Value-Sensitive Therapy:

Learning from Ultra-Orthodox Patients

SAMUEL C. HEILMAN, Ph.D."

ELIEZER WITZTUM, M.D.""
This paper explores the issues that arise when psychotherapists and patients
do not share a common value system. Using three case studies of ultra-
Orthodox Jewish patients who hold religious values and beliefs, the paper
illustrataes and defines a strategy of "value-sensitive therapy." It argues for
treating patients without demeaning or dircounting their values and beliefs.

Part of the process of therapy assumes that at some point in their

encounter, both patient and therapist will share a common perception of
what is wrong, what needs to be corrected, and how the latter can help the
former in effecting that repair. Furthermore, behind this fundamentally
cognitive assumption is yet another supposition: that they both hold a
common value orientation about what would in fact be a satisfactory
resolution of the distress that has brought the patient to the therapistal
When, however, the therapeutic encounter takes place between healers and
patients who do not share a common culture, either cognitively or affec-
tively, and who also do not share common values, the entire course of the
therapy-to say nothing of the character of the encounter-is influenced.
Not only does this sort of incongruence change the symbolic matrix within
which the therapy occurs, with the result that the patient and therapist may
not be heading for the same goal and may not equally value or evaluate the
outcome of the therapy as "successful;" but it also-perhaps more impor-
tantly-calls for a modification in the strategies for interaction.*
These modified strategies require both therapist and patient to find
some common cultural ground on which to meet in order to enable them to
"speak some common language." In most cases, this calls for the patient to
learn and accept the standard metaphors of illness and therapy-"doctor

*Harold M. Proshansky Professor of Sociology and Jewish Studies, City University of New York.
Mailing address: Department of Sociology, Queens College C.U.N.Y.,Flushing, N.Y. 11367.
*"Director of Psychotherapy Supervision, Beersheeba Mental Health Center and Community and
Associate Professor, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheeba,
Israel.
AMERICAN
JOURNAL OF PSYCHOTHERAPY, Vol. 51, No. 4, Fall 1997
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

talk." Moreover, it often also requires the patient to accept the therapist's
"judgments concerning the desirability and advisability of various courses
of action."' Sometimes, as has been argued in the literature on the
development of "culturally sensitive" mental health training (particularly in
the context of those from the dominant culture treating those of a minority
culture), it simultaneously calls for the mental health professional to
reframe his or her diagnosis and try to perceive the reality of the situation
not simply through the therapists' explanatory framework but also through
the prism of the patient's cultural metaphor^.^^
When the divide across which the therapy occurs also not only defines
different cultural realities but contradictory and clashing values, a cognitive
comprehension of differences may be insufficient. The therapist must also
pursue a therapeutic strategy that is sensitive to the patients' values, even
when this seems to oppose commonly accepted therapeutic approaches, so
that patients do not emerge from the encounter having not only been
healed but also "converted" to a new set of values that undermine a sacred
or social order that matters, deeply to them. Perhaps nowhere do these
issues become clearer than in the case of an encounter between a secular
therapist, trained in modern therapeutic methods, and a religious patient,
bonded to a traditional community of believers whose heritage and folk-
ways are incongruent with the values and cultural assumptions that most
psychotherapists share.
For such patients, therapy may be an encounter fraught with danger. In
large measure this is because commonly there is the risk that, as Allen
Bergin has articulated it, "therapists, as secular moralists, may promote
changes not valued by the [religious] client or the community."' Moreover,
even if particular practitioners are determined not to promote such changes,
the fact remains that, as Aponte and others have demonstrated, "values
frame the entire process of therapy," and thus even religiously tolerant
therapists, as they "establish criteria for evaluation, fix parameters for
technical interventions and select therapeutic goals" may remain insensitive
to and unable "to understand and maintain an empathic respect for
patients' religious orientations and beliefsn8
To be sure, the very act of seeking therapy from someone who does not
share one's religious values and outlook should force the potential patient
to confront the possibility that the therapist may disapprove or devalue the
religious way of life and try to deconvert the believer as part of the therapy
or at the very least "argue with the patient about the patient's doctrine
because the therapist regards it as destructive or theologically incorrect,
even though it is normative for the patient's den~mination."~ Moreover,
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because-as Jerome Frank and others have argued-people tend to seek

healing when the "assumptive systems" as to the nature of their world begin
to be threatened, they should be prepared for some attack on their values
and culture. Yet, it is also true that, although they should do so, many
patients may not think through the consequences of their therapy because
they are simply overwhelmed by pain or so disturbed that they cannot get
beyond their immediate problems.1° Thus it becomes the therapist's respon-
sibility to look out for the wider value interests of the patient even when
these may clash with certain commonly accepted therapeutic approaches
and when the patient may, because of his or her problem, be temporarily
oblivious of the threat to them that therapy engenders. We call this
therapeutic approach being "value-sensitive."
By "values" we mean-borrowing from Walker, Ulissi and Thurberl1-
"judgments (based on behavioral, cognitive and affective appraisals) as to
what is good (what ought to be) and what is bad (what ought to be
avoided)." A value-sensitive therapeutic approach both respects and leaves
intact the values of religious patients (even when these seem to conflict with
the general world view and common goals associated with contemporary
psychotherapy) and at the same time treats the patients by making use of
the idioms, symbols, and culture from which they come to help them
resolve the problem that has stimulated them to seek help. It calls for an
ability to look at the world through the eyes of the patients-understand
their cognitive perspective-and through their hearts-grasp their affec-
tive perspective and their way of life-and, perhaps most crucially, to
comprehend their behavior and the cultural or social framework in which
they will continue to live. In addition, we believe, this approach may at
times require therapists to settle for less than a full resolution of the
problem and only deal with some of its limited symptoms. It may require
that the therapist acknowledge that some solutions to their religious clients'
problems may be effected not by the therapists themselves but by religious
practitioners or that some problems are simply not resolvable if the patient
seeks above all else to remain within his or her social and cultural universe.
To be value-sensitive, of course is not to be value free. As Bergin7 (and
before him Max Weber) has reminded us, a totally "value-free approach is
impossible.'' Therapists will always make judgments and perhaps give off
messages that indicate their own competing values.12 Furthermore, we are
not arguing, as some have done, "that when religion and psychology clash it
is the latter that must give way."13 We are, however, arguing that in some
cases, the psychotherapist who wishes to be value sensitive and culturally
sensitive may have to recognize that pursuing the goals of the therapy as
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

defined by the values and outlook of the discipline may be counter-

productive for the cultural well-being and value orientations of the patient.
Put simply, in some cases what would appear to be a therapeutic triumph
may simultaneously bring about a social and cultural breakdown in the
patient's life world. To put it in terms provided us by Stanley R. Graham14
and Jan Ehrenwald,15there may be occasions when the therapist's efforts to
reconcile the patient's "who I am" with "who I wish to be" leads necessarily
to an "existential shift" that may in turn undermine the patient's deeply
held religious values and attachments to a society of believers. This is
~articularlytrue in religious groups where individual happiness, self-
actualization, and autonomy are secondary in importance to maintaining
corporate belonging and group solidarity or acting in the service of God
and those who believe in him. In such a situation, particular sensitivity is
called for by the therapist who, in trying to help the patient, must answer to
more than one master.
In what follows, we shall present three case histories that demonstrate
this sort of situation and a value-sensitive approach. All of them come from
the ultra-Orthodox or haredi Jewish community in Jerusalem. In each case,
we believe that the religious culture and values of the patient play a
significant role in the definition of the problem, in its presentation, and in
the strategies for as well as decisions about the character of the therapists'
intervention or decision to not intervene.
Who Are the Haredim?
While this is not the place to fully define haredi society, for our purposes
here we may point out several essential features.16 Haredi Jews constitute
about 250,000 to 350,000 of Israel's Jews and about 200,000 of America's-
the two main centers of Orthodox Jewry. The term "haredi" is commonly
reserved for those most extreme of Orthodox Jews who claim they have
refused to make any compromises with contemporary secular culture or
essential changes in the way they practice their Judaism from what the
tradition and halacha (Jewish law, literally "the way") has sanctified.
Sustaining these values and way of life, they believe, requires them to
maintain a social solidarity among themselves and a cultural distance from
(and often a hostility toward) the surrounding larger secular society. On the
surface, they have used some relatively simple instrumental mechanisms to
accomplish this. These include dressing (and grooming themselves) in ways
that make them clearly stand apart from those in the surrounding culture.
For men this means wearing a beard and long earlocks as well as caftans
and black hats and for women it means modest clothing covering most of
AMERICAN JOURNAL O F PSYCHOTHERAPY

the body and for the married among them, a head covering that may range
from a kerchief over a shorn head for the most extreme to a wig for those
less so. Haredim also distinguish themselves by speaking in Yiddish, a
Jewish language that increasingly is limited only to them. In addition, they
have created environmental and residential barriers-segregated neighbor-
hoods, for example-behind which they build their relatively insular
communities. They also send their children to private Jewish schools in
which only those who share their values and lifestyles are included. They
are overwhelmingly endogamous, arranging marriages rather than allowing
individuals to find mates according to the demands of romantic love.
Although haredim appear to constitute a single ultra-Orthodox group,
they are in fact subdivided into hasidim, who are organized around their
fidelity to a particular charismatic rabbi-leader or rebbe on the one hand,
and b'nai those who identify with a particular academy of Jewish
learning and its leading scholar (Rosh Yeshiva), students, and interpretive
traditions, on the other. Within each of these two subcultures, there are
further divisions. Hence one sect of hasidim may strictly distinguish itself
from another, while those who are attached to one yeshiva may have little to
do with those associated with another. Thus a haredi is either a particular
kind of hasid or a member of a particular yeshiva community, follower of a
particular rabbi's interpretation of Jewish law.17 The divisions may be so
great as to erupt in conflict and even violence. Yet what divides these
haredim from one another pales in comparison with what divides haredim
in general from the rest of society.
Nowhere is this division clearer than in the psychosocial world view that
haredim share. This is defined by their common (often hostile) perception
of a secular world that opposes them and seeks to undermine their
attachments to one another and to the tradition. As one man said to one of
us (SCH): "In today's world, Yidn Dews1 are alone and Yiddishkeit
[Judaism and the Jewish way of life] is under attack." (Haredi Jews often
refer to themselves simply as Yidn, assuming that all others who call
themselves Jews are really counterfeit.) They see themselves "as a [lonely]
force endlessly combating obstacles," convinced that "catastrophes of
existence come as the inevitable culmination of past choices and experi-
ences," which most contemporary members of secular society have made
and had.l8 While a few haredim-most prominently LubavitcherKhabad
hasidim-have tried to engage and reach out to this world in order to try to
bring it in line with their image of what is authentic, most haredim are
content to try to struggle against it by demanding it provide protection for
their way of life or at the very least leave them alone. They view the culture
Value-Sensitive Therapy: Learning from Ultra-OrthodoxPatients

of yesterday (as imagined nostalgically) as inherently more authoritative

than today and as a genuine guide for tomorrow. They consider their lives
as a service to God and Jewish tradition, and the only true merit that which
is prescribed by the Torah and its accepted rabbinic interpretations.
Individuals only have merit insofar as they serve God and follow the
dictates of tradition; that is their primary raison &&re. To know precisely
how to go about this, they must be guided by those who know the law and
whose understanding is informed by the tradition-the rabbis.
In this world view, the modern world may be used as an instrumentality
to improve this service to God, but there is nothing about modernity-
including science, medicine, and technology, all of which haredim utilize
and exploit-that has ontological value in and of itself. Studying Torah for
as long as possible is the ideal for men, while women are expected to marry,
give birth to and rear children who will serve God and grow to be Torah
scholars or the wives and mothers of scholars.
Although there are many other elements that distinguish haredim from
other contemporaries, Jews and even other Orthodox Jews, perhaps one of
the most outstanding and related to matters that the therapist often
encounters has to do with the attitude toward sexuality. Unlike mainstream
society and even so-called modern Orthodox Jews who allow for the free
mixing of males and females in social and educational settings, haredim are
scrupulous about separating the sexes from the earliest years of life. Not
only do they offer separate education for males and females, they also
discourage dating and the free selection of marital partners. As noted, they
rely on arranged marriages, usually governed by parental decision and
completed by the very early twenties or late teens. While the haredi has the
right to refuse a proffered match, the grounds for refusal are relatively
limited and these rights infrequently exercised.
Although there are variations within the haredi world, for the most part
sexual relations between husband and wife are strictly regulated by Jewish
law, custom, and habit. The ultimate aim of sexual relations is procreation.
Haredi men and women are expected to be fruitful and multiply; a childless
haredi couple is a rarity, their situation invariably the result of fertility
problems. While pleasure plays a part in sexual relations between husband
and wife, it is not expected to become central to the relationship. In some
groups, for example, followers of the Ger hasidic dynasty, sexual relations
between a married couple are to be as brief and unemotional as possible.
Others allow for extended ascetic practices. But even in the most liberal of
haredi groups, sexuality is to be rigorously regulated. Among all haredim,
husband and wife may only have sexual contact at certain times of the
527
AMERICAN JOURNAL OF PSYCHOTHERAPY

month (specifically, only from seven days after the end of the woman's
menstrual period and after she has immersed herself in a ritual bath or
mikveh) and even within the permitted period there are those haredim who
consider some times superior to others (the Sabbath, for example).16
CASE STUDIES
All this serves as background to the case histories of three haredim from
Jerusalem. All were seen clinically by one of the authors (EW) who,
although he is a secular Jew, serves as a psychiatrist to a large haredi
clientele. The cases were then discussed and analyzed with the other author
(SCH), a social anthropologist, who has specialized in haredi life and
culture.
CASE1: NOTENOUGH LOVE
Hannah, a 24-year-old haredi woman, had immigrated to Jerusalem
from Western Europe. At the time she was first seen by the therapist, she
suffered from acute sleeplessness, high tension, and free-floating anxiety.
She had been married four years, was the mother of two young children,
and her husband was a full-time student in a kollel, a yeshiva for married
men. As is common in the haredi world, Hannah's marriage was the result
of matchmaking. Yet, while Hannah accepted the match offered, she
claimed that she did so against her d for from the first time she met her
husband to be, she decided that she did not like him very much. In fact,
according to her testimony, she married simply in order to conform with
the expectations that are part of the haredi patterns of marriage.
Hannah was the middle one of three daughters. The eldest, a more
assertive woman, when presented with a match she did not like, was able to
reject it. She left home, moved to Jerusalem, and found someone acceptable
to marry. The youngest daughter, to the contrary, submissively married the
first person her parents selected for her and stayed close to home in Europe
after her wedding. Hannah, however, while trying to be as compliant as her
younger "good" sister but also wishing to be no less willful and assertive
than her elder one, found herself in a situation where on the one hand, like
her younger sister, she married the first person her father selected for her,
but, on the other-in a way emulating the willfulness and rejection of her
older sister-remained unhappy with that choice and moved away to
Jerusalem.
Nevertheless, she continued to believe and hope (as her parents assured
her would be the case) that in time, as was common in the haredi world,
love and contentment would follow marriage and she would become
attached to this husband of hers. But, though they had the two children,
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

this love did not come. Instead, she grew even further alienated from her
spouse, refused finally to have sexual relations with him, and reached a
point of such desperation that she threatened suicide. It was at this point
that she came for a consultation at the urging of her elder sister.
On the basis of a psychiatric evaluation, Hannah showed no evidence of
a major psychiatric disorder, such as depression or psychosis. She did
present symptoms of acute anxiety. When she was asked by the therapist
what precisely was her problem, she said she needed a partner she would be
able to love. She simply felt that she did not have enough love for her
husband. In the course of the interview, she allowed this was not his fault,
that on the contrary he treated her well, and loved her (indeed, he admitted
that he was ready to do anything she asked to help her love him more). Her
reply was that she simply did not love him, and she could not continue to
live any more without such love. She wanted a husband to love, a husband
who was, to be sure, a "ben torah," (a yeshiva student in the haredi world)
but one she could and would love.
Divorce was not an option. She knew that as a divorcee with two
children, who had left her husband because she did not love him, she
would be perceived in the narrow confines of the haredi world as "damaged
goods," as would her husband. Both would find it enormously difficult to
remarry, particularly if the reason for the divorce were this curious (and in
the haredi world culturally irrelevant) lack of love. To the haredi world, this
sort of reason for a divorce would stigmatize her as "crazy," and a
troublesome woman. It would also make her husband seem to be a vaguely
unsatisfactory partner. The result would be to throw both into a social
limbo out of which it would be difficult if not impossible to escape. For her
part, she would be unlikely to find another match with any among the
superior yeshiva students, the population among whom she sought some-
one to love. Moreover, she knew that to get a divorce, she needed her
husband's agreement for according to Jewish law, he alone could initiate
such an action. So while divorce was possible, from Hannah's perspective it
was enormously complex and in many ways culturally unthinkable. Thus,
she contemplated suicide and subsequently settled on the solution that
her's was a medical problem for which the doctor could somehow find a
miracle cure. She wanted a pill to make her love her husband.
The Therapist's Dilemma
Should the therapist ignore the demands of her religion and culture and
confront her with the fact that they are part of the etiology of her problem?
Should he encourage her deferred rebellion against her father's will and
AMERICAN JOURNAL OF PSYCHOTHERAPY

problems of separation which took the form of wanting to reject his choice
for her? Should he tell her to pursue her personal pleasure and happiness
even if this will cause a breach between her and her haredi values and
community? Should the therapist help her to gain personal independence
and self-actualization and in the process abandon the haredi world in order
to seek her true love? In short, should he follow the recommendation of
Perry London that, "if he believes that the client's religious convictions help
sustain the disorder, a confrontation with those convictions may be inevi-
table?"l9
Or, seeking to pursue a value-sensitive approach, should the therapist
consider other alternatives? He might conclude that Hannah's is not a case
for him at all, that a value-sensitive approach should move him to send her
instead to a community counselor or a rabbi or someone within the haredi
community who shares its values and might therefore find a solution
informed and shaped by those values and that culture and society. O r else,
the value-sensitive therapist might recognize that at most his role is to make
Hannah come to terms with the fact that her personal happiness might not
be the most important goal in her life. Or, as a third alternative, he might
help her to learn how to transform her desire for autonomy so that it allows
her to make peace with what she has, even at the expense of her personal
feelings and fuller expression of autonomy.
In fact, to try the first alternative ran the risk of stigmatizing Hannah
and her husband by highlighting her unusual concerns with romance; that
was why Hannah had come to the "outsider" psychiatrist in the first place.
The value-sensitive therapist instead chose a combination of the second
and third alternatives, assuming that if these did not work, Hannah herself
might choose to go elsewhere for help. After exploring the feelings of the
patient and offering her an empathic understanding, the therapist advised
her that from his point of view she had no real psychiatric problem. This
was a crucial message both for her and her family as it immediately allayed
their anxieties that they might all be stigmatized by virtue of her being
judged to have a psychiatric disorder. (In the haredi community such a
stigma can prove socially fatal and lead to a decline in social status and the
opportunities for other members of the family to find appropriate marriage
partners.) Rather, he suggested, her conflict emerged from the incongruous
expectations that she had absorbed from her European surroundings
which idealized romantic love and the cultural constructions of her haredi
social reality which, on the contrary, emphasize the nonerotic, non-
romantic elements of marriage and emphasize the positive aspects and
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

greater importance of family life.20That is, the problem was not her fault or
her husband's.
In an effort to provide some room for Hannah's expression of autonomy
and personal initiative which underlay her desire for greater emotional
expression in her marriage, the therapist reframed the choice before her
and suggested that this was perhaps the first time in her life that she herself
- -

had an opportunity to decide on her own fate and she should

grasp the opportunity. If she chose to stay in her marriage, and to remain
within the framework of the haredi world, even though it would seem to
diminish her personal liberty and would, therefore, be hard for her to do,
she would be doing this as a result of her choice and no longer anyone
else's. H e assured her there was no pill for love. But he did give her a
limited amount of benzodiazapines that would further diminish her anxi-
eties, enable her to sleep at night, and get rid of the overwhelming tension
that had been building up during the preceding few weeks so that, when
she did make her choice, it was not under a condition of intense stress. Her
lack of sleep had intensified her anxieties and made her problem feel even
worse. With this limited help, she could go back to the life she led,
comforted if not altogether happy. After two weeks, she called to say she
felt better, and she claimed to need no further visits to the therapist.

A comparable value-sensitive reframing is described by Huguette Wie-

selbergZ0in which a family therapist encountered a hasidic couple in which
the wife lacked a uterus and had been assured by medical specialists that a
desired pregnancy was impossible but was nevertheless assured by a rabbi
in whose powers she and her husband believed that prayers would bring
about a miracle and the desired baby. The couple, valuing their rabbi's
counsel and committed to believing in him, were stymied; they could not
express anger at their rabbi for fostering this hope and yet it prevented
them from coming to terms with the medical realities and getting beyond
the level of prayer. Recognizing the importance of, and sensitive to, this
value, the therapist reframed the rabbi's prediction and "asked if it was
possible that the [Rabbi] had indeed predicted a miraculous event bringing
a child through prayer, but through the adoption rather than through the
wife's body. Both [husband and wife] instantly cried out 'yes' and a huge
burden seemed visibly shed as they relaxed and smiled broadly. They
subsequently stopped mentioning miracles and were later approved for
adoption."20
Had these two therapists not been acting in a value-sensitive manner,
they might have responded to the cases in altogether different ways. In the
AMERICAN JOURNAL OF PSYCHOTHERAPY

first case, the therapist could have pursued a long course of therapy that
would have perhaps explored Hannah's psychodynamic conflicts with her
father, their oedipal overtones and complex developmental issues of iden-
tity. H e might have tried to help her reach some level of self-actualization,
sought to encourage her tentative feelings of assertiveness and personal
independence, allowing her to separate from her husband and the loveless
marriage.*l But in the process, he might have also subverted her deeply
held community and religious attachments, and left her alone in limbo. In
brief, he might have solved one problem and created another.
Similarly, in the second case, the therapist might have allowed the
husband and wife to deal with their ambivalence by expressing their anger
at the rabbi for his false hope, by enabling them to separate from their
dependence upon him, and helping them take responsibility for their own
lives and family decisions. Yet here too, he would have done so by
essentially undermining their fundamental connection to the community
and religious beliefs that sustained them and that operate for hasidim
through their unquestioning reliance upon and trust in the rabbi.
CASE2: THEHOMOSEXUAL RABBI
Rabbi Eliezer was a 52-year-old, severe-looking, haredi man from
Jerusalem. A product of the yeshiva world, he excelled in his Torah
scholarship and became a Rosh Yeshiva. He was married and father to five
children, ranging in age from an 18-year-olddaughter to a 25-year-old son.
Suffering from sudden impotence, Rabbi Eliezer first visited a urologist.
Finding no organic reason for the problem, the urologist referred him for a
psychiatric consultation.
During the intake interview, Rabbi Eliezer kept his features tightly
controlled most of the time. In response to probing questions, he revealed
that his impotence emerged about four months after his youngest daugh-
ter's wedding. Describing the wedding, he spoke glowingly of his new
son-in-law, and when he did so, he became animated and his severe features
visibly softened. He characterized the young man as an outstanding
rabbinical student-which is the standard positive qualities by which
young males (so-called b'nai torah) are described-especially by someone
who is a Rosh Yeshiva. But then, he went beyond this characterization and
declared additionally that his new son-in-law was a handsome lad. To
describe him he made use of a biblical phrase (Sam. I 16:12), calling him
"admonee v'yefay einaim v'tov roeey," ruddy with beautiful eyes and
good-looking, an expression used to describe the legendary King David.
Although couched in Scriptural language, this sort of description referring
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

to a young man's physical appearance is unusual in the world of haredi

rabbis. These are simply not qualities that are expected to prominently
feature in a rabbi's assessment, even of his son-in-law. This is because the
rabbi is supposed to be concerned with the young man's interior, his mind,
his learning-but definitely not his body. If he shows any concern for his
appearance, it would normally be something that referred to his modesty or
his humble dress. But Rabbi Eliezer focused on the young man's physical
beauty.
After additional probing, he further revealed that he was extremely
fond of the young man. In the world of the haredim, where all marriages are
arranged, this young man had been put forward by a matchmaker. How-
ever, when Rabbi Eliezer met him, he was very much taken with the boy
and strongly encouraged his daughter to accept the match and embrace the
marriage. And, indeed, the daughter acceded to her father's wishes, which
were not at odds with her own.
After the wedding, the young couple lived for three months near the
bride's parents. During that time, Rabbi Eliezer found himself often
daydreaming about his new son-in-law. As he described these visions, he
said he dreamt that he was sitting studying Torah with the young man,
activities that he did indeed also carry out in actuality during that period.
H e also dreamt about the young man at night. H e denied that there was any
erotic element in these dreams, but admitted that they were quite clear and
focused on the young man.
When asked, he claimed that he had never had such dreams before in
his life. As for his own sons, he would only say that he was an extremely
strict father to them, perhaps-he admitted-too strict. Conversely, to-
wards his daughters, he claimed he was too lenient and forgiving.
A computation of the age of his children and his own age reveals that
Rabbi Eliezer did not marry until the age of 27, a most unusual fact in the
haredi world where most males marry somewhere between the ages of 18
and 22. To have wed at 27 suggests that Rabbi Eliezer had some difficulties
in finding a mate, that the matchmakers could not "sell" him on the market.
When asked to account for his late marriage, he explained that "no girl was
good enough for hirn,"and therefore it was he who rejected many of the
matches. Finally, his father grew ill and revealed to him that his continuing
status as a single man was deeply disturbing to him. Just at that point, he
received an offer for a wife from America which, under the circumstances,
he accepted.
For many years, his sex life was, according to him, quite satisfactory, and
the fact was he had fathered five children. His wife confirmed later that she
AMERICAN JOURNAL OF PSYCHOTHERAPY

had no complaints about his sexual behavior until the onset of his
impotence. This impotence came when, four months after their wedding,
the daughter and son-in-law, following a common haredi practice, moved
away to another city where they had found an apartment they could afford
and where the young man found habilitation as a student in a kollel. Within
the course of a month following their departure, Rabbi Eliezer said he
longed powerfully for the young man. It was then that he also grew
impotent.
It is important to note that the rabbi did not himself make the explicit
connection between these two events, indeed ignored any possible linkage
between them. Rather, he worried that he had somehow sinned-though
precisely in what he could not say-and that was the reason this grievous
illness had come upon him. Although he suspected a religious root to his
problem, he had not taken up the nature of his sins with any other rabbis
because of what he viewed as the intimate and embarrassing nature of his
affliction.
Later, when Rabbi Eliezer's wife came for her own interview with the
therapist, she was the one who inquired as to whether there could be a
association between her husband's condition and the departure of the
young man, whom, as everyone by now knew, the rabbi adored. Tentatively
broaching the subject in a subsequent interview, the therapist asked Rabbi
Eliezer if he had encouraged his daughter to marry the young man in order
to "acquire" him for himself through the medium of his daughter. Rabbi
Eliezer nodded in the affirmative. Yet, what Rabbi Eliezer believed he was
admitting was not any illicit desires but rather that he had acquired the
son-in-law as a student and disciple.
The Therapist's Dilemma
In the evaluation of the therapist, this was a case of latent and repressed
homosexuality, something that probably contributed to his earlier inability
to find any woman good enough for him to marry. Sensing his erotic
feelings for his son-in-law, Rabbi Eliezer had perhaps become over-
whelmed and frightened by his own homosexual desires and having lost the
young man found that his libido had become totally inhibited. Alterna-
tively, the impotence could be explained as an effort on the rabbi's part to
"punish" himself for his forbidden desires and appetites, thus removing all
potential sexual satisfaction from occurring. Finally, his impotence might
be explained as a self-inflicted brake or inhibitor that would prevent his
desires from driving him toward an act of sexual satisfaction (either
homosexual or masturbatory, both of which were strictly prohibited) that
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

he would regret forever. Whatever explanation one accepts, each one has,
as its precipitating factor, the latent homosexual desire for the young man, a
desire that is totally incompatible with Rabbi Eliezer's haredi religious and
cultural values, which view homosexuality as an abomination.
In fact, the problems from which Rabbi Eliezer suffers could potentially
be alleviated by a therapy leading to his recognition and ultimate accep-
tance of his homosexual or bisexual character. However, while this might
solve the problem of his impotence, it would at the same time forever ban
him from the only world and set of values he has ever known and leave him
all alone in the world. Ironically, he would be even further from his love
object by virtue of this disclosure and life change than he now was. Even
were he not to express his homosexuality but simply admit it, this revela-
tion would have the same culturally disruptive and emotionally burden-
some effects.
The therapist is confronted by a dilemma here. Should he reveal to the
rabbi his apparent homosexual or bisexual nature or is his role to help the
rabbi suppress that nature or sublimate it so that he can continue to live in
the sexually regulated and highly structured haredi world where no
variations on the basic monogamous heterosexual union are tolerated or
even legitimately contemplated? In value terms, what is good and what is
bad here? The desirable is far from clear.
Clearly, therapists are in some way agents of the social and cultural
order, and their decision as to what strategy to take is affected not only by
the desire to make the patient well, but by a judgment as to which world
and value system can the patient be part of in order to be well. What
constitutes wellness in Greenwich Village or the San Francisco Bay area is
very distant from what does so in and around the haredi neighborhoods of
Jerusalem where Rabbi Eliezer made his life. Hence therapy requires a clear
sense of where in the world the patient is being sent when he gets well. The
therapist must thus not only cure the patient but also relocate him into one
world or another. That decision must be made in concert with the patient
and in such a way that will not cure the illness but leave the patient a
socially crippled individual and cultural solitary,
In this case, the psychiatrist dealt with the symptoms focally by medica-
tion and relaxation techniques and intentionally avoided giving a psycho-
dynamic interpretation of the symptoms that would allow the rabbi to face
the underlying issues of his sexuality. In brief, he decided not to share with
Rabbi Eliezer his own knowledge and insights, and told his wife that it was
not a good idea to explore the reasons for his impotence too deeply-a
restriction which she was able to accept (the notion that there are some
AMERICAN JOURNAL OF PSYCHOTHERAPY

matters which should not be explored too deeply is well rooted in haredi
life which emphasizes the restriction of free inquiry).
Ironically, the rabbi himself began to reach some insights into the
sources of his problem and himself raised the possibility of his homosexual-
ity which he immediately denied, adding that if it were true, he would kill
himself in some camouflaged way so that no one would know he had
committed suicide-but he would not continue to live. This, the therapist
concluded, was a not very disguised way of the rabbi's ratifying the
therapist's value-sensitive approach and that he, the rabbi, did not want to
know, or have confirmed these suspicions of his homosexuality. He would,
he indicated, rather deal with the symptoms than the root cause. The
therapist, in a value-sensitive response, therefore tried to provide the
treatment the culture and the patient wanted. This turned out to be the
successful approach.
CASE3: THEASCETIC HASID
Gabriel, a thirty-one-year-old man, married, with four children, was a
so-called repentant Jew (ba'al t'shuuah) who for the last seventeen years had
been a Breslaver hasid. In his youth, Gabriel had been a member of a
nonreligious kibbutz. At the time of his visit to the therapist, he was
suffering from a schizo-affective disorder that resulted in his displaying
mood disturbances with accompanying psychotic features. For five years,
Gabriel was in remission, dealing successfully with his life while on his
maintenance dose of the antipsychotic, thorazine.
When asked why he chose to express his religiosity in the form of
Breslav hasidism, which is filled with mystical practices and emphasizes
emotions and the importance of solitariness, he replied that he could
empathize and identify with the struggles of the sect's founder, the eigh-
teenth century Rabbi Nachman who in his collected writings describes
similar experiences2*In a way, his choice of Breslaver hasidism was his way
of dealing with sexual difficulties that he experienced as a newly religious
man. Because Orthodox Judaism forbids and negatively sanctions mastur-
bation and even nocturnal emissions, something that, as an 18-year-oldwho
was becoming religiously observant, Gabriel still experienced, he found
himself forced to come to terms with his sexual appetites that expressed
themselves in this forbidden way. H e did not know how to solve this
problem over which, on the one hand, he had no control physically and on
the other, he came to believe more and more was a mortal sin. Breslav
hasidism seem to offer him a solution.
In its practices, this sect pays special attention to the matters of sexual
 I

Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

sins and onanism. To do penance for this sin or somehow cancel its
consequences, the Breslaver hasidim have a ritual which they call "tikkun
klalli," or universal repair. This ritual requires the mantra-like recitation of
particular psalms and prayers and immersion in a mikueh or ritual bath,
both of which serve to wipe clean the slate of sins caused by the emission
and sexual urges while providing some sort of protection against their
continued expression. Asceticism and sexual abstinence are not discour-
aged.
When he presented himself to the therapist, although not suffering from
any psychotic or affective episodes, Gabriel claimed to have two problems.
Specifically, Gabriel was disturbed by a vision he had. In it he beheld what
he believed were supernatural female figures from the netherworld who, he
concluded, were trying to seduce and hence corrupt him, drawing him
away from the path of righteousness that he had so long struggled to follow.
Secondly, he claimed to have problems with his wife.
In line with the norms of haredi life, his wife would immerse herself in
the mikveh seven days after the end of her menstrual cycle. That same
evening, according to custom and religious practice, she was once again
permitted (indeed, encouraged) by Jewish law and custom to renew sexual
relations with her husband-something strictly forbidden from the onset of
her period. The husband was expected to fulfil his conjugal obligations
upon her return from the mikveh or later that night. But this became
increasingly difficult for Gabriel. Although he fulfilled these conjugal
obligations, he felt that the entire day afterwards he was unable to focus his
energies or attentions on what he viewed as his primary religious and
vocational responsibility: the unending study of and meditation upon
Torah and other Jewish scholarly or mystical texts. Beyond this sense of
distraction, he also felt deeply that he had somehow become defiled. To
solve this, he would, as other hasidim sometimes do, immerse himself in the
mikveh afterwards. But all this was to no avail, as he came out of the
purdying waters still feeling defiled and impure.
To deal with these problems, he had for the last three months avoided
all sexual activity. While he was pleased with this ascetic solution, not
altogether out of line with some of the more extreme Breslaver customs, (in
fact some of Gabriel's peers considered him a holy man, a zaddtk), his wife
was deeply distressed by this cessation of sexual relations and felt rejected
and denied. More than Gabriel, she wanted to consult with the therapist,
and a week later she too arrived at the clinic, expressing great anxiety over
her husband's ascetic turn. At first she had believed that her husband was
acting this way because he had become more religious, something which in
537
AMERICAN JOURNAL OF PSYCHOTHERAPY

itself was a good thing in the world they inhabited. But though greater
religiosity was good, she could not tolerate a complete moratorium of her
sex life. Consequently she consulted one of the rabbis in their community
and told him the whole story seeking to know whether her husband was
doing the religiously correct thing. The rabbi, aware of Gabriel's medical
history, took a neutral position; he explained that, by religious law, her
husband was obligated to satisfy her sexually, but that certain ascetic
practices were also within the realm of the permissible. H e therefore
suggested that the couple see a doctor for advice to see if Gabriel's actions
were driven by his illness or not. Whatever the doctor who had been
treating her husband would say that would, he concluded, constitute the
rabbinic verdict as well. Reluctantly, the wife was ready to grant Gabriel his
zaddik status, if that was what drove his actions. But if he was sick, she
wanted a remedy. Gabriel and even more so his wife now wanted an answer.
The Therapist's Dilemma
In effect, the therapist, personally committed to a secular world view
and ethos, had been designated by the rabbi to decide whether Gabriel's
behavior was a genuine religious expression of asceticism or a symptom of
an affective disorder and, hence, in the rabbi's terms, an illness.
Now in fact, the difficulties that Gabriel had with sexuality all his adult
life were successfully handled by avoidance behaviors, which were legiti-
mated and even sanctioned by Breslav hasidism. H e had found a perfect
and institutionalized framework for handling his problem. In his value-
sensitive approach, the therapist also saw in Gabriel's actions an element of
normalcy within the framework and context of Breslav hasidism. In other
words, Gabriel was clearly within a typology, albeit perhaps at an extreme,
of Breslav religious lifestyle. For his wife, however, Gabriel's solution was
anathema.
In an effort to find a solution that would at once be value-sensitive and
provide some remedy for the wife while not calling into question Gabriel's
hard-won status as zaddik, the secular therapist decided to draw from
Jewish tradition for his solution and quoting the medieval Jewish sage,
Maimonides, whom the consulted rabbi had cited in his partial response,
argued for the golden mean that would require Gabriel to offer his wife
some sexual satisfaction but which would also require that she in turn
minimize her demands upon him in this regard. Now, while Gabriel was
familiar with the text, the fact that both the rabbi and the doctor cited the
same religious authorities in urging him to diminish his asceticism with
Value-Sensitive Therapy: Learning from Ultra-Orthodox Patients

regard to sexual activity with his wife was for him a divine sign that this was
the proper path. Both accepted the solution quickly.
For two years, Gabriel and his wife have found peace. Although Gabriel
continues to complain whenever he comes to renew his prescription that he
finds it difficult to comply with even the modified sexual demands of his
wife, he does so. That he no longer dreams about supernatural female
figures from the netherworld, who are trying to seduce and corrupt him, he
takes as a sign that the recipe for relations with his wife that he was given is
the correct one.

CONCLUDING REMARKS
In all these cases, there is a cultural conflict between the value system
and norms of the haredi client and those of the western civilization from
which the therapist comes. In some cases, the value-sensitive therapist
views the problem as not being psychological in its origins but rather
generated by the tension between the cultures and natural psychosexual
drives that express themselves as a problem for the client. He tries always to
keep a balance between the patient's complaint and the values that
otherwise sustain the patient and play an important role in who he is and
where and what he wants to be (even if these are at odds with the therapist's
own values). In a sense, he follows the recommendations of Hawkins and
Bullock2' who have argued that therapists should seriously address the
importance and impact of patients' values or religious beliefs for, if they do
not, they effectively "discount" and discriminate against their religious
clients.
In the case of not enough love this required offering the patient only
limited autonomy and encouraging her to make her own choice even if this
modified independence led to her inhibiting her passions, assuring her she
had no psychiatric problem but rather a cultural and interpersonal one for
which no one was to blame.
In the case of the homosexual rabbi, the therapist allowed the client to
deal with his symptoms but did not engage in a therapy that would force
him to confront his latent homosexuality and hence excise him from the
only world he knows and values. Thus the therapist chose to allow the
client to camouflage and treat his latent homosexuality as a disorder rather
than a lifestyle.
Finally, in the case of the ascetic hasid, the problem was dealt with in a
value-sensitive therapy that drew on a literature and value system that
would alter behavior according to the terms of the culture from which the
client comes. It did not try to deconvert the patient from his sexual
539
AMEIUCAN JOURNAL O F PSYCHOTHERAPY

inhibitions but recognized the value of what he had accomplished spiritu-

ally even as it suggested some minor but significant adjustments in his
ascetic practices.
What all these cases demonstrate is that a therapist can offer treatment
that recognizes that the religious and cultural values held by his clients may
be at least as important as treating the underlying deeper problem with
which the patient presents. Furthermore, they offer an illustration of how
the reality of a cultural and value incongruence between healer and patient
does not make a therapeutic encounter impossible or ineffective. They
suggest rather that it is not always necessary to impose the therapist's values
of getting to the bottom of the problem and providing an existential shift or
self-actualization that may lead to a value change in the patient. The
therapist may settle for what seems like less but which may still be more
than enough. The patient, similarly, may be ready to settle for even a little
help. In short, the therapist need not always act as an omnipotent figure;
acting as a traffic cop who helps patients more efficiently get to where they
want to be may be just as good or even better.
SUMMARY
Using the example of three case studies of ultra-Orthodox Jewish
patients who hold highly structured sets of deeply held values and beliefs
and who have been treated by a therapist with a different (perhaps
competing) set of beliefs and values, this paper has suggested that even
when psychotherapists and patients do not share a common value system,
therapists can and should nevertheless remain sensitive to the deeply held
values of those patients. Toward this end the paper has illustrated and
defined a strategy of "value-sensitivetherapy," an approach that recognizes
that at times a quest for a pure cure by an omnipotent-even a value-
neutral therapist-is not possible. Our experience suggests that a mental
health professional's responsibilities include not only helping patients to
resolve their particular psychological distress, but also looking out for their
wider value interests. This is appropriate even when these value interests
are incongruent with the therapist's value interests or with the classic
professional stance of value-neutrality or even when the patients, because
of their immediate distress, may be temporarily oblivious of the threat that
their therapy occasions to their own deeply held values.
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