Working With Jewish Patients

YORAM BILU AND ELIEZER WITZTUM
WORKING WITH JEWISH ULTRA-ORTHODOX PATIENTS:

GUIDELINES FOR A CULTURALLY SENSITIVE THERAPY
ABSTRACT. The epistemological gap between the medical reality of mental health
practitioners and the sacred reality of their Jewish ultra-orthodox patients poses a major
challenge for therapy. Based on our work with psychiatric patients from the ultra-
orthodox community of northern Jerusalem, we propose a set of guidelines to cope with
this challenge. Basically, we seek to incorporate religiously congruent elements,
composed of metaphoric images, narratives and actions, into the wide range of our
"secular" treatment modalities in order to respond to the patient's suffering, often
expressed through distinctively religious idioms of distress. This endeavor calls for "a
temporary suspension of disbelief' on both sides.
The guidelines presented include three sets of factors which appear pertinent to
working with ultra-orthodox patients. The first set is contextual in nature, dealing with
the image of the clinic and its physical setting; the second discusses the necessary role
requisites of the therapists; and the third one, accorded a central importance, deals on
various levels with the therapeutic interventions administered in terms of form and
content. Several case vignettes are presented to illustrate three classes of religiously
informed interventions: healing rituals, dream interpretation, and the use of culturally
congruent metaphors and stories. In the concluding part we discuss ethical and instrumen-
tal issues that the proposed therapeutic guidelines may raise.
INTRODUCTION
In recent years, following the implementation of a community model of mental

health centers, the psychiatric services in Jerusalem were reallocated on a
regional basis (Aviram and Levav 1981). This reorganization transformed the
Jerusalem Mental Health Center-Ezrath Nashim, located in the heart of the
Jewish ultra-orthodox neighborhoods of northern Jerusalem, into the major
setting for providing outpatient psychiatric care to strictly religious individuals.
The present paper is an attempt to systematize some of the experiences accumu-
lated during the uneasy encounters between mental health practitioners and
patients from this sharply segregated and otherwise barely accessible com-
munity. We seek to distill from these experiences, awkward and based on trial
and error as they often were, a set of guidelines for treating ultra-orthodox
patients in a culturally competent way. While in terms of content these
guidelines are specifically tailored to the community under study, we hope that
the conceptual framework which generates them may apply to other cultural (or
rather multicultural) clinical settings. Before embarking on the peculiar features
of the therapeutic encounters with ultra-orthodox patients, however, a general
portrait of this well-bounded community is in order.
Culture. Medicine and Psychiatry 17." 197-233 1993.

9 1993 KluwerAcademic Publishers. Printed in the Netherlands.
198 YORAM BILU AND ELIEZER WITZTUM
THE ULTRA-ORTHODOX COMMUNITY
In terms of religious commitment, Isreali Jews are distributed along a very wide
spectrum, from complete atheists to devout observants (see Sobel and Beit-
HaUahmi 1991). The small sector designated ultra-orthodox is located at the
uttermost religious pole of the continuum. The members of this sector, clearly
distinguished by their peculiar appearance (beards, side curls, head covers and
sect-appropriate, old-fashioned black uniforms for men; wigs or headdresses and
modest clothes for women), are noted for their uncompromising adherence to
the strictest versions of Halacha (Jewish religious Law). As a result, every
minute aspect of their daily life is regulated by religous precepts.
The unifying factor of Jewish orthodoxy, augmented by deliberate attempts to
retain socio-cultural life patterns as crystallized in the traditional Jewish
communities of former centuries, has reinforced the popular but erroneous view
that the ultra-orthodox constitute a monolithic bloc. In fact they are sharply
divided into very many sects and factions, constituting a brittle social fabric
marked by bitter struggles over material resources and religious hegemony
(Shilhav and Friedman 1985).
The various ultra-orthodox goups also differ in their attitudes towards the
Zionist state, ranging from reserved acceptance to total condemnation of Israel
as a political entity. The groups are united, however, in their unequivocal
opposition to the modern secular life-style of mainstream Israeli society. They
strive at all costs to insulate themselves from the polluting effects of secular
modernization, therefore they tend to concentrate in well-delineated neighbor-
hoods. Due to its holiness, Jerusalem has housed in recent centuries the largest
ultra-orthodox community in the country. In the mid-1980s this community
numbered about 80,000 (Shilhav and Friedman 1985).
Life in the ultra-orthodox neighborhoods unfolds according to socio-cultural
codes so much at odds with those of the rest of society as to fashion a sharply
distinct subculture which institutes (and is being instituted by) a social reality of
its own. For those immersed in this subculture the twin spiritual ideals to be
relentlessly pursued are the strict fullfilment of all religious precepts and the
study of Jewish sacred texts in religious academies (yeshivot). Women are
expected to contribute to the second goal, limited to men only, by taking care of
the household and, if necessary, by becoming the breadwinner.
The puritan character of the family is manifest in an elaborate decorum of
modesty and a strict separation of the sexes. Outside the family, the most
important institution for the ultra-orthodox man is the synagogue where he prays
three times a day. Of immense importance are also the spiritual leaders of the
community, always ordained rabbis, whose moral authority and advice is sought
and accepted without challenge.
Despite their separatist ideology, the ultra-orthodox are not self-sufficient
WORKING WITH JEWISH ULTRA-ORTHODOXPATIENTS 199
enough to entertain a complete disengagement from the secular society within

which they are uncomfortably situated. Medical care, and even more so mental
health care, are among those few contact zones in which the ultra-orthodox
reluctantly face and interact with specialists pertaining to the "world out there."
MENTAL HEALTH AMONG THE ULTRA-ORTHODOX
In terms of health seeking behavior, it appears hardly surprising that for strictly
religious people modem psychiatric services are deemed the very last resort.
This "unacculturative sequence" (Schwartz 1969) may account for the fact that
the ultra-orthodox are overrepresented in the severe psychiatric categories, such
as schizophrenic and major affective disorders (cf. Rahav et al 1986). In the
absence of independent epidemiological studies, however, one should not
extrapolate from case registry to general prevalence rates of psychopathology in
this population. Small-scale clinical studies regarding the association between
ultra-orthodoxy and psychopathology often yield contradictory results.
On the one hand, researchers have specified a host of risk factors peculiar to
growing up in a strictly religious ambience (see, for example, Goshen-Gottstein
1987). The exaltation of spiritual concerns, religious studies, and uncompromis-
ing observance at the expense of mundane pursuits may indeed exert a heavy
psychological toll on the members. On the other hand, it is not unlikely that
certain life aspects peculiar to these communities may have ameliorative effects
on certain vulnerable individuals. Thus the structured milieu and the moratorium
from many life-tasks provided by the yeshiva may appear extremely beneficial
for some marginally adjusting students, despite the intellectual requirements and
self-discipline that this setting usually demands.
The benefits of the structured religious framework are particularly noted in a
special sub~oup among the strictly observant - ba'alei teshuva("masters of
repentence"), or newly orthodox Jews (Aviad 1983; Beit-Hallahmi 1991; Shafflr
1991). In terms of both prevalence and severity of psychopathology, ba'alei
teshuva have been significantly overrepresented in the population of the clinic.
Since about two thirds of them suffered from psychiatric difficulties prior to
religious change but came for psychiatric help only five years later (in average),
we assume that the initial effects of joining the ultra-orthodox community were
positive. 1 Only after the invigorating effects of change, affiliation to a suppor-
tive group and subsequent marriage were abated, did psychopathological
patterns resurface (Witztum, Greenberg and Dasberg 1990).
Given the all-embracing quality of religion for the ultra-orthodox, it is
expected to manifest itself in their idioms of distress and symptom vocabulary
(see Good and Good 1986). Clinical studies have confirmed these expectations.
The obsessive ideation and compulsive rituals of strictly observant patients are
replete with religious contents centering around purity, liturgy, and dietary laws
(Greenberg and Witztum 1991). When the ultra-orthodox fall prey to depression,
guilt and self-incrimination may be expressed in terms of concern over religious
negligence and lack of piety (Witztum, Greenberg, and Buchbinder 1990); and
the psychotic among them harbor delusions with elaborate mystical and folk-
religious themes (Perez 1977; Bilu, Witztum, and Van der Hart 1990; Witztum,
Buchbinder, and Van der Hart 1990). As we later seek to show, a culturally
sensitive treatment must take into account this religious elaboration.
The diagnostic problems that emerge in the encounter with ultra-orthodox
patients deserve a separate discussion. It should be noted, however, that despite
the massive coloring of mental disorders by religious contents, the boundaries
between normal and pathological religiosity are usually not difficult to set. Thus,
for example, compulsive behavior that involves religious practice is likely to
either exceed or disregard the requirement of religious law to such extent that its
symptomatic character is discernible from both emic (intragroup) and etic
(psychiatric) viewpoints (Greenberg 1984; Greenberg and Witztum 1991). Even
in those extreme cases where the distinction between religious devotedness and
individual pathology is not easily noticed in the behavior p e r se (e.g. mystical
experiences involving social withdrawal, dissociation, and "visions"), it is often
manifest in the wider context, when other extra-behavioral variables are taken
into account (e.g. duration of the mystical episode, voluntary control of onset,
after-effects of mystical experiences).
WORKING WITH ULTRA-ORTHODOX PATIENTS:

GENERAL CONSIDERATIONS
Given the cardinal role of religion in shaping the lives of the ultra-orthodox, it
appears safe to contend that the Jerusalem Mental Health Center is a multicul-
tural setting p a r excellence. Moreover, we would like to argue that the challenge
posed to mental health practitioners by the ultra-orthodox patient is more
unsettling than that inherent in "ordinary" transcultural therapy. Notwithstand-
ing the fact that the ultra-orthodox are part and parcel of the Jewish majority in
Israel, the gulf between them and the secular mainstream is based on moral-
ideological foundations which make it more difficult to bridge than, say, the
division between Ashkenazi (European) and Sephardi (Mideastern) Jews. The
latter cleavage, built of genuine cultural differences and deepened by ethnic
tension and acrimony (particularly felt by underprivileged Sephardim), is
nevertheless reparable. While differential access to socioeconomic resources
still nurtures interethnic bitterness and hostility, it is noteworthy that the rate of
(intra-Jewish) ethnically mixed marriages, a significant index of integration,
comes close to 25%.
WORKING WITH JEWISH ULTRA-ORTHODOX PATIENTS 201
These integrative processes do not apply to the ultra-orthodox community,

where cultural distinctiveness is fuelled by religious zeal and accentuated by
self-imposed physical segregation. From the ultra-orthodox perspective, the fact
that the secular unabashedly breach the religious commandments viewed by the
observant as the sine qua non of Jewish life makes contacts with them in many
spheres of life (let alone marriage) entirely impossible. Moreover, it situates
them in a morally inferior and condemnable position, part of the impure world
of sin.
This caste-like exclusion makes the multicultural encounter in the mental
health clinic particularly problematic. The gap between sacred and medical
realities is not exhausted by the divergent, often incompatible explanatory
models that the parties hold. Underlying it is a moral dimension which threatens
to put the therapist, as a representative of the impure, evil world of secular
progress, in a very untoward position even before the commencement of
treatment. Yet, despite these adverse preconditions, we seek to create in the
clinic - an alien and menacing setting for the ultra-orthodox patient - a meaning-
ful therapeutic discourse, a persuasive rhetoric of healing, tailored to the
patient's cosmology and all-embracing value system.
The point of departure for a therapeutic dialogue with the ultra-orthodox
patient should be the recognition that for the latter the holy, as a
"phenomenological constant" (Csordas 1985: 107), is the idiom through which
illness experiences are articulated. Having recognized this, therapy should
creatively incorporate elements from this sacred reality - religious symbols and
rituals, mystical practices, etc. - in the pursuit of a twofold objective: gaining
the patient's trust and cooperation and, following that, empowering him through
culturally sanctioned channels to effect cure. Some case vignettes illustrative of
this empowerment process in the clinic are presented in a subsequent section.
Despite our heavy reliance on cultural materials in designing therapeutic
interventions, we are reluctant to subsume our approach under "ethnocultural
psychotherapy models" (Jackson 1990). While we agree with many of the
notions underlying the developments of culture-specific programs, it should be
noted that we, unlike most mental health professionals who initiated these
programs (ibid), do not seek to establish a distinct theoretical and clinical model
based on a separate "ultra-orthodox psychology" (cf. Nell 1990). Situated within
the modern health care system, we do not preach "going native" in the sense of
an epistemological immersion in the sacred reality of our patients. The fact that
we are not religious - although some other members of the staff in the clinic are
- precludes this possibility in the first place. Moreover, even the observant
practitioners among us would find it difficult, if not absurd, to forsake medical
theories of illness for divine causes, in forging their explanatory models. In
some respect, we assume the classic shamanistic role of moving between
worlds, of seeking to bridge and reconcile divergent realities (cf. Myerhoff
1976), but there should be no doubt as to where we are located epistemologi-

cally. In Jackson's (1990) terms our approach may be felicitiously viewed as
pertaining to the "combined cultural and traditional models" (note that by
"traditional" Jackson means Western).
The aforementioned "shamanistic movement" does not entail a conviction
that the gap between a religiously incongruent psychodynamic understanding of
an illness and a religiously informed, strategic treatment can be easily traversed.
On the contrary, we are aware of the fact that different symbolic realities,
grounded in divergent epistemologies, are not commensurable, therefore the
translation of an experience articulated through religious idioms into the
psychodynamic vocabulary of, say, unconscious motivations and intra-psychic
conflicts can never be exhaustive. Our work thus entails an immanent tension
between a too facile tendency, rooted in our professional background, to
psychologize the religious contents presented by the patients, and an awareness
of the fact that religious experiences cannot be reduced into medical events,
even if they are part of what is consensually perceived as illness episodes.
Maintaining the delicate balance between these contrasting vectors is a major
challenge in our work.
An ethical criticism may be raised against the employment of religiously
based interventions by therapists who are not religious themselves. In the same
vein, it might be argued that rabbis and other religious practitioners are better
candidates for the implementation of this kind of therapy. These arguments will
be addressed in the concluding discussion, after the reader gains a better view of
our work. Suffice it to say here that a therapeutic attitude expressing genuine
respect for the religious values and behavior of the patient is indispensible in a
setting like ours. This demand is not a clich6 nor can it be dismissed as lip-
service, since it is tested and challenged time and again by many a patient. It
may require, for example, the therapist's readiness to withstand unevasively a
thorough inquiry by the patient in personal matters regarding his own religious
faith and to engage in a discussion which in "standard" psychodynamic therapy
would be deemed an unwarranted capitulation to the patient's transferential
desires (cf. Spiegel 1971, pp. 324-336). "Frankness" alone is not enough,
however, as it can lead to counterproductive religious disputations. By and large,
a tolerant, benevolent orientation toward the religiosity of the patients must be a
central value of the nonreligious therapist, guiding him in the moral and ethical
minefield that this peculiar therapeutic setting constitutes.
Finally, we tend to a ~ e e with Sue and Zane (1987) that cultural knowledge
and culture-specific techniques are not in themselves a panacea in multicultural
clinical settings. Rather they should serve as means for enhancing the image of
the therapist as credible and giving in the eyes of his patients.
In what follows we discuss several analytically discernible factors which
appear pertinent to working with ultra-orthodox patients. The first set of factors
is contextual in nature, dealing with the image of the clinic and its physical
setting. The second set discusses the necessary role requisites of the therapists;
and the third one, accorded a central emphasis in this article, deals on various
levels with the nature of the therapeutic interventions administered in terms of
form and content.
CONTEXTUAL FACTORS
Image
The image of the clinic in the eyes of potential ultra-orthodox clientele is given
primacy in the presentation because of the critical role it plays in shaping the
decision whether or not to consider mental health facilities as a legitimate
resource, a viable option of health seeking behavior. Before reviewing the
specific accommodations made in the clinic to facilitate acceptance by the target
popultion, two general background factors should be noted. These factors
concern the attitude of the classic rabbinical sources to medicine and therapy at
large and the position taken by key figures within the ultra-orthodox community
toward the employment of mental health facilities in particular.
The attitude of the Jewish sources towards the medical profession is am-
bivalent at best (Preuss 1978: 25-26). For the devout, there exists an inherent
tension between the ideal of total reliance upon God's miraculous help and the
recurring need to be assisted by mortals, whose main asset is expertise, not
boundless faith. This tension, aggravated by witnessed cases of medical failure,
has produced an upsurge of negative evaluations of physicians in rabbinical
writings. At the same time, however, positive voices have never been missing
from the classic sources and, in practice, most of the great rabbinical figures
have not refrained from employing medical care or recommending it to others in
time of need. The tension between relying on heavenly care and on human
assistance could be relieved or mitigated by portraying the physician as God's
messenger. As such he could be viewed as only a means to execute His Will
(Preuss 1978).
The ambivalence towards the medical profession is particularly salient in
regard to mental problems. From a religious perspective, this domain of human
affliction is open to moral interpretations which question the pertinence of
medical interventions. This is true, for example, when the deranged behavior is
deemed a retribution from heaven for religious transgressions. By and large,
metaphysical explanations of mental disorders, whether directly inflicted by God
or mediated through external agents with special ontological status (e.g. angels
of destruction, wandering souls of notorious sinners, demons), abound in the
religious community. The prominence of these explanations constitutes a barrier
for psychotherapeutic interventions, since the latter are predicated on theories of

causation based on moral premises and modes of responsibility at odds with
metaphysical explanations. This gap may make psychology and psychiatry,
insofar as they are based on "naturalistic" rather than "personalistic" explana-
tions (see Foster 1979) suspect if not heretical in the eyes of ultra-orthodox
Jews.
However, despite the inherent incongruence between the basic assumptions
underlying the religious and the psychiatric systems in regard to mental
problems, the barriers above-mentioned are not insurmountable. Significant as
they may be, they should be viewed as constraints which call for flexible
accommodations in administering treatment. Since these accommodations are
elaborated in what follows, we limit ourselves here to calling attention to the
ambivalence that mental health facilities may stir in the religious community.
Sensitivity to this ambivalence should aid in alleviating apprehension regarding
therapy by creating and spreading an image of mental health practitioners
compatible with religious perceptions.
A major factor in facilitating the acceptability of mental health facilities as a
legitimate resource involves the support of key rabbinical figures within the
religious community. As the unchallenged loci of authority, whose advice is
sought and meticulously obeyed, these rabbinical figures play the role of
gatekeepers regarding a wide plethora of domestic matters, including the use of
psychiatric facilities.
Over the years we have managed to convince several rabbinical figures that
the therapy administered in the clinic is not designed to sap the foundations of
the patients' faith. As a result we won their cooperation in admitting a number
of severely disturbed individuals, mostly yeshiva students, to the clinic.
Setting
Location. Located in an inconspicuous three-story apartment house turned into

a clinic, the Community Mental Health Center is situated in the heart of the
ultra-orthodox community of Northern Jerusalem. Given the strivings of the
ultra-orthodox to minimize their contacts with the nonreligious world, this
location serves to mitigate to some degree the aberrant meaning of seeking help
there. In addition, the unimpressive site of the clinic, barely noticeable from
other houses in the neighborhood, complements its location in reducing the
inhibitions of seeking its services.
Edifice. Within the clinic, various arrangements may serve as cues that at least
some religious precepts are adhered to. Thus, for example, mezuzoth (sing.
mezuzah, a piece of parchment bearing passages from Deuteronomy rolled up in
wooden or metal cases) are attached to all the doorposts, as the Law commands,
and pictures of venerated rabbinical figures decorate some of the walls. These
cues may assist the orthodox patient in feeling more at home in the clinic. That
the ground he enters is not entirely alien is also indicated b y the presence of
male and female religious staff members, easily identified by their skull-caps
and modest dresses, respectively.
The fact that most of the staff is not religious can be easily noticed; yet their
adherence to some basic rules of decorum dictated by orthodox tradition may
serve to increase their credibility in the eyes of their patients (Sue and Zane
1987). Given the strict segregation between the sexes in the ultra-orthodox
community, for example, minimizing the contacts of the patients with staff
members of the other sex may soften the menacing aspects of the encounter.
ROLE REQUISITES
As noted before, mental health practitioners and ultra-orthodox patients are

enmeshed in entirely different symbolic realities, which give rise to divergent
explanatory models regarding the patients' afflictions (Kleinman 1978, 1980).
This therapist-client incompatibility, an immanent ingredient of multicultural
settings, is detrimental to therapeutic efficacy, as, indeed, is documented in
many instances of therapy administered cross-culturally (cf. Draguns 1981;
Pande 1968; Torrey 1972). Given this unfavorable starting point, the challenge
is to make medical and sacred realities complementary rather than antagonistic
(cf. Csordas 1985), or, at least, to soften the contrasts between them.
One obvious step in this direction is to employ religious therapists in the
clinic, since these practitioners appear to embody the possibility of bridging the
gap between the two realities. Indeed, we believe that the presence of religious
professionals in the staff has generally been conducive to reducing the patients'
apprehension and estrangement in the clinic. This is not a panacea, however,
since, apart from the small number of religious therapists, most of them, as
"modern orthodox" (Helmreich 1982), are still worlds apart from their ultra-
orthodox patients. Moreover, precisely because of their religiousness they might
be deemed "double agents" or "traitors" (cf. Comaz-Diaz and Jacobsen 1991,
p. 395), particularly when it becomes evident during the sessions that their
primary commitment is given to the medical reality.
One general and seemingly self-evident prescription for therapeutic efficacy
in multicultural settings is to become acquainted with the client's culture as
much as possible. For secular therapists in our clinic this means investing effort
in gaining knowledge of religious beliefs, practices, precepts, customs, and lore
which, taken together, shape and monitor their clients' entire lives. It is true that
without translating it into specific guidelines for therapeutic interventions,
cultural knowledge p e r se is distal to therapeutic results (Sue and Zane 1987).
Yet, following Good and Good (1986), this knowledge may help them feel close
to the patient thus facilitating the establishment of intimate relations with him or
her; the management of "affective distance" in therapy (Scheff 1977) in
culturally appropriate ways; the elicitation of key cultural metaphors and their
symbolic manipulation to effect healing (Bilu, Witztum, and Van der Hart
1990); and the recognition and management of culturally based issues of
transference and countertransference (Good et al. 1982). How the first three
aspects of a culturally competent therapy are specifically managed and mediated
is demonstrated in the case vignettes that we present in the section on
therapeutic interventions. Here we would like to dwell on the role of cultural
knowledge in inducing a cure-facilitating atmosphere and then on issues of
reflexivity and transference.
The acquisition of basic knowledge of Jewish culture may enhance the
therapist's sensitivity to the basic etiquette and modes of communication
endorsed by the ultra-orthodox community (cf. Sue 1990). Meeting the patient
with the proper blessing, embedding biblical verses and talmudic idioms in the
discourse (particularly scriptural injunctions that entitle doctors to practice),
demonstrating knowledge of approaching religious festivals, citing from the
weekly Torah reading, showing due respect to a religious scholar, whether a
patient or his company, and avoiding excessive eye contact with female patients
or companions - all these behavioral items and their like may assist in creating
an atmosphere of acceptance and enhance the therapist's credibility as a
trustworthy and effective helper.
The proper and flexible employment of "ritual language" (Csordas 1983;
McGuire 1983) is particularly important in this context. The discourse of ultra-
orthodox patients is often ornate and archaic, replete with associations from the
scriptures, and rich with religious metaphors. Familiarity with this religious
rhetoric may enable the therapist to recognize the metaphors that have power
within the patient's discourse and to manipulate them symbolically to effect cure
(cf. Dow 1988).
Questions of transference and countertransference are particularly pertinent in
the setting under discussion. As mentioned before, secular therapists may be
outrightty rejected as sinners and heretics by ultra-orthodox patients. At best,
they may be approached with ambivalence and suspicion, as they would always
be considered representatives of the evil nonreligious world. The therapists, on
their part, may react to the ultra-orthodox clients' all-embracing religious
commitment, odd mannerisms and traditional garments with a mixture of
puzzlement, repugnance, and fascination. Our experience has taught us that
some of the responses of the therapists to their ultra-orthodox clients were
extremely biased, ranging from a total idealization of their value system to, more
frequently, manifest hostility and rejection (cf. Comas-Diaz and Jacobsen 1991,
pp. 396-398).
Even though a closer familiarity with the patients' cultural background and
milieu does not constitute a guarantee against such attitudes, it may help to
divest some of their stereotypically distorted aspects. In any case, we believe
that an ongoing readiness to recognize and examine the "religious" component
in the transferential (and countertransferential) relationship that might develop
in therapy is a crucial requisite of mental health practitioners working with ultra-
orthodox patients.
Given the difficulties inherent in the incongruent dyad of a nonreligious
therapist and an orthodox patient, it is hard to foresee how the former can
survive professionally without entertaining respect for the religious principles
and precepts of the latter. Since in the course of therapy the therapist's attitudes
towards religion are likely to be tested time and again, this regard must be
genuine and deep-felt. We believe that a general sympathetic attitude towards
the ultra-orthodox patients' faith, together with the concomitant conviction that
the therapeutic process would never be advertently used to weaken this faith, are
minimal requirements from the nonobservant therapist in a setting like ours.
Given the secular, if not antireligious worldview of many therapists these
requirements are not easy to absorb. A s a result, manifestations of frustration
and ambivalence loom high on both sides of the therapeutic dyad. We hope to
deal with these issues of transference and countertransference and the role they
play in therapeutic success or failure in a separate essay.
FORMAT OF THERAPY
Attendance and Regularity of Meetings. Ultra-orthodox patients seldom reach

the clinic without company. In part, this is due to their severe psychiatric status,
as many of them suffer from acute psychosis or severe depression. But no less
than that, it reflects the close-knit organization of the orthodox community and
its massive intervention in the life of the individual. We have found out that the
presence of the accompanying person in the initial interview, and often in the
ensuing sessions as well, reduces the resistance of the patient and increases his
willingness to cooperate with the therapist.
Rather than being regarded as a passive observer, the companion should be
actively drawn into the discussion, becoming an active part of the treatment and
sharing the responsibility for its smooth conduct. Therapy is facilitated when
conclusions and decisions to be undertaken are reached in concert with the
patient and his companion. Such a group decision may take the sting out of the
patient's apprehension that upon entering the clinic he has come under the evil
influence of heretics and sinners.
Our experience has taught us to be as flexible as possible with the appoint-
ments, since we are dealing with reluctant patients who, apart from being
severely disorganized, never get rid of their ambivalence toward the clinic and
do not perceive therapy as a long-term undertaking. As a result, many of the
treatments, including some of the more successful ones, have taken a very
irregular course.
Teamwork. Along the lines of the "cultural consultation clinic" (Good et al.
1982), we find it advantageous that in some cases the patient will be seen by a
team of two or even three cotherapists. Ideally, the team should be mixed,
including a religious member, and, in any case, a "cultural specialist," that is, a
therapist with intimate knowledge of Jewish religion. Cotherapists are especially
important in organizing a dramatic ritual during therapy (see below) and for
post-session discussions of each other's "blind spots" and countertransferential
attitudes. While the presence of more than one therapist might exacerbate the
patient's fears, it is countervailed to some degree by the participation of the
latter's companions in the sessions.
THERAPEUTIC INTERVENTIONS
The Role of Medication

Since many of the ultra-orthodox patients who reach the clinic suffer from
severe disorders with massive malfunctioning, administering psychiatric
medication in the course of therapy often appears indispensable. The patients are
usually very reluctant to take these medications which they consider as the
embodiment of the dangerous and frightening medical interventions.
We employ various strategies in order to alleviate their apprehension. While
administering the prescription we modestly emphasize that, since healing is
from God, the doctor should be viewed as God's vehicle to combat illness. By
quoting from those classic sources that endorse medical assistance we seek to
legitimize medication intake. In addition, medical intervention is wrapped with
religious contents by accommodating it to the traditional idioms used by the
patients. To patients with auditory hallucinations, for example, which they
interpret as persecutions by evil spirits, anti-psychiatric drugs are presented as
operating to create a mystical wall against demonic assault. In addition, we seek
to win the support of the patient's rabbi for medication intake. Once this support
is gained, we encourage the patient to take counsel with the rabbi.
In most cases we can assure the patients that the medication will not interfere
with daily religious ritual. More often than not, the patient's resistance will be
dispelled by the noticeably beneficial effects of the drugs on his anxiety or
depression.
Religiously-informed Interventions in Therapy

As we noted previously, cultural knowledge as such does not guarantee
therapeutic efficacy in mutticultural settings. To facilitate culturally sensitive

psychotherapy, it should be distilled and translated into specific operations that
hold a direct bearing on the patient's malfunctioning. In what follows, we
discuss three classes of traditionally informed interventions employed with
ultra-orthodox patients: healing rituals, dream interpretation, and the use of
culturally congruent metaphors and stories. Several case vignettes are presented
to illustrate these interventions.
1. Healing Rituals
Unlike modem psychotherapies, traditional healing methods are replete with
ceremoniality and often involve dramatic and intricate rituals. Since Frank's
classic "Persuasion and Healing" (1973), many social scientists, interested in
symbolic healing, have highlighted the curative mechanisms underlying rituals
(see, for example, Atkinson 1987; Dow 1988; Moerman 1979; Scheff 1977). In
view of this literature, some attempts have been made recently to incorporate
rituals and ceremonial elements into modem psychotherapy, particularly by
nondynamic therapists espousing strategic methods (Haley 1963; Van der Hart
1983, 1988).
Ceremonial elements from Jewish traditions which we use in the treatment of
ultra-orthodox patients include prayers, magical incantations and exorcistic
formulae and rituals, directed against traditional agents of affliction, such as
demons, spirits of the dead and vindictive angels. Most of these means were
extracted from Jewish mystical sources (Trachtenberg 1974). The first case to be
presented illustrates how a ritual for summoning spirits was employed in the
course of treatment to relieve a penitent patient with psychotic depression from
the persecutions of a vindictive angel. Other therapeutic guidelines discussed
before - i.e. team-work and the active involvement of a companion - are also
demonstrated in this case. As the opening case in a series of illustrations, it is
portrayed in some detail.
Example 1: Summoning a vindictive angel

Ezra, a newly orthodox young man, married and the father of one baby girl, was
brought to the clinic by his older brother, himself a long-time penitent who
became rabbi, because of "bizarre behavior." He appeared unkempt, uncoopera-
tive, severely depressed, and only partially oriented to place and time. His
formal thought processes were intact, but the content of his thinking indicated
auditory and visual hallucinations of a persecutory nature. He was diagnosed as
suffering from a major depressive episode with psychotic features.
Psychodynamically, the major source of the Ezra's problems could be traced
back to the traumatic death of his father, a chronic alcoholic, when he was 15
years-old. Underestimating his father's deteriorating condition, he refused to
stay by his side during what turned to be the father's last night, and this
irrevocable negligence made him guiltridden and despondent. He developed a

depressive reaction and started using hard drugs. At 18, however, under the
corrective influence of his brother, he quit taking drugs and joined the military
service.
Two years prior to admission, following his brother's footsteps, Ezra became
religiously observant, married, and started praying for a son to name after his
late father. When instead of the desired son his wife gave birth to a girl, his
distress and shock were unbearable. He started hearing voices which he
identified as coming from a vengeful angel who was sent to punish him for the
neglect that had led to his father's death. To absolve himself, the angel ordered
him to afflict himself by fasting frequently and otherwise eating minimally, by
abstaining from sexual relations, and by wearing old and tattered clothes. Aside
from these ascetic behaviors, Ezra immersed himself in various mystically-based
practices to obtain forgiveness: he frequented the sanctuaries of popular saints
all over the country and engaged himself in nightly rituals to mobilize their
assistance.
Treatment was conducted by two therapists, a nonreligious psychiatrist and a
religiously orthodox clinical psychologist, himself a penitent. Ezra's brother
took upon himself to bring him to the sessions and actively participated in all of
them. He also tried to convince Ezra to take the medication he was prescribed -
a small dose of antipsychotic medication (mellaril) to which clomipramine
(anafranil) was later added to combat depression - but here his success was
modest at best.
The thrust of the therapy was aimed at relieving Ezra of the excruciating guilt
feelings that underlay his pathological mourning over his father. Recognizing
the penitential nature of his ecstatic religious experiences, the therapists started
by offering him a "functional equivalent" for his mystical pursuits: they
encouraged him to write his father a letter in which he would ask his forgiveness
and permission to go on living. In addition, they sought to moderate his ascetic
and other self-afflictive practices by quoting classic Jewish sources forbidding
excessive mourning or self-neglect.2 However, these and other interventions
were proven quite ineffective against the angel's iron fist on Ezra. To any
symptomatic improvement he would respond with new threats (e.g. insisting that
in his afterlife Ezra is bound to reincarnate as a stone3), compelling the patient
to initiate even harsher ascetic practices. Under these circumstances, it was
decided to confront the punishing agent directly.
The first task was diagnostic in nature. In line with the Jewish mystical
tradition (see below), Ezra viewed the angel as an ally rather than an adversary,
yet the punitive nature of this personal angel was evident. Given this ambiguity
(recognized as an externalized manifestation of the patient's self-recrimination),
the therapists urged Ezra to investigate the angel's name, nature, and celestial
affiliation. The angel refused to divulge his personal identity but did inform the
patient that he belonged to the inner circle of the angel Raziel. 4 It was not
haphazard that for summoning the angel, Ezra employed a text from the
mystical tract bearing the angel's name, The Book of The Angel Raziel. 5 He used
to read the text ceremonially over eight lighted candles, aligned in a specific
geometric form.
Once the patient divulged the summoning ritual he was using, the way was
open for confronting the angel directly during therapy. In order to enhance the
effectiveness of the ritual, the therapists resolved to situate it in a most dramatic
setting. They asked Ezra's brother to join them in a lay Jewish religious court of
three,6 seeking to exploit the legal authority of this body to reframe the modus
operandi of the angel by transforming him into a benevolent ally. Ezra himself
gave his consent to the enactment of the ritual in the clinic under these cir-
cumstances.
At the designated hour, the brother transformed the treatment room into a
ritual setting by locking the door, turning off the lights, and closing all windows
and shades. Ezra set up the candles he had brought with him in an eight-
stemmed candelabrum. After he lit them, the brother and the therapists
ceremonially declared that a Jewish court of three was formally established.
Leading the ritual, the brother asked one of the therapists to read the text from
the Book of Raziel, employed by Ezra to conjure the angel.
During the reading Ezra spontaneously began swaying, moving his body and
head in an increasingly rhythmic, vigorous manner. He seemed to enter a trance-
like state, adding to the recitation his own ecstatic singsong of a two-syllable
phrase with increasing loudness and force. Suddenly he became quiet and
informed the others that the angel was present. The atmosphere in the room
became so electrified that the brother could barely stand the tension. He
hurriedly declared that, on behalf of the court, he was ordering the angel to cease
harassing Ezra and to return no more for "good or bad" - not even to reveal
mystical secrets. In so doing, the brother deviated from the therapists' original
program to initiate a dialogue with the angel in order to convert him into an ego-
supportive ally. Nevertheless, they accommodated themselves to the "exorcistic
twist" initiated by the brother and, as members of the court, joined him in
announcing that from now on Ezra was a free man, under his own control.
In the following sessions it was found out that the ritual, despite its truncated
form, had been conducive to liberate Ezra from the angel's despotic domination.
The apparitions became more rare, and their content changed, interestingly
enough, in line with the therapists' unrealized objective: the commands to
engage in harsh penitential practices were replaced by benign instructions to
study various classic texts, ranging from Torah and Talmud to the mystical
Zohar. Consequently, Ezra shifted back to normal eating habits, started to relate
to his infant daughter, and resumed sexual relations with his wife. By and large,
he was functioning better at home, was more sociable, and took better care of
himself. The improvement was reflected in Ezra's reported dreams of his father.
Whereas before the father had appeared as a mournful old man in a black cloak,
he now appeared dressed in white and bathed in light. However, despite the fact
that Ezra had chosen life, as his brother noted, he still showed depressive affect,
and it was evident that he still lamented the loss of his father. He agreed to
resume taking his antidepressant medication. At this point the sessions had to be
stopped because Ezra moved to another town, where his brother became head of
a religious academy.
The general improvement in Ezra's condition was maintained during a one-
year follow-up, in which he attended his brother's religious academy full-time.
During this year the angel appeared to him several times, but then only in a
benign form, as an ally rather than an adversary.
Comment: Ezra's case is an illustration of the extent to which religious beliefs
and mystical practices can mold psychopathology. Analytically it can be
approached from different psychiatric perspectives: e.g. biomedical (the
biological basis of depression), psychodynamic (pathological mourning over the
father nurtured by remorse and self-incrimination), and structural-"dissociative"
(the angel as an alternate personality, comparable to those of patients with
multiple personality disorder). But these psychiatric accounts must take note of
the cultural matrix of Jewish mysticism which shaped Ezra's peculiar
symptomatology. Ezra's experience of the angel, viewed as nonpossession
trance in Bourguignon's (1979) terms, appears to be specifically informed by the
Jewish mystical phenomenon of the maggid - an angel who conveys esoteric
knowledge to scholars worthy of this communication (Dan 1972b). While
maggidim (pl.) are deemed benevolent allies rather than merciless foes, there are
intriguing similarities between the ascetic orientation of Ezra's angel and the
maggid of the great rabbinical luminary of the 16th Century, Rabbi Joseph Caro
(Werblowsky 1977).
Given the massive religious construction of Ezra's symptomatology, it is hard
to fathom how therapy could have proceeded without recourse to strategic
treatment techniques sensitive to the patient's symbolic universe and belief
system. The active involvement of the brother - a rabbi and a moral authority
for the patient - in the therapy and the recurrent attempts to use religious
injunctions against the excessive mourning and penitential practices were part of
these culturally congruent interventions, which reached their dramatic climax in
the summoning ritual. It should be noted that in seeking to confront the angel
and to negotiate with him a more benign influence the therapists were inspired
by modern therapeutic approaches to the treatment of malevolent alternate
personalities in MPD patients (Putnam 1989). Yet they capitalized on Jewish
practices in designing this therapeutic move to enhance its effectiveness. They
meticulously followed the patient's induction technique, a somewhat
idiosyncratic combination of diverse mystical sources, but creatively increased
their moral authority and the ceremoniality of the setting by transforming it into
a religious court, a familiar, authoritative institution to the ultra-orthodox.
The premature sealing of the ritual by the brother reflects an interesting clash
of paradigms which demonstrates the intricate nature of working in a multicul-
tural setting. The therapists, attuned as they were to the cultural meaning system
of the patient and his brother, decided to advocate a dialogue with the angel in
order to transform him into a benevolent ally. They selected this option because
it appeared to resonate with the highly positive nature generally ascribed to
maggidim in mystical traditions as well as with modern strategies for treating
MPD patients. The brother, however, in line with the Jewish treatment of
malevolent spirits (see Bilu 1985), espoused an exorcistic model, contraindi-
cated in the modern treatment of alternate malevolent personalities (Putnam
1989). These differences of opinion, reflecting perhaps the differential status
accorded to "control" and "cathartic" therapies in traditional and modern
setttings, respectively (see Wallace 1970: 236-239), fortunately were not salient
enough to counter the therapeutic effects of the ritual.
A major source of affliction in Jewish folk-religion is the impure world of

wandering spirits and demonic beings. While spirits of the dead usually seek to
take possession of their victims (a phenomenon known as dybbuk; see Bilu
1985), demons are capable of injuring human beings without penetrating their
bodies. The following case, a religious penitent like the previous one, illustrates
the use of magical incantations to thwart demonic attack.
Example 2: Withstanding a demonic attack

David, a 29 year old father of three, was brought to the clinic by a relative, as he
had become increasingly bizarre and isolated. He reported visual hallucinations
and acute sense of derealization. In addition he started wetting his bed and had
impulsive outbursts in which he had beaten his children. On examination, he
appeared miserable and anxious, and avoided eye contact. He mentioned
laconically and vaguely "visitors" who had been harassing him to such an extent
tha~ he contemplated suicide.
David had become ultra-orthodox during his military service, nine years ago,
and immediately immersed himself in the study of kabbala (Jewish mysticism)
with one of the leading Jewish mystics in the country. Gradually he started to
report uncanny experiences - strange visions and dreams - which had left him
bewildered and apprehensive. One ominous experience to which he was exposed
while visiting with his mentor the shrine of a popular saint, had a particularly
adverse effect on him. He was sleeping in the precinct of the sanctuary when an
old man with a white beard woke him up and ordered him to light a candle.
Panic-stricken, he fainted and could not therefore carry out the assignment.
Although he recovered quickly, he considered his omission ill-fated and
foreboding - all the more so after his mentor had rebuked him for not having
complied with the instruction of the old man whom he identified as the saint
they were visiting.
Following this episode, David began to experience visitations by supernatural
beings which he vaguely identified as spirits. Initially the encounters with the
spirits were quite gratifying but gradually they were transformed into persecu-
tions launched by scary demons. David deemed these attacks a retribution for
his sinful life prior to repentence as well as for transgressions he had commited
in his previous incarnations. In line with mystical doctrines, he believed that
through his current suffering his soul would be eventually rectified and purified.
As the demonic attacks grew in intensity and in frequency, he delved deeper into
mysticism, dividing his time between studying the Book of Gilgulim, a text
containing esoteric knowledge about the transmigration of souls (Scholem 1954)
and frequenting tombs of popular saints. Following the death of his mentor,
three years before referral, he became more isolated, his appetite diminished,
and he began to suffer from sleep disturbances.
Upon referral, David was prescribed neuroleptic and antidepressant medica-
tion to render him more alert and cooperative. Following medication intake he
became indeed more communicative and reported his tribulations at the hands of
the demons. He related how he tried to combat them using various religious
means (e.g. prayers), but to no avail. Given David's profound involvement with
mystical teachings, the therapists decided to provide him with a protective tool
from the kabbalistic arsenal, known to have been used by his late mentor. This
was a short incantation addressed to the assaulting demons and phrased as
follows:
Leave this place, you who belong to another domain!
You do not belong in this world!
You have no fight to bother or interfere with me!
In face of attack, the patient was instructed to recite the spell thrice in a solemn,
assertive manner. This terse and direct incantation proved quite efficacious in
alleviating the patient's fears. In the following sessions he demonstrated how he
had driven the demons away using this formula. An external evidence of
David's zeal and earnest determination in confronting the demons came from his
wife who contacted the therapists and asked them to convince her husband that
the incantation remains effective even if not thundered at the top of his voice.
While his other problems have not been substantially improved, the persecutions
by demons were contained.
Comment: As against the elaborate summoning ritual of the previous case, the
intervention described here is modest and simple, and the suggestive message of
the text, devoid of metaphoric import, appears direct and concrete. What
transforms these phrases into "words of power" (McGuire 1983) for the user is
their context of elicitation, namely, the fact that they constitute a powerful
kabbalistic incantation sanctioned by a venerated mystic. The solemn recitation

and the threefold repetition add to the ritual quality of the incantation, while the
popular belief that normatively human beings and demons should dwell in
adjacent but separate worlds (Bilu 1979a) endows it with a culturally congruent
rationale.
Unlike the previous case, the ritual here did not have a substantial influence
on the course of treatment. While the anti-demonic formula clearly empowered
the patient through its performative aspects, its effects were limited to
symptomatic relief in one circumscribed area.
The fact that the patient's difficulties were aggravated by a sinister experience
on a visit to a saint's grave should not detract from the general therapeutic value
of such visits. In the folk-traditions of Jewish religion saints, conceived of as
idealized authority figures, benevolent, omniscient and omnipotent, are believed
to act from their graves as intermediaries between God and their devotees. The
central role of the saint is particularly emphasized in mystical cosmologies
(Scholem 1954). As we have seen, both Ezra and David were engaged in visits
to saint sanctuaries. The ritual activities performed in the precinct of the shrine -
e.g. fervent prayers while prostrating on the tombs or encircling them, lighting
candles, reading Psalms, and consuming festive meals - amount to attempts at
self-healing. Therefore we usually encourage patients to exploit this cultural
resource, particularly during the auspicious time of the saint's death anniversary,
when his therapeutic influence if deemed all the more potent.
2. Dream Interpretation
Dream interpretation techniques are prevalent in both modern and traditional
therapies, yet dreams are comprehended very differently in these two systems.
While in modern settings dream contents are taken as symbolic manifestations
of unconscious aspects of the dreamer's inner life, traditionally dreams have
been considered as omens reflecting messages from God or other supernatural
entities (O'Nell 1976; Tedlock 1987). In Jewish classic sources references to
dreams are abundant, representing a wide plethora of views (Bilu 1979b).
However most of these texts, some surprisingly "modern" Talmudic discussions
of dreams notwithstanding, 7 abide by the traditional assumption that renders the
dream external to the dreamer and situates it on a cosmological, rather than a
psychological plane.
Mystical doctrines add an active dimension to the external approach: while
sleeping, the soul departs from the body and commences a nightly voyage to
heaven. Its destination is the feminine counterpart of God, the Shekhina, with
whom it yearns to unite. Dreams reflect the experiences of the wandering soul,
and their character and outcome derive from the nature of the entities encoun-
tered on the way. As such, dreams are taken very seriously by religious people,
and a lot of effort may be invested in discerning the moral standing of the
protagonists in the dream plot. Special attention is given to visitational dreams

in which messages from deceased relatives are conveyed. The notion that most
dreams are meaningful and decipherable, and that their messages spill over to
and affect reality, has given rise to many written texts of dream interpretation
techniques. Most of these methods rely heavily on religiously based cultural
vocabularies of symbols.
The following case illustrates how a culturally-congruent dream interpretation
may be incorporated into the treatment together with a leave-taking ritual.
Example 3: Coming to terms with a deceased husband

Sara, an observant woman in her late fifties and a mother of nine children, lost
her husband one year prior to treatment. She responded to the death with a
severe mourning reaction that soon developed into a full-blown depression. She
turned sad, hopeless and extremely unhedonic, lost a lot of weight, and could not
sleep well. In treatment Sara was found to be a very difficult patient as both
antidepressent medication and standard psychotherapy, offering ventilation and
support, failed to have any effect on the symptoms. This therapeutic stalemate
was changed, however, when Sara started to mention frightening dreams that
were frequenting her almost every night. She was encouraged to write them
down in a special "dream booklet" which soon became the prime focus of the
treatment.
Many of the dreams appeared to touch upon the death of her husband, who
passed away after a chronic disease. In a typical dream of this kind she found
herself going far away in order to obtain a much needed medication. She
managed to get the medication, but on her way back she found herself stranded
in a closed bazaar. Despite her pleas, the gatekeepers would not let her go before
sunset. Sara could recognize that the dream plot was linked to the death of her
husband and even identified, in line with traditional symbolic vocabularies, the
day and the bazaar as standing for life as against the night symbolizing death.
However, she found it difficult to articulate the acute sense of missed oppor-
tunity that the dream conveyed through an internal tenor (e.g. guilt feelings for
not being able to prevent the husband's death); rather she looked at it as a
sinister communication from the world of the dead.
Another common dream recurring in many variations was interpreted by her
in the same vein. In this kind of dream she would find herself buying various
products, from fruits and vegetables to wine and utensils, only to find out that
the beautiful and attractive facade of these objects was false and deceiving: the
red, ripe apples were rotten, the inviting wine was sour, and the well-shaped
pottery - cracked and fragile. Again, she pondered these objects as foreboding
messages from heaven, sent perhaps by the spirit of the husband, rather than as
reflections of inner states. But beyond the recognition that these dreams were
negative, she groped in the dark as to their specific meanings.
Then Sara had another dream which made her more aware of the "unfinished
business" in her relationship with her late husband. In this dream she found
herself located in an opaque structure, devoid of any opening, after having
wandered in a strange unknown landscape. She could hear scary cries coming
from outside which made her believe that terrible things were taking place out
there.
After a lengthy discussion with the therapist, Sara reached the conclusion that
the dream setting was, in fact, a cemetery, and the structure in which she had
found herself was a mausoleum for her husband. She was guided in the inter-
pretation by the uncanny atmosphere at the site, fitting with her traditional
notions of "the land of the dead," rather than by any physical similarity to her
husband's cemetery. Still she was ignorant as to the specific message of the
dream. At this point the therapist intervened to point out a possible interpreta-
tion. Since the dream was dreamed one year after the husband's death - a
significant date for the commemoration of the deceased in the Jewish religion -
he suggested that it communicated the request of the husband that his wife visit
him in his resting place. In order to transform the visit into a lever for settling
Sara's relationship with her husband, she was instructed to write him a letter
(see case 1) assuring him that she had not forgotten him but at the same time
demanding that he should let her live her life and not upset her with ghastly
dreams.
The next session took place in the cemetery. Dressed in black and choked
with emotions, Sara prostrated herself on her husband's tomb and then, sobbing
and crying, read the letter. Outside the cemetery she ritually washed her hands,
as Jewish religious law requires. The therapist did the same, announcing that the
line between the living and the dead was thus delineated anew.
Following the visit she reported a modest but steady improvement in her
situation, even though the dysphoric affect was not abated. This positive change
was reflected in her dreams. In one of her recent dreams her husband appeared -
this time in person - and sent her to bring him wine for havdala (a religious
ritual conducted on Saturday evening to separate between the holiness of the
departing Sabbath and the mundane quality of the coming week). Unlike
previous dreams, this time the wine sought and found did not turn sour.
Moreover, the incorporation into the dream of a ritual devoted to differentiation
and delimiting (this is the meaning of the word havdala) may indicate that the
patient had absorbed the therapist's solemn assertion in the cemetery regarding
the disengagement of the living from the dead. For the dreamer, in line with the
traditional understanding of dreams, it was her late husband who conveyed his
consent to the separation.
Comment: In this case the combined use of a traditional dream interpretation
and a leave-taking ritual is illustrated. The notion that Sara's dreams stemmed
from an unfinished business with her dead husband, though far from self-
218 YORAM BILU AND ELIEZER WFI'ZTUM
evident, appears acceptable to both modem psychological and Jewish traditional

approaches. The difference lies, of course, in the diverse epistemologicai
groundings of the dreams within these paradigms. While the therapist tended to
attribute Sara's dreams to guilt feelings regarding the death of her husband
(during therapy she expressed remorse for not having taken better care of him in
his last days), Sara herself deemed the dreams objective messages, cryptic in
content yet negative in essence, coming to her from the abode of the dead,
probably from her late husband. Note that the two explanatory models focus on
the same character; yet Sara, a very unintrospective patient, was not able to
reconcile them. Nor did the therapist try to bring her to espouse the
psychodynamic model. He deliberately suspended his understanding of the
dream, offering her an interpretation (for the cemetery dream) in accord with the
traditional view of visitational dreams.
Admittedly, the interpretation granted was only tenuously related to the
manifest content of the dream, let alone to that of her previous nightly ex-
periences. But this symbolic-interpretive thinness was redressed by the fact that
the therapist's account objectified the dream experience and highlighted its
performative function. The notion that the dream calls for specific actions
resonated well with the patient's religiously informed dream understanding.
After all, she was interested in the symbolic meanings of her dreams as future
oriented instructions or admonitions which should be meticulously followed to
increase her well-being or forestall an imminent calamity. Whether or not the
contents of her dreams derived from painful experiences associated with the
death of the husband, the ritual activities undertaken in keeping with the
assumed dream messages appear to have had a soothing effect on the distress
that these experiences entailed.
Aside from dream interpretation, Jewish religious texts offer a handful of

practices aimed at bringing about specific dream contents or at diverting
putatively dire dream consequences. The calculated use of one such technique is
exemplified in the following case excerpt.
Example 4: Ameliorating adverse dreams

Daniel, a newly married young patient, became strictly observant after a long
and arduous soul searching voyage. Before he embarked on ultra-orthodox
Judaism he spent some time in an oriental esoteric cult despotically led by a
charismatic guru called "the master." It is possible that his repentance was,
among other things, a desperate attempt at self-cure, following the psychological
breakdown precipitated by the cult experience. In this case, however, self-
reconstitution in the Jewish mold dit not prove therapeutic, as David's condition
continued to deteriorate. He became very negativistic, drastically cutting his
social ties and showing extreme self-neglect. In addition, he experienced
auditory hallucinations of persecutory nature. He was diagnosed as suffering

from a paranoid schizophrenic disorder.
Upon examination, it was found out that the scary figure of the "master," a
vestige of the patient's cult experience (now self-denigrated as pagan),
predominantly figured in his hallucinations. The "master" commanded him to
forsake his recently acquired orthodox identity, threatening to kill him if he
dared emancipate himself from his tutorship. David sought the help of several
rahbi-healers in his attempts to redeem himself, but to no avail.
The therapeutic interventions commenced with neuroleptic treatment
(hallidol) which proved quite effective in controlling the hallucinations.
However the place of the voices was taken by nightmares in which the master
resumed his frightening assaults on David. In these dreams David was typically
situated at home while the master was outside, trying to break through. Despite
David's attempts to stop him at the door, he would force his way in and seize the
frightened ex-devotee, demanding absolute fidelity and obedience. Since the
patient was overwhelmed by these frightening dreams, it was decided to help
him contain or "domesticate" them through a peculiar ritual of "dream ameliora-
tion" (hatavat halom) recommended in the Talmud 8 (Babylonian Talmud, Seder
Zera'im, 1958). This ritual is a magical device designed to restructure "a dream
which makes one sad" by giving it "a good turn."
The therapist, a psychiatrist, meticulously followed the talmudic prescription.
Since it requires three participants aside from the dreamer he invited over two
colleagues of his to take part in the ritual. In the designated session the three
therapists and the patient stood face to face in the treatment room. The patient,
vaguely familiar with the ritual but ignorant as to its specific contents, was
instructed in his role beforehand.
Daniel started by declaring earnestly and emphatically: "I have seen a good
dream," to which the therapists ceremonially responded: "Good it is and good
may it be. May the All-Merciful will turn it to good; seven times may it be
decreed from heaven that it should be good." After a short pause they went on
uttering in concert three sets of short biblical texts, containing three verses each.
The verses in each set were selected from different books in the Bible, but they
deal with the same topic, respectively: turning something from bad to good (e.g.
"Thou didst turn for me my mourning into dancing," Psalms 30, 12), redemption
(e.g. "He has redeemed my soul in peace..." Psalms 55, 19), and peace (e.g.
"Peace, peace to him that is far off and to him that is near," Isaiah 57, 19). This
chorus-like incantation sealed the ritual.
The ritual did ameliorate the patient's dreams to some extent. He left the
clinic high-spirited and later reported a substantial decrease in the prevalence of
nightmarish dreams. The master persistently continued to annoy him, but could
not terrorize him as he did before. In addition, he reported a further decrease in
the auditory hallucinations (with medication intake remaining constant) which
he also attributed to the ameliorative ritual.

Comment: The importance of healing rituals, highlighted in the previous
section, is reiterated in the cases discussed here, since in Jewish traditional
context dream interpretation has an explicit performative aspect, grounded in
ritual. Again, the faithful reconstruction of a talmudic ceremony, fraught with
magic, 9 in a modern, scientifically governed clinic may appear bizarre and ill-
located. It should be noted, however, that the centrality of the ritual in our
presentation is somewhat deceiving. Without underestimating its importance, it
was nevertheless but a one-time episode in the lengthy course of a conventional
treatment.
Moreover, given Daniel's psychotic features, the magical drama in which he
participated, simple, direct, concrete, and forceful, could have a strong effect on
him. This is particularly true for a patient who made the Bible his whole world
and turned to it on manifold occasions for inspiration and comfort as well as for
specific answers to bothering problems (cf. Stromberg 1985). In this sense the
ritual could have held for Daniel a transformative function as well (McGuire
1983), given the potentially rich metaphoric usages of the biblical verses. It is
not impossible that for someone so enmeshed with the Scripture, the biblical
themes of transformation, redemption, and peace, absorbed and molded against
the anvil of his personal suffering, could later articulate his dream experiences
more positively. This argument brings us to the last therapeutic intervention -
the employment of culturally congruent metaphors and stories.
3. Metaphors and Stories

One of the critical factors in symbolic healing is the culturally-appropriate use of
idioms and metaphors (Good and Good 1986; Fernandez 1977; Witztum, Van
der Hart and Friedman 1988; Crapanzano 1975; Lrvi-Strauss 1967). If the
experience of distress is articulated in cultural idioms, then the metaphors
embedded in these idioms can be symbolically manipulated to facilitate change.
The religious language of the strictly observant is replete with metaphoric
statements and expressions, mainly derived from the Bible and from subsequent
sacred texts. The following example demonstrates how the rich metaphoric
layers in the symptomatology of an ultra-orthodox patient can be elaborated to
facilitate cure.l~
Example 5: Combatting cultural idioms of distress

Avraham, a 35 year-old ultra-orthodox yeshiva student of Mideastern extraction,
was brought to the clinic by his wife. In the examination he cried and moaned as
if in acute pain, but could not verbalize these affective signs of distress. His
problems started after he found himself involved in a lethal terrorist attack near
the Western Wall in Jerusalem. Although he was not hurt physically, the trauma
left him withdrawn and deranged. He had spells of crying, was panic-stricken at
times, consumed huge quantities of food, and experienced severe sleep distur-
bances. Displaying extreme self-neglect and lack of concentration, he had to quit
the yeshiva. The disengagement from "the abode of Torah" further exacerbated
his depression, because open-ended religious studies modestly supported by
charity grants (a course of life unique to ultra-orthodox communities) were his
sole vocation since he was eight years old. At that age his family disintegrated:
the father, a respected rabbi, was killed in a car accident and the mother
responded with a severe depression. Since then, religious institutions and
yeshivot (pl.) became Avraham's home and, given his marginal life-style,
remained his safe resort even after he had married and became the father of five.
Avraham was treated by a psychiatrist and a clinical psychologist using a
combination of strategic methods, based on hypnosis, and drug therapy
(antidepressant and sedative medications). They received a lot of assistance
from Avraham's wife who participated in all of the sessions and meticulously
documented his behavior between them. Her help was particularly important in
the first phase of therapy when Avraham, while gradually betraying a clinical
picture akin to post-traumatic stress disorder, was very resistant to any interven-
tion. The true nature of his distress was only gradually exposed through
hypnosis (which he entered very easily). During trance he described a black,
menacing figure which terrorized him time and again at night threatening to kill
him. These visual hallucinations were explicitly associated with the late father.
He appeared in many of them, assuming meek and subservient position and
being ridiculed by the black aggressor who boasted that it was he, in fact, who
had killed the father. However, since all attempts to examine directly the impact
of the father's untimely death on Avraham's current plight only aggravated his
situation, it was decided to suspend psychodynamically based interventions for
more culturally congruent ones.
Having identified the black figure as a demonic agent, 11 the therapists
provided Avraham with anti-demonic formulae (see example 2) from the Jewish
folk-religious arsenal. They also taught him relaxation techniques using self-
hypnosis. These means helped Avraham cope better with the demonic persecu-
tions. In addition, the therapists sought to structure the hypnotic sessions
through guided imagery. Since the patient used spatial images such as "desolate
place" and "arid land" to describe his feelings of loneliness and hopelessness,
the therapists selected the metaphor of marching alone in the desert as the basic
scene for imagery work under hypnosis. They urged him to traverse this
imaginary setting in order to find a more benign environment where he could
find shelter and protection. After a long march the patient spotted a patch of
green in the horizon which became his destination.
A significant therapeutic turn occurred between the sessions, when Avraham
paid a visit to the tomb of a popular saint, Rabbi Chaim ben-Attar, on the day of
his death anniversary. Following the visit he felt that the saint was personally
taking care of him, and this protective cover gave him a sense of empowerment.
In the following sessions, under hypnotic induction, he was drawing nearer to
the green spot, now revealed as a walled oasis, using the saint's name in order to
thwart the assaults of the demon and his aides. Eventually he forced his way into
the site, and found himself in a beautiful garden, laced with pure spring pools,
saturated with sweet odors, and inhabited by pious and sainted figures, including
his late father. Burnt with ecstasy, he identified this magnificent place, where
eventually he was relieved from demonic persecutions and could unite himself
with his lost father thus redressing his childhood trauma, as no less than the
earthly site of Paradise.
This peak experience Avraham deemed a unique mystical revelation. He was
very grateful to the therapists who, despite their manifest nonobservance, could
guide him so skillfully through his other-worldly odyssey, yet he refused to
detract from its singular significance by going back to hypnotically based
imagery work. A two-year follow-up showed that his refusal was well taken, as
most of his symptoms decreased dramatically following the visit to the Garden
of Eden. The demonic affliction disappeared altogether.
Comment: Skipping the rich details of the case, presented before (Bilu,
Witztum, and Van der Hart 1990), we would like to dwell here on the elaborate,
symmetrically arrayed metaphoric construction of the patient's idioms of
distress and empowerment. The therapeutic drama involved two pairs of
contrasting metaphors, viewed as cultural antagonists. The first pair, demon vs.
saint, constitutes a personified metaphorization of configurations of negative and
positive experiences, respectively. During treatment, the demonic persecutions
were crystallized as Avraham's main idiom of distress articulating his helpless-
ness and despair following the traumatic loss of his father.
The mobilization of the saint against the demon - whether a metaphoric
manifestation of the development of endogenous healing processes in the patient
during therapy or an available metaphoric option that activated this auspicious
development (or both) collapses the vicious circle of hopelessness and despair.
Note that it was the patient rather than the therapists who molded his plight and
deliverance in the cast of culturally congruent metaphors. In this sense much of
the treatment ought to be viewed as self-healing. The therapists, however, were
quick to seize upon these idioms and to amplify the therapeutic possibilities they
retain. This was done, among other things, by situating the cultural identities of
demons and saints in a fitting setting, the spatial metaphor of a desert, bound to
encapsulate the patient's life-predicaments. Serendipitously, The wanderings in
the desert led Avraham to Paradise, a contradistinctive spatial image which,
from a religious point of view, is the most appropriate arena for self-reconstruc-
tion and transformation.
As an axis mundi, the sacred abode of health-bestowing saints, the place
where one can reunite himself with painfully missed ancestors and mentors, a
golden age lying in the beginning of things where the earliest privations can be
relived and redressed - as all these and more, Paradise is a key symbol, a
multivocal idiom for empowerment, deliverance and healing. It is no wonder,
then, that in reaching Paradise, Avraham could better cope with the primal
trauma of his childhood as well as with the secondary trauma that precipitated
his symptoms. The traumatic loss of the father was countervailed by the reunion
with him in the Garden of Eden and the traumatic terrorist attack near the
Wailing Wall, the sacred site in the West, was undone by a miraculously safe
visit to Paradise, another sacred navel of earth, located in the East.
In addition to metaphoric images, strategic therapies often recommend the

employment of metaphoric narratives, or stories (Gindhardt 1981; Gordon 1978;
Peseschkian 1981). When used competently, such stories can contribute to
therapeutic progress by reframing and redefining problems, by modelling a way
of communication, and by seeding ideas and suggesting solutions to problems
(Zeig 1980). The use of stories is particularly indicated with ultra-orthodox
patients because religious culture exposes them to a wide selection of
metaphoric narratives, spanning different periods (e.g. biblical, talmudic,
kabbalistic, hasidic, modem) and embracing diverse genres (e.g. mythic,
historical, moralistic, mystical, hagiographic). Story telling is a deeply ingrained
tradition in hasidic circles. The wealth of therapeutic possibilities enveloped in
hasidic tales has been pointed out by various students of therapy (e.g. Polsky
and Wozner 1989).
The case of Avraham, presented previously, may be pondered as a metaphoric
narrative which came to a closure with the climactic experience in Paradise. But
there the therapeutic drama itself constituted the story which was forged jointly
by the therapists and the patient. Here we deal with a story in the strict sense,
related by the therapist to the patient in order to bring about some behavioral
change in the patient. This use is exemplified by the following case.
Example 6: Dispelling self-destructive ideas

Nathan, an ultra-orthodox young man, member of the Bratslav hasidic sect, had
been suffering for a long time from depression with psychotic features. He was
prescribed antidepressant medication which stabilized him to some extent, but
could not eradicate his suicidal ideation. To abate these ideas, which were
getting more pervasive and more serious, the therapist (a psychiatrist) recited the
Jewish religious law which considers suicide a terrible inexpiable sin, 12 but to
no avail. Even the exhortations of hasidic rabbis, mobilized by the therapist,
were not effective in dissuading Nathan from his ill intent. Recognizing that by
taking his own life he would commit his soul to unfathomable tribulations in the
afterworld, he still maintained that this world is too abominable a place to live
in.
Intriguingly, Nathan's gloomy world view might have been informed by the
teachings of Rabbi Nachman, the venerated founder of the Bratslav sect. This
"tormented master" himself was prone to bouts of depression (Green 1981),
elicited by a strong sense of sinfulness. However, for Rabbi Nachman and his
hasidim the predominance of the "dark side" in the world has been the impetus
for transforming it into an abode of joy, hope, and faith. To achieve this
transformation, the sect has been embracing ecstatic and meditative practices
which appear esoteric and bizarre to many other hasidim. At the same time,
however, this license to lose oneself in extreme behavior has been a source of
attraction and inspiration for a disproportionately high number of emotionally
disturbed individuals (see Witztum, Greenberg, and Buchbinder 1990).
Nathan might have been one of those who became followers of Bratslav to
assuage and come to terms with their own distress. Yet he picked up selectively
the gloominess, despair and sense of sinfulness inherent in Rabbi Nachman's
teachings without embarking on the ecstatic joy and exuberance which are no
less an integral part of the Bratslav doctrine. Consequently, he was not im-
pressed with the manifold statements of Rabbi Nachman which condemn despair
and fear even though they do not repudiate their existence (e.g. "The entire
world is a very narrow bridge; the main thing is to have no fear," or "sadness is
the root of all evil"), lavished on him by the therapist. Since these behavioral
prescriptions had failed to remove the imminent threat of suicide, the therapist
resolved to combat this threat through the less explicit means of metaphoric
narrative. Apart from its (metaphoric) relevance to the problem at hand, the
story belongs to the corpus of folk hasidic tales, an integral part of the patient's
cultural milieu. It was presented to the patient as follows:
A famous righteous rabbi, head of a hasidic sect, passed away and his son stepped into
his place. One of the hasidim, an ardent devotee of the father, found it difficult to accept
the son as a worthy successor of the late rabbi, believing that he lacked his father's
profound wisdom. In order to test the new rabbi's intelligence he undertook to confront
him with an apparently 'no win' situation. He came to the rabbi with a live butterfly
hidden in his clenched hand and asked him: "Rabbi, I hold something in my hand. Tell
me, is it dead or alive." If the rabbi would say it was dead, the hasid contemplated, he
would open his hand, letting the living butterfly fly away. If, however, the rabbi would
insist that it was alive, then he would clench his hand, kill the butterfly, and prove the
rabbi mistaken once more.
The rabbi stared at the hasid, sighed, and smoothed his beard. Then he said quietly:
"It's all in your hand, my son."
Nathan was much taken with the story. Surprised and amused, he appeared to
have grasped the relevance of the tale to his personal problems, even though the
therapist did not make any attempt to explicate or elaborate on it. In the
following sessions he mentioned the story several times, praising the therapist
for his sagacity and wit. Following the recounting of the story, Nathan's verbal
accounts of his self-destructive ideation markedly decreased, even though his
core symptoms were not eliminated.
Comment: In this case vignette, the metaphoric narrative was found superior to
other interventions in battling suicidal ideas (or, put more cautiously, in
decreasing their verbalized expressions). Note that the patient was not moved by
the sheer admonitions against suicide found in the Jewish canonical texts with
which the therapist and some well-known rabbis profusely provided him. Nor
could the teachings of Rabbi Nachman himself, the sect's founder and venerated
tsaddiq, with their dialectic twist from the depths of sadness to the heights of
ecstatic joy - presumably tailor-made for a depressed patient - liberate him from
his life-threatening intent. Against the inefficacy of these religiously congruent
interventions, the main asset of the story-qua-therapeutic device supposedly
resides in the wide metaphoric space it creates within which the patient can
discover fresh, unanticipated perspectives for refraining and redefining his
problem. The indirect, subjuncfivizing mode of the story, sharply contrasted
with the other religiously based interventions in this case, enlarges the pos-
sibilities of the patient to ground his experiences in the dense narrative web of
symbolic associations. This fusion of symbol and experience may serve as an
effective lever for change (cf. Obeyesekere 1984, 1990).
In the case presented here the specific associations of the patient to the story
were not available. Nevertheless, some circles of relevance can be easily pointed
out. First, the story was taken from the hasidic lore and its plot deals on the
manifest level with an issue too well known in hasidic sects, namely, the
tensions between the hasidim and a recently enthroned rabbi, often selected
despite the bitter opposition of certain factions in the sect. 13 Second, the story
revolves around the question of life and death, echoing the existential dilemma
which haunts the patient. Third, in the mystical tradition the butterfly is a
common symbol for the soul. 14 This symbolic equation makes the story, with its
implied conclusion to take responsibility for one's life, all the more pertinent to
the patient.
CONCLUSIONS
Admittedly, the clinical material discussed above was selected for presentation
because it contained therapeutic interventions that proved efficacious in treating
strictly religious patients. We plan to discuss the major pitfalls in our work in a
separate essay. Yet even the relatively successful cases discussed above give rise
to various issues that have not been fully addressed hitherto.
The first set of issues questions the moral justification of nonreligious
therapists to engage in therapeutic interventions based on religious premises. We
believe that our endeavor is defensible on moral grounds as long as the follow-
ing requirements are fulfilled: the therapist does not hide his basic nonreligious
identity under false pretenses; he genuinely respects the principles of faith and
226 YORAM BILU AND ELIEZER WITZI'UM
the religious practices that guide his client's life; he is willing to discuss his own
personal attitudes on religious matters, if challenged to do so by the patient, in a
manner which is open yet unprovocative and devoid of disputation; he does not
seek to shake his patients' belief system even in those cases where he is
personally convinced that religious commitment exacerbates psychopathology.
Under these conditions the venture of nonreligious practitioners into the fabric
of Jewish religion is not a ploy. Rather, it should be viewed as a sincere attempt
to enter the religious patient's sacred reality and enhance communication with
them in order to render the therapeutic discourse more fruitful.
Even if the aforementioned conditions eliminate most of the moral and ethical
concerns that therapy with ultra-orthodox patients might elicit, the problems of
working in a multicultural setting still must be addressed. Notwithstanding the
relative success of the interventions illustrated above, the attempts to incorporate
religiously congruent elements into "secular" therapy may be seen as ill-located,
given the existence of religious specialists whose authority and erudition in
religious matters give them a clear advantage over the therapists. Instead of
playing rabbis in the clinic, the therapists should be urged, perhaps, to refer their
reluctant patients to real rabbis, particularly to those who engage in religious
counseling and healing.
This argument can be addressed on various levels. First, the observed
sequence of health seeking behaviors among the ultra-orthodox clearly indicates
that they tend to employ traditional curing devices before turning to the clinic
(perceived, as mentioned before, as the last resort). Empirically, then, in many a
case the very decision to attend the clinic furnishes evidence that religious
healing had been attempted and failed.
More important, the focus in this essay on religiously based interventions
overshadows the fact that these interventions are embedded in a nonreligious
therapeutic framework which draws on a wide range of treatment modalities.
The therapeutic tools we use include psychiatric medication, support, and
strategic methods based on behavior modification techniques, hypnosis, imagery
work, and leave-taking rituals. Moreover, although the role of explicit insight-
evoking interpretations in treatment is quite marginal, given the enormous
difficulties of ultra-orthodox patients to reconcile it with their belief system, our
understanding of the cases is basically psychodynamic. Wherever possible, this
understanding has guided the selection and modes of employment of the
religious idioms elicited in therapy. This point, somewhat lost in the rich
tapestry of each particular case presented above, is more visible when a more
comprehensive view of the cases is taken.
The fact that a depressive component recurred in all of the presented cases is
consistent with high prevalence of depression among ultra-orthodox patients. In
three of the cases - those of Ezra, Sara, and Avraham - the core-symptoms were
convincingly linked to guilt and self-incrimination following a traumatic loss of
a father (in the male patients) or a husband. The therapeutic interventions, while
using religious idioms and rituals, involved a deliberate attempt to bring these
guilt feelings to the fore, to establish their connections to the loss, and to work
them through. The decision, only partly realized, to summon Ezra's persecuting
angel and negotiate with him a more benign influence rather than altogether
exorcize him was directed by the wish to give these feelings a voice through the
guise of the supernatural adversary. The interpretation of Sara's cemetery dream
was designed to draw her nearer to her "unfinished business" with her late
husband. And the guided imagery of crossing the desert offered to Avraham was
constructed with the hope that he would meet his father at the end of the trip. In
all three cases, then, these were psychodynamic considerations that set the
religion-congruent interventions in motion.
As we have tried to show, strategic methods can be flexibly accommodated to
include the employment of religious symbols and practices, whether in the form
of metaphoric images and narratives (dream interpretation, story telling, guided
imagery) or of metaphoric actions (rituals). We believe that this framework
enables us to respond to the patients' suffering, often expressed through
distinctively religious idioms of distress, with a unique kit of therapeutic
devices, unavailable to traditional healers. Obviously, the ingredients in this kit
should not be viewed ,as discrete and separate. Even in the case of drug prescrip-
tion we have found out that often the same antipsychotic or antidepressant
medication, which was found entirely ineffective initially, turned out to be quite
potent when accompanied by a religiously informed intervention, which granted
the drug a proper "symbolic space" (cf. Moerman 1979, 1983).
An intriguing question involves the therapists' decided preference to work
within the religious symbols encountered in treatment without challenging them
through confrontation, interpretation, or other forms of deconstruction. As
implied before, this putative readiness to accord epistemological validity to the
sacred reality in which the patients are immersed does not stand for a methodol-
ogy of "going native." Rather it represents a role enactment which calls for a
"'willing suspension of disbelief" on the therapist's part. Difficult as this role-
taking may be for a therapist who tends to imbue religious systems with
metaphoric rather than ontological significance, we feel that with patients like
ours, whose idioms of distress are formed by personal symbols from sacred
reality (i.e. collective representations subjectivized in the mold of their personal
anguish), it would be futile to discuss their religiously constituted symptoms
using psychological interpretations. While it is not impossible to give interpreta-
tions in multicultural settings by creatively using the patients' symbolic
language, we feel that in order to do this, we would have to transform the
rudimentary guidelines presented here into a more integrative model.
The importance of appropriate interpretations notwithstanding, we believe
that a crucial curative factor operative in all of the cases outlined above is the
relationship established between the therapist and the ultra-orthodox patient. Our
experience has taught us that it was the therapist's ability to gain access into the
sacred reality of the patient and to work within it, rather than his clinical skills in
emitting shrewd interpretations, that contributed most to the forging of a
meaningful, cure-enhancing relationship.
Finally, we feel that we have to address an anticipated criticism from
disappointed readers whose notion of Judaism is very different from the
presented picture of magical incantations, mystical-esoteric rituals, and folk-
beliefs in saints and demons. Admittedly, this picture selectively represents one
narrow layer of Jewish religion, reflected through the distorting prism of
severely disturbed psychiatric patients, many of them with clear psychotic
features. The fact that a large segment of our clientele (strongly represented in
the case vignettes) have been newly orthodox youngsters of Sephardic
(Mideastern and North African) extraction is significant as this group is
particularly mystically inclined. Even though many of the ultra-orthodox
attending the clinic have been religious students, usually they are too regressive
and incapacitated to engage in abstract theosophical, moral, or existential issues
- the gist of Judaism in the eyes of many. Rather they are attracted to folk
aspects of Judaism, where they can find concrete idioms, replete with magic and
mysticism, to articulate their suffering. Against these tangible idioms of distress,
we deploy our therapeutic interventions, extracted in part from the same
mystical and folk traditions, to serve as idioms of hope and healing.
Department of Sociology & Social Anthropology

Hebrew University of Jerusalem
and
Jerusalem Mental Health Center- Ezrath Nashim
NOTES
1 We do not wish to imply that the return to Judaism is a psychopathological process.

Since most of the penitents do not have a psychiatric history, we deal here with a small
exceptional group.
2 According to talmudic traditions, mourning over parents should not exceed one year
(see Encyclopedia Hebraica Vol. 1, p. 164).
3 On the belief in transmigration (gilgul) in Mystical Judaism see Encyclopedia Judaica
Vol. 7, pp. 573-577.
4 In Jewish mysticism Raziel is an important angel connected, as his name denotes in
Hebrew, with the mysteries of God.
5 A collection of Jewish mystical, cosmological, and magical materials, first printed in
1701 and reprinted many times because of the popular belief that the book protects its
owner's house from fire and other dangers (Dan 1972a).
6 Lay Jewish religious courts have been common in Jewish communities since the first
or the second century A.D. Their authority was restricted to civil matters and their
composition was quite flexible, as only one of the three judges had to be well-versed in
Jewish law (see Encyclopedia Hebraica Vol. 24, pp. 685-686).
7 For example, one of the sages claimed that the source of all dreams is "the"pondering
of the heart."
8 The ritual is described in Tractate Berakoth 55b (Babylonian Talmud, Seder Zera'im,
1958).
9 Note the predominance of the formulary numbers three and seven. A fairly similar
ritual existed among the ancient Babylonians (Oppenheim, 1966).
10 This case was presented in detail in CMP (Bilu, Witztum, and Van der Hart 1990).
11 Avraham described the persecuting agent as big and black in color, with red eyes and
cock' s legs. This depiction accords with the appearance of demons in Jewish folklore.
12 For an exhaustive review of the Jewish traditional view regarding suicide see
Encyclopedia Judaica Vol. 15, pp. 490--491.
13 Admittedly, this tension is less of a problem in Bratslav, the only hasidic sect which is
not based on a family succession of tsaddiqim. For the followers, Rabbi Nachman was
too pious and sublime to have successors.
14 The butterfly is deemed "among the ancient, an emblem of the soul..." (Cirlot 1962).
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Working With Jewish Patients

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YORAM BILU AND ELIEZER WITZTUM

WORKING WITH JEWISH ULTRA-ORTHODOX PATIENTS:

In recent years, following the implementation of a community model of mental

Culture. Medicine and Psychiatry 17." 197-233 1993.

THE ULTRA-ORTHODOX COMMUNITY

enough to entertain a complete disengagement from the secular society within

MENTAL HEALTH AMONG THE ULTRA-ORTHODOX

WORKING WITH ULTRA-ORTHODOX PATIENTS:

These integrative processes do not apply to the ultra-orthodox community,

1976), but there should be no doubt as to where we are located epistemologi-

for psychotherapeutic interventions, since the latter are predicated on theories of

Location. Located in an inconspicuous three-story apartment house turned into

As noted before, mental health practitioners and ultra-orthodox patients are

Attendance and Regularity of Meetings. Ultra-orthodox patients seldom reach

The Role of Medication

Religiously-informed Interventions in Therapy

therapeutic efficacy in mutticultural settings. To facilitate culturally sensitive

Example 1: Summoning a vindictive angel

irrevocable negligence made him guiltridden and despondent. He developed a

A major source of affliction in Jewish folk-religion is the impure world of

Example 2: Withstanding a demonic attack

kabbalistic incantation sanctioned by a venerated mystic. The solemn recitation

protagonists in the dream plot. Special attention is given to visitational dreams

Example 3: Coming to terms with a deceased husband

evident, appears acceptable to both modem psychological and Jewish traditional

Aside from dream interpretation, Jewish religious texts offer a handful of

Example 4: Ameliorating adverse dreams

auditory hallucinations of persecutory nature. He was diagnosed as suffering

he also attributed to the ameliorative ritual.

3. Metaphors and Stories

Example 5: Combatting cultural idioms of distress

In addition to metaphoric images, strategic therapies often recommend the

Example 6: Dispelling self-destructive ideas

Department of Sociology & Social Anthropology

1 We do not wish to imply that the return to Judaism is a psychopathological process.

Witztum, E., D. Greenberg, and H. Dasberg

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