HOWARD C. MARGOLESE, M.D.C.M.*
The literature related to the unique issues of engaging in psychotherapy with Orthodox Jewish patients is critically reviewed. Various forms of psychotherapy, including psychodynamic, cognitive, behavioral, couple, family, and group therapies, as conducted with Orthodox Jews, are discussed. The importance of examining transference and countertransference reactions with religious content is highlighted. Methods to help enable meaningful psychotherapeutic encounters with Orthodox Jewish patients that will be of benefit to both patient and therapist are suggested.
The American Psychiatric Association's official guidelines regarding possible conflict between psychiatrists' religious commitments and psychiatric practice states that psychiatrists (1) "should maintain respect for their patients' beliefs" and (2) "should not impose their own religious, antireligious, or ideologic systems of beliefs on their patients."1 This is a long way from Freud's view of religion as "a universal obsessional neurosis"2 or "a system of wishful illusions together with a disavowal of reality, such as we find nowhere else but in amentia."3 Although many therapists still identify with Freud's views, there are a growing number who acknowledge that the two can coexist and do not represent a threat to one another.4 It is in this context of increased cultural sensitivity and awareness that this paper will examine the unique issues of engaging in psychotherapy with Orthodox Jews. While this paper emphasizes these unique issues, it is presented with the hope that providers of mental health to all minority groups can gain from some of its conclusions.
Minority groups in the United States5,6 and Britain,7 and Orthodox Jews in Israel 8 have all been shown to underutilize the mental health services provided by the predominant culture. They are offered psychotherapy less often and have a higher dropout rate.9 Minority groups are also more likely to be given medication or electroconvulsive therapy.10 Some authors describe a "religiosity gap" that exists between patients' and therapists' religious values. This may help to explain why many patients consult with clergy prior to looking for help from health care professionals.11
The concern that religiousness may promote psychopathology has been expressed by some clinicians. Several recent reviews of the literature have failed to find such an association. In fact, it was found that religious commitment had much more frequently a positive association with mental health than either a neutral or negative association for the parameters in which associations could be found.12,13 Religious ceremony, social support, prayer, and relationship with G-d were all found to have positive associations, while religious meaning was found to have a negative effect.12 When patients present with religious problems, it is more probable that the psychopathology is the cause of the distortion in religious observance rather than vice versa.14
So far, there are no scientifically rigorous studies that examine psychotherapy with Orthodox Jews. In fact, all of the literature to date is based on the clinical experience and observations of those who provide mental health services. This paper is an attempt to summarize and collate these expert opinions.
Background Information on Orthodox Judaism
The following is meant to orient the reader to the relevant issues and complexities in the delivery of mental health care to the Orthodox Jewish community.
An Orthodox Jew is one who adheres to the traditional form of Judaism.15 This involves strict adherence to the Torah (see appendix: glossary of terms), both the written (5 books of Moses) and oral (mishnah) laws, which Orthodox Jews believe was handed down from G-d to Moses at Mount Sinai.16 Within the Torah, there are 613 mitzvot or commandments, both positive and negative, which Jews must follow. …