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Sanity and Sanctity

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

David Greenberg
Eliezer Witztum
Copyright Date: 2001
Published by: Yale University Press
Pages: 400
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  • Book Info
    Sanity and Sanctity
    Book Description:

    Ultra-orthodox Jews in Jerusalem are isolated from the secular community that surrounds them not only physically but by their dress, behaviors, and beliefs. Their relationship with secular society is characterized by social, religious, and political tensions. The differences between the ultra-orthodox and secular often pose special difficulties for psychiatrists who attempt to deal with their needs.In this book, two Western-trained psychiatrists discuss their mental health work with this community over the past two decades. With humor and affection they elaborate on some of the factors that make it difficult to treat or even to diagnose the ultra-orthodox, present fascinating case studies, and relate their observations of this religious community to the management of mental health services for other fundamentalist, anti-secular groups.

    eISBN: 978-0-300-13199-4
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-x)
  4. 1 To Begin, Just Say, “How Are You?”
    (pp. 1-4)

    The scene is the office of an Israeli psychiatrist. An ultra-orthodox Jewish man is sitting in the patient’s chair.

    “How are you?” asks the psychiatrist.

    “May God’s name be blessed,” replies the patient.

    “Er, how are you feeling?” continues the psychiatrist.

    “Blessed is He and blessed is His name,” comes the reply.

    The psychiatrist may be forgiven for presuming that his question will lead to a description of the patient’s condition. The patient may be forgiven for replying to this greeting in the customary way among ultra-orthodox Jews. He is not being evasive. He is fulfilling the injunction in the...


    • 2 The Initiation of Mental Health Care for the Ultra-Orthodox
      (pp. 7-13)

      Community psychiatry in Jerusalem began about three decades ago. In 1972 the Ministry of Health divided the Jewish section of the city into four zones, and mental health clinics were opened in each, administered by the city’s four psychiatric hospitals. The northern quarter, home of the ultra-orthodox community of Mea Shearim, was assigned to Ezrat Nashim Hospital.

      Ezrat Nashim is the oldest psychiatric hospital in Israel, founded at the close of the nineteenth century by an enlightened group of women who wished to provide care for the mentally ill, untreated in Ottoman Palestine. The hospital was situated at the edge...

    • 3 Changing Attitudes in Cultural Psychiatry
      (pp. 13-17)

      Cultural psychiatry is a combination of anthropology and psychiatry. Whereas anthropology studies the unique aspects of cultures around the world, and psychiatry treats disturbances of mental health, cultural psychiatry attempts to understand the influence of culture on the presentation and management of psychiatric disorders.

      The attitudes and underlying theories of anthropology and cultural psychiatry toward the disorders of society and their management have changed radically in the past decades.¹ The early anthropologists and psychiatrists came from the Western world, and they tended to view their own culture as civilized and mature, the cultures they were studying as uncivilized or primitive....

    • 4 A Match Is Arranged Between Cultural Psychiatry and Ultra-Orthodox Judaism
      (pp. 17-21)

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

      We have structured this chapter around the concept ofshidduch,the arranged matrimonial match.¹ The groom is a composite of two male Israeli psychiatrists who work closely with the ultra-orthodox Jewish population. Both are part of...

    • 5 Varieties of Religious Identification
      (pp. 21-26)

      Like all long-standing religious groups, Judaism is composed of many different strands, for divisions are inevitable within any organization that has withstood the stress of time. Three thousand years ago, in biblical times, Jews were categorized as priests, levites, and common folk; two thousand years ago they were Pharisees, Saduccees, and Essenes. (Their later reputation among Christians notwithstanding, the Pharisees believed in the potential development of the oral law and in the ultimate value of scrupulous religious observance.) The journey into “exile” led to separate ethnic communities, including Ashkenazi and Sephardi, and two hundred years ago the emancipation of European...

    • 6 The Parable of the Turkey
      (pp. 26-34)

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

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


    • 7 Beliefs and Delusions
      (pp. 37-51)

      All religions may be said to have two principal components: beliefs (creeds) and practices (cultus). A devout member of a religious society who becomes psychologically unstable is likely to express her disturbance through the creeds and cultus of her religion. Two central symptoms, or expressions of disturbance, in psychiatry, delusions and compulsions, are respectively defined as excessive beliefs and excessive practices. Howa psychiatrist who is not a practitioner of a particular religion can understand what is “excessive” and what is not has exercised cultural psychiatrists for decades (Murphy, 1967; Westermeyer, 1987; Greenberg and Witztum, 1991a; Post, 1992). At the simplest...

    • 8 Visions and Hallucinations: ANGELS IN TODAY’S WORLD
      (pp. 52-59)

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

      And it came to pass, when Joshua was near...

    • 9 Nocturnal Hallucinations
      (pp. 60-71)

      Throughout this book we have claimed that just as no two cultures are identical, so the presentation of psychological difficulties varies from culture to culture, reflecting the preoccupations, fears, rules, and values of a society and the idioms of distress peculiar to it. The presentations of psychopathology that are unique to a particular setting are known as culture-bound syndromes, a concept first defined by Pow Meng Yap (1969).¹ A list of culture-bound syndromes published in 1985 contains descriptions of 162 clusters of patterns of behavior peculiar to certain societies, including voodoo death, amok, susto, koro, and latah (Hughes, 1985). Koro,...

    • 10 “A Big Man Dressed in Black Is Hitting Me”: DECONSTRUCTING THE NARRATIVE
      (pp. 71-86)

      By day, fellow students are found to be aggressive and shaming, while the night is populated with frightening figures who hit, rebuke, and threaten death. Why do young men with long-standing learning difficulties who drop out of yeshiva select this particular narrative to express their distress?¹ Their personal inner world and external actions, their family life and history, their immediate circle, the overall ultra-orthodox community, and Israeli society in general are all factors that lead certain young men to select these particular idioms of distress. In this chapter we shall deconstruct their narrative to examine its social and cultural influences....

    • 11 Phenomenology and Differential Diagnoses of Nocturnal Hallucinations
      (pp. 86-93)

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

    • 12 Normative Rituals
      (pp. 93-107)

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

      As Freud wrote (1959 [1907]): “I am certainly not the first person to have been struck by the resemblance between what are called obsessive actions in sufferers from nervous affections and the observances by means of which believers give expression to their piety” (p. 117). Like belief, a central feature of religion, ritual—a particular way of performing a behavior, usually in accordance with certain...

    • 13 Ritual as Psychopathology, or Is the Code of Jewish Law a Compulsive’s Natural Habitat?
      (pp. 108-125)

      Rabbi Israel Salanter (1810–83) was scrupulous in his observance of all 613 commandments of the Torah. It was his custom when Passover approached to personally supervise the baking of matzos in his town, to make sure it was done according to the time-honored ritual regulations.

      On one such occasion, when Rabbi Salanter was laid low by illness, his followers volunteered to supervise the baking of the matzos.

      “Instruct us, Rabbi,” they said. “Tell us all the important things we have to watch for.”

      “My sons, see that the women who bake the matzos are well paid,” was Rabbi Israel’s...

      (pp. 125-134)

      Let us consider two opposing views of the function of the Torah commandments. The first is from the Talmud:

      The Rabbis teach, “It is written, ‘And you shall put the words of my Torah in your hearts’ (Deuteronomy 11:18) and the word ‘you shall put’ [Hebrew:Samtem] can also mean ‘a perfect medicine’ [Hebrew:Sam Tam], for the Torah can be compared to a life-giving medicine.

      “This may be expressed as the following parable: A man once hit his son and gave him a serious wound. He put a bandage on the wound and said, ‘My son, as long as...


    • 15 The Baal Teshuva and Mental Health, or Why the Camel Changed His Burden, and How He Felt About It
      (pp. 137-151)

      Shortly after the founding of the state of Israel in 1948, Prime Minister David Ben-Gurion visited the religious authority of the ultra-orthodox community in Israel, Rabbi Avraham Yeshayahu Karelitz, known as the Hazon Ish.¹ The Hazon Ish asked Ben-Gurion to exempt ultra-orthodox yeshiva students from army service. Ben-Gurion understood that the request stemmed not only from the ultra-orthodox credo that men were to immerse their lives in Torah study alone but also from an antagonistic attitude toward the values of the modern secular state.

      The Hazon Ish began with a parable: “There is a halakhah that if two camels meet...

    • 16 Mental Illness and Religious Change: The Chicken or the Egg
      (pp. 151-163)

      Let us begin with another parable.

      One day, Rabbi Yohanan, who was renowned for his beauty, was swimming in the River Jordan. Resh Lakish, a very powerful man who at that time was a robber, dived into the Jordan after him.

      Rabbi Yohanan said to him, “Your strength belongs to Torah.”

      Resh Lakish said to him, “Your beauty belongs to women.”

      Said Rabbi Yohanan, “If you come back to Torah, I will give you my sister who is more beautiful than me.”

      Resh Lakish agreed, and, as he tried to jump back to the side of the river, found he...

      (pp. 163-178)

      To an outsider, the world of ultra-orthodox Judaism appears monochromatic. Every day is programmed according to a single rule book, and every ultra-orthodox Jewish man looks like every other: black hat, beard and sidecurls, long black coat. Such a perception of sameness is the view of outsiders, who inevitably think that their own way is independent and varied. For those on the inside, however, the ultra-orthodox community is not a single unit. There is, first of all, a basic ethnic division between Jews of Eastern Europe origin, who are known as Ashkenazim, and those from Africa and Asia, who are...

    • 18 Mysticism and Psychosis: THE FATE OF BEN ZOMA
      (pp. 178-193)

      Four eminent rabbis entered the garden of mystical speculation.

      Ben Azzai glimpsed and died.

      Ben Zoma glimpsed and was damaged (lost his sanity).

      Elisha ben Avuyah lost his faith.

      Rabbi Akiva departed in peace.

      In this story from the Talmud (Hagiga 14b), mystical speculation is seen as dangerous for our physical and psychological welfare: only one of the four rabbis was unhurt, and Ben Zoma became mentally ill (Ostow, 1988; Scholem, 1960; see A. Goshen Gottstein [1995] for an analysis of alternative interpretations of the text). Elsewhere the Zohar tells of three students who died while experiencing mystical ecstatic states....

      (pp. 193-210)

      In this chapter, we shall examine the appeal and impact of a visit to Jerusalem from the perspective of psychiatric disorder. Our inquiry leads to two separate topics: tourism and Jerusalem. The motivation for tourism has been conceptualized along a spectrum that includes escaping one’s daily life, seeking relaxation, and searching for a new direction for existence. The facilities of the holiday resort reflect these motives, from the seaside hotel to the ashram: the former lack intellectual stimulation, the latter beach and bar. Jerusalem is not only closer to an ashram as a tourist site, but it has a long...


    • 20 Ultra-Orthodox Attitudes Toward Mental Health Care
      (pp. 213-224)

      In the next two chapters, we shall consider the difficulties of establishing a structural and ideological framework for the provision of mental health care to the ultra-orthodox community. We have referred several times to the antipsychotherapy attitudes of ultra-orthodox religious leaders. In this chapter we shall try to understand these in the context of the history of psychotherapy and its attitudes toward religion and religious leaders, as well as of the structure and hierarchy of the ultra-orthodox community.

      The guidelines for behavior and opinion in the ultra-orthodox world were established by the writings of the leading rabbis of earlier generations...

    • 21 Improving Mental Health Care for the Ultra-Orthodox
      (pp. 224-240)

      The factors that prevent a working relationship between patient and therapist exist within the psyche of the therapy-providing community as much as within ultra-orthodox society. In this chapter, we shall suggest ways of surmounting these difficulties to improve the quality of care for the ultra-orthodox community. As a consequence of the relatively large size of ultra-orthodox families, more than 50 percent of all Jewish primary school children in Jerusalem are ultra-orthodox.¹ Within a single generation, the ultra-orthodox may become the largest group in the Jewish community in the nation’s capital. The issue of provision of mental health care is therefore...

    • 22 Treating Depression in the Community by the Community
      (pp. 241-250)

      “Several disciples of Rabbi Nahum of Tchernobil came to him and wept and complained that they had fallen prey to darkness and depression and could not lift up their heads either in the teachings or in prayer. The zaddik saw the state of their hearts and that they sincerely yearned for the nearness of the living God. He said to them, ‘My dear sons, do not be distressed at this seeming death which has come upon you. For everything that is in the world, is also in man. And just as on New Year’s Day life ceases on all the...


    • 23 The Soldier of the Apocalypse
      (pp. 253-269)

      In this section, we describe in detail the management of three cases. In the first, the therapists were relatively passive participants. In the other two cases, however, they undertook to join the patient’s world of concepts and performed rituals calculated to remove or improve his symptoms. The reader will have to decide whether the therapists were acting as professionals, proceeding on the basis of their training, behaving intuitively yet still as therapists, or playing games, respecting neither professional rules nor professional intentions. Each case instructed the therapists in different aspects of their work.

      The case of Benjamin, soldier of the...

    • 24 The Healing Power of Ritual
      (pp. 270-289)

      We have mentioned that it is critical in working with patients from a minority culture for the therapist to have credibility and be able to give the patient something meaningful at the beginning of the intervention. We here present two cases to illustrate these ideas. In the first case, neither goal was achieved; in the second both were.

      Samuel came to see us when he was fifty years old. He was accompanied by his twenty-three-year-old son Eli, who preceded his father into the room and sat in the chair nearest to the therapist. With mild reluctance Samuel assumed the “patient’s...

      (pp. 290-306)

      In this chapter we again delve into a world we initially found bizarre and to which we responded as professionals with such terms as “psychotic” and prescriptions of large doses of antipsychotic medication.¹ Our inability to help the inhabitants of this world led us to try alternative avenues, including hypnosis and guided imagery. We made assumptions about the links between events and symptoms and then tested them in the natural laboratory that is our community mental health center. We relate here a story of the apparently delayed effects of loss and recurrent trauma, and how they were mitigated by a...


      (pp. 309-326)

      In our years of work in the field of mental health, we have yet to encounter a patient who claims to be a turkey, let alone behaves like one. Our knowledge of the history of psychiatry also encourages us to think that neither two hundred years ago, when Rabbi Nahman wrote his story, nor in any earlier period was mental illness portrayed in this way. Furthermore, we doubt that mental illness can be cured by the treatment described, an example of the modeling and role-playing typical of behavior therapy. The successful use of a behavioral program would imply that the...

    • 27 Broken Souls Are Not Easily Mended
      (pp. 326-332)

      If this were a novel by Charles Dickens, our task at this stage would be to tell the reader what happened to all our characters, who married whom, how many children they had, and just how happily ever after they all lived. The ends would be neatly tied; the reader would have a sense of satisfaction and security. But our project has not been a novel, and there are not always happy endings. Further, we are aware of the many loose ends we have left dangling: the mental health problems of ultra-orthodox women in particular, sexual dysfunction, marital difficulties and...

  11. Notes
    (pp. 333-356)
  12. Glossary
    (pp. 357-362)
  13. Bibliography
    (pp. 363-382)
  14. Index
    (pp. 383-389)