Orthodox Judaism: Features and Issues for Psychotherapy

20 Mar 2013

Kate Miriam Loewenthal, Psychology Department
Royal Holloway University of London
Egham Surrey TW20 0EX UK

Important aspects of Orthodox Judaism.
What are the most fundamental aspects of orthodox Jewish beliefs and life-style? Which are most salient for psychology and psychotherapy?

Since the destruction of the second Temple nearly 2,000 years ago, many Jewish were dispersed from the land of Israel, but the longing for a restoration of the Temple, and of a complete return of the Jewish people to the land of Israel, has remained a key feature of Jewish prayers and identity in the centuries that followed.

There are about 14 million Jews in the world today. About 3-4 million live in Israel, with a similar number in the USA, and in the former Soviet Union, and the remainder scattered in communities in every continent. The orthodox can be broadly divided into two categories:

– The strictly- or ultra-orthodox. In Israel, Jews in this group are called the charedim, and the men wear conservative dark clothes, black skull-caps (yarmulkes) black hats, and are often bearded. The women wear modest dress (skirts and sleeves below the knees and elbows, high necklines, and cover the hair, sometimes with a wig). There are many groups within charedi circles, of which the most noticeable are the pietistic Chasidim, numerous groups, each clustered around a charismatic leader, a Rebbe. They are particularly likely to encourage religious enthusiasm and mystical experience.
– The traditionally and modern orthodox. In Israel, Jews in this group may be called daatim (though his term sometimes covers the ultra-orthodox as well). Men will dress more casually than in ultra-orthodox circles, but may wear skull-caps, often crocheted, and not black, and the dress of women, while modest, may not follow completely the strict dress code of the ultra-orthodox.

I have described the dress of the two groups because dress sends important signals about religious identity and group membership. The strictly orthodox may comprise about 10% of world Jewry, though estimates are hard to obtain. Estimates of the numbers of traditionally and modern orthodox are even harder to make, but perhaps about one-third to one-half might identify themselves as traditionally or modern orthodox.

Judaism is the oldest monotheistic religion, and belief in the unity of G-d, the origin and continuous source of creation, is by definition central. Orthodox Jews believe that G-d revealed teachings to humanity, via Moses, and passed down and elaborated by generations of pious scholars. There are laws applying only to particular categories of people – Jewish kings for example, or women who have recently given birth to a child, or priests, or non-Jews. But there is a large body of law and custom widely accepted and practiced by all orthodox Jews. There are minor variations in detail between different sub-groups of orthodox Jews. The common features of all varieties of orthodox Judaism include observance of the dietary laws, Sabbaths and festivals, the sanctity of marriage (strict monogamy), encouragement of regular prayer and religious study, and a high value placed upon the Jewish home and family as the centre of religious life. The education of children is an esteemed activity. Especially among the more strictly orthodox, children are regarded as blessing of which one cannot have too much – so family size is normally very large: averages have been estimated at about 6 children per family. The core ethical teaching is widely quoted as “Love your neighbour as yourself” (Lev 19:18), and Jewish communities are characterized by high levels of communal good works, with a wide range of charitable and support institutions (Holman & Holman, 2002). Mystical experience and religious enthusiasm are valued particularly among the more strictly orthodox, famously in hasidic groups.

Orthodox Jews, then, have monotheistic religious belief, a love of Israel, and follow strict laws regarding diet, Sabbath observance, sexual behavior and other aspects of daily life. Family life, education and practical kindness are all highly valued.

The epistemological tools acknowledged and supported by orthodox Judaism
What are legitimate sources and kinds of knowledge for orthodox Jews?

Among the very strictly orthodox Jews, secular study is not highly-regarded. Some areas of study may promote values which are seen as antithetical to Jewish values, for example with respect to sexual behavior. For strictly-orthodox men, particularly in Hasidic circles, a life-time career in religious study, and often teaching, is the most esteemed career track. The intellectual demands are high, but the focus of study is Jewish law and lore, with no significant attention being given to wider cultural, literary, artistic or scientific topics. Women in such circles may have a wider education than the men. However women will prioritise marriage and family commitments. These are likely to be heavy given the value place on having as many children as possible. Women will commonly contribute to the family livelihood, sometimes being principal breadwinners in order to free their husbands for religious study. Time is usually made for communal charitable activities by both men and women. University education is rare, but technical training may be undertaken, with the computer industry proving very popular. Small business management and administration is another popular livelihood, and, in some strictly orthodox circles, medical and para-medical training and careers are religiously acceptable and commonly undertaken, including counseling and psychotherapy.
The traditionally and modern orthodox will not eschew secular study, and as is known, Jews have made significant contributions in science, medicine and the arts. Medicine, law and business are popular careers. As among the strictly orthodox, women are free to devote themselves to family care if they wish, but it is common for women to be economically active.

Literal interpretation of scripture – in its normally-understood sense of the term – is not valued by orthodox Jews. Scriptural study is said to involve several levels: the P’shat, the plain meaning, and proceeding to more profound levels of mystical and kabbalistic interpretation and understanding. Every level of understanding (including the plain meaning) is open to differing interpretations. Scriptural study normatively involves a small piece of text in centre of the page, surrounded by hundreds or even thousands of words of commentary, offering diverse interpretation. “These and these are the words of the living G-d” and “There are seventy faces to the Torah” are commonly quoted in the face of apparently irreconcilable views, expressing Judaism’s valuing of diversity of interpretation. Nevertheless, scriptural interpretation is not a free-for-all, and only interpretations offered by competent orthodox religious authorities are accepted.

Although academic education is regarded with some suspicion, “pure” science, medicine and mathematics are regarded as legitimate areas of activity by most orthodox religious authorities. The Code of Jewish Law (Shulchan Aruch, which is adhered to by the strictly orthodox) (see Ganzfried, 1850) states that while choosing a teacher, one should be careful that s/he be a G-d fearing individual. However when choosing a medical practitioner, one is obliged to seek the most professionally competent, regardless of his or religiosity.

With regard to psychotherapy and counseling, it can be seen the guidance of the Code of Jewish Law is unclear – is one getting “teaching”, or medical help? In practice, the more strictly orthodox and their rabbis have been negative about using mainstream psychotherapy and counseling services. The reasons will become apparent later in this chapter. Spitzer (2003) regards it as essential that orthodox and Hasidic patients with psychiatric and psychological disturbances are seen only by professionals from a similar cultural background. Spitzer and others argue that the behavior and feelings of orthodox patients cannot be understood by others, and appropriate help and treatment can only be developed by those with a full immersion in the cultural and religious values and practices of the community.

Theory of personality.
The psychic structure inherent in Judaism involves a divine soul (Nefesh Elokis) and an animal soul (Nefesh HaBehamis). One aspect of the animal soul is the intelligent soul (Nefesh HaSichlis) (See e.g. the Hasidic work, Tanya by Shneur Zalman of Liadi). This is not unlike Freud’s later structural theory, which suggested three psychic functions – .id, ego, super-ego, which roughly correspond to the animal, the intelligent and the divine soul. Indeed the similarities between Freud’s thinking and that of Jewish tradition have been noted by several commentators (e.g. Bakan, 1958). The divine soul apprehends spiritual reality, and strives to cleave to G-dliness. The animal soul seeks material and self-centred pleasures, and the intelligent soul may be employed by either. The animal soul and the divine soul often have conflicting interests, and different Jewish mystical and ethical systems propose varying methods of dealing with this conflict of interests, notably whether to suppress the animal soul and its demands by abstinence and fasting, or whether to train the animal soul by teaching it to enjoy things done for the service of G-d. The latter path has probably been more popular. Judaism does not regard the animal soul as the work of the devil, but as a source of challenges to be dealt with in the right way. The source of animal soul is divine, although this is not obvious and apparent – hence the apparent “reality” of evil.

Among western Jews, the study of Jewish mysticism was largely confined to Hasidic circles. Among oriental Jews, the study of mysticism is more widespread. oriental Jews. More recently, Jewish mysticism has become a more generally popular topic for study in orthodoxy generally. Study includes the mystical systems of the Zohar, and of Lurianic kabbalah, and systems for contemplation and meditation.

The idea of a lifelong moral struggle, which humans are inherently equipped to win, but in which they have complete free choice, is the simple but pervasive theme underlying Jewish ethical teaching and Jewish accounts of personal development. It is closely tied to the Jewish view of human development.

Human development.
Development is a lifelong process, in the Jewish view. In Judaism, no-one has ever “made it” in the sense that some religious traditions may offer the hope of enlightenment or salvation, after which achievement there has been a personal transformation and after which struggles for salvation are at an end.. Even the totally righteous individual is engaged in a constant developmental struggle. Awareness of G-dliness is seen as an inherent human potential, but achieving this awareness is an ongoing process, and a necessary precondition to the spiritual-moral struggles that are the main purpose of existence.

Education, too, is a life-long process – training in religious awareness and spiritual work begin before birth, and all Jews are seen as having an obligation both to learn and grow, and to facilitate the learning and growth of others. The study of religious texts and adherence to the myriad details of Jewish law are the key vehicles of this process.

Here are some examples:

Pregnant women and young children should avoid contact with non-kosher species of animal, for example should not be given toy bears to play with, as they may cause spiritual harm, by their predatory nature.
Very young children should be taught to say blessings before and after eating and drinking, to remind them that the food is not there solely to be enjoyed, but is from G-d, and the strength derived from eating is to be used for good activities.

Teachers and parents should encourage children and adolescents to study and lead a religious life, but this should be in a way of pleasantness and firmness, without shouting, shaming or using physical force – these latter methods produce short-term compliance but have no beneficial long term effects.

One area of personal development very popular in orthodox circles is the study and practice of the laws relating to guarding the tongue (Shmiras HaLoshon). Bad-mouthing, slander and even gossip and chat, may all cause tremendous harm, to the tellers, the listeners and to the object of discussion (Pliskin, 1977). Careful attention, detailed knowledge and continual awareness are needed to maintain and develop standards in everyday social talk (Glinert, Loewenthal & Goldblatt, 2004).

Giving charity is seen as an obligation for all; even the poorest person should give a proportion of what s/he receives. This should be done several times daily, and implies the acknowledgement that G-d is the source of all material goods.

These are just a few examples of the kinds of detail involved in Judaism’s approach to ongoing personal development and how it relates to involvement in family and society. The age of transition to full adult moral and spiritual responsibility is clearly given as 12 (for women) and 13 (for men).

Psychological health and psychopathology.
Traditional Jewish sources are said to describe a range of psychopathology that corresponds to what we are familiar with today (Loewenthal, 1995). Accounts of well-being and psychopathology can also be found in traditional sources, and there are many references in the book of Psalms and elsewhere to the importance of religious faith and trust: positive well-being is suggested to result from trust in G-d, not consorting with bad people, not relying on the powerful and mighty, and serving G-d with joy. The other important therapeutic tool frequently advocated in traditional Jewish sources is the importance of offering assistance, comfort and all forms of practical support to those in need – the regular charity to the chronically poor, consoling the bereaved, visiting and assisting the sick, lending money to those who have suffered financial set-backs to enable self-support. These are religious obligations – commandments (mitzvot), and it is known that these forms of social support have powerful protective effects in preventing the onset of psychopathology among those who have suffered severe stress.

Interviews with lay people and religious leaders in the orthodox Jewish community indicate that normatively, the causes of mental illness are seen as both social – particularly all forms of stress – and biological, perhaps particularly for psychosis (Cinnirella & Loewenthal, 1999; Loewenthal & Cinnirella, 1999; Greenberg & Witztum, 2001).

The idea that psychological disorder is solely spiritual in origin e.g. the results of the machinations of the evil inclination (Yetzer Hora), appears not to be widespread. However all would agree that succumbing to the evil inclination is spiritually unhealthy and psychologically damaging – but there are other causal factors in mental illness as well.

Theory of human change.
Although there are frequent references to the importance if religious trust for well-being, this is not usually seen as a panacea, particularly not for serious psychopathology, either in religious traditions, or among contemporary religious leaders or among the lay orthodox-Jewish public.

Jewish tradition has always endorsed the obligation to seek medical treatment, and the doctor is empowered by G-d to heal.

Medical treatment for psychosis – particularly medication – is seen as appropriate. There are no problems in Jewish law in seeking and obtaining this.

For the “minor” disorders (depression, anxiety), and for social problems, there are reservations among orthodox Jewish authorities about seeking counseling and psychotherapy, as described above and as will be discussed. There appear to be no problems in religious law with taking medication. Many lay people however doubted whether medication does more than “relieve symptoms” without touching the underlying causes (Loewenthal & Cinnirella, 1999). Own-group counselors and psychotherapists, with religiously-approved training and known to be G-d fearing individuals, may be consulted. However, some lay people have reservations about own-group counselors, particularly with respect to confidentiality, and about the level of professionalism (Loewenthal & Brooke-Rogers, 2004):

“I wouldn’t consider going to someone like Mrs X. I might be sitting next to her at a simcha (festive meal) the next evening, and I wouldn’t like the idea that she might say something I don’t want everyone to hear.”

Some religious leaders may suggest that religious faith, prayer, and other activities may be sufficient:

“We treat such problems in the community. We give the person with difficulties a boost, talking about belief, and trust in G-d, saying we must not despair…everything is from Heaven. We encourage him to listen to nigunim (Hasidic song), to read stories of miracles from the great rabbis “. (Ultra-orthodox rabbi, quoted by Greenberg & Witztum, 2001).

Thus while faith, prayer and other religious activities are widely seen as helpful, particularly in promoting positive well-being, a small minority endorse religious beliefs and activities as the sole panacea for psychological disorders.

Common moral issues encountered
There are several areas in which the values of Orthodox Judaism may conflict – or appear to conflict – with the needs of psychotherapeutic work. These conflicts and apparent conflicts are primary reasons for the reluctance of many orthodox rabbis to endorse unconditionally the use of counseling and psychotherapy. Orthodox counselors and therapists will have received training and guidance in dealing with these issues, and will liaise closely with the rabbinate in their day-to-day work, so their work is usually endorsed by the rabbinate.

First, Jewish law does not condone homosexuality, masturbation, extra-marital or pre-marital sexual relations. Thus any indication that these practices can be condoned or supported is not appropriate for orthodox Jews, even though of course all these practices can and do happen. Therapists who do not share orthodox Jewish values and beliefs may think or suggest that an orthodox Jewish client is being made guilty or anxious as a result of religious prohibitions about sexual behavior. Appropriate therapeutic support can only be given by a therapist who understands that the religious prohibitions are givens, and the feelings and conflicts of clients must be dealt with in the context of the clients’ probable acceptance that the laws about sexual behavior are right, even if s/he does not find them easy or convenient.

On a more minor level, touching and other contact with people of the opposite sex is not approved, and therapists would need to be aware not to offer to shake hands or touch strictly orthodox clients of the opposite sex. Necessary contact for medical, life-saving purposes is permitted.

Second, more strictly orthodox clients may be troubled by the issues thrown up by the laws regarding respect for parents and teachers, and prohibiting speaking badly of another person. This can lead to difficulties for clients particularly in talking about abuse. There is complete rabbinic support for the disclosure of abuse, and taking appropriate steps to prevent its repetition, as well as dealing with the traumatized individual. But clients need to be aware that there is such rabbinic support, and of course, as one orthodox therapist has said: “I can’t give guidance on Jewish law, that’s not my remit, and clients couldn’t and shouldn’t accept what I say – it has to come from a Rov (rabbi) that the client trusts”. It is important for the therapist to be familiar with the issues in religious law, and to have appropriate rabbinic contacts, and for the therapist to be able to make suggestions about seeking appropriate rabbinic advice if clients seem likely to have reservations about making disclosures. It is also important for the therapists to liaise with rabbinic authorities with regard to child protection issues. Rabbinic authorities have developed policies and practices in this area, consistent with the law, and have close liaison with the statutory authorities. It is important to know what these are and to act accordingly, since therapists and clients who report child protection issues to the police or social services without appropriate liaison with the rabbinic authorities may find themselves ostracized by lay people in the strictly orthodox community, who find it hard to accept that an often respected member of the community has behaved abusively. The accused may be hotly defended as an innocent upright person, who is being maliciously slandered by a disturbed individual. If lay members of the community can be made aware that there is rabbinic support for the steps being taken, this will defuse any counter-productive attempts to protect the abuser and delay protective measures.

Thirdly, somewhat similar issues can beset attempts to deal with violent or abusive marriage relationships. Marriage is regarded as a holy and desirable state, and every attempt to preserve a marriage is regarded as praiseworthy and religiously meritorious. Nevertheless, there is no rabbinic support for domestic violence or other forms of abuse. Again it is important for therapists to be aware of the complex issues in religious law, and to have appropriate rabbinic contacts.

Among the many other issues that may be important is the issue of child-bearing. Jewish law is clearly negative about the use of contraception, unless life is endangered, in which some but not all forms of contraception are permitted. Moreover among the strictly orthodox, children are regarded as a blessing. Family sizes may be very large, and women (and men) may find themselves with inadequate resources to cope with parenting the very large numbers of children they have been blessed with. Here, it is important for the therapist not only to liaise with rabbinic authorities acceptable to the client, but also to have a good knowledge of the many support organizations within the community, specializing in this central dimension of orthodox Jewish life.

These are the salient moral dilemmas involved in psychotherapy and counseling with orthodox Jewish clients. There are clear conflicts with values that are normative in wider society, and there are complex issues in Jewish law that might best be dealt with by a therapist who is familiar with the strictly orthodox community, its personnel and mores. However, many clients will prefer to seek help and support from professionals from outside the community clients. This is often the case when the client seeks anonymity, and does not want to risk disclosing unpleasant and shameful secrets to someone who is part of the same community. It can be helpful for therapists and counselors to be aware of the issues and conflicts that may be troubling their clients, and to reflect on and assess their own views on these moral dilemmas, and how these views might affect their therapeutic practice.

Common clinical issues.
Prevalence studies have suggested that patterns of psychiatric disorder differ in the Jewish community compared to other groups. Bipolar disorder is said to be more prevalent, as are mood disorders in general. This latter effect is now established to be the result of a higher prevalence of (major depressive disorder) in Jewish men, possibly connected to the lower prevalence of alcohol abuse among Jewish men (Levav, Kohn, et al 1993, 1997; Loewenthal, Goldblatt, et al 1995; Loewenthal, MacLeod, et al 2003).

There are assertions that obsessive-compulsive disorder (OCD) is more common among orthodox Jews than in other groups, but there is no reliable prevalence work, and Lewis (1998) has concluded that while obsessionality as a personality trait is more likely among the religious, probably as a result of the religious valuing scrupulosity, OCD as a psychiatric disorder is not more likely in any of the religious groups studied, compared to the general population. Greenberg & Witztum (1994) concluded that religious can provide the framework for the expression of OCD symptoms, but is unlikely to be a direct cause.

But prevalence is not necessarily reflected in the referral situation. The clinical problems and dilemmas in the consulting room are not a clear reflection of the distinctive patterns of prevalence of disorder in the Jewish community.

Important clinical dilemmas with respect to diagnosis and treatment have been reported in dealing with orthodox Jewish clients.

First, there are difficult issues in diagnosis that arise with religious behavior and ideas. Clients may fear misjudgment, and these fears may be well-founded. They may be reluctant to seek professional help for psychological distress, for fear of being misunderstood. This is ample evidence to show that clinicians may indeed misjudge religious behavior as evidence of psychopathology, and may see religious clients as more likely to be disturbed (Gartner et al, 1990; Littlewood & Lipsedge, 1997; Yossifova & Loewenthal, 1999; Loewenthal, 1999). For example an orthodox Jewish man who declined to shake hands with a psychiatrist (on religious grounds) was diagnosed as withdrawn and catatonic. Only advisors from the patient’s own religious group are able to clarify whether the behavior is pathological or normative. Spitzer (2003) asserts that orthodox Jewish professionals are better qualified to detect whether a particular religious practice is pathological or normative. Greenberg & Witztum (2001) offer some helpful guidelines in making this decision with respect to orthodox Jewish clients. Again, rabbinic advice may be necessary, especially if it is appropriate to tell the client that a particular piece of behavior is not religiously advisable – for example spending several hours repeating a particular phrase from the prayers to make sure it has been correctly said.

The other major group of clinical issues focuses on treatment. Which treatments are acceptable? Which treatments are seen as likely to be helpful?

We have seen that psychotherapy may not be acceptable – therapists may be seen as unsympathetic, lacking in knowledge of the values and mores of the orthodox Jewish community, and likely to misjudge religious behavior and ideas. Own-group therapists may not be trusted – the concerns here have to do with confidentiality and professionalism. Prayer, religious trust and direct consultation with rabbis and other religious leaders are inexpensive, confidential and relatively accessible. Religious support may therefore be sought as a first resort, and there is considerable evidence that at least some significant forms of psychopathology may be helped by prayer, religious faith and other religious means (e.g. Koenig, MacCullough & Larson, 2000; Loewenthal, MacLeod et al, 2000). A common issue today is the extent to which therapists may recommend or even employ religious techniques. MacLachlan (1997) has recommended treatment plans which incorporate clients’ beliefs about the causes of their distress and symptoms, and which cover all feasible methods of alleviation. Greenberg & Witztum (2001) offer fascinating accounts of interventions including combinations of medication, a range of psychotherapeutic techniques, including visualization, cognitive and psychoanalytic therapy, and religious techniques including forms of exorcism. An important feature of Greenberg & Witztum’s work is close liaison with the religious authority most acceptable to the client. They have emphasized the importance of working within the client’s frame of interpretation. Symptoms may be seen as idioms of distress. The therapists’ acceptance of the cultural-religious framework improves client trust, and work within the framework can produce beneficial results. For example:

Ezra was a 24-year-old married man who had been a Jewish penitent for two years. He was brought by his brother to the clinic because of “bizarre behavior”. During the previous six months, while Ezra had been immersed in studying the Zohar (the key Jewish mystical text), he had heard voices and had dreams in which his late father appeared as a threatening black apparition. Ezra engaged in ascetic practices: he fasted frequently, wore tattered clothes, and visited the graves of Zaddikim (Jewish saints). He lit ritual candles on these graves, and at home. After the birth of his first child, a girl, these practices became more intense, and four months later he was brought by his brother to the clinic and admitted. Ezra appeared unkempt, and was not completely oriented to place and time. His cooperation was minimal. He was depressed in mood, but his formal thinking was normal. He reported visions of a personal angel, and also nightmares in which his father appeared, dressed in black and with a sad, suffering face. These visions and nightmares had started after the birth of his daughter.

Ezra was the younger of two sons of North African descent. His father had been a quiet, sad mad, who had begun drinking in mid-life, and had become a chronic alcoholic. At home, he would drink himself to oblivion at home, and fall asleep in his own vomit. One night, wen Ezra was 15, the father called Ezra to bring him a glass of water. Ezra brought the water, but when his father asked him to stay with him, Ezra refused. In the morning, the father was found dead.

Ezra became depressed and guilt-ridden, blaming himself for his father’s death. He began taking hard drugs. His brother persuaded him to quit drugs, and to join the army, which he did. After two years’ military service, Ezra left the army, became religiously observant and married. He prayed for a boy to name after his father.

When Ezra’s daughter was born, he was shocked. He began to hear a voice, which he identified as belonging to his personal angel. The angel said that instead of protecting him, he was punishing him for the neglect that lead to his father’s death. The angel told him to fast, wear tattered clothes, visit the graves of saints, abstain from sexual relations, and generally to afflict himself. Then he might be forgiven.

In therapy, the therapists suggested to Ezra that in Jewish law, it is forbidden to mourn a dead relative for more than a year. They appreciated that he was seeking an ecstatic religious experience which would signify that he had been forgiven, and attempted to encourage this, for example by asking him to bring his father’s photograph to sessions. Ezra wrote a letter to his father asking for forgiveness, and also looked intently at his father’s picture in a therapeutic session, and began to weep. The therapists also asked Ezra to investigate the angel: what were its intentions? What was its name? Was it really an evil spirit in disguise? In the 13th session, the therapists, together with Ezra’s brother who was a religious authority, attempted to exorcise the angel. Leading the ritual, the brother asked one of the therapists to read a formula from mystical-magical work The Book of the Angel Raziel, which Ezra used to summon the angel. During the reading, Ezra began to sway, moving his body and head in an increasingly rhythmic and vigorous manner. He added his own ecstatic sing-song of a two-syllable phrase, and seemed to enter a trance. Suddenly he became quiet and informed the others that the angel was present. Ezra’s brother informed the angel that on behalf of the religious court, he was ordering the angel to leave, and to return no more, neither for good, nor for bad, not even to reveal mystical secrets. Ezra seemed stunned and confused, because of long, intense, ambivalent relationship with the angel. One of the therapists explained that from then on, the angel had no right to disturb him because the angel belonged to another realm. The brother, tense and emotional, told Ezra to complete the exorcism by blowing out the candles. Ezra did this, and he was declared a free man, under his own control.

The therapists had intended to convert the angel from a punitive enemy, to an ego-supportive ally. Ezra’s brother had thwarted this intention, by his statement that the angel must not return again, for good or for bad. However, ultimately, the angel behaved according to the therapists’ expectations by returning occasionally, always in the role of an ally. (Witztum, Buchbinder & Van Der Hart, 1990)

While prevalence studies have suggested particular patterns of disorder in the Jewish community, in the consulting room the most common clinical issues focus on diagnosis and treatment – when is religious behavior pathological, which treatments are religiously acceptable, and which religious treatments can be recommended or even used?

Additional Resources.
Here is a brief list of some useful sources of further information on the topics covered in this chapter, and research and clinical support for some of the suggestions made.

• Useful journals include The Journal of Psychology and Judaism, Mental Health, Religion and Culture, The International Journal for the Psychology of Religion, and Social Science and Medicine.
• Important books include Greenberg & Witztum’s fascinating accounts of their mental health work among ultra-orthodox Jews in Jerusalem, and Littlewood & Lipsedge’s fascinating accounts of their mental health work among Hasidic Jews in North London. Bulka (1987), Spero (1985) and Spitzer (2003) all offer helpful suggestions about working with orthodox Jewish patients.
• Useful articles on psychotherapy with orthodox Jewish patients include Rabinowitz (2002), and Margolese (1998).
• More general works on religion and mental health, which can help to put the understanding of psychological issues among orthodox Jews into the broader context of work on religion and mental health, include Koenig, MacCullough & Larson (2001), Loewenthal (1995), and Pargament (1997).

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MacLachlan, M. (1997) Culture and Health. Chichester: John Wiley & Sons.
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