To appear in BDD vol.

32 – Bar-Ilan University Press

MEITAL HAIMOVICH & DAVID LEISER*

Ultra-Orthodox Jewish Perceptions of

Psychotherapy and Psychopathology

During recent decades, the ideologically self-secluded ultra-Orthodox society in Israel has become
increasingly open to ideas and practices of the general Israeli society. The present study examines
socially constructed knowledge about psychology and psychopathology among Israeli ultra-Orthodox
Jews. It aims to study conceptions regarding psychological treatment, in relation to other types of
treatments and with regard to different mental conditions.
We ran a questionnaire study (N= 242) including questions on the characteristics of the
psychological treatment, as well as questions regarding 13 case vignettes, each describing a different
psychopathological condition. The results showed a surprisingly solid recognition of psychologists as
mental health professionals. The rabbinic authority is perceived as the person to turn to for normal,
everyday life problems, whereas the psychologist is perceived as the proper address for abnormal or
crisis-related problems.
The respondents’ understanding of concrete psychological conditions appears at times to be
superficial and relies on heuristics. For some conditions, this uninformed approach can be misleading,
and potentially prevent patients or their families from seeking help.
The findings are discussed within the context of the unique characteristics of the ultra-
Orthodox society.

ULTRA-ORTHODOX JEWISH PERCEPTIONS OF PSYCHOTHERAPY

Traditionally, the ultra-Orthodox community has maintained a secluded position within Israeli society.
The characteristics of this ideological self-seclusion are gradually changing, especially in the past two
decades, as the ultra-Orthodox community becomes increasingly established, self-confident and well-
integrated into influential power positions in Israeli society. These significant changes have contributed
to the ultra-Orthodox society’s increased willingness to embrace ideas and practices of the general
Israeli culture, and thus allow new authority sources to emerge alongside the traditional ones. One of
these gradually assimilating knowledge fields is that of psychological thinking and practice (Caplan &
Stadler 2012).
The current research examines socially constructed knowledge regarding psychology and
psychopathology among Israeli ultra-Orthodox Jews. It aims to examine lay concepts and lay theories
regarding psychological treatment in relation to other types of treatments and with regard to different
mental conditions. These concepts will be discussed within the context of the unique characteristics of
the ultra-Orthodox society.
The theoretical introduction will first survey conceptions about mental health held by lay
people. Following a brief description of the unique characteristics of the ultra-Orthodox society, we
will discuss this population’s fraught dialogue with the field of mental health in general and psychology
in particular. Finally, a brief summary of the unique patterns of mental health seeking behaviors in the
ultra-Orthodox society will be presented.
*Author Note – We would like to thank Aviad Raz for his helpful comments, Rachel Arbiv, Avigail ben-Moshe, Shoshana
Rosen and Revaya Cohen and Dana Granit for assistance with obtaining and analyzing the data.
Research of popular conceptions and beliefs about mentally disabled people systematically
reveals disregard and ignorance among the public about every kind of mental disorder (Furnham &
Chan 2004; Angermeyer & Dietrich 2006). For example, a research about major depression and
schizophrenia found that the general public in Western society tends to believe that these disorders
originate from one’s social environment and stressful life circumstances. This conception is at variance
with current professional opinion that holds that the origin of these disorders is biological, whereas life
events usually merely provide the trigger for the manifestation of the disease (Angermeyer & Dietrich
2006; Jorm et al. 1997). The public attitude toward psychiatric disorders affects people’s perception of
the disorder itself, its diagnosis, treatment and rehabilitation process (Ozmen, Ogel, Aker, Sagduyu,
Defne, & Cumhur 2005). Distorted or false conceptions might therefore dramatically hinder the social
readiness to support the suffering ones.
Social and cultural conceptions essentially influence and construct lay knowledge. Indeed,
previous research has demonstrated that cultural perceptions of mental disorders have much influence
on patients’ help-seeking behavior, and on the way they are treated by specialists and by the public
(Furnham & Baguma 1999; Angermeyer & Dietrich 2006; Jorm et al. 2005).
We will next discuss the ways in which the unique characteristics of the Jewish ultra-Orthodox
(haredim) influence their conception and approach to mental health. Before considering the ways in
which the Jewish faith influences and is being influenced by psychological approaches, the main
characteristics of the ultra-Orthodox, or haredi, society, will briefly be reviewed.

The Haredim (ultra-Orthodox)

Ultra-Orthodox Jews (haredim) constitute more than 11 percent of Israel’s Jews. They are characterized
by their commitment to the study of the Torah and Talmud in Yeshivas (religious academies) and by
strict adherence to the Jewish law, the “Halakhah,” which covers every aspect of everyday life
(Margolese 1998). They live in segregated neighborhoods and send their children to separate haredi
schools, thus excluding people who do not share their values and lifestyle (Witztum & Goodman 1999).
Haredi society is not homogenous and there are differences among haredi sects. However, despite the
differences and even rivalry that prevails between the haredi sects, they are all united in their complete
rejection of the secular world (Bilu & Witztum 1993). In Hasidism, a branch of ultra-Orthodox Judaism,
each Hasidic group follows a particular dynasty of rabbinic leaders, or Rebbe. Hasidic Jews tend not to
make major decisions without consulting at least their local rabbi. His authority extends to personal,
religious, and social matters, and is rarely disputed. Non-Hasidic ultra-Orthodox Jews differ from
Hasidic Jews in their dress and wider range of occupations. They also pay great respect to their leaders,
but their influence is more often restricted to ritual matters and they are generally not involved in
personal life choices.
The growing demographic and political power of the haredi society in recent decades has
contributed to the emergence of a new sense of “self-confidence” when facing the surrounding world
(Caplan & Stadler 2012; Fuhrer 2001). Far from being a completely closed society, the ultra-Orthodox
community can be portrayed as constantly moving across the boundaries, as even the most extreme of
the ultra-Orthodox must use secular services. The emphasis on learning the Torah has limited the ability
of the ultra-Orthodox to provide necessary services from within their own community (Witztum 1999).
One of the few instances in which the ultra-Orthodox community sustains close contact with specialists
from the “other world,” is in the case of mental health services (Bilu & Witztum 1993). However, it is
not unlikely that the new sense of confidence mentioned above, and not just the paucity of parallel
haredi institutional infrastructure, might account for the growing willingness of the haredi society to
turn to secular services and institutions. This willingness to seek help from psychologists (or
educationalists) is far from natural, since the field of intervention, the human psyche, is to be controlled
by religion according to the ultra-Orthodox worldview (Caplan & Stadler 2012). The growing openness
and willingness to contact health care services is part of a gradual change of attitude in the haredi
society toward disabilities and abnormalities, which have moved from shame and concealment to a
better understanding of the necessity to deal with the problem and treat it. More and more haredi
institutions for treatment and rehabilitation in different fields have been established in the past years,
including a small number of mental health care institutions (Fuhrer 2001).

Jewish Ultra-Orthodoxy and the Mental Health Field

Religion plays a central role in the lives of religious groups, and particularity among haredi Jews, who
embrace the most conservative and intensive form of Orthodox Judaism. Religion provides its followers
with an organizing set of beliefs, values and behaviors, social norms and communal institutions. These
have a mediating effect on the way individuals perceive and adopt ideas and practices.
Since the emergence of psychology as a professional discipline, it has been running a dissonant
dialogue with religion, due to an overlap regarding issues that concern both fields. Psychology aims to
understand the individuals, alleviate their emotional anguish. This could also be considered as one aim
of religion. However, their goals, values, and means are different. Mental health specialists have often
viewed religion as a pathological condition that requires treatment, whereas psychology, viewed
through the religious perspective, has been conceived as a method that undermines the very
fundamentals of religion, or even wishes to replace them with its own (Hoffman & Rossman 2012).
The Israeli researchers Bilu and Witztum (1993) identified several points of tension between
religion and psychology. They observe that the historical attitude of Judaism toward psychology, as
revealed in generations of rabbinic writings, could be characterized as ambivalent. To begin with, the
contrast between the ideal of complete trust in the curative power of God and the need to address flesh
and blood doctors leads to an unavoidable dissonance. This dissonance is manifested as ambivalence
toward medical doctors and especially for mental health.
Another problem that derives from this gap is that translating an experience expressed in
religious terms into a psychoanalytic language of unconscious drives and conflicts can never be
comprehensive, and might not be in line with the subjective perspective of the client. Therapists,
consciously or unconsciously, transmit Western, secular values (Heilman & Witztum 1997; Spero
1989), often radically different from those of religious patients. Unlike the Western liberal perception,
which gives priority to individual liberty and thus encourages values of independence and autonomy,
the religious perception emphasizes obedience to the divine law and to the rabbinic authority who leads
the community and is committed to its wellbeing, and thus does not encourage values of independence
and autonomy but rather tradition and conformity (Frosh 2004). These fundamental differences are
bound to challenge the compatibility between therapist and patient in terms of treatment goals, etc.
Thus, ultra-Orthodox patients might be concerned that a therapist of different cultural and religious
background might not agree with their values and way of living. Moreover, the therapist might even
try to influence the patient’s values or attack them (Gilglio 1993). As a result, many haredim regard
staff members of mental health services as representatives of the decadent, immodest world, from
which they strive to seclude themselves and their families (Bilu & Witztum 1993).
Fear of stigmatization, too, makes turning to mental health services difficult (Greenberg &
Witztum 2001). In the ultra-Orthodox society, psychiatric patients and especially their families make
great efforts to hide the disease from their environment, out of fear that revealing it might cast a stigma
on the suffering one and his/her family. One dominant concern is that it might affect the chances for
them and their siblings for good matchmaking. The fear of marrying a mentally ill person exists in
every society, but is especially relevant for haredi society, where marriage is pre-arranged (Witztum &
Buchbinder 2001; Hildsheimer 1982). Among ultra-Orthodox Jews, and especially among Hasidic
ultra-Orthodox, one’s lineage is an important component of social status. Although, so far, no
quantitative comparison regarding stigma of mental illness in different Jewish religious affiliations has
been made, mentally ill people have been reported to be highly stigmatized among ultra-Orthodox Jews,
resulting in low social status. It has been noted that the ultra-Orthodox underutilize public mental health
services, while newly religious (“born-again”), whose lineage is essentially nonexistent, tend to utilize
them relatively more freely (Greenberg & Witztum 2001). Fear of stigmatization is one reason for the
ultra-Orthodox preference for pharmacological therapy versus psychotherapy, according to Gersten
(1979). He found that taking psychiatric medication is perceived as a medical rather than psychological
intervention, and is therefore socially more acceptable. However, another study reported contradictory
findings, according to which ultra-Orthodox patients are often reluctant to take psychiatric medications
that are perceived as intimidating and dangerous medical interventions (Bilu & Witztum 1993). The
results of the latter research are in line with those of a recent large scale, meta-analytic review that
examined patients’ preference for psychological vs. pharmacological treatment of psychiatric disorders.
The meta-analysis showed a significant preference among adult patients for psychological treatment
over the use of psychiatric medication (McHugh, Whitton, Peckham, Welge, & Otto 2013). In light of
these findings, which refer to the population at large, Gersten’s findings may reflect the high sensitivity
regarding social stigma of the haredi society.

Mental Health Seeking Behavior in the Haredi Society

In light of the difficulties and obstacles reviewed above, it comes as no surprise that haredim are
reluctant to turn to mental health services, with the expected consequences (Greenberg 1991; Witztum,
Greenberg, & Buchbinder 1990). The ultra-Orthodox are under-represented in new referrals to mental
health services, in comparison with the general population; the delay before turning to mental health
services is especially long; the ultra-Orthodox are over-represented in major psychiatric disorders, and
under-represented in minor ones, as ultra-Orthodox patients turn to mental health services only when
the problems become acute, and quit the treatment process before it ends (Greenberg & Witztum 2001).
According to Buchbinder (1988), the scarcity of referrals indicates that the ultra-Orthodox community
tends to turn to mental health services only when the situation is too severe to be ignored or dealt within
the means of the subculture, i.e. religion. His explanation for the over-representation in the major
disorders is that minor disorders, such as adaptation problems or minor depression, are treated by rabbis
and social welfare services from within the community, or autonomously by the patients themselves,
through implementing religious practices such as praying (Buchbinder 1988). This pattern is consistent
with the well-established finding, according to which people first exhaust their personal resources at
times of distress, then turn to their natural support system, and only as a last resort turn to the formal
support system. The natural support system’s aid is mainly expressed by listening and supplying advice.
Its advantage rests on its ability to respond in an immediate and flexible way, due to its proximity to
the supported person; in the emotional identification with him or her; and in the common moral and
conceptual ground they share (Fuhrer 2001). This explanation is supported by the findings of a study
that examined attitudes toward psychotherapy among Orthodox, Conservative, and Reform Jewish
groups in the United States. The results reveal positive attitudes among all affiliations, with Orthodox
Jews significantly more likely to turn to their rabbi for psychological counseling and perhaps as a
conduit to professional treatment (Kaminetzki & Stricker 2000).

THE PRESENT STUDY: METHOD

We devised a detailed questionnaire asking about the meaning and purpose of psychological therapy,
and presented a range of conditions listed in the DSM-IV, asking several questions on each on how
best to deal with the condition, its etiology, severity, and expected duration. The questionnaire was
completed by a large sample of haredi respondents. We will present and discuss the pattern of responses
in the following sections.
We based the research questionnaire on a format developed for a previous study, conducted by
Granit-Lichtmeyer (2009), with some special emphases. We aimed to investigate whether the lay
haredi respondent would display ambivalent attitudes in relation to psychology, as was found regarding
rabbinic figures’ attitudes to psychology. We also were interested to examine potential patterns linking
perceived etiology, perceived severity, and preferred treatment of different mental conditions, as well
as to understand the unique role of rabbinic authority in relation to that of psychologists. These cardinal
questions lie at the basis of the current research and guided the formulation of the questionnaire.

Participants
The research questionnaire was completed by 242 respondents, 203 women and 39 men, in the age
range of 19 to 63, all of whom were self-defined as ultra-Orthodox Jews. The average age was 24 (SD=
10.89) and the average for years of education completed was 14.26 (SD=8.63). No respondent had been
formally educated in any of the fields related to mental health (psychology, psychiatry, social work,
etc.). Under 18-year-olds were excluded (6 boys and 20 girls), bringing the new total sample to 216, of
whom 183 were women and 33 men.
The respondents form a convenience sample. Due to the secluded nature of haredi society, it
was not possible to form a random research sample, since finding potential respondents was no simple
matter. Two female haredi experimenters, who approached a varied sample of people to whom they
had access on a professional or personal basis, therefore assisted us. Most of the female respondents
were students in teachers’ training colleges in Jerusalem, Rehovot, and Ashdod. About 25 male
respondents were students in Yeshivas and Kollels in Jerusalem, Bnei Brak, and Rehovot. Other
respondents, male and female, were students at the Haredi College of Jerusalem, in social science and
communication disorders programs, and medical laboratory sciences. In addition, about 20 respondents
were personal acquaintances of the research assistants.

Tools
All participants answered an anonymous self-appraisal questionnaire. The questionnaire (see
Appendix) comprised two parts. The first part addressed lay conceptions of psychological treatment by
eliciting metaphors and goals for such treatment. Participants were asked to select up to five out of
thirteen metaphors that best resembled, in their opinion, the psychological treatment (see the list of
metaphors in the Appendix).
Participants were then presented with ten possible goals for the psychological treatment, and
had to choose up to three goals that, in their opinion, were most accurate. The list of goals consisted of:
Understanding and insight regarding the meaning of life; Spiritual healing; Expressing emotions;
Release of inhibitions; Listening ear; Diagnosis of problems and advice on coping; Gaining a sense of
relief; Self-acceptance; Gaining a better understanding of oneself; Changing unwanted behavioral
patterns.
The second part of the questionnaire included thirteen case vignettes, describing people who
suffer from different psychological conditions: schizophrenia, obsessive compulsive disorder (OCD),
antisocial personality disorder, timidity, eating disorder, alienation, hypochondria, post-traumatic
syndrome disorder (PTSD), and depression. One of the test cases (number 6) was used as a filler. For
each vignette, the participants were asked to estimate its severity, and choose its optimal treatment, its
etiology, and estimated length of recovery. All vignettes were written according to psychopathological
conditions’ definitions of the DSM-4, in a format adapted to the ultra-Orthodox population. The
questionnaire ended with demographic questions about gender, age, education, occupation, religious
belief, etc.

RESULTS

Lay Conceptions of Psychological Treatment

Metaphors: The distribution of answers for the first section, which referred to the way the psychological
treatment was metaphorically perceived, is presented in Figure 1.

Insert Figure 1 about here

The results presented in Figure 1 show significant differences, confirmed by a one-way ANOVA (F(13,
3107)=52.839, p=0.0001). The dominant metaphors are: Excavation (allows to reveal hidden contents);
Construction (helps forming the self); Emotional release (in order to open the heart); and Personal
coaching (brings out the best in you).

Insert Figure 2 about here

Goals. The distribution of answers for the perceived goals of psychological treatment is presented in
Figure 2. The most widely recognized goals were (in descending order): Diagnosis of problems and
advice regarding coping; Spiritual healing; Release of inhibitions; Gaining a better understanding of
oneself; and Listening ear. A one-way ANOVA showed that the mean values are significantly different
(F(9, 2142)=50.974, p=0.00001)

Vignettes evaluations
The second part of the questionnaire presented thirteen short vignettes describing conditions of
various severity, and the same set of questions was asked about each (see Appendix 1). We will first
present average findings, across all vignettes, then examine the differences between conditions.

Preferred treatment
Insert Figure 3 about here

The first question that followed each vignette concerned the recommended source of help or treatment.
We averaged the answers across all vignettes, and the distribution of answers for this question is
presented in Figure 3. Some treatments are more popular than others [F(5,1190)=297.41; p=.00001)].
Participants show significant preference for turning to a psychologist (63.82 percent). The second most
chosen option was turning to someone close (38.31 percent), then to a rabbinic authority (25.21
percent), then coping alone (22.15 percent), and giving no treatment (6.43 percent). Of all optional
treatments, medication was the least chosen (14.54 percent). The distribution of data for preferred
treatment by psychological condition is presented in Table 1.

Insert Table 1 about here

Table 1 allows examining the pattern for each psychological problem separately. The rows do not sum
up to 100 percent each, since participants could choose more than one option for this question. As
indicated before, according to the overall result, people recommend turning to a psychologist for most
of the psychological conditions (63.82 percent). There were, however, a few exceptions to this. First,
for alienation, the dominant preference was to turn to someone close (53.99 percent), then to a rabbinic
authority (46 percent), and only last to a psychologist (24.88 percent). For OCD, participants preferred
turning to someone close (61.5 percent), then to a psychologist (38.97 percent). Another unusual pattern
concerns the choice of medication, which is higher than average (14.54 percent) for eating disorders
(34.91 percent) and autism (27.70 percent).

Etiology
The second question asked following each vignette concerned the attributed etiology of each condition.
Interestingly, the most popular explanation is that in terms of life events experienced by the patient.
The patient’s own choices come second, and biological etiology comes third. (Again, the percentages
do not add to 100 percent since participants were allowed to mark several causes.)

Insert Table 2 about here

The distribution of data for postulated etiology by psychological condition is presented in Table 2.
Conditions that were mostly perceived as biologically based were autism (73.24 percent), antisocial
personality disorder (71.36 percent), and timidity (57.28 percent), whereas conditions that were mainly
seen as resulting from personal choices were alienation (57.82 percent), eating disorders (55.66 percent)
and depression (51.42 percent). The three conditions most related to life experiences were PTSD (95.31
percent), schizophrenia (87.79 percent), and panic attacks (79.15 percent).

Severity
Several questions addressed the issue of severity and prognosis of the condition. We asked about the
expected duration of the conditions, and their perceived severity. These two variables were found to be
strongly positively correlated (r=0.49, p<0.00001). Next, we examined whether preferred support or
treatment source would be related to these correlated variables. To bring out the pattern of inter-
correlations, we performed a hierarchical cluster analysis on the following variables: treatment
possibility, etiology, perceived duration and perceived severity (see Figure 4). Cluster analysis involves
two parameters: the definition of distance between items (here, the variables), and the clustering
method. We used the most common definition of distance, namely, the geometric distance between
them in the multidimensional space spanned by the participants. Clustering was performed according
to “Ward's method” (Statsoft, Inc. 2010). This method is a kind of reverse analysis of variance, and
attempts to minimize the sum of squares of any two clusters that can be formed at each step. The
meaning of clustering, with this method, is readily intelligible.
 Insert Figure 4 about here

The resulting tree diagram shows two distinct patterns of positively correlated factors, one of which
includes turning to a psychologist and the other to a rabbinic authority. The branch that includes turning
to a psychologist also includes (perceived) severity and duration; the more severe and enduring the
problem, the higher the tendency to refer it to psychological treatment. The other branch suggests that
turning to a rabbi correlates with conditions caused by personal choices, and less strongly to life
experiences, and with conditions that could be solved also by self-management, by turning to someone
close, or that do not require any treatment.
Another pattern revealed by Figure 4 is the link between biologically-based conditions and
choice of a medical treatment. Both these variables are related to psychological treatment, severity and
duration, so that conditions seen as biologically based were also perceived as being more severe and
longer lasting, and as needing psychological and/or medical treatment.

DISCUSSION

The current research aimed to examine the lay perceptions of ultra-Orthodox participants regarding
psychology and psychopathology. Due to the secluded nature of haredi society and the difficulty in
finding potential respondents, we chose to use a convenience sample. We were therefore assisted by
two female haredi experimenters, who helped us approach a varied sample of people to whom they had
access on a professional or personal basis. We ran a self-appraisal questionnaire study (N= 216), as a
means to avoid halakhic yichud situations. All of the respondents were self-defined as ultra-Orthodox
Jews, and none had been formally educated in any of the fields related to mental health.
The research questionnaire referred to the participants’ general conceptualization of the
psychological treatment, and to the way they perceived its actual goals. In addition, it examined their
perception regarding a list of psychological conditions, on several dimensions: preferred treatment,
psychological or other, for the depicted problem; etiology; the estimated treatment duration; and its
perceived severity. The results showed a surprisingly solid recognition of psychologists as mental
health professionals. The rabbinic authority was perceived as the person to turn to for normal, everyday
life problems, whereas the psychologist was perceived as being the proper address for abnormal or
crisis-related problems. The respondents’ understanding of concrete psychological conditions appeared
at times to be superficial and relied on heuristics.
Participants’ general conceptualization of psychological treatment was evaluated by a list of
metaphors. It was found that the most popular images for psychological treatment were Emotional
release, Excavation, Construction, and Personal coaching. These images are quite different from one
another and suggest a quite versatile perception of the psychological treatment: Emotional release
refers to the emotional aspect; Excavation and Construction can be viewed as different aspects of a
cognitive, analytic–constructive act; Personal coaching signifies the cognitive and behavioral aspects
of the psychological treatment. Taken together, the three images form a comprehensive and not
unrealistic image of a process that relates to the main human faculties of emotion–cognition–behavior.
We may also interpret the results regarding the perceived goals of the psychological treatment
as relating to these same dimensions. The goal identified most often, Diagnosis of problems and advice
regarding coping, represents the cognitive (diagnosis) and behavioral (coping) aspect of the
psychological treatment; Gaining a better understanding of oneself represents the cognitive
(understanding) aspect; and Listening ear can be perceived as one of emotional connotation. The two
remaining goals of Spiritual healing and Release of inhibitions can be taken as general images that do
not represent any specific aspect. However, they both mark potential points of dissonance with the
religious worldview mentioned in the literature: Release of inhibitions might lead to subversion of the
basic ultra-Orthodox stance, which is founded on an uncompromised observance of the halakchic codex
(Margolese 1998), and therefore constantly requires high levels of self-control (Fuhrer 2001). In
addition, attributing the goal of Spiritual healing to the psychological process depicts it as
knowledgeable and competent regarding the human psyche, and hence delegates it with an authority
that is external to the Torah and therefore threatens its status (Sosevsky 2002; Fuhrer 2001). The
appearance of these two goals as one of the five leading perceived goals of the psychological treatment
by this population is very significant.
These results might indicate, at least on the theoretical or conceptual level, a quite open-minded
approach on the part of the ultra-Orthodox public toward the subject, as opposed to the literature
regarding the officially ambivalent attitudes of ultra-Orthodox rabbinic figures toward psychology
(Bilu & Witztum 1993). This may be explained as a gap between the basic position toward mental
health treatment and the actual behavior, as found in the research of Hildesheimer (1982) regarding
ultra-Orthodox teachers. It is possible that a similar gap also exists between the theoretical recognition
by the ultra-Orthodox public of the potentially beneficial effects of psychotherapy, and their actual
willingness to seek help from mental health care services.
This assumption finds support in the finding that respondents show preference for psychological
treatment over all other proposed treatments, including turning to someone close or a rabbinic figure,
in the case of psychological behavioral problems and emotional distress. This reflects recognition of
the necessity of psychological treatment in case of mental health problems. Conversely, previous
researchers note the reluctance among the haredi population to use mental health care services, and
that haredim underuse mental health care services in relation to the general population (Bilu & Witztum
1993; Greenberg 1991; Witztum et al. 1990). This incongruity can be understood in terms of a gap
between the conceptions and stances of individuals and their actual behavior, a gap that is inherent to
a collectivist community regulated by strong social norms. Unlike the solid support of psychological
treatment, the use of medication is the least chosen of all treatment options. This pattern might offer
support to the finding of Bilu & Witztum (1993) that ultra-Orthodox patients are reluctant to take
psychiatric medication, perceived as intimidating and dangerous medical interventions. These findings
regarding treatment preference are consistent with those of Angermeyer & Dietrich (2006), who
surveyed more than 60 population-based attitude studies in psychiatry over a period of fifteen years,
most of which were conducted in Europe. They found that all studies using case vignettes agree that
public beliefs regarding psychological interventions (e.g. psychotherapy or counseling) are
predominantly favorable, while very negative views prevail regarding the use of pharmacological
treatment.
We also found a strong tendency to recommend turning to someone close for help. This is
consistent with the literature regarding the haredi close-net social support system, which serves as an
available, normative and reliable source of help. Cohen (1975) writes about the emphasis of the Jewish
religion on mitzvahs (commandments) that relate to interpersonal relationships. Not only does religion
enhance solidarity and collectivism, the Jewish standpoint permits, and even obligates, interference in
the lives of individuals and of the community when assistance is needed.
We saw that psychological treatment is the preferred choice for mental health conditions,
followed by turning to someone close, and explained this by the growing recognition of the need for
psychological treatment, as well as the strong social support norms in the ultra-Orthodox society. How
can we account for the low preference for rabbinic intervention? This finding comes as a surprise, given
the predominant position of the rabbinic authority and its high involvement in every aspect of
community life, including the referral to health care treatments (Fuhrer 2001). The explanation may be
found in the results of the cluster analysis that covered treatment preference, perceived severity,
duration, and etiology. The more severe and longer lasting the condition, the higher the participants’
tendency to refer it to a psychologist. Conversely, turning to a rabbi is related to conditions seen as
being caused by personal choices and life experience, problems that could also be solved by self-
management or turning to someone close, or ones that need no treatment at all. In other words, it seems
that minor and transient problems, those that barely pose any problem or that can be dealt with using
immediately available, personal, familial, and social resources, would be referred to a rabbi. This
finding is consistent with an earlier finding, according to which minor disorders are often treated by
rabbis and social welfare services from within the community, or autonomously by the patient through
implementing religious practices, such as praying (Fuhrer 2001). Conversely, in cases perceived as
severe and persistent, cases that the immediate environment lacks the resources to deal with, they would
be referred to psychological treatment. The rabbinic authority is seen as the proper figure to address
normal, everyday life problems, whereas a psychologist is perceived to be the right address for
abnormal or crisis-related problems.
Requiring rabbinic guidance correlates with conditions seen as being caused by personal
choices. This suggests that referral to a rabbi would be made in cases when an individual seeks guidance
about the right choice for them. On the other hand, psychological treatment is related to problems
perceived as biologically based, suggesting that referral to a psychologist would be made in conditions
perceived as harder to alter. This finding resonates with one of the claimed differences between
psychology and religion, as the former is to some extent related to determinism and the latter to freedom
of choice, which is a fundamental tenet of Judaism (Sosevsky 2002). Hence, it seems that conditions
perceived as potentially controllable will lead to consulting a rabbi, whereas conditions that seem to
have gotten out of hand will require turning to a psychologist.
Detailed information about basic conceptions of the ultra-Orthodox sample regarding different
aspects of the research subject will be revealed by a closer examination of this general pattern. A
correlation was found between the perceived severity of mental conditions and their perceived duration,
that is, the idea that the more severe a problem is, the longer it takes to treat it. This rather simplistic
conception is misleading. To give but one example, depression was conceived as being significantly
more severe than timidity; however, symptoms of severe major depression could be pharmacologically
treated within a few months, whereas symptoms of timidity might never be successfully treated. The
correlation between the mental disorders’ severity and duration may have been inspired by the typical
healing process of physical traumas, often characterized by a longer healing period for grave injuries
and disease. “Borrowing” from this common knowledge regarding the physical healing process, and
applying it to the field of mental health, may have served as a misleading heuristic.
In addition to the high correlation found between the variables of perceived severity and
duration, another correlation was found between the perception of a condition as biologically based
and recommending pharmacological treatment. This correlation could be explained by a tendency to
identify “biologically based” with “physical” or “material,” and therefore treat it by means of
conventional medicine, i.e. medication. That is, as described above, a tendency to “borrow” knowledge
from the field of physical conditions to the field of mental health conditions, as in the case of the
severity–duration correlation, relying on this intuitive conception could be misleading.
The most commonly attributed etiology was life experience, then personal choices, and finally
biological or innate factors. This finding is consistent with those of Angermeyer & Dietrich’s survey
(2006), which found that all studies using vignettes concluded that lay beliefs regarding the causes for
mental disorders clearly differ from those of psychiatric research in that psychological factors,
particularly psychosocial stress, are predominant in comparison with biological factors. Lay etiology
is subject to conceptions considered scientifically inaccurate.
It seems that the respondents’ general conception of the psychological treatment, as manifested
through their choice of metaphors, definition of goals for treatment, and their referral to treatment,
indicates a quite solid recognition of psychologists as mental health professionals.
Beyond the specific perceptions and varied heuristics used by the lay respondents, an overall
conception may be seen to emerge. This general perception recognizes the role of psychologists as
mental health specialists, and distinguishes between their function and that of rabbis in a way that
allows both instances to act within the community, or even cooperate. In light of previous references
to the ambivalent haredi position toward psychology, this finding might seem surprising. However,
previous research found that the ultra-Orthodox society does accept the need to use mental health
treatment and its reluctance has to do with approaching therapists of a different cultural background
(Fuhrer 2001; Hildsheimer 1982). The ultra-Orthodox ambivalence toward mental health care services
is less related to psychological thinking per se than to the threatening meeting with representatives of
a different worldview. This finding suggests that moderating or softening this meeting point might
facilitate the acceptance of psychological ideas and practice by the haredi society.
Up until the current research there has been no significant reference to the relevant perceptions
of the general, lay haredi population that are highly influential in the process of referral to mental health
services. In this sense, seen as a pilot research, the current work might serve as a basis for broadening
our understanding regarding the different ways in which psychotherapeutic conceptualization and
practice could more sensitively and effectively be integrated within the ultra-Orthodox social
framework.

REFERENCES

Angermeyer, Matthias C., & Sandra Dietrich. “Public Beliefs about and Attitudes towards People with
Mental Illness: A Review of Population Studies.” Acta Psychiatrica Scandinavica, 113 (2006):
163-79.

Bilu, Yoram, & Eliezer Witztum. “Working with Jewish Ultra-Orthodox Patients: Guidelines for a
Culturally Sensitive Therapy.” Culture, Medicine and Psychiatry, 17 (2) (1993): 197-233.

Brown, Tony N., Katherine M. Donato, Mary Therese Laske, and Ebony M. Duncan. “Race, Nativity,
Ethnicity and Cultural Influences and the Sociology of Mental Health.” In Handbook of the
Sociology of Mental Health. Netherlands: Springer, 2013, pp. 255-76.

Buchbinder, Tuvya. “Health Care Services and the Ultra-Orthodox Community [Heb]. Be’or Hatora,
7 (1988): 69-77.

Caplan, Kimmy, & Nurit Stadler. From Survival to Consolidation: Changes in Israeli Haredi Society
[Heb]. Jerusalem, Israel: The Van Leer Institute, 2012.
Cohen, Oved. The Conflict between Religious and Non-religious: Solidarity and Social Distance
among Israeli High-school Teenagers [Heb]. Unpublished doctoral dissertation, Hebrew
University, Jerusalem, Israel (1975).

Frosh, Stephen. “Religious Influences on Parenting.” In Handbook of Parenting, ed. Masud S.

Hoghughi & Nicholas Long. London: Sage Publications, 2004, pp. 98-109.

Furnham, Adrian. “Psychiatric and Psychotherapeutic Literacy: Attitudes to, and Knowledge of,
Psychotherapy.” International Journal of Social Psychiatry, 55, 6 (2009): 527-37.

Furnham, Adrian, & Peter Baguma. “Cross-cultural Differences in Explanations for Health and Illness:
A British and Ugandan Comparison.” Mental Health, Religion and Culture, 2, 2 (1999): 121-
34.

Furnham, Adrian, & Esther Chan. “Lay Theories of Schizophrenia: A Cross-cultural Comparison of
British and Hong Kong Chinese Attitudes, Attributions and Beliefs.” Social Psychiatry and
Psychiatric Epidemiology, 39 (2004): 543-52.

Fuhrer, Miriam. Using Professional Mental Health Care Services by Ultra-Orthodox Population
(unpublished Master’s thesis) [Heb]. Ramat Gan, Israel: University of Bar-Ilan, 2001.

Gersten, Leon. “The Mental Health Needs of the Pious.” Sh’ma: A Journal of Jewish Responsibility, 9
(1979): 52-55.

Gilglio, Julie. “The Impact of Patients’ and Therapists’ Religious Values on Psychotherapy.” Hospital
and Community Psychiatry, 44 (1993): 768.

Granit-Lichtmeyer, Dana. Lay Perceptions Regarding Psychological Treatment and Psychotherapy:

Comparison between Non-religious and Religious Populations (unpublished Master’s thesis)
[Heb]. Be’er Sheva, Israel: Ben-Gurion University, 2009.

Greenberg, David, & Jonathan D. Huppert. “Scrupulosity: A Unique Subtype of Obsessive-Compulsive

Disorder.” Current Psychiatry Reports, 12 (4) (2010): 282-89.

Greenberg, David, & Eliezer Witztum. Sanity and Sanctity: Mental Health Work among the Ultra-
Orthodox in Jerusalem. New Haven: Yale University Press, 2001.

Heilman, Samuel, & Eliezer Witztum. “Value-sensitive Therapy: Learning from Ultra-Orthodox
Patients.” American Journal of Psychotherapy, 51, 4 (1997): 522-41.

Hildsheimer, Yehudit. Ultra-Orthodox Religious Circles’ Attitudes toward Psychotherapy

(unpublished Master’s thesis) [Heb]. Israel: University of Tel Aviv, 1982.

Hoffman, Seymour, & Leah L. Rossman, Psychotherapy and Judaism [Heb]. New York: Golden Sky
Books, 2012.
Hong, Ying Yi, Sheri R. Levy, & Chi-yue Chiu. “The Contribution of the Lay Theories’ Approach to
the Study of Groups.” Personality and Social Psychology Review, 5, 2 (2001): 98-106.

Jorm, Anthony F., Alisa E. Korten, Patricia A. Jacomb, Helen Christensen, Bryan Rodgers, & Penelope
Pollitt. “Mental Health Literacy: A Survey of the Public’s Ability to Recognize Mental
Disorders and their Beliefs about the Effectiveness of Treatment.” The Medical Journal of
Australia, 166 (1997): 182-86.

Kaminetzki, Gabrielle, & George Stricker. “Does Religiosity Predict Attitudes Toward
Psychotherapy?” Journal of Psychology and Judaism, 24, 4 (2000): 251-60.

Margolese, Howard C. “Engaging in Psychotherapy with the Orthodox Jew: A Critical Review.”
American Journal of Psychotherapy, 52, 1 (1998): 37-53.

McHugh, R. Kathryn, Sarah W. Whitton, Andrew D. Peckham, Jeffrey A. Welge, & Michael W. Otto.
“Patient Preference for Psychological vs Pharmacologic Treatment of Psychiatric Disorders: A
Meta-analytic Review.” The Journal of Clinical Psychiatry, 74, 6 (2013): 595-602.

Moscovici, Serge. “On Social Representations.” In Social Cognition. Perspectives on Everyday

Understanding, ed. J. Forgas. London: Academic Press, 1981, pp. 181-210.

Moses, Tzvi. From the conference “Judaism and Psychology – Shall they Walk the Same Path?” [Heb].
Israel: Shiloh institute, Bar-Ilan University and “Tzohar” rabbinic organization, 2004.

Ozmen, Erol, Kultegin Ogel, Tamer Aker, Afsin Sagduyu, Defne Tamar, & Boratav Cumhur. “Public
Opinions and Beliefs about the Treatment of Depression in Urban Turkey.” Social Psychiatry
and Psychiatric Epidemiology, 40 (2005): 869-76.

Raz, Aviad E., & Yafa Vizner. “Carrier Matching and Collective Socialization in Community Genetics:
Dor Yeshorim and the Reinforcement of Stigma.” Social Science and Medicine, 67,(9) (2008):
1361-69.

Sosevsky, Bella. Psychotherapy and Judaism: Conflicts and Solutions [Heb]. Jerusalem, Israel: Atid
publication, 2002.

Spero, Moshe H. “Current Trends in Psychotherapy, Clinical Social Work, and Religious Values: A
Review and Bibliography. Journal of Social Work and Policy in Israel, 2 (1989): 81-110.

Witztum, Eliezer, & J. Tuvya Buchbinder. “Strategic Culture-sensitive Therapy with Religious Jews.”
International Review of Psychiatry, 13 (2001):117-24.

Witztum, Eliezer, & Yehuda Goodman. “Narrative Construction of Distress and Therapy: A Model
Based on Work with Ultra-Orthodox Jews.” Transcultural Psychiatry, 36 (1999): 403-36.

Witztum, Eliezer, David Greenberg, & J. Tuvya Buchbinder. “‘A Very Narrow Bridge’: Diagnosis and
Management of Mental Illness among Bratslav Hasidim.” Psychotherapy, 27 (1990): 124-31.
APPENDIX:
Research questionnaire
Framing
BEN-GURION UNIVERSITY OF THE NEGEV
THE JERUSALEM HAREDI COLLEGE
THE DEPARTMENT OF PSYCHOLOGY
Dear Participant,
We are researching the subject of dealing with problems and hardships.
G-d tests man in various ways, and we are ordered to try our best.
We all have different ideas and beliefs and so we would like, with the help of this questionnaire, to get
to know your ideas and beliefs.
The questionnaire is anonymous. Your answers will not be revealed to anyone, and will serve only for
purposes of this research.
We thank you for your cooperation and your participation in the research.
If you have questions about the research, please contact those responsible for the research.
Responsible Faculty: Prof. David Leiser and RA (name and contact)

General questions
What does the process of psychological treatment resemble? (Please mark up to 5 answers that seem to
be most correct to you)
- Guidance – Does not provide many insights, but facilitates a process
- Holistic treatment – Impossible to define how it helps, but it does
- Construction – Helps in shaping the self
- Personal coaching – Helps in bringing out the best in you
- Emotional release – In order to open the heart
- Reading an informative book on the human psyche
- Excavation – Allows hidden inside content to be revealed
- Surgery – Diagnoses a specific problem and solves it
- Cosmetic treatment – Does not make essential changes, but fixes small problems and defects
- Intervention of a person with special powers, to provoke change
- Confession and soul searching
- Retreat – temporary separation from the environment in order to establish communication with
G-d
- Removal of obstacles to the worshiping of G-d
- Other: ___________________________________________________________

What are the goals of the psychological treatment? (Please mark up to 3 answers)
- Understanding and insight regarding the meaning of life
- Spiritual healing
- Expressing emotions
- Release of inhibitions
- Listening ear
- Diagnosis of problems and advice regarding coping
 - Gaining a sense of relief
- Self-acceptance
- Gaining a better understanding of oneself
- Changing unwanted behavioral patterns
- Other: __________________________________________________________

General questions about treatment 7-point scale (1=strongly disagree; 7= fully agree)
1. People can decide for themselves whether they need treatment
2. A person must tell everything to the attendant, even if he thinks this is not required for the
treatment
3. The attendant is the one who has to guide the process of treatment
4. The success of the treatment depends on the efforts made by the person being treated in order
to improve his/her condition
5. The success of the treatment depends on the qualifications of the attendant

Two illustrative vignettes

1. Israel hears voices and he cannot decide whether they are real, or only his own thoughts. He
experiences situations where he does not have control of his behavior. Sometimes he says things
that he did not mean to say. It is difficult for him to be in the company of other people other than
his family. He says that it is very difficult for him to be outside his home because he feels threatened.

2. Shlomi is a businessman. Two years ago, he failed in a deal. Ever since, Shlomi cannot stop thinking
about his failure, speaking about it and developing alternative scenarios in his mind. All of these
perturb and trouble him while at work or during other activities.

Questions asked after each vignette

A. Mark all the answers that you consider correct:
- The case described does not require treatment
- A person can deal with his/her problems alone
- A person may be helped by someone close in order to alleviate the condition from which they
are suffering
- S/He must go to a rabbi/rabbi’s wife in order to be assisted
- It is recommended that this person seek psychological treatment
- In order to alleviate this condition, they must take medication

B. Mark all the answers that you consider correct:

- The condition described is biologically based
- The person’s choices brought him/her to the present condition
- Life circumstances caused the condition

C. Please grade the severity of this person’s condition between 1 (minimal severity) up to 7
(maximum severity).

D. How long will it take for the condition to disappear with the help of proper treatment, if required?
(Less than three months; Half a year; One year; It will never really go away.)
Table 1 Treatment preference by psychological problem

No treatment Alone Close Rabbi Psych Medic

Schizophrenia 1.41 10.33 33.8 20.66 81.69 21.7
OCD 7.51 41.78 61.5 29.11 38.97 0.94
Antisocial 5.63 37.09 38.5 35.85 51.89 9.39
Timid 10.8 30.99 56.34 22.07 55.87 1.41
Eating 2.36 14.55 17.37 8.92 84.04 34.91
Filler 16.43 39.62 68.4 41.51 23.94 2.36
Alienation 19.72 47.89 53.99 46 24.88 1.41
Hypochondria 7.04 12.68 31.92 21.23 68.07 15.96
PTSD 0.47 3.76 21.6 23 92.49 19.25
Depression 0 11.74 36.62 36.15 75.12 21.6
Panic 3.76 14.08 30.48 18.78 74.53 19.25
Phobia 4.23 16.43 31.6 14.15 77 13.15
Autism 4.25 7.04 15.96 10.33 81.13 27.7
Average 6.43 22.15 38.31 25.21 63.82 14.54
Table 2 Perceived Etiology

Biological Experiences Choices

Schizophrenia 21.6 87.79 13.21
OCD 9.39 71.56 42.45
Antisocial 71.36 39.91 42.25
Timid 57.28 60.56 30.05
Eating 35.21 53.05 55.66
Filler 7.98 62.26 57.55
Alienation 20.19 51.66 57.82
Hypochondria 19.25 63.85 36.79
PTSD 2.83 95.31 8.45
Depression 15.49 67.14 51.42
Panic 15.49 79.15 26.54
Phobia 49.77 60.56 23.47
Autism 73.24 38.5 15.96
Average 29.05 63.95 35.51
Figure Captions
Figure 1: Metaphors for psychological treatment

Figure 2: The perceived goals of psychological treatment

Figure 3: Preferred coping methods with psychological conditions

Figure 4: Correlations between Treatment preference, Perceived etiology, Perceived duration

and Perceived severity of the conditions
 Proportion selected

0.0
0.2
0.4
0.6
0.8
1.0
Figure 1

excavation

construction

emotional release

coaching

surgery

obstacles

confession

guidance

reading

retreat

holistic treatment

special powers

cosmetic treatment

other
 Proportion selected

0.0
0.2
0.4
0.6
0.8
1.0
Figure 2

spiritual healing

expressing emotions

release inhibitions

listening ear

diagnosis/advice

emotional relief

self-acceptance

self-understanding

behavioral change

meaning of life

other
Figure 3
1.0

0.8
Proportion selected

0.6

0.4

0.2

0.0
not a problem close person psychologist
coping alone rabbi medication
Figure 5

not a problem

coping alone

close person
NORMAL DIFFICULTIES
life experiences

rabbi

choices

psychology

severity
EXCEPTIONAL CRISES
duration

medication

biology

0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

Linkage Distance