When ritual becomes obsession

A ritual hand-washing sink near a synagogue. (photo credit: Deror Avi)
A ritual hand-washing sink near a synagogue.
(photo credit: Deror Avi)
Ritual complements ethics in Jewish law, butOrthodoxy and ultra-Orthodoxy seem in recent years to have put greaterstress on ritual and on praising those who observe it pedantically.Thus it may be difficult to distinguish a simply devout person who ismeticulous in his observances from one who suffers fromobsessive-compulsive disorder (OCD).

While experts say OCD is not more common among observant Jews than in any other group, when the observant dosuffer from OCD, the symptoms usually relate to ritual observance,causing them to carry out practices compulsively in prayer, ritual handwashing, milk/meat separation, family purity or personal hygiene.

In 2001, psychiatrists Prof. David Greenberg and Prof. EliezerWitztum of Jerusalem's Herzog Hospital wrote their pathfinding volume Sanity & Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem,published by Yale University Press, that devoted a few chapters to OCDin this community. But it was an academic volume and not a guide to thetreatment of OCD.

Now Dr. Avigdor (Victor) Bonchek (drbonchek@013.net), along-time Jerusalem psychologist and ordained Orthodox rabbi, haswritten a $30 book called Religious Compulsions and Fears: A Guide to Treatment.Released by Feldheim Publishers (www.feldheim.com) in Jerusalem, it isprefaced with a note of approval by Rabbi Abraham Twersky, a hassidicscholar and well-known psychiatrist living in New Jersey whospecializes in treating substance abuse. His name on the cover alone isenough to encourage many observant Jews to read it. Twersky writes thatin his 45 yeas as a psychiatrist, he has noted a "marked increase" inthe prevalence of OCD. "It is unclear whether this is due to a greaterawareness of the condition or an actual increase in its incidence."

Twersky notes that OCD is known among professionalsas "the doubting disease" because its sufferers "cannot be sure ofanything. [Someone] may have washed his hands many times or spent hoursin the shower, but still doesn't feel clean. He may have repeated aword in davening [praying] many times, but may feel it has notbeen pronounced correctly... An OCD sufferer may take on absurd andtotally unnecessary precautions to avoid mixing milk and meat... Inshort, he is tortured by persistent doubt."

GREENBERG TOLD The Jerusalem Post that his and Witztum'sbook "covered a wider range of disorders, but - written more for theprofessional - it looked at the meeting [point] between the religiousworld and the therapy world and the problems that arise." Written inEnglish and more useful to the layman, he continued, Bonchek's book is"a guide to treating phobias and obsessions using behavioral andcognitive techniques aimed at the religious Jewish community." It is acomprehensive treatment guide that is eminently useful for sufferers,family members, rabbis, teachers and therapists. Very readable, thebook promotes the understanding, recognition and treatment of OCD.

Born in Cleveland, a student at Ponevezh Yeshivain Bnei Brak, ordained by the Ner Israel Rabbinical College inBaltimore and a graduate in clinical psychology from New YorkUniversity, Bonchek came on aliya with his family in 1971. He taught atthe Hebrew University of Jerusalem's School of Education and School ofSocial Work for 30 years, and has long had a private practice, duringwhich he treated a large number of OCD patients, many of themreligious.

He gives partial credit for his ideas and techniques to twomentors: Dr. Joseph Wolpe of Temple University who pioneered behaviortherapy in the 1950s and Dr. Giorio Nardone of Italy, a strategictherapist with whom Bonchek studied for several summers. While he wouldlike OCD sufferers and family members to read his new book, Bonchekdoesn't regard it as a "Do It Yourself" volume allowing people to treatthe condition without being examined and supervised by a professional.

A father of six, Bonchek compares observing the commandments ofthe Torah to "holding a young dove in one's hands. If he grasps it tootightly, he kills it. If he does not hold it firmly enough, it will flyaway, and he will lose it. There needs to be a delicate balance tofulfill the Torah's commandments in a healthy way."

From the moment of getting up in the morning until the moment he closes his eyes at night, a devout Jew is guided by mitzvot,Bonchek writes. "This fact, taken for granted by the observant Jew, isnevertheless unique when compared to the relatively sparse behavioralrequirements of other religions, and certainly when compared to thelives of the non-religious." The Jerusalem psychologist adds thatreligious manifestations of OCD might be similar among Muslims who prayfive times a day and perform ablutions, but Christian ritual is muchless demanding.

OCD IS classified as an anxiety disorder, with the anxietypossibly stemming from disturbing obsessive thoughts (such as "Maybesomebody will die because of what I just did?") and a compulsion torepeat behavior for no real reason. It is a "stubborn problem... butnot surmountable," writes Bonchek. As Jewish law demands and encouragesritual observance, minimizing excessive ritual may be more difficultfor religious sufferers.

Cleanliness, especially before reciting prayers, is required bythe Torah, so having a clean body after relieving oneself is demanded.But OCD patients may spend an hour in the bathroom making sure they areclean before thrice-daily prayers. This adds up to a lot of wastedtime. One yeshiva student named "Chaim" who had this compulsion wouldoften sleep late because the thought of going through all thispreparation was too exhausting. Bonchek recalls that sometimes hewouldn't pray at all since his "preparations" were too energy sapping.

Religious women who observe family purity laws and suffer fromOCD can get completely bogged down once a month when examiningthemselves for blood to determine when they are permitted to go to theritual bath. Such compulsions can make it impossible for them to getpregnant.

"Dovid," a 29-year-old married kollel yeshivastudent, had an uncontrollable urge to give charity; he never turneddown a beggar or even a mailed request for a contribution, and earnedless than he handed out.

Kashrut is another halachic demand that lendsitself to obsessions. OCD patients may constantly look for insects inthe vegetables, beans or rice, or endlessly wash their hands aftertouching a "meat" spoon before touching a dairy one. Despite suchrepeated tasks, worry about having a "non-kosher" kitchen can become aconstant fear.

Sufferers may personally make a vow about such observances, andwhen they are unable to carry it out, they will feel even more fearfuland guilty.

Observant Jews are not permitted to throw away papers printedwith God's name (in Hebrew) or other holy writings. These are saved andthen deposited in a genizah, a storage place, from which theyare taken and buried. But compulsive hoarders will go out of their wayto look for fragments of papers to see if the Tetragrammaton appearsthere. The phylacteries (tefillin) must be worn on the head andarm just right. An OCD patient who insists that everything be "inorder" could suffer from a compulsion that forces him to put theleather box and straps on "exactly right."

Bonchek notes that Sigmund Freud , the best-known psychiatristof the 20th century, researched and treated OCD but was "not verysuccessful with his cases." But that changed with treatments developedover the past 35 years.

As Freudian psychoanalysis (dynamic psychotherapy) to enableadults to "return" to their childhood and discover motivations for OCDcan take years, if it is effective at all. Bonchek prefers CognitiveBehavior Therapy (CBT), in which a therapist helps the patient"unlearn" his compulsive behaviors and obsessive thoughts. This usuallyworks even if the OCD resulted from an imbalance of neurotransmittersand shows up in irregular brain patterns or damaging childraisingbehavior such as forcing unready toddlers to give up their diapers.

Bonchekwrites that when asked whether OCD is a medical disease or apsychological one, he answers that it is probably a "complexcombination of both. It is classified as a psychiatric disorder, butthat doesn't mean sufferers are 'mentally ill.'"

The third approach is drugs usually prescribed by apsychiatrist. Some of these are also given for depression and othermental conditions and may have unpleasant side effects. They are not100% effective, but the success rate is higher when combined with CBT.When going to a psychologist for CBT therapy, which Bonchek regards ashaving the highest potential to treat or even cure OCD, one must choosesomeone who has training, experience and success in using it.

WHEN A compulsive ritual is performed, the person feels"immediate relief" afterward from his "inner tension." If somethingpositive occurs after the behavior, it is reinforced. If a negativeevent occurs after the behavior, it is regarded as punishment. If thereis no significant event after the behavior, there is "extinction," andthe act will eventually "fade out." When a patient is helped toproperly confront his behavior, extinction can get a boost. Sometimes,says Bonchek, a "buddy" who is regularly in the patient's environmentcan help when the therapist is not around. An important principle inCBT treatment, he writes, is that it has to proceed gradually, step bystep, and in a precise order. In addition, guided imagery is useful.

One of the interesting case studies Bonchek presents is that ofa 39-year-old married actuary working for a municipality and the fatherof a toddler. He was unable to go to work for nearly a year because ofhis compulsions, which involved bathroom rituals and cleanliness. Thepsychologist slowly exposed the man to what caused his fears, usedguided imagery, discussed his progress with him and even rehearsed acircumcision ceremony for his just-born son. The patient finally feltconfident enough to return to work, armed with a credible explanationof why he had disappeared.

Bonchek concludes by calling for flexibility in ritualobservance. The great medieval scholar and physician Maimonides oftenstressed the "Golden Path" of moderation. "Sometimes less is more. Andwhat I learned," stresses Bonchek, "is that sometimes less devotion in mitzva observance can lead to more devotion in serving [God]."

Given the extremism we often see in Jerusalem and elsewhere in the Jewish world, one can add: Amen!