night, he reveals secrets. I mustn’t tell. My grandfather told me in a dream because I looked after him a lot at home. It is only for exceptional individuals.’’ The emerging picture was familiar: a subnormal man, missing his grandfather, has symptoms that are quasi-psychotic but

 / Conclusion

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probably reflect his difficulty in comprehending death and expressing grief. I moved to his orientation in time and place and general religious knowledge, and he seemed to confuse months, festivals, and fasts, always volunteering answers that were wrong. I tried his knowledge of blessings (all religious Jews say blessings before they eat, and there are different blessings for fruit, vegetables, cakes, and bread). Instead of the blessing for apples, he gave the one for cake, explaining that apples are ‘‘food [cake] that nourishes.’’ ‘‘The blessing for fish?’’ He answered, ‘‘The ground’’ (the blessing for vegetables), adding, ‘‘Water is over the ground.’’ I was feeling uneasy. These could be concrete responses, but they were always wrong and always followed by an answer that was slightly too clever. ‘‘What are you like at math?’’ ‘‘Excellent.’’ This response could be consistent with a subnormal boy who finds comforts in viewing himself as among the elite who are taught kabbala by Rabbi Shimon bar Yohai. ‘‘ + ?’’ ‘‘.’’ ‘‘ + ?’’ ‘‘.’’ ‘‘ + ?’’ A pause. ‘‘I don’t know.’’ ‘‘Show me two fingers.’’ He produced three fingers. I touched the middle one and said ‘‘Count.’’ ‘‘One,’’ he replied. I touched his ring finger. ‘‘Three-quarters,’’ he replied. I touched his little finger. ‘‘Half.’’ ‘‘All together?’’ ‘‘Two.’’ he answered. I was feeling very uncomfortable. Perhaps he was not sub-

Betrayal / 

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normal. Perhaps he was psychotic and was continually being distracted by inner experiences. But then why the consistent errors? I turned to Rabbi Lerner. ‘‘What do you know about him?’’ ‘‘Moshe is my cousin. As a child he did not settle in the yeshiva. He never learned properly, just heard tales, stories about the rabbis. He can only read punctuated Hebrew and doesn’t understand it. He was very childish and shy.’’ I was listening to the classical account of the management of subnormality in the ultra-orthodox community, reported to me by Rabbi Lerner in exactly the same way that he had reported it so many times before. ‘‘They found him a match, no brighter than he. Their first child was retarded, also paralyzed. Since then, he has gone downhill. The other children are pretty bad, all in special education. He is very attached to his oldest child and wants to get back to him in America.’’ Rabbi Lerner produced the child’s medical summaries from the United States. These mentioned visits in which the child’s situation was explained to his parents; in none were the parents said to be limited in any way. I was feeling miserable and confused; I could not understand my reluctance to write a letter to the army about Moshe. The questions crystallized as I wrote. ‘‘How can a man in this state, subnormal since childhood, who doesn’t know  + , know the concept of three-quarters? What about the too-clever answers concerning the blessings and some of the phrases he used?’’ I presented most of our conversation and my subsequent dilemmas in the letter and left the decision to the army. A week later, the psychiatrist who examined him asked him the questions again. This time the replies were all correct! That Moshe malingered and I was able to detect it are not the issue here. We are concerned with my feelings toward Rabbi Lerner and his toward me. Was ours a trusting relationship, or was I a gullible, useful instrument? Had all the other cases he  / Conclusion

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brought me been frauds as well? Only after Rabbi Lerner had left did I realize how angry I was. A week later, Rabbi Lerner called me. ‘‘It is not going smoothly at the army. They are not letting Moshe travel. He is worse. Will you see him again and maybe write another letter? I don’t understand, after he saw an expert like you.’’ I explained that the decision was the army’s and my letter was merely meant to assist them. He should bring Moshe again only if he needed help, not for another letter. He did not bring the young man again. It has been many months since Rabbi Lerner and I last spoke. Should I have confronted Rabbi Lerner? I felt sure that he would deny everything. In all my experience, no ultra-orthodox patient has admitted, ‘‘You are right, I have been shamming to get out of army service.’’ Y   R’ L

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Most of Israel’s psychiatrists play a dual role: they do regular civilian work and, in addition, they make use of their professional skills in reserve army duty. One of the functions of the army psychiatrist is to examine young men whose suitability for service is in question before call-up. One can argue that this is a therapeutic role, for the wrong decision could be damaging: enlisting an unstable young man who goes on to commit suicide during service or, alternatively, not enlisting a man who will then feel stigmatized and will have missed a socializing process that would have contributed to his development. Overall, however, the psychiatrist’s role is more similar to that of judge than therapist; trust is not an integral or necessary feature of the process. At times, both of us have filled this role for the Israeli army. We do not examine people we know personally or have treated in Betrayal / 

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civilian life, for there may be a conflict of interest. On one occasion, I was examining young men at a call-up office and received a file before the next interview. The file’s contents included a letter from an eminent rabbi, known in the call-up office for his elegantly worded, detailed, and perceptive descriptions of his students. This letter was no exception. It contained references to the young man’s delusions, the effect of a traumatic event five months earlier, his subsequent deterioration, and the impact his health was having on the lives of his wife and children. The young man was invited in. He entered with his eyes closed, accompanied by another man from the yeshiva, who treated him as if he were ill. The young man sat hunched over, shaking. He buried his face in a text and started swaying energetically. I started at the sight of him, then noted the name on the file, the address, and the names of spouse and children, and said to the officer in charge, ‘‘I am sorry, but I cannot see this case. I know this person well.’’ I felt confused and embarrassed. I had met the rabbi who had written his letter and had been impressed by him. In fact, I had treated the rabbi’s daughter for two years before discharging her as well six weeks earlier. As an ultra-orthodox young woman, she had always come with her husband, a shy, withdrawn young man, respected for his spirituality, who normally sat studying quietly during the interview. At the end of her session he would smile coyly and speak briefly but courteously. It was this young man who was sitting before me! The rabbi had written a report about his son-in-law which did not mention their relationship, describing his own daughter simply as the young man’s wife. Furthermore, the letter described the young man as having been sick for many years and having deteriorated into a nonfunctioning psychotic state five months earlier. During this time, I had seen him four times, and  / Conclusion

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he had been as well as ever. The young man had already had one evaluation by an experienced army psychiatrist, who had found him to be psychotic at around the date of my last interview with his wife, whom he had accompanied. The interview in the call-up office was brief. ‘‘Yechezkel,’’ I began, ‘‘As we know each other, it is not appropriate for me to interview you. You will have to be examined again.’’ The young man stopped swaying but his head remained bent over. He neither spoke nor looked up. The person with him took him by the arm and led him away. How did I feel? Depressed. I liked the young man and I liked his wife. They came from a different world, but they had always been courteous and grateful for what I tried to do for them. I had been impressed by the rabbi, aware of the impact he had as a religious leader. The psychologist and officer in charge who were present during the interview were quiet and sympathetic, aware of how I was feeling. I tried to justify the actions of Yechezkel and his father-in-law: Yechezkel is indeed too retiring for regular army service; maybe he really does have delusions, and they just never came up while I was seeing his wife. But the rest of the day seemed heavy and depressing. I suspected everyone of malingering. I was tortured by the knowledge that if I hadn’t known Yechezkel personally, he would not have been ‘‘caught,’’ yet I felt personally betrayed, even though I knew he had come for his own purposes and not to spite me. As the days passed, I became increasingly angry at the rabbi for his disingenuous letter. Did he not represent certain moral standards? I felt that the army should prosecute him for providing a false report and angry at the ultra-orthodox community for shirking their responsibility. When I spoke to an ultra-orthodox colleague about the incident, he said immediately, ‘‘Of course, I’m not surprised. Why, the founding rabbi of that group was a malingerer himself. The entire group would definitely condone Betrayal / 

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such behavior if they were convinced it would help the young man avoid contact with the forces of evil, which is how they view army service: working alongside women, in the army of the secular state.’’ Several days later, Yechezkel called me. His voice was as clear as usual, retiring, yet courteous. ‘‘I would like to apologize for our meeting at the call-up office. It was very unpleasant. I would like to thank you for the way you handled it.’’ ‘‘I was very surprised,’’ I said cautiously, ‘‘that you should appear in that way and behave like that.’’ ‘‘Well,’’ he said, ‘‘you don’t really know me.’’ ‘‘And the comments in your father-in-law’s letter, dates and all . . .’’ ‘‘Well, everything written there was true.’’ ‘‘Yes? And the way you appeared and spoke and at the previous interview with the psychiatrist?’’ ‘‘Well . . .’’ ‘‘Compare it with how you are speaking to me now. Tell me, why don’t you get a regular exemption as a yeshiva student?’’ ‘‘Well, that’s a complicated issue. I would like to thank you for the way you handled it.’’ Slight pause. ‘‘Excuse me, but did you say anything to them about me?’’ ‘‘I did not say how I know you, but when I was asked whether that is the way you usually are, I said no.’’ ‘‘Ah.’’ There was a pause. ‘‘What do you think I should do now at the call-up office?’’ ‘‘I would be straightforward with them. Be honest; otherwise it could be worse. I would suggest that your father-in-law do the same.’’ I was perplexed. Why did he call? Was it in order to apologize? If so, he did not go so far as to say that he was sorry for putting on an act in front of me, even after I had confronted

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him. Or did he call in order to find out how much I had said and therefore the extent to which his deception had been revealed to the army? His initial gratitude at my ‘‘handling’’ of the incident implied that he hoped I had merely said ‘‘I know him, therefore I cannot see him.’’ Once it was apparent that I had not maintained neutrality, he simply prepared himself for the next step.1 M  E

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Moshe and Yechezkel were malingerers, feigning mental illness in order to evade army service, which in their eyes was to be avoided at all costs. The price was a performance of mental illness and, in one case, a letter from an eminent rabbi containing detailed lies. Was this a breach of trust? Not by Moshe. He had never met me before. Nor by Yechezkel. He had not known he would meet me. True, both were acting. We could ask, How can they behave this way? Are they not bound by codes of honesty? Or, considering their values and their attitudes concerning the army, we should think about whether this constitutes only a white lie for them, aimed at achieving a greater good: discharge from the evil influence of the secular army. But what of Rabbi Lerner and Yechezkel’s father-in-law? They seem to have been able to exploit both of my functions, as therapist and writer of reports. To the therapist they related the problem, encouraged the patient to be open; to the writer of reports they played a game in order to deceive. This splitting of behavior patterns seems highly amoral. Yet I must consider whether I am out of touch with my own feelings. Do I not also switch roles from one moment to the next, depending on my task? As an army psychiatrist I represent the army above the

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individual. As a community psychiatrist, the reverse is usually true, although at certain moments I may sacrifice a trusting relationship for other considerations. We are all used to changing roles. We do so every time we walk from our bedroom into our children’s room or leave the house to go to work. At issue here is the trust that I thought existed in our working relationships. But perhaps I am still being naive or even dishonest. How many of us are warm and open during personal contact yet say disparaging things behind the other’s back? And is the trust we encourage in our work a professional ploy? Trust and truth come from the same source, and neither is an absolute value. Moshe and Yechezkel and the prince and the wise man have taught us that.

 Broken Souls Are Not Easily Mended He heals the broken hearted. —Psalms :

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If this were a novel by Charles Dickens, our task at this stage would be to tell the reader what happened to all our characters, who married whom, how many children they had, and just how happily ever after they all lived. The ends would be neatly tied; the reader would have a sense of satisfaction and secu / Conclusion

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rity. But our project has not been a novel, and there are not always happy endings. Further, we are aware of the many loose ends we have left dangling: the mental health problems of ultraorthodox women in particular, sexual dysfunction, marital difficulties and childrearing problems, the treatment of children and the elderly, the rehabilitation of the chronically mentally ill, and others. In some of these cases, for example marital and family difficulties, we do not consider ourselves in a position to present useful findings. In others, such as the mental health problems of ultraorthodox women, we have formed impressions in certain instances but do not feel ready to write in general about these yet.1 Although we have both treated many ultra-orthodox women over the years, most came for evaluation, medication, or shortterm therapy. A certain number informed us that they were in longer-term therapy and were being seen by female therapists. There are other areas, such as rehabilitation, in which we have extensive experience, but we are still gathering impressions before publication.2 It is a matter of debate among students of literature as to whether an author’s task is complete only when the loose ends are not only tied up but he or she has also brought about some ‘‘improvement’’ in the reader. Such a demand would undoubtedly be leveled at himself by Rabbi Nahman, who, in the tradition of the Midrash, composed deceptively simple stories that were the purveyors of messages for self-evaluation and selfinstruction. What message does this book convey? Is our message meaningful for everyone working with minority populations, or is it valid only for those working with the ultra-orthodox Jewish population, or only for those working with baalei teshuva and Bratslav hasidim? Or could there be a common message for all populations of therapists and patients? It is our belief that some Broken Souls Are Not Easily Mended / 

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of the conclusions from our work can be generalized and applied to all therapeutic situations. In a narrow view, our work demonstrates the issues that arise when patient and therapist come from different cultures. In this situation, the therapist may make basic errors in evaluation and be unable to utilize the full arsenal available to the psychotherapist, particularly dynamic psychotherapy. This difficulty is especially poignant in communities like the ultra-orthodox because the setting and content of the therapeutic encounter may be experienced by the patient not only as meaningless but also as offensive: his society actively rejects basic tenets of the approach. We have presented a culture-sensitive approach to evaluation and management that demonstrates that these barriers to compliance and relevance can be overcome. These principles can be generalizable to work with other minority communities. There is, however, a broader perspective. Individuals, especially members of a majority culture, tend to be unaware of the cultural features that characterize their own identity. How often are we aware of the impact on our thoughts and behavior that arise out of our gender, skin color, race, age group, occupation, and the like? This book concerns a minority group that is continually aware of its definition of self, both cultural and religious. As we stated at the onset, nonultra-orthodox readers may have started reading to gain an understanding of what they view as an exotic group, isolated from general society. We hope that while they read the narratives of the people described here, these readers have tried to understand their situation. If our patients have thereby become less exotic and more understandable, then perhaps the awareness of cultural-religious self-definition is a feature that readers have tended to ignore in themselves. If our reader is a therapist, he may tend to be unaware of his own self-definition as a member of the culture of mental health professionals, and how this shapes his beliefs and behavior. If  / Conclusion

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so, it is also likely that he is less aware of the cultural self of his patients. The reader may distance himself from such selfquestioning by asserting that the need to be sensitive to matters of culture is obvious in a country like Israel, composed of recent immigrants drawn from a wide range of cultures. But in fact, in the year  this characteristic is not unique to Israel. There is hardly a country in the world that does not contain a variety of cultures and religions, whether historically or as a result of recent immigration. The view of previous decades, reflecting the confidence of social policy makers, was that these societies constituted a ‘‘melting pot,’’ in which the variations between cultures would be assimilated and a ‘‘modern global identity’’ would emerge, a utopian Brave New World. Despite the facility of international travel, multimedia and communication, and global markets, nevertheless, the sense of being part of a culture, the pride in belonging to a nation, and the beliefs and behaviors of members of religions, have defied this process of melting, and national and cultural identity remain salient throughout the world. The therapist who ignores this aspect of himself and others is diminishing his own ability to understand, and consequently his ability to be effective. The realization that each of us has beliefs, value systems, and behaviors that are a consequence of a group identity undermines the comfortable idea that we, unlike others, are balanced, flexible, and tolerant. This realization is a necessary conclusion of our presentation here and inevitably leads to a tension that must be resolved. If we are also products of a culture or religion, then we maintain particular beliefs and elitist ideas (for example, ‘‘Only someone who has gone through my training can be truly open and tolerant’’) and behaviors. If we work with patients from other cultures, we must be ready to acknowledge the relativity of our position and be willing to accept that the patient lives, and will continue to live, within the code of his Broken Souls Are Not Easily Mended / 

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own culture. A good if extreme example is the ultra-orthodox community. We must accept the social structure of rabbi, rosh yeshiva, teacher, and parent. Every society or culture has its own hierarchy, and a mental health worker or general physician must not imagine that its structure will be suspended in honor of the illustrious expert. The other side of this dialectical tension is the self-respect of the therapist. A therapist must be able to work with these issues without perceiving them as obstacles or insults. He must respect the patient for her views and accept her social milieu, without being swamped by the sense of being an object, valued for its use, discarded when no longer required. He needs to be sufficiently comfortable with his identity as a therapist that he does not feel angered or belittled when, as social structure demands, the patient tells him that treatment must be permitted by a spiritual leader. A study of community mental health centers in the United States found that  percent of new referrals had consulted a religious mentor before referral (Beitman, ). After the patients sought help, the rate of failure to return for a second appointment was about  percent in the s and about  percent in the s in the state of Washington (O’Sullivan et al., ). The significant rate of nonattendance for second interviews has many explanations. It may be that some of the referrals spoke to their religious mentor, others to a spouse, friend, child, grandparent, aunt, or other figure whose opinion they valued before deciding whether to accept help. Unless we can respect this freedom in our patients, our own narcissism will impede our effectiveness. One way to diminish cultural differences between therapist and patient is to train therapists from within the community.3 We have seen impressive results in the United States when therapists from the minority culture were employed, for example in  / Conclusion

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the decreased failure-to-return rate in the Washington study reported above. But training indigenous therapists is no small obstacle in Israel. The ultra-orthodox, particularly boys, do not study secular subjects beyond childhood. Although girls’ education is broader, and training courses are being developed in social work, the community has yet to consider training in psychology. Nevertheless, training has begun in such specific areas as sex education and marital counseling. These subjects are of great importance to the ultra-orthodox, and the professional community should welcome approaches from the community, and encourage members to train to a high standard. In the actual therapies we have described, we have sought to understand our patients’ idioms of distress and also to develop interventions that are meaningful and acceptable to them. These cases are first steps in the development of a culturesensitive therapy. The importance of narrative as a means of overcoming cultural and religious differences has been apparent, although we continue to debate among ourselves just how feasible such interventions are and whether the therapist is encroaching on the role of shaman (without his status) or is using a ploy, albeit for positive ends. It is appropriate to end with the knottiest problem we have encountered in dealing with the ultra-orthodox: whether the therapist has the right to intervene in God’s world. A stimulating consequence of our clinical work was our exposure to Jewish texts, particularly those that acknowledged the existence of these important philosophical issues, for the world of ultraorthodoxy, as of other cultures or religions, is one of intellectual honesty and perception. Appropriately, the midrash with which we close takes place in the streets of Jerusalem, and the rabbis make their point by forcing their pupil to recognize his inability to be intellectually honest with himself—a key theme of our final chapter. Broken Souls Are Not Easily Mended / 

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T F I  D On one occasion Rabbi Ishmael and Rabbi Akiva were walking with a man through the streets of Jerusalem. They met a sick man, who said to them, ‘‘My teachers, instruct me how I can be cured.’’ They said to him, ‘‘Take this and that until you are cured.’’ The man who was with them said to them, ‘‘Who gave him the illness?’’ They replied, ‘‘The Holy one, Blessed be He.’’ He said to them, ‘‘And you allow yourselves to interfere in a matter that is not of your doing? He gave the illness, and you can cure it?’’ They said to him, ‘‘What is your trade?’’ He replied, ‘‘I am a farmer, and here is my scythe.’’ They said to him, ‘‘Who created the land?’’ He replied, ‘‘The Holy one, Blessed be He.’’ They said to him, ‘‘And you allow yourself to interfere in a matter that is not of your doing? He created the land and you eat its fruit?’’ He replied, ‘‘Do you not see this scythe in my hand? If I did not go out and plow the land, then mow it, then fertilize it, then weed it, nothing would grow.’’ They said to him, ‘‘You fool! Have you not learned that it is written of your work, ‘As for man, his days are like grass’ (Psalms :)? 4 Just as the plant, if not fertilized, weeded, and plowed, will not grow, or if it does grow but is not then watered and fertilized does not live but dies, so too is the body as the plant, the fertilizer is the medicine, the farmer is the doctor’’ (Midrash Shmuel, ).

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N

  To Begin, Just Say, ‘‘How Are You?’’ . Hughes and Okpaku () described a similar situation fraught with misunderstandings when a Western-trained psychiatrist interviewed an elderly Navajo. ‘‘How old are you?’’ No reply. ‘‘When were you born?’’ No reply. The Navajo man looked away. Hughes and Okpaku explain that concepts like age do not matter in Navajo life. The interviewer would have more success if he asked, ‘‘Can you remember what the old people said was happening about the time you were born?’’ Similarly, if the interviewer asked the man for details about dead family members, he would be greeted by a silence that overlies fear, for Navajos believe that speaking of the dead can evoke their ghosts.   The Initiation of Mental Health Care for the Ultra-Orthodox

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. These religious distinctions will be discussed in Chapter . The term ultra-orthodox is used throughout as the accepted term of a range of English-language texts. It should be noted, however, that the prefix ultra is judgmental, implying excess, rather than the more value-free very (Weill, ). The term used by the community to refer to itself is haredi, a Hebrew word that means ‘‘anxious’’ or ‘‘tremble,’’ referring to the overriding concern among the haredim with the performance of Torah commandments. Haredi appears several times in the Bible with this meaning, for example: ‘‘Hear the word of the Lord, you that tremble at His word’’ (Isaiah :). . An example of this mocking interest in the ‘‘strange and primitive’’ can be seen in a recent report in the international newspapers, picked up from the Israeli press, of a discussion by a leading rabbi of the ultra-orthodox community on the subject of whether it is permissible to pick one’s nose on the Sabbath.



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  Changing Attitudes in Cultural Psychiatry . For an authoritative account of the changes during the twentieth century and the new challenges facing cultural psychiatry, see Lewis-Fernandez and Kleinman (). . In a classic work, Jerome Frank () compared religious healing, placebo effects, and psychotherapy. Considering the long-standing denigration of medical doctors for other methods of healing, he quotes the following sobering statement: ‘‘The history of medical treatment until relatively recently is the history of the placebo effect’’ (A. K. Shapiro, , p. ). . See the excellent section on colonial psychiatry in Littlewood and Lipsedge () and the review on racism in psychiatry in Fernando (). In the nineteenth century, white theorists claimed that slavery protected blacks from depression and that they therefore should not be freed. However, some slaves suffered from the condition known as ‘‘drapetomania,’’ an ‘‘irresistible propensity to run away’’ from their slavery. These authors trace similar statements up to the present, demonstrating the extent to which psychiatric theory and practice continue to be influenced by racist beliefs and attitudes. . The recent vicissitudes in the status of these two conditions reflect the flux and change in cultural psychiatry. Neurasthenia was first defined by George Beard in the United States in , when the lassitude, hypersensitivity, and irritability it described were widespread, affecting such figures as William and Henry James and Sigmund Freud. In the s the diagnosis was adopted into Chinese psychiatric texts from the accounts of Beard and others and became increasingly common. Meanwhile, neurasthenia was discredited in the United States, considered an inaccurate and meaningless diagnosis. The American Psychiatric Association’s Diagnostic and Statistical Manual removed it from the list of psychiatric disorders in . Yet its incidence in the East is still widespread, and there is increasing debate as to whether it describes a genuine symptom or merely depression in another garb, and whether chronic fatigue is its present-day Western equivalent (Kleinman, ; Ware and Kleinman, ). Anorexia nervosa was also first described in the nineteenth century (Lee, Ho, Hsu, ). Initially it was viewed as a condition that was mainly found in the middle to upper classes in the industrialized West, but today we know that it reaches all classes, and it has been identified in many cultures, although its higher incidence in industrialized nations  / Notes to Pages -

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has led to the view that it is a Western culture-bound syndrome (Swartz, ). (This is one of the first examples of a label previously reserved for the ‘‘primitive and exotic’’ being applied to the West and its ailments.) Banks () has challenged the association of anorexia nervosa with the pursuit and adulation of thinness in an overfed society; he maintains that fasting is the historical antecedent of the condition, and that it has several similarities with asceticism. Lee () views it as a product of ‘‘modernity,’’ rather than a Western condition, and suggests that the publicity it receives is partly responsible for its increasing prevalence. See Weiss () for a thoughtful presentation of the many aspects to this debate. . Taijin-kyofu-sho differs from social phobia in two important ways. First, the term is used to cover a range of conditions, from a phase of shyness in adolescence to social phobia to delusions about bodily odors to a fullblown schizophrenic state. Second, taijin-kyofu-sho is clearly related to the distinctive social mores of Japanese society: Japanese children are taught that their misbehavior primarily affects their family and society and that rather than expressing individual wishes, they should anticipate other people’s needs and feelings (Kirmayer, ). A study of students in Japan and the United States found symptoms of taijin-kyofu-sho and social phobia equally distributed in both samples, suggesting that it is not the presence of the symptom that creates the syndrome but rather the emphasis that the particular culture places on differing aspects of the problem (Kleinknecht et al., ).   A Match Is Arranged Between Cultural Psychiatry and Ultra-Orthodox Judaism

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. In talmudic times, marriages were usually arranged by the heads of the families, and to marry a woman without a shidduch was deemed licentious and worthy of punishment (Talmud, Kiddushin b), presumably because this encouraged social mingling of the sexes with its associated risks. In the Middle Ages, the role of the matchmaker was critical to national survival at a time when communities were being decimated by persecutions and emigrations (Ausubel, ). The present-day role of the shidduch in the ultra-orthodox community is as the keeper of the Talmud’s injunctions to prevent singles mixing socially. . Yichus is a Hebrew term meaning ‘‘relationship.’’ It is used colloquially among the ultra-orthodox to refer to lineage. Someone from a family

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with a long line of eminent rabbis will be said to have ‘‘yichus,’’ one of the main characteristics of a desirable matrimonial match. . The extent of parareligious beliefs in nonultra-orthodox society in Israel was demonstrated in a study of  adolescents, of whom  percent believed in the effectiveness of petitions at the Wailing Wall of the Temple, . percent believed that their behavior could tempt the devil to punish them, and  percent believed in the mystical concept of transmigration of souls (Zeidner and Beit-Hallahmi, ).   Varieties of Religious Identification . More than two hundred years ago, the process of emancipation in Europe was associated with a movement toward education and integration into the general society. The various approaches included total integration into the non-Jewish world (the enlightenment movement of Moses Mendelssohn), self-imposed isolation from it (the ultra-orthodoxy of Hatam Sofer), and the attempt to participate in general education and political life while maintaining Jewish observance (the neo-Orthodoxy of Samson Raphael Hirsch). These different perspectives can be seen as forerunners of the situation at the close of the twentieth century (Sachar, ; Sacks, ). . The ultra-orthodox community in Israel has been the subject of sociological evaluation (Heilman, ), political analysis (Landau, ), and a colorful account by a journalist (Levy, ). Mintz () describes the internal social politics of several hasidic groups in the ultra-orthodox community of New York, including the provision of mental health facilities for the community in Borough Park, Brooklyn; Helmreich () depicts the culture of yeshiva life in the United States.   Beliefs and Delusions

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. One suspects that Nachmanides’ pronouncement was influenced somewhat by the circumstances. He knew that by participating in the religious disputation he was risking death as a ‘‘heretic’’ in Christian terms. Indeed, he eventually had to flee the country as a result of his participation. . In  Zevi was arrested by order of the sultan of Turkey, and later that year he was offered death or conversion to Islam. More prudent than the false Messiah of Yemen, Zevi converted. He retained followers until his  / Notes to Pages -

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death, and groups of Sabbateans continued within Judaism and Islam for more than a century; the Donmeh sect in Turkey continued into the twentieth century. . Brian Fallon and Ewald Horwath () described a man hospitalized during a self-imposed six-day fast. There had been an earlier forty-day fast that ended in the patient’s being admitted to the hospital for dehydration, hypothermia, and cardiac arrhythmias. He had given up his job managing an insurance company and gone to live in the park, seeking a more spiritual life. On admission he explained he was emulating Christ, Buddha, and the Desert Fathers but denied having special powers. The authors debated whether his change in way of life and his unusual beliefs meant the patient was psychotic, for if he was, so was Saint Francis of Assisi. The patient declined medication and eventually dropped out of treatment and returned to fasting in the park. Fallon and Horwath reported that he was admitted after a further fast to a different ward, where the therapists decided he was psychotic. Tantalizingly, Fallon and Horwath do not report whether this reevaluation led to medication and a different outcome. . See Balaban (–) for an account of the Frankist movement.   Nocturnal Hallucinations

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. The intrepid Captain Cook was the first foreigner to note the culturebound condition of amok in Malaysia in  (Gaw and Bernstein, ). More than a century later, the localized occurrence of conditions such as amok, latah, and koro was noted by physicians (Levine and Gaw, ). Pow Meng Yap () defined these syndromes as culture-bound in that certain values, social structures, and shared beliefs produce unusual forms of psychopathology in specific geographical areas. Cheryl Ritenbaugh () claimed that this definition is itself ethnocentric, based on a view of Western conditions as real and other presentations as exotic, folk, or nonscientific. Using anemia and obesity as models, she demonstrated that Western medical concepts are not always based on biological data and are equally culture-bound. She suggested that culture-bound syndromes should be redefined as constellations of symptoms that ) cannot be understood apart from their cultural context; ) have an etiology and symbolism arising out of cultural norms; ) are reliant on culture-specific technology and ideology for diagnosis; and ) can only be successfully treated by members of the culture. Notes to Pages - / 

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Raymond Prince (), noting that this expanded the definition of culture-bound syndromes to include all physical and mental disorders, considered that the term had thereby been rendered meaningless. He suggested that whereas the signs and symptoms that constitute a syndrome are a constant, concepts of etiology and local names given to conditions are transient and variable and therefore should be excluded; he redefined ‘‘culture-bound’’ as a collection of signs and symptoms found in a limited number of cultures as a result of certain psychosocial features. The interested reader is referred to a later presentation of his thesis (Prince and Tcheng-Laroche, ), which is followed by commentaries from a number of experts. A definition of culture-bound syndromes that was included for the first time in the latest edition of classification of psychiatric disorders in the United States (American Psychiatric Association, , Mezzich et al., ) is a compromise between Prince and Ritenbaugh, adding to Prince’s restricted definition the local recognition of it as a disorder that also gives meanings to these patterns of behavior. . Every ultra-orthodox male, including those adults who work, tries to study religious texts every day. All of the young men described in this chapter had stopped attending regular lessons in yeshiva. Some were allowed to attend the study hall irregularly, even though they did not go to the regular daily lessons. Others would study at home with their fathers, or another young man would be paid a small sum to study with them regularly. In Yaacov’s case, as noted later, his grandfather told him Bible stories daily.   ‘‘A Big Man Dressed in Black Is Hitting Me’’

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. The story a person relates about himself has become an important component of understanding the suffering a patient experiences (Kleinman, a). It has become the focus of some forms of psychotherapy (Omer and Alon, ; Freedman and Combs, ). The underlying concept is, Know my story, know me. In our personal narratives, we are the heroes, our lives are a drama, and we can give them a coherence that is the essence of our sense of identity (McAdams, ; Sarbin, ). The importance of understanding a patient’s narrative has been emphasized in cultural psychiatry ( Jones and Thorne, ) and will be an underlying theme in later chapters in this book. . ‘‘Rashi script’’ is a misnomer; the commentator actually used an earlier form of cursive script. The form used for all commentaries on the Talmud  / Notes to Pages -

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text is referred to by philologists as Sephardic mashait script. Many letters resemble the usual print, known as square script, but many differ, and are confusing. For example, the letter for ‘‘M’’ at the end of a word in square script looks like a letter sound ‘‘Sh’’ in mashait script. . In Jerusalem, among the nonultra-orthodox male population, . percent work full time, . percent work part time, and  percent are unemployed. Among the ultra-orthodox population, . percent work full time, . percent work part time, and . percent are unemployed (DeHaan, ). . The development we describe within this life cycle resembles that of the pioneering approach of Erik Erikson () more than that of Sigmund Freud. Whereas Freud focused on psychosexual development, Erikson saw life as including a series of stages in which the individual encounters a new, expanding environment and has to develop psychosocial skills with which to negotiate it. The stage from age six to adolescence is conceptualized as when the child steps out from the family and begins to socialize with other children and spend time in school. This stage is understood as critical because it is the time when the child learns to apply him- or herself and feel good about personal achievements. The next stage is adolescence, in which the milieu broadens to become a world of peers. Now the child learns to form friendships; his own identity begins to form, distinct from his family. For a detailed discussion of the theories of development and their implications for psychopathology, see Fonagy et al. (). . The powerful response to loss by people with learning difficulties was confirmed in a study of fifty adults with learning difficulties (mostly moderate to severe) who had suffered the loss of a parent. This group was compared with a matched sample of adults who had not suffered a loss. The bereaved group exhibited more behavioral disturbance and were more likely to be diagnosed as suffering from depression, anxiety, and adjustment disorder. Half the sample had attended the funeral, but only eight had visited the grave afterward (Hollins and Esterhuyzen, ).   Phenomenology and Differential Diagnoses of Nocturnal Hallucinations

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. It was not always possible to discern whether the hallucinatory experience was a dream. Children with frequent nightmares are more likely to have schizotypal personalities and to develop schizophrenia; nightNotes to Pages - / 

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.

.

.

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.

mares are sometimes considered indistinguishable from acute psychotic episodes (Levin, ). Hypnagogic hallucinations are defined as vivid perceptual experiences or intense dreamlike imagery that appear just before the patient falls asleep. Hypnopompic hallucinations are the same experiences occurring just after awakening (McKellar, ). A survey of , persons in the United Kingdom who were all more than fifteen years old found that the commonest form of either of these experiences was ‘‘a feeling that you will soon fall into an abyss.’’ Both types of experience emerged as common: hypnagogic hallucinations were reported twice a week for a year by  percent of the sample, and hypnopompic hallucinations were reported by . percent of the sample (Ohayon et al., ). Ihsan Al-Issa () has suggested that the attitudes of a society toward hallucinations influence the willingness of the members to report them, as well as whether to relate to them as real or not. Western society, with its predilection for the rational and scientific, looks askance at such experiences, whereas in other cultures the concept of reality includes hallucinations and altered states of consciousness, ‘‘and people react to these experiences not ‘as if ’ they are real but ‘as’ real’’ (p. ). Support for the notion that hallucinations are a normal feature of life in all societies comes from surveys of hallucinatory experiences that found that – percent of the general population have such an experience at some point in their lives (Slade and Bentall, ). Hallucinations have been reported among small children that derive from the normal fears of childhood (Kotsopoulos et al., ). Preschool children under stress may see or feel animals and insects, but the experience usually passes quickly. Although the patients in our sample were much older, their mental age was often not dissimilar, and the content of their fears (robbers, Arabs, policeman) resembles that of other ultra-orthodox children in Israel. It should be noted that whereas the average child in the West may perceive policemen as benign, throughout the brief history of the state of Israel the ultra-orthodox community in Israel has used demonstrations of protest in a range of public issues. These demonstrations have been violent, for example, involving throwing stones at cars, and the police have used force in turn. Children are often present at these demonstrations; it is for this reason that the police feature as frightening for many of our sample. Robert King and Joseph Noshpitz () describe the unraveling of the normal fears of childhood. Noises, heights, darkness, and strangers predominate in the first two years; these are replaced in the preschool years  / Notes to Pages -

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by fears of the ghosts and monsters typical of the child’s particular culture, resulting in fears of the dark and bedtime. Once school begins, these fears gradually diminish and may be replaced by realistic fears of injury, danger, and death. From the age of eight, fears about school and friendships surface, and concerns about being mocked or not being socially accepted predominate into the teen years. All these fears are represented in our sample. . It is arguable whether one should attempt to categorize a collection of culture-specific symptoms within standard Western concepts. Guarnaccia and Rogler () have argued that the inclusion of culture-bound syndromes in the DSM-IV is a recognition that they will not fit a single category and should not be put in one. Rather, we should try to understand the cultural meaning of the symptoms. . The low prevalence of alcohol dependence often quoted among Jews is thought to be a consequence of the hallowed role of wine in Jewish ritual (Zimberg, ). In the ultra-orthodox community, alcohol abuse is frowned upon in daily life, although on one day a year, the festival of Purim, it is a mitzvah to get drunk. ‘‘Rava said, ‘On Purim, a man is duty bound to get drunk to the extent that he cannot distinguish between cursed is Haman [the villain of the story of Purim in the book of Esther read on Purim] and blessed is Mordechai [the story’s hero]’ ’’ (Talmud Megila b). Joseph Westermeyer () applies the concept of ‘‘enculturation’’ (acquiring the values, norms, and skills of one’s cultural group while growing up so that one can live congenially within the group) to include its attitudes toward substance use and abuse, referring to this as ‘‘substance enculturation.’’ Poor role modeling, substance abuse or mental illness in parent(s), absence of wholesome parent-child interactions, and other factors may lead to weak enculturation. Certainly, the ultra-orthodox community is not exempt from members whose religious practice may be weak, who may behave in a criminal way, or who may abuse alcohol or drugs. Once Jews reject their traditional culture, subsequent generations are less immune from alcohol dependence. . According to the statistics of the Ministry of Religion, the number of married Yeshiva students has increased by  percent, from , to , between  and  (Haaretz,  March ).

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  Normative Rituals . This perception of adolescence is consistent with that of Erik Erikson (), described earlier, as a phase of ‘‘identity crisis.’’ Erikson is not depicting the phase as bound to be problematic; rather he notes that every phase in life contains special psychosocial issues that a person must resolve. In a provocative, basically cynical, evaluation of the concept of adolescence, Robert Hill and Dennis Fortenberry () have argued that adolescence is an ‘‘age-based culture-bound syndrome’’ in the industrialized countries. Whereas most adolescents describe themselves as well-adjusted (a similar percentage to that found in any of the recent epidemiological studies of psychiatric disorders among adults), adults perceive adolescents in consistently negative terms, and psychiatrists and physicians, perceiving the possibility of staking a new claim for healthfund reimbursement, have created specialty clinics to deal with this ‘‘disorder.’’   Ritual as Psychopathology

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. An intriguing component of OCD concerns the transfer of responsibility (Salkovskis and Kirk, ). Just as sufferers may ask their spouse repeatedly whether they are clean, itself a form of compulsion when a positive reply brings only temporary relief from anxiety, so they may get others to take over their concerns. An OCD sufferer who has spent hours checking locks and windows as a precaution against thieves may be sent to bed by his wife with the parting comment: ‘‘I’ll finish your checking.’’ Even if his wife retires to bed a minute later, he is not concerned. He knows that she has not actually checked, but it is her responsibility and not his. The fascinating aspect is that if his concern were really the thieves, he could never have permitted a ‘‘slipshod’’ check. Similarly, if John’s concern were for a truly kosher kitchen, how could he sanction a solution whereby he avoided helping with the washing up? It is in these tricks of logic that the OCD sufferer shows his insight into whether he is a fastidious person or a victim of OCD. . As will be described later, the authority of the rabbi in ultra-orthodox Judaism is sacrosanct. The rejection by an ultra-orthodox man of the responses of a series of eminent rabbis is therefore of particular note in distinguishing between a search for devout religious observance and  / Notes to Pages -

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OCD. A similar example of obsessive concerns overwhelming the belief in religious authority is found in scrupulosity, a term used by Catholic counselors to describe excessive concern over moral judgments that leads to repetitive confession. ‘‘It causes ordinary, everyday questions to be viewed as impenetrable and insoluble. Decisions require a disproportionate amount of time and energy, and are always accompanied by feelings of guilt and doubt. . . . Confessors were cautioned to expect numerous questions, repetitious in form and content, and to be prepared to find their advice habitually ignored, misinterpreted, or challenged. . . . Although they readily seek relief in going to confession, absolution provides them only with reason to doubt their sincerity and the validity of the Sacrament’’ (Harney, ). . Before he left Catholicism, Martin Luther was a devout monk who spent many hours daily at the confessional. ‘‘Luther would repeat a confession and to be sure of including everything, would review his entire life until the confessor grew weary and exclaimed: ‘Man, God is not angry with you, you are angry with God; don’t you know that God commands you to hope’ ’’ (Bainton, ).   Religious Ritual and OCD

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. A religious symptom of OCD is one in which the patient is concerned with fulfilling the Torah’s commandments. A nonreligious symptom is a concern that is not motivated by Halakhah. Example: A patient has just paid her bill at the store. She now stands next to the cashier carefully counting and recounting her change. If she is afraid that she might have received too much change and is therefore guilty of theft (gezelah: the commandment that most patients refer to appears in Leviticus :), her symptom is religious. If instead she wants to be absolutely sure she knows exactly how much she received, her symptom is nonreligious. . In a review of ten studies of the topics of OCD in eight countries, we found that religious symptoms were present in up to  percent of samples from the United States, Great Britain, Denmark, Japan, and India; in more than  percent from Saudi Arabia and Egypt; and in  percent of the sample we have presented here (Greenberg and Witztum, a). In an ongoing study of a separate sample of twenty-eight ultra-orthodox patients with OCD, twenty-six exhibit religious symptoms. . Siri Dulaney and Alan Page Fiske () have carried out the most

Notes to Pages - / 

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thorough comparison of cultural rituals and OCD to date. They extracted from the psychiatric literature a list of twenty-five characteristic features of obsessive concerns and compulsive behaviors in OCD. In a series of ethnographic accounts of rituals around the world, they found that all twenty-five features were present, demonstrating that, consistent with our own findings, the features of OCD are to be found in cultural rituals. They then randomly selected twenty cultures from ethnographic accounts by professional anthropologists that included descriptions of both ritual and work. The accounts were rated for the presence of the twenty-five features by three separate assessors. The descriptions of ritual were four times more likely to have OCD features than the work accounts. The features of OCD that were particularly common in the rituals were the fear that something terrible would happen, that the patient might cause harm, or that the patient should take measures to prevent harm; concern or disgust with bodily wastes or secretions; attention to thresholds or entrances; giving special significance of colors; and repetitive actions. Although Judaism was not one of the cultures measured, their findings make it clear that Judaism is no different from other cultures in having a body of ritual that contains OCD-like behaviors. Dulaney and Fiske concluded that normal ritual ‘‘enables people to mark and constitute life transitions, to reinforce and transform social relationships, to cure illness and cope with misfortune’’ (p. ), whereas OCD ‘‘involves a malfunctioning of the psychological mechanism underlying the process by which people generate culturally legitimated rituals with shared meanings’’ (p. ). . In the argument following, lifetime and point-prevalence rates will be presented from epidemiological studies. Epidemiology is the study of disease in relation to populations, and the results are taken from studies of psychiatric disorders carried out in the general adult population in a range of countries. In psychiatry, a diagnosis is made on the basis of an interview, and in the following studies structured interviews were used that had, in most cases, undergone rigorous validation studies before use. The results are expressed in terms of prevalence rates. Lifetime prevalence is the proportion of the study population who have received the particular diagnosis in the course of their life previous to the interview. Point prevalence is the proportion of the study population who receive the diagnosis at the time of the interview. . We do not discuss treatment here. The interested reader is referred to Greenberg (), Greenberg and Witztum (b), and Fallon et al. ().  / Notes to Pages -

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  The Baal Teshuva and Mental Health . Hazon Ish was the title of Rabbi Karelitz’s first work on religious lore, published in ; the title’s literal meaning is ‘‘A man’s vision,’’ but it is in fact ‘‘The vision of Ish’’—the initials of his name in Hebrew. Rabbi Karelitz (–) was an example of a natural leader: he did not serve as a rabbi to a community or head a yeshiva and held no public office during his lifetime, yet his pronouncements on agricultural and calendar issues were definitive. He settled in Palestine in  and was the unquestioned leader of ultra-orthodoxy. His modest home was crowded by people seeking his advice and support, and during his lifetime he produced more than twenty volumes on Halakhah (Feuchtwanger, ). At a time of crisis for ultra-orthodox Jewry, he encouraged the founding of new yeshivas and emphasized the careful enactment of Halakhah, defining the weights and measures applied in many religious practices. Known as ‘‘the Hazon Ish measure,’’ these have become increasingly accepted throughout the ultra-orthodox community (Horowitz, ). It was his attitude to involvement in the secular state that led ultraorthodox parties to participate in government. The meeting described in this chapter took place on  October . A crowd of ultra-orthodox people and journalists were waiting outside the Hazon Ish’s home in Bnei Brak, but only three people were present at the conversation, which was conducted in Yiddish. The third person, Ben-Gurion’s secretary Yitzhak Navon, later the fifth president of Israel (–), provided the account in this chapter (Horowitz, ). . The transformation of the meaning of certain words from traditional to modern Hebrew as a reflection of the secularization of Jewish values will be discussed in Chapter . Here a reverse process is noted: words returning to their traditional meaning. For example, the word bitachon in modern Hebrew refers to security in the military sense, but it also can mean trust in God. Many of those brought up on the military meaning of ‘‘security’’ turned to its traditional meaning. . Herbert Danziger () studied American and Israeli baalei teshuva, including modern orthodox and ultra-orthodox, in a sociological analysis of the process of religious change. He noted significant departures among the baalei teshuva in America from those experiencing a renewed interest in Christianity in many details: for example, the gradual nature of the process owing to the need to learn a new series of practices, and the importance of being a part of or establishing a family. Additionally, because Notes to Pages - / 

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Judaism is the dominant religion in Israel, the baal teshuva movement there was more open and assertive, daring people to ‘‘try religion,’’ while the normative American view of orthodox Judaism as strange and cultlike led adherents to maintain a lower profile. . In psychological terms, the yeshiva and the surrounding society provide a ‘‘holding environment’’ (Winnicott, ), in which students are able to experiment with novel concepts and behaviors. D. W. Winnicott coined this term to describe the environment provided by loving and supportive parents for a growing child, who ventures into new situations. The baal teshuva needs space to experience the events of yeshiva life; meanwhile, the teachers and older students are ever present to answer questions and listen to his accounts of his ideas and feelings. This paradigm has been applied to psychotherapy as well: adequate psychotherapy must provide a milieu where the patient can feel able to examine previously hidden and painful aspects of herself and her life (Holmes and Crown, ). The baal teshuva may be compared to the psychotherapy referral in that he arrives, at best, in a state of aimlessness and ennui, at worst, in a condition of doubt and misery; typically he describes an unhappy childhood and adolescence and a turbulent relationship with his father (Ullman, ; Buchbinder et al., ). . A ‘‘world between worlds’’ is another term that has psychotherapeutic connotations. D. W. Winnicott () defined a ‘‘transitional space’’ in which patient and therapist are able to experiment and be creative, similar to the concept of the holding environment mentioned earlier.   Mental Illness and Religious Change

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. A study of , psychiatric admissions in West Australia found that  were Jehovah’s Witnesses, most of whom were schizophrenics and paranoid schizophrenics. As this was an overrepresentation by  percent, the author concluded that ‘‘either the Jehovah’s Witnesses sect tends to attract an excess of pre-psychotic individuals who may then break down, or else being a Jehovah’s Witness is itself a stress which may precipitate a psychosis’’ (Spencer, , p. ). Rothberg () challenged Spencer’s findings, claiming that factors other than membership in Jehovah’s Witnesses could have been responsible for the results, and this point is well taken in our own study because baalei teshuva are certainly of low socioeconomic status.

 / Notes to Pages -

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. In  Edwin Starbuck published a study in which he showed that conversion is very common in adolescence and has many features common to it: a sense of incompleteness and imperfection, brooding, depression, morbid introspection, a sense of sin, anxiety over the hereafter, and distress over doubts. The outcome is also the same as entering adulthood: relief, objectivity, and self-confidence. ‘‘Theology takes the adolescent tendencies and builds upon them; it sees that the essential thing in adolescent growth is bringing the person out of childhood into the new life of maturity and personal insight’’ (p. ).   ‘‘A Very Narrow Bridge’’ . At that time, the population served by the clinic was about ,, of whom about , would be males. The size of the male population over the age of seventeen would be about ,. In  there would have been no more than  Bratslav hasidim in the area, representing . percent of the male population.   Mysticism and Psychosis

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. The similarity between the Hebrew words for demon (shed or shade) and breast (shahd ) has been noted by Berke and Schneider () as an example of antithetical meanings within one word and its psychoanalytic implications. . Emin is a cult that was formed in the early s around an Englishman named Raymond Armin. The group established small, select memberships in the United States, Canada, and Australia and began work in Israel in . The beliefs of the society are difficult to ascertain from present and past members (G. Zohar, ). Benjamin Beit-Hallahmi () describes a belief in the forces that established the world, the dynasties that were the bases of world religions, and evaluations of people based on colors, ‘‘electromagnetic fields of human precincts,’’ and tarot cards. Despite its obscure nature, the following gives a sense of the ideas of the Emin society: ‘‘Electrical stumps travelling through the astral light can attach themselves in the way of a barnacle or limpet, to the human aura’’ (Armin, , p. ). In  the group’s membership in Israel was – persons; they still have a settlement in west Upper Galilee.

Notes to Pages - / 

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  ‘‘Jerusalem Syndrome’’ . A study of seven autobiographies written by inhabitants of Jerusalem at the end of the nineteenth and beginning of the twentieth century revealed that the phenomenon of psychotic visitors in the Holy City is not new (Witztum and Kalian, ). In this account, one Bertha Spafford-Vester describes ‘‘several messiahs wandering about’’ at the turn of the century, while Clorinda Minor arrived from Philadelphia to witness the Second Coming as early as . In most cases the travelers were delusional before they left home.   Ultra-Orthodox Attitudes Toward Mental Health Care

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. Moshe Feinstein was a rabbi for twenty-six years in Belorussia before arriving in New York in . The many volumes of his teshuvot published under the title Igrot Moshe (The letters of Moshe) are considered the authoritative statement on most issues. . The ‘‘Hatam Sofer’’ was the leader of ultra-orthodox Jewry in Europe, known for his radical rejection of many features of religious change in the modern world. He died in , so it is clear that he was not referring to the theories of Sigmund Freud or clinical psychology, neither of which existed. . Aneini is a Hebrew word meaning ‘‘answer me.’’ It is taken from Psalms :: ‘‘And as for me, let my prayer to you, O Lord, be at an acceptable time. . . . Answer me.’’ It is an interesting choice of title for an ‘‘answering service’’ and implies that the callers receive more than a hearing. . Herbert Strean (), a psychoanalyst in New York, has described analytic psychotherapy with four orthodox Jews. Consistent with Freud’s extrapolations from individuals to a psychopathological conception of religion, Strean ‘‘psychoanalyzed’’ Judaism, as is shown in such statements as, ‘‘The notion of a God in Orthodox Judaism is a fantasy of those who worship him’’ (p. ), and ‘‘Orthodox Jews, constantly angry at their God until the Messiah arrives, but feeling guilty for opposing their omnipotent parent, are constantly feeling sinful and seeking forgiveness’’ (p. ). Although Strean’s point is that therapy is effective and does not detract from religious observance, he nevertheless concludes in a somewhat patronizing way that orthodox Jews can be helped by psychoanalysis to practice their Judaism ‘‘more maturely and with more pleasure and flexibility’’ (p. ).  / Notes to Pages -

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It should be noted that his clinical population were modern orthodox Jews living in the United States. . The idea that psychiatric interventions can be value-free has been criticized from many standpoints. The Committee on Religion and Psychiatry set up by the American Psychiatric Association to develop guidelines on the conflict between a psychiatrist’s religious commitments and psychiatric practice concluded that ‘‘some version of these difficulties is potentially present, at least subtly, in any psychiatrist’s practice’’ (APA Official Actions, , p. ). The classification of psychiatric disorders in DSM-IV has been shown to have antireligious attitudes (Post, ), and it is inevitable that therapists will convey their attitudes toward religion during the course of psychotherapy (Giglio, ). . Moshe Halevi Spero, a professor of social work, a psychologist, and a rabbi, rejected the idea that psychoanalysis is intrinsically atheistic; he has proposed an integration of object relations theory and Halakhah (Spero, ). Matching a religious therapist to a patient may be a barrier to embarking on serious therapy and not necessarily a prescription for success. Spero describes psychotherapy with a religious patient who bombarded him with intellectual exercises from talmudic study and hasidic anecdotes. Spero had to interpret that the patient was ‘‘searching for the ‘yeshiva boy’ in me, attempting to collude on a no-interference pact between the therapeutic part of me and himself ’’ (p. ).   Improving Mental Health Care for the Ultra-Orthodox

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. The average ultra-orthodox family in  has seven children, three times higher than the average for nonultra-orthodox families. At this rate, the community will double its present size within eighteen years (Haaretz,  March , p. B). . The overdiagnosis of serious psychiatric disorder in a patient from a different culture has been a recurring theme in this book. In the United Kingdom schizophrenia has been found to have a higher incidence in blacks than whites, and the former are more likely to be hospitalized by commitment. This led to claims that the exotic was being labeled mad and violent, and that a range of disorders were being called schizophrenic by uncomprehending psychiatrists. If this is true, we can assume that long-term follow-up would reveal these misdiagnoses. On the one hand, comparative follow-up studies of African Caribbeans in the United Kingdom did not reveal instability of diagnosis over three years (Harrison Notes to Pages - / 

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.

.

.

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.

et al., ) and five years (Goater et al., ). On the other, when the diagnostic evaluations of a Jamaican psychiatrist were compared with those of British psychiatrists they disagreed in the cases of sixteen out of twenty-nine African Caribbean hospitalized patients. The disagreement was not of a particular type of disease; the two groups diagnosed schizophrenia equally often, for example but in different cases (Hickling et al., ). Nissan Rubin () traces the development of the concept of nefesh. Throughout Bible times up to the early talmudic period, body and soul were indistinguishable, interchangeable terms for a living person. This monistic theory, inconsistent with the concept of an afterlife, was succeeded by a dualistic concept apparent in the later talmudic period. Philo of Alexandria, a philosopher who lived at the beginning of the first century .., was the first Jewish writer to separate body and soul, based on Plato’s division of the material and spiritual. Joseph Westermeyer () has described the difficulties of interviewing across cultural boundaries. He considered the presence of a translator, friend, or relative of the patient to be helpful in determining the limits of normality within the patient’s culture, as well as reassuring to the patient that the therapist is there to help. He referred to the person accompanying the patient as a ‘‘culture broker,’’ a term we have found appropriate to the delicate negotiations described here (Heilman and Witztum, ). This attitude to the medical profession is well expressed in the Mishnah: ‘‘The best of doctors go to Hell’’ (Kiddushin :) (Greenberg, ). The quotation continues ‘‘And the most able of animal slaughterers is the partner of Amalek.’’ Although it is apparent from the parallel phrase that it is the surgical skill of the physician that provokes the statement, the first part has become a familiar adage for expressing the public’s concern at being in the power of the physician, or a warning to physicians not to be overly confident in their own skills, rather than recognizing that they are God’s agents. For a delightful evaluation of the phrase, and attitudes to physicians in Jewish sources, see Aminoff, . Zelig Pliskin () compiled a guide to overcoming depression. ‘‘Happiness,’’ he states, ‘‘is a skill that can be learned. To acquire this skill it is necessary to master two things: the ability to focus on happinessproducing thoughts instead of those which cause unhappiness; and the ability to evaluate events and situations as positive instead of negative, or at least to lower the degree of negativity (rather than considering minor discomforts as tragedies, evaluate them as minor’’ (p. ). The methods described clearly derive from Ellis () and Beck et al. (). These  / Notes to Pages -

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innovators from the secular world are not mentioned, but the text consists of a series of quotes from Jewish sources, and stories from the lives of spiritual leaders. Avraham Greenbaum () has written a guide to spirituality based on Rabbi Nahman’s tale of the turkey. He gives clear behavioral prescriptions, teaching progressive relaxation, enjoining his reader to ‘‘get into the habit of always singing a tune’’ (p. ) and dancing alone in his room, on joyous festivals, or with friends at the end of daily prayers. On the management of depression, he quotes Rabbi Nahman: ‘‘If you are disturbed and unhappy, you can at least put on a happy front. Deep down you may be depressed, but if you act happy, you will eventually be able to attain true joy’’ (p. ). In a novel approach, Mordechai Rothenberg () has formulated a theory of psychotherapy based on the narrative style of parables told for self-improvement used in the Midrash. The text that describes the four rabbis who entered the garden of mystical speculation (see Chapter ) is also used by Rothenberg (, ) as a model for a psychotherapeutic theory. . A comparable list of seven do’s and don’t’s in counseling the culturally different was formulated by Derald Wing Sue and David Sue ().

. Do not invalidate the indigenous cultural belief system of your patient. . Become knowledgeable about indigenous beliefs and practices. . Participate in the community, including attending meetings. . Avoid overpathologizing and underpathologizing your patients. . Be willing to seek the advice and services of traditional healers. . Accept that spirituality is an intimate aspect of the human condition and a legitimate component of mental health work. . Be ready to expand the role of helper to include working within the community.

  Treating Depression in the Community by the Community

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. Neither of the rabbis is a Bratslav hasid, although both mentioned terms—the world is a narrow bridge—and methods—the patient should cry to God—that derive from Bratslav hasidism and the many statements on the management of despair made by Rabbi Nahman. . The debate between the two rabbis and all the subsequent discussion is Notes to Pages - / 

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founded on a play on words between the Hebrew word used in Proverbs :—yashchena—and the terms yaschena, meaning distraction, and yesichena, meaning conversation or advice. . ‘‘Baal HaTanya’’ is the popular name for Rabbi Shneur Zalman of Lyady (–), who was an early leader of hasidism and founder of Lubavitch hasidism. In  he published a philosophical work, known as Tanya, which means ‘‘it is learnt’’ in Aramaic, and is the opening phrase of the book. Baal HaTanya means master of the Tanya. . The term ‘‘you gave me breadth’’ in Psalms : is likely to mean ‘‘you answered my prayers (when I was in sorrow).’’ Rabbi Nahman, however, reads more into it than simple relief. Crisis, he implies, expands one’s horizons, puts other pressures in perspective, and enables one to appreciate other aspects of life normally taken for granted. Alternatively, Nahman may be perceiving the moment of crisis as a chance for personal growth (broadening), commonly described in theories of crisis management (Caplan, ). . Ahitophel was the adviser of King David who deserted his patron and supported and advised the king’s son Absolom in his rebellion against his father (II Samuel: , , ). When he saw that his advice had not been taken and the cause was lost, Ahitophel committed suicide. In the Midrash, Ahitophel is an example of a person of great prophetic powers whose greed for power led him astray.   The Soldier of the Apocalypse . Two versions of the story of Rabbi Joseph de la Reyna are recorded by Berdyczewski (), one situating him in the city of Safed, the other in the city of Hebron. Both accounts record that Rabbi Joseph came to a lecherous ‘‘bad end’’ after joining the forces of evil. He committed suicide when he was caught using magical powers to bring a beautiful queen to have sex with him every night.   The Healing Power of Ritual

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. Our healing work differs from that of anthropologists because our presence is justified by our function as therapists. Anthropologists do not attempt to be the shaman or the rabbi but rather observe the process of healing; they may also speak to the healers and the healed. Thomas Csor / Notes to Pages -

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das () has studied charismatic healing in the United States for more than two decades. He rejects the reduction of symptoms and methods of healing to processes understood in Western science and redefines the task as a search for a cultural phenomenology. The patient who turns to a religious healer is perceiving suffering in religious terms; the function of the healer is to facilitate the patient’s contact with his or her sacred self. . Reincarnation as a stone is a punishment mentioned in the Book of the Angel Raziel.   Paradise Regained . During the treatment of Avraham, the case described here, Eliezer Witztum worked with Onno van der Hart. With the consent of Avraham and his wife, the sessions were taped. For a near-verbatim account, the reader is referred to Bilu et al. (). . On  October , at the close of an Israel Defense Force swearingin ceremony at the Western Wall, as families of soldiers were dispersing, hand grenades were thrown into the crowd, killing one and injuring seventy. Several days later three members of a terrorist group living in nearby Silwan were arrested. They told the police that they had selected the location because of its religious significance.   Betrayal . It is interesting to consider whether there was a breach of confidentiality in this case. Yechezkel was not a patient of mine, and I was not imparting medical information. Ideally, I should have instructed the army not to send him to me at all. Medical confidentiality is also an issue in the publication of this and other cases. In some cases, patients consented to publication. In others, many of the details have been altered to avoid identification of the individual.   Broken Souls Are Not Easily Mended

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. Esther Goshen-Gottstein, a clinical psychologist in private practice in Jerusalem, has published studies based on clinical work with thirty-eight ultra-orthodox clients and observations of mother-child interactions in Notes to Pages - / 

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eighteen families (, ). She concludes that boys are more vulnerable than girls during development, whereas women carry a greater burden than men, running a home with a large family on a low budget, often while working. It should be noted that she used neither comparative samples nor measures. Her findings differ from those of Kate Loewenthal, who carried out an epidemiological study of depression among Jews in the United Kingdom (Loewenthal et al., ). In a sample of  men and  women who were either traditional or strictly orthodox, Loewenthal found that depression was equally common among men and women. This is in contrast to most epidemiological studies, which find higher rates of depression among women than men. In addition, there was not a higher rate of depression among either form of orthodoxy. Loewenthal and her colleagues suggested that orthodox Jewish women suffer depression less often than the general population because they spend their day based in the home looking after their families, with a lot of social support. Her sample of strictly orthodox women in the United Kingdom may differ from our ultra-orthodox population in that many are not ultra-orthodox (‘‘strictly orthodox’’ for Loewenthal meant affiliation to a particular type of synagogue, the Union of Orthodox Hebrew Congregations), and many ultra-orthodox women in Israel have to work in addition to running the home. Goshen-Gottstein () has suggested that our view will inevitably be slanted by virtue of our being males; for reasons of modesty, ultra-orthodox women will be unlikely to seek our help. . There are three centers for the rehabilitation of the chronically mentally ill in north Jerusalem. All three are private ventures, begun by rabbis or private families, now supported by the Ministry of Health. All are run by ultra-orthodox organizations. They are open to everyone and do not demand religious behavior, but inevitably religious people feel more at home in them, working at the work center and living in the protected housing provided. Two of the centers provide protected housing and offer two unique features. The first is the religious structure—prayers thrice daily and study sessions during the afternoon hours. For the chronically mentally ill, this allows them to feel akin to their contemporaries in the yeshiva world they have left. It also provides structure at the point in the day when many chronically mentally ill either retire to bed or are inactive. The second feature is the unfathomable dedication of those who run the centers. Anyone concerned in the rehabilitation of the chronically mentally ill in Jerusalem knows of the devoted personalities at each center: Simha at the Hazon center, Gershon and Moshe at Horev, and  / Note to Page 

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Hana and Binyomin at Hesed Ve’Emuna. Their day has no end, and they usually spend their Shabbat—a day of rest!—with members of the center as honored guests at their table. Of course, most successful projects have deeply devoted leaders. What we consider unique here is the motivation of these workers: they are truly humble people who believe they are vessels who have been allowed to perform a mitzvah. . A crucial component in our work in north Jerusalem over the years has been the presence of Dr. Tuvia Buchbinder. Dr. Buchbinder is a baal teshuva and a clinical psychologist whose professionalism and personal and religious integrity have been an important credential for the local community. . The choice of a particular biblical quotation in a midrash is never random. Psalm  also contains a blessing of the Lord ‘‘who heals all your illnesses’’ (v. ); the one psalm thus presents in juxtaposition the two functions, physician and farmer, that are ascribed to God but undertaken by man, ‘‘created in the image of God’’ (Genesis :).

Notes to Pages - / 

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G

amidah (literally ‘‘standing’’) The main prayer recited at every service, consisting of seven blessings on Sabbaths and festivals, and nineteen blessings on weekdays. Ashkenazi Jews (also called Occidental) who trace their descent from settlements in northwest Europe in the early Middle Ages. The original Ashkenaz is a great-grandson of Noah and is named in the Torah. The term came to refer to German Jews in the time of Rashi. From the end of the thirteenth century recurrent persecutions spread the communities across Europe to Poland and Russia. Ashkenazi Jews say their prayers with a distinctive wording and order, and the melodies for prayer and other readings are unique. baal shem (literally, ‘‘master of the name’’) A person who has knowledge of the secret name of God and can perform miracles. The title has been in use for more than a thousand years, and referred to people who wrote amulets containing God’s name starting in the thirteenth century. Starting in the seventeenth century the term has referred to people who had powers to heal the sick using practical kabbala, prayer, amulets or remedies (Scholem, a). The most famous baal shem was the founder of hasidism, known as the Baal Shem Tov. baal teshuva, baalei teshuva (literally, ‘‘master of repentance’’) In the Talmud the phrase meant a Jew who had become irreligious or sinful and who had now repented. Recently it has come to refer to a Jew reared in a nonorthodox home who chooses to become orthodox. Book of Raziel Originally published under the title ‘‘This is the book of the first Adam which the angel Raziel delivered to him.’’ A collection of Jewish mystical, cosmological and magical material, first printed in Amsterdam in  and reprinted many times because of the popular belief that the book protects its owner’s house from fire and other dangers. Book of Transmigrations (Sefer Ha-Gilgulim) A book of kabbala written by one of the foremost kabbalists, Hayyim Vital. It describes the concept



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of the transmigration of the soul as defined by Vital’s teacher, Isaac Luria. Book of Visions (Sefer Hahezyonot) A largely autobiographical text written by Hayyim Vital at the end of his life in Damascus around . Code of Jewish Law (Shulhan Arukh) The title given to the collection of laws and rulings on sabbath and festival practices, prayer, sacrifice, marriages, divorces, contracts and all aspects of life. Codes were collected by Maimonides and Jacob ben Asher, among others, but the Code of Jewish Law accepted as the most authoritative and accessible is that of Joseph Karo, compiled in the sixteenth century. Divine Presence (Shekhina) A postbiblical phrase that refers to the presence of God in a place in the world. The Talmud relates that the Shekhina is present when people pray or study together. It goes into exile with the Jewish nation and returns when the people return. dvar Torah (literally, ‘‘word of the Torah’’ or ‘‘matter of the Torah). An idea from the Torah or Talmud presented at a gathering of people, especially a wedding, Shabbat, or other festive meal. The underlying concept is well expressed in the Mishnah: ‘‘Two who sit together and there are no words of the Torah between them, then it is a meeting of fools . . . while two who sit and there are words of the Torah between them, then the Divine Presence is also there’’ (Avot :). evil tongue Gossip. The Torah forbids talebearing (Leviticus :), and major biblical figures are considered to have been punished for gossiping (Sara, Joseph, Miriam, and the ten spies). A widely read text (‘‘Shmirat halashon,’’ literally guarding the tongue) encourages care in this commandment. halakhah (literally, ‘‘the way one walks’’). The practical laws of Judaism. Halakhah refers to the corpus of legal Judaism, and each detail is also called a halakhah. hasidism (literally, ‘‘piety’’) A movement founded in Poland in the mideighteenth century by Israel Baal Shem Tov. Hasidim are led by a zaddik (righteous one) or rebbe; they emphasize joy as a central theme and means of achieving closeness to God. The hasidim are one of the central groups of ultra-orthodoxy today. hatikkun hakkelali (literally ‘‘the general repair’’; see tikkun) The ten psalms that Rabbi Nahman of Bratslav said would heal nocturnal emissions. ‘‘For there is a power in the saying of Psalms that extracts the drop from the shell that received it, for the numerical value of psalms is equal to the value of Lilith plus the letters of her name’’ (Likkutei Moharan, Part , ). In Hebrew every letter has a numerical value.  / Glossary

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The drop of semen is a form of evil taken up by the shells. The shells, or kelipot, are a concept from the kabbala of Isaac Luria; they are the source of evil in the world. kabbala (literally, ‘‘reception or tradition’’) The general term for Jewish mystical writings, particularly from the twelfth century. kavvanah (literally, ‘‘intention’’) Concentrated devotion in prayer. There are many disputes in the Talmud about whether particular commandments can be fulfilled properly only if the person had the intention in his thoughts of carrying out the commandment. Those that argue against the requirement of this mens rea maintain that the action is what counts. kosher (literally, ‘‘fit’’) The term has come to refer to food that can be eaten by a religious Jew, by virtue of the species, the method of slaughter, or the method of preparation. Likkutei Moharan ‘‘The collected writings of our rabbi and teacher Rabbi Nahman.’’ The central work of Bratslav hasidism, compiled by Nahman’s follower Nathan Steinhartz from Rabbi Nahman’s teachings beginning in  until after his death mezuzah (literally, ‘‘doorpost’’) The scroll containing two paragraphs of the Shema attached to the right side of the doorway in Jewish homes. Based on Deuteronomy : and :. Mishnah (literally, ‘‘repeat’’ or ‘‘learn’’) A collection of the statements on Jewish laws by various rabbis. Initially passed on by oral tradition, it was redacted by Judah the Prince in the second century and was the basic text on which the Talmud commented. In contrast to the Bible, known as the Written Law, the Mishnah and the Talmud are known as the Oral Law. mitzvah A commandment. The  laws in the Torah are all mitzvoth, commandments. When you tell someone that he or she is ‘‘doing a mitzvah’’ you are saying that he or she is doing a good deed, performing the requirements of God. niggun Tune. Singing is a central feature of the joyful spirituality of hasidism. A niggun can be a wordless tune or may have a brief text, sung repeatedly over many minutes, often during prayer or while dancing. The Baal Shem Tov, founder of hasidism, left tunes, as did Shneur Zalman, the first leader of the Lubavitch hasidim, and Rabbi Nahman of Bratslav. Passover The spring festival, lasting seven days (eight days outside Israel). The first night has a festive meal that commemorates the Exodus from Egypt. Matzoh is eaten instead of bread, which must not be neither Glossary / 

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eaten nor seen. Orthodox Jews clear their homes punctiliously in the weeks before to be sure there is no bread or food containing bread products. Purim (literally, ‘‘lots’’) A late-winter festival lasting one day, commemorating the events related in the Book of Esther, in which a Persian prime minister named Haman drew lots to choose the date on which he would destroy the Jews. Purim is the celebration of his defeat, a festival of uncharacteristic merrymaking. rabbi (literally, ‘‘my master’’) A Jewish religious authority, who can make decisions on matters of religious practice (halakhah). The title was initially used in the second century and meant a sage who interpreted the written and oral law. Since the Middle Ages the term has come to mean a spiritual head of a community. Rashi Foremost commentator on the Bible and the Talmud, who flourished in France and Germany in the eleventh century. Rosh Hashanah (literally, ‘‘head of the year’’) The Jewish new year, which lasts two days in the autumn. rosh yeshiva The head of the academy for talmudic study, a religious authority. Sephardim (literally, ‘‘Spanish’’) Jews descended from the people expelled from Spain and Portugal in . Widely but erroneously used to refer to all non-Ashkenazi Jews. Shabbat The Sabbath, on which no work is done (Genesis :–). The Mishnah defines thirty-nine types of work prohibited on the Sabbath. Shabbat begins at sunset on Friday and ends at nightfall on Saturday night. Shema (literally, ‘‘hear’’) The first word of the sentence ‘‘Hear, O Israel, the Lord your God, the Lord is One’’ (Deuteronomy :), a declaration of God’s unity that is the high point of Jewish prayer. It is the first line of three paragraphs referred to collectively as the Shema, which are recited every day in the morning and evening prayers. The laws concerning its recitation are debated in the Mishnah. Owing to its importance, it should be pronounced with kavvanah. sitra ahra (literally, ‘‘the other side’’) The ‘‘left side’’ of Creation; the side of the demons. Talmud (literally, ‘‘study’’) The commentary on the Mishnah. The commentaries collected until the end of the fifth century in Babylon are known as the Babylonian Talmud; those collected in Palestine at the same time are called the Jerusalem Talmud. The former is the more widely used.  / Glossary

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tefillin Phylacteries in the form of two leather boxes, each containing four paragraphs from the Torah, which are worn during weekday morning prayers. tikkun (literally, ‘‘repair’’) A theosophic kabbalistic concept describing the role the spiritual life of a Jew has in perfecting the Creation and even the Creator. The concept was developed by Isaac Luria, who lived in sixteenth-century Safed. Torah (literally, ‘‘law’’ or ‘‘teaching’’) The five books of Moses, the holiest text in the Jewish religion. According to tradition the Torah was given to the Children of Israel at Mount Sinai by God through Moses during the Exodus from Egypt. tzitzit A term used in the Torah (Numbers :–) to describe the threads tied on to the edges of four-cornered clothing worn by men. Tzitzit are worn as an outward sign to keep the Jewish man mindful of his obligation to fulfill the commandments of the Torah. yeshiva (literally, ‘‘sitting’’) An institution for talmudic studies. The Babylonian and Jerusalem Talmuds were produced in academies of study, but the present form of the yeshiva may be traced to the eighth century in Spain and north Africa. yichus (literally, ‘‘relationship’’) Used colloquially among the ultraorthodox to refer to the lineage of a person. Someone coming from a family with a long line of eminent rabbis will be said to have ‘‘yichus,’’ one of the main characteristics of a desirable matrimonial match. Yom Kippur (literally, ‘‘day of atonement’’) The fast day that takes place a week after Rosh Hashanah. The most sacred day of the Jewish calendar, in which individuals ask for God’s forgiveness. Most of the day is traditionally spent in communal prayer and fasting (Leviticus :–). zaddik, zaddikim (literally, ‘‘righteous one’’) The term used by hasidim for their leader. Zohar (literally, ‘‘splendor’’) A set of works that form the main kabbalistic text. Although an eponymous work in the name of the second-century Rabbi Shimon bar Yohai, it is generally thought by academics to have been written in whole or mostly by Moses de Leon (based on work of some of his contemporaries), a kabbalist who lived in Spain at the end of the thirteenth century.

Glossary / 

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research in Asia and the Pacific, ed. W. Caudill and T. Y. Lin. Honolulu: East-West Center, –. Zaehner, R. C. . Mysticism: Sacred and profane. London: Oxford University Press. Zeidner, M.; and Beit-Hallahmi, B. . Sex, ethnic, and social-class differences in parareligious beliefs among Israeli adolescents. Journal of Social Psychology :–. Zimberg, S. . Sociopsychiatric perspectives on Jewish alcohol abuse: Implications for the prevention of alcoholism. American Journal of Drug and Alcohol Abuse :–. Zohar, A. H.; Ratzoni, G.; Pauls, D. L.; Apter, A.; Bleich, A.; Kron, S.; Rappaport, M.; Weizman, A.; and Cohen, D. J. . An epidemiological study of obsessive-compulsive disorder and related disorders in Israeli adolescents. Journal of the American Academy of Child and Adolescent Psychiatry :–. Zohar, G. . Eternal happiness: On the phenomenon of mystical sects, new groups and psychological marathons in Israel. Tel Aviv: Saar (Hebrew).

 / Bibliography

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I

from, ; more common among nonultra-orthodox referrals, ; Rabbi Shechter on,  Apikores, ,  Arabs, –,  Army service, , , ; avoided by ultra-orthodox, ; exemption from, , , , , –, , –, , – ; influence on adolescence, ; patients who completed, , , , , , , ; physical unfitness of ultraorthodox for, ; terminated due to mental problems,  Asher, Richard, on malingering,  Ashkenazim, ,  Authority, versus innovation, , – Autism, nocturnal hallucinations can resemble, 

Abraham,  Adjustment disorder, after loss of parent,  Adolescence: conversion common during, ; described by Erikson, ; development of religiosity among ultra-orthodox during, –; increase in mystical belief during, ; nocturnal hallucinations and, ; shyness in, as part of taijinkyofu-sho, ; of a socially isolated ultra-orthodox boy, –; teenagers seen as well adjusted by themselves but not by others,  Aggadah,  Akiva, Rabbi, ,  Alcoholism, , ,  Amok,  Anemia, as culture-bound,  Angels: belief in, ; guardian, ; inhabiting a psychotic patient’s world, –; personal, – ; used in fighting evil, ; in visions, – Anorexia, ,  Anorexia nervosa, ,  Anxiety, ; after loss of a parent, ; as a result of neglecting OCD rituals, ; during adolescence, ; freeing a patient

Baalei Teshuva, –, , ; appeal of mystical study to, ; case involving, , , , , , –; excessively pedantic about keeping commandments, –; having revelations, ; lacking restraints of generations, , running amok on Temple Mount, ; study of American and Israeli, 

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Baalei Teshuva (continued ) –; troubled by previous sexual activity,  Baal Shem Tov, Rabbi Israel, –, ,  Bar-Kochba,  Bar Yohai, Rabbi Shimon: in hallucinations or visions, , , ; quoted, ; and Rabbi Nahman, –; visiting grave of,  Behavior: bizarre, , , , ; strange, ,  Ben Attar, Rabbi Hayim, , , – Ben-Gurion, David,  Ben Zoma,  Bhagavadgita,  Bipolar disorder, , , , ,  Boisen, Anton,  Bratslav, Rabbi Nahman of: appearing in hallucinations, , ; attraction of patients to, – passim; biographical details, –, , ; parable of the turkey, –, ; quoted, , , , ; stories by, ; visiting grave of,  Bratslav hasidim, , , : history of, –; neurotic disorders among ; number of, in catchment area, ; nocturnal visits to fields, ; patient,  Buddha, , 

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Catatonia, , –; ‘‘Mea Shearim syndrome,’’  Childhood: beliefs and fears dur-

ing, , –; education, –, ,  Cholera,  Christianity, , ,  Circumcision,  Cleanliness: before prayer, , –, , ; hand washing, , –, –, ; improved after medication, , ; menstrual purity, –, , ; neglect of, ,  Community versus individual,  Cults: Divine Light Mission, ; Emin, , ; Hare Krishna, ; ISKCON, ; Jehovah’s Witnesses, ; rise of, in Western society, –; Scientology, ; Unification Church, ,  Cultural blind spot syndrome,  Culture-bound disorders, , –, – Cultus and creed, , – Daniel,  David, King, ,  Death, ,  Delusions: among tourists to Jerusalem, ; and beliefs, – , , ; delusory cultural beliefs, , –; grandiose, –, , , , –; mood congruent, ; persecutory, , , ; private, described by Murphy,  Dementia,  Demons, , ; Ashmedai, –; battling with, , – ; and Bratslav hasidim, ;

 / Index

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created by sins, , ; descriptions of, ; fear of, ; in Judaism, ; persecution by, , , , ; receiving orders from, –; visions of, , , , – Depression: after loss, ; among disciples of Rabbi Nahum of Tchernobil, ; among travelers, ; and Bratslav hasidim, , , ; case involving, , , –; during adolescence, ; endogenous and exogenous, –; and hallucinations, –; in a mystic, ; of John of the Cross, ; manic, –; overcoming, , ; relatively rare among ultra- orthodox referrals to CMHCs, ; of Resh Lakish, ; seen as punishment by God, ; severe, more common among ultra-orthodox referrals,  Diabetes, cultural differences in understanding,  Dissociative identity disorder,  Dogs, –,  Douglas, Mary,  Drapetomania,  Dreams. See Nightmares Dress, of ultra-orthodox, , , – Drug abuse, ; cases involving, , , , , ; hashish and opiates, ; induces possession trances, ; uncommon among ultra-orthodox,  Dualism, 

Ecstasy, ,  Education, ultra-orthodox, , –, , ,  Elijah (prophet), ,  Enoch,  Erikson, Erik, ,  Esau,  Faith, loss of, , – Fasting,  Fatigue, chronic,  Feinstein, Rabbi Moshe, ,  Florence Syndrome, – Frank, Jacob, , ,  Freud, Sigmund, ; affected by neurasthenia, ; attitude toward sex, ; focused on psychosexual development, ; on obsessions, , – Fundamentalism,  Gender, , ; differences between the sexes, , –; hallucinations predominantly among males, , –; sons preferred to daughters, ,  Gilgul,  Glossolalia,  Graetz, Heinrich,  Grandparents, –, – Graves, visiting, – passim, –, ,  Grief: after loss of relative, –, –, –, , ; after Yom Kippur war, ; coping with, ; hallucinations in, ; pathological, ; similarity to mystical states, 

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Guilt feelings: among Bratslav referrals, ; over loss, , –, , –,  Ha-Levi, Judah, , ,  Hallucinations: about relatives, –, –; auditory, , , –; differential diagnoses of, , ; effects of medication on, ; hypnagogic and hypnopompic, ; hysterical, , ; mood congruent, ; nocturnal, –; persecutory and grandiose, ; tactile, ; visual, , , , , , , . See also Angels; Demons Hasid, Rabbi Judah, , , ,  Hasidim, , , . See also Bratslav hasidim Hatam Sofer, , , ,  Hazon Ish, , , ,  Hebrew language, –,  Herzl, Theodore,  Hinduism,  Hirsch, Samson Raphael,  Hoarding,  Homes, ultra-orthodox, ,  Homosexuality, , , ,  Hospitalization, more likely for blacks,  Hygiene. See Cleanliness Hypnosis, , – Hypomania,  Hysteria, , 

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Identity, varied,  Ignatius of Loyola,  Illusions, , 

Individual versus community,  Innovation versus authority, , – Insight: description of, –; existing with OCD, , , , ; lack of, among people with psychotic hallucinations, , ,  Insomnia, ,  Isaac,  Ishmael, Rabbi,  Islam, ,  Israel: state of, disapproved of by ultra-orthodox, ; wars of, –. See also Army service Jacob, ,  James, Henry,  James, William, , , ,  Janet, Pierre,  Jaspers, Karl, on delusions, ,  Jealousy, pathological,  John of the Cross,  Joshua, ,  Judah the Prince, Rabbi, ,  Kabbala, – passim; description of night in, ; kabbalists of northern Israel, , , –; practiced by a patient, –, , –; studied by a patient, , –,  Kanievski, Rabbi Yaacov,  Karo, Rabbi Joseph, –, – Kleinman, Arthur,  Koro, ,  Kosher, ; Mary Douglas on, ; motivation for keeping, –; in OCD, , –, –

 / Index

6240 Greenberg / SANITY AND SANCTITY / sheet 397 of 399

Kotsk, Rabbi Menahem Mendel of,  Lamed-Vav Zaddikim,  Language, Hebrew versus Yiddish,  Latah,  Learning difficulties, – passim; – passim,  Lewis, Aubrey: on Karo’s Maggid, ; on symptoms of OCD,  Lilith, –, ,  Loss, –, , . See also Grief Lubavitch, –,  Luria, Isaac, , ,  Luther, Martin, 

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Madness, as punishment by God,  Maggid, –,  Maimonides: on baalei teshuva, ; on the Messiah, –, –; on study of Kabbala, –; on treating depression,  Malingering, , , , , –, – Masturbation, , – passim Medication: antidepressant, –  passim, ; antipsychotic, , –, –, , – ; effect of, , ; minority groups and, ; reluctance or refusal to take, , , ; versus spiritual help,  Meditation,  Mendelssohn, Moses,  Messiah: and Bratslav hasidim, – passim; messianic beliefs versus delusions, –; mes-

sianic fervor, , ; messianic tourists to Israel, –, ; and the reestablishment of a Jewish nation, ; pretenders, . See also Frank, Jacob; Shabbetai Zevi Minorities, and mental health care, –, , –,  Miracles,  Moses, –,  Multiple personality disorder,  Murphy, Henry, , ,  Music, as remedy for depression, ,  Mysticism: dangers of mystical study, –; mystic imagery in fears, , –, , –, –, , –; and Sephardic communities, , , , . See also Kabbala; Zohar Nachmanides, –, ,  Navajo,  Navon, Yitzhak,  Neurasthenia, ,  Niggunim,  Night, significance in Judaism, – Nightmares, , – Obesity, as culture-bound concept,  Obsessional neurosis, Freud on, , – Obsessive-compulsive disorder (OCD), –, –, – ; aggression against God in, , , ; anxiety as a result of neglecting rituals, ; excessive politeness characteristic of,

Index / 

6240 Greenberg / SANITY AND SANCTITY / sheet 398 of 399

OCD (continued ) , ; indecisiveness characteristic of, –, –; insight existing with, , , , ; and laws of kosher, , –, –; prevalence of in villages, ; transfer of responsibility in,  Oedipus complex, and religious conversion,  Paranoid thoughts, , , , , , –,  Paul (Saul of Tarsus),  Philo of Alexandria,  Placebo effect, ,  Postpartum risk of recurrence of psychiatric disorder,  Posttraumatic stress disorder, , , ,  Prayer, – passim, – passim Principles of Faith, Thirteen, ,  Projection,  Psychodynamic theory,  Psychosis: acute, ; affective, , ; hysterical, ,  Purity, menstrual. See cleanliness Pzhysha, Rabbi Yaacov Yitzhak of, 

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Racism, in psychiatry,  Rashi, ,  Raziel, book of, , , ,  Regression,  Resh Lakish, – Reyna, Rabbi Joseph de la, – 

Salanter, Rabbi Israel,  Samael, ,  Samsara,  Satan,  Schizoaffective disorder, ,  Schizophrenia: among Baalei Teshuva, –; among travelers, , ; distinguishable from mystical states, ; with hallucinations, , –, ; higher risk of developing, , , , –; paranoid, , , , ; and taijinkyofu-sho, ; term introduced by Bleuler, ; undifferentiated,  Schizotypal personality disorder, – Scholem, Gershom, ,  Scrupulosity,  Sephardic communities, and mysticism, , , ,  Shabbetai Zevi, –, , , , ,  Shach, Rabbi Eliezer,  Shechter, Rabbi Yaacov Meir, on anxiety, – Sheinberg, Rabbi Hayyim, on overcoming depression,  Shidduch, –,  Siddhartha, Gautama,  Social phobia: compared to taijinkyofu-sho,  Social withdrawal, , , , , ,  Soul,  Steinsaltz, Rabbi Adin,  Stendhal Syndrome, – Sternbuch, Rabbi Moshe, , , 

 / Index

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Stigma, against mental health services,  Stigmata,  Suicide: attempts among Jerusalem tourists, , –; commanded by demons, – ; during army service, ; halakha and, ; risk of, if psychiatric advice not sought,  Taijin-kyofu-sho, ,  Talmid Hacham, – Tefillin, –, – Theosophy,  Therapy: cognitive-behavioral, , , , ; dependence on therapist, , –; electroshock, ; idealization of therapist, ; manipulation in, –; trust between therapist and patient, – Theurgy, ,  Thirteen Principles of Faith (Maimonides), ,  Tikkun,  Tikkunei Zohar,  Tolerance,  Tourism, – Trachtenberg, Joshua,  Trances,  Transference, 

Transmigration, , ,  Transmigrations, book of,  Trauma, , , . See also Posttraumatic stress disorder Unio mystica,  University: not attended by ultraorthodox, ,  Vilna Gaon: on suffering,  Visions. See Hallucinations Voices. See Hallucinations War: Gulf, –; Israeli, – Washing. See Cleanliness Yeshiva ketana,  Yichus, , , ,  Yiddish, – Yihud,  Yohanan, Rabbi, – Zar, – Zevi, Shabbetai. See Shabbetai Zevi Zohar: dangerous application of, ; descriptions of demons in, ; example of Theosophy, ; quoted, , ; and Rabbi Nahman, –, and Sephardim, ; studied by patient, , , , 

Index / 