Culture shock therapy

Why is it so important for a therapist to be mindful of a patient’s culture?

By ABIGAIL KLEIN LEICHMAN
Studying Torah (photo credit: ILLUSTRATIVE: MARC ISRAEL SELLEM)
Studying Torah
(photo credit: ILLUSTRATIVE: MARC ISRAEL SELLEM)
As a member of Jerusalem’s religious community, clinical psychologist Dr. Yisrael Levitz receives plenty of wedding invitations.
But one in particular stood out from a former patient of the program Levitz founded in 1999, the Family Institute of Neve Yerushalayim, which pioneered postgraduate training in counseling and family therapy for religious psychotherapists, and offers low-cost counseling for the religious community.
When B. was a teenager, his brother was killed in a bus bombing in Jerusalem. His parents avoided speaking about the loss, and he became depressed and angry, and disrespectful at home and at yeshiva. Concerned, the head of the yeshiva referred B. to the Family Institute, where a therapist guided him – and eventually his whole family – through a healing mourning process.
“Now he’s getting married and he’s doing great,” Levitz reports.
While a non-religious psychotherapist might have used identical methods, haredi (ultra-Orthodox) families tend not to seek help from non-religious therapists for fear of being judged or misunderstood, Levitz explains. And many simply can’t afford professional help.
“Any competent therapist, religious or not, can be equally helpful to a client, but members of religious communities want someone who understands the nuances of their lifestyle and cultural norms,” says Levitz, a professor emeritus and ordained rabbi who initiated the study of rabbinic counseling at Yeshiva University’s theological seminary before making aliya 18 years ago.
Understanding those nuances helps a therapist identify pertinent questions and pick up on subtleties others might miss. For example, a religious counselor intrinsically understands that a family may be in crisis if a teenage son changes his style of kippa or a 28-year-old daughter is single, or they are unable to conceive a third or fourth child, he says.
A rabbinic authority is on staff at the Family Institute to provide halachic guidance on issues that arise during therapy for both patients and therapists.
An entire body of rabbinic responsa, scholarly articles and books has been published over the years to address such questions, says Dr. Seymour Hoffman, psychotherapy supervisor of clinical psychology interns at Marbeh Da’at Mental Health Center at Mayanei Hayeshua Medical Center in Bnei Brak, which is under haredi auspices and whose practitioners are all Orthodox or haredi.
Questions include: How is a person obligated to honor an abusive parent? Is it permissible for therapists to treat patients of the opposite sex? Is psychotherapy for believers possible with unbelievers? “Many mental health professionals are of the opinion that it is essential that Orthodox and haredi patients with psychiatric and psychological disturbances be treated only by professionals from a similar cultural background,” says Hoffman.
Cultural fluency can be critical not only in helping religious patients overcome obsessions and preoccupations regarding adherence to the minutiae involved in such rituals as prayer, immersing in a mikve and kashrut, but also in aiding them with more universal problems such as parenting, domestic abuse and addiction.
“The behavior and feelings of Orthodox patients cannot be understood by others [non-Orthodox], and appropriate help and treatment can be developed only by those with a full immersion in the cultural and religious values and practices of the community,” Hoffman says.
“Full immersion” in a haredi enclave such as Bnei Brak extends to the treatment setting. Staff are modestly attired, preferences for gender separation are respected and the waiting room has no magazines or pictures that would offend haredi sensibilities.
Hesitance to seek help outside one’s cultural or religious comfort zone is not specific to Orthodox Jews.
Studies in the United States and United Kingdom have shown that minority groups are reluctant to seek mental health services in the majority culture, and that those who do, are more likely to drop out.
Differences in communication style, body language and nuances in vocabulary can create misunderstandings between patients and therapists from differing cultures, according to Dr. David Greenberg, coauthor of Sanity and Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem. Greenberg is director of the Community Mental Health Center at Herzog Memorial Hospital in Jerusalem, which has an ethnically diverse patient base.
“It is very important to be handled by professionals who know the community and the ultra-Orthodox life inside,” says Dr. Esther Hess, a haredi psychotherapist in private practice and a supervisor at the outpatient and men’s inpatient departments at Marbeh Da’at.
In her previous work at a psychiatric hospital, Hess was often asked to consult on cases involving haredi patients.
“For example, there was a teenage haredi girl assigned to a therapist who dressed in a very revealing manner and the girl did not want to cooperate with her. The staff discussed the problem and some even felt this therapist would be beneficial for her because she seemed inhibited. No one realized how many obstacles have to be overcome for a girl educated in a Bais Yaakov seminary to seek psychological help after years of suffering. To sit down and talk about her difficulties with someone dressed immodestly is an impossible task for her,” recalls Hess.
Among those obstacles, she says, is the fear of becoming emotionally and financially dependent on the therapeutic process, as well as the widespread belief that psychiatric professionals harbor a Freudian disdain for religion.
“As a result, the tendency is to end the misery as quickly as possible by searching for practical solutions.
Therefore, cognitive therapy, behavioral therapy and cognitive behavioral therapy (CBT) are very prevalent among haredim in recent years because these sound more reasonable in terms of the length of treatment, and because they are more focused and less personally revealing,” says Hess, noting that she does not use these methods.
In recent years, haredim have become more willing to consider counseling due to an increase in accessibility to information and efforts to raise awareness and reduce stigma associated with therapy.
“But there’s a catch: As awareness increases in the haredi community, therapists who are often unprofessional and amateur have sprung up and multiplied like mushrooms,” says Hess, citing an abundance of CBT “charlatans.”
“People in the haredi community do not demand the same level of professionalism in a psychological practitioner that they do in a medical practitioner. We must better educate the community that the mind is as important as any other organ in the body and has an effect on the whole body’s health. And we must ensure that therapists have the necessary professional knowledge and appropriate training.”
It was precisely this need that Levitz sought to fill when he founded the Family Institute.
“We provide the opportunity for men and women in the dati leumi [national religious] and haredi communities to develop a high level of professional competence within a supportive, culturally sensitive environment,” says Levitz.
In an average week, the institute treats about 350 patients from across Israel, a majority of them religious. Subsidized fees are low, and no one is turned away for lack of funds. Currently, some 50 therapists in the advanced two-year internship program see patients under the mentorship of 10 experienced family therapy supervisors.
“Religion and spirituality have recently been recognized as a potentially powerful component of psychotherapy. Faith, a sense of divine purpose and a spiritual meaning to personal challenges can provide powerful psychological support during trying times,” says Levitz.
This is not the same as religious guidance or advice, he explains.
“Rather, therapy helps people within a safe, trusting relationship to discover options, regain will and make better choices.”
About 200 graduates of the institute are working throughout Israel, “many in communities that did not have welltrained therapists before – and they are having a significant impact,” says Levitz.
One alumna, Dvora Corn, cofounded Gisha L’Chaim (Life’s Door) in 2004 with her husband, radiation oncologist Ben Corn, to tend to the psychosocial well-being of terminally ill patients from all sectors of society.
She says the training gave her “the general skill set to be a true professional and yet, truly understand the specific needs of a particular demographic.
“Once a therapist has the skills to listen to the needs and values of the ‘other,’ including his or her particular demographic norms, rituals and stigmas, he or she can engage the client in a meaningful therapeutic process.
Respecting and honoring the values of a particular sector allows us to foster a safe place that offers a context of comfort while exploring often challenging and destabilizing life issues,” says Corn.
In haredi culture, serious illness is fraught with taboos, she explains.
“People don’t even use the word ‘cancer,’ and I am more sensitized and respectful of that nuance because of my experience at the Family Institute.
If you can keep people in their comfort zone and explore issues in that comfort zone – if you understand what their environment offers them in terms of support – you have the best chance of helping them.”
She adds that despite the taboos, when an illness or other challenge become known within the haredi community, there is an outpouring of peer support, what she calls “a big hug.”
Any competent therapist must try to understand clients’ cultures, says Corn.
“If you practice in Beersheba, you’d better know the Beduin population, and in Ashdod, the Russian population. If you don’t know their culture, you can’t do the good work.”


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