Ritual complements ethics in Jewish law, but Orthodoxy and ultra-Orthodoxy seem in recent years to have put greater stress on ritual and on praising those who observe it pedantically. Thus it may be difficult to distinguish a simply devout person who is meticulous in his observances from one who suffers from obsessive-compulsive disorder (OCD). While experts say OCD is not more common among observant Jews than in any other group, when the observant do suffer from OCD, the symptoms usually relate to ritual observance, causing them to carry out practices compulsively in prayer, ritual hand washing, milk/meat separation, family purity or personal hygiene. In 2001, psychiatrists Prof. David Greenberg and Prof. Eliezer Witztum 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 OCD in this community. But it was an academic volume and not a guide to the treatment of OCD. Now Dr. Avigdor (Victor) Bonchek (email@example.com), a long-time Jerusalem psychologist and ordained Orthodox rabbi, has written a $30 book called Religious Compulsions and Fears: A Guide to Treatment. Released by Feldheim Publishers (www.feldheim.com) in Jerusalem, it is prefaced with a note of approval by Rabbi Abraham Twersky, a hassidic scholar and well-known psychiatrist living in New Jersey who specializes in treating substance abuse. His name on the cover alone is enough to encourage many observant Jews to read it. Twersky writes that in his 45 yeas as a psychiatrist, he has noted a "marked increase" in the prevalence of OCD. "It is unclear whether this is due to a greater awareness of the condition or an actual increase in its incidence." Twersky notes that OCD is known among professionals as "the doubting disease" because its sufferers "cannot be sure of anything. [Someone] may have washed his hands many times or spent hours in the shower, but still doesn't feel clean. He may have repeated a word in davening [praying] many times, but may feel it has not been pronounced correctly... An OCD sufferer may take on absurd and totally unnecessary precautions to avoid mixing milk and meat... In short, he is tortured by persistent doubt." GREENBERG TOLD The Jerusalem Post that his and Witztum's book "covered a wider range of disorders, but - written more for the professional - it looked at the meeting [point] between the religious world and the therapy world and the problems that arise." Written in English and more useful to the layman, he continued, Bonchek's book is "a guide to treating phobias and obsessions using behavioral and cognitive techniques aimed at the religious Jewish community." It is a comprehensive treatment guide that is eminently useful for sufferers, family members, rabbis, teachers and therapists. Very readable, the book promotes the understanding, recognition and treatment of OCD. Born in Cleveland, a student at Ponevezh Yeshiva in Bnei Brak, ordained by the Ner Israel Rabbinical College in Baltimore and a graduate in clinical psychology from New York University, Bonchek came on aliya with his family in 1971. He taught at the Hebrew University of Jerusalem's School of Education and School of Social Work for 30 years, and has long had a private practice, during which he treated a large number of OCD patients, many of them religious. He gives partial credit for his ideas and techniques to two mentors: Dr. Joseph Wolpe of Temple University who pioneered behavior therapy in the 1950s and Dr. Giorio Nardone of Italy, a strategic therapist with whom Bonchek studied for several summers. While he would like OCD sufferers and family members to read his new book, Bonchek doesn't regard it as a "Do It Yourself" volume allowing people to treat the condition without being examined and supervised by a professional. A father of six, Bonchek compares observing the commandments of the Torah to "holding a young dove in one's hands. If he grasps it too tightly, he kills it. If he does not hold it firmly enough, it will fly away, and he will lose it. There needs to be a delicate balance to fulfill 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, is nevertheless unique when compared to the relatively sparse behavioral requirements of other religions, and certainly when compared to the lives of the non-religious." The Jerusalem psychologist adds that religious manifestations of OCD might be similar among Muslims who pray five times a day and perform ablutions, but Christian ritual is much less demanding. OCD IS classified as an anxiety disorder, with the anxiety possibly stemming from disturbing obsessive thoughts (such as "Maybe somebody will die because of what I just did?") and a compulsion to repeat behavior for no real reason. It is a "stubborn problem... but not surmountable," writes Bonchek. As Jewish law demands and encourages ritual observance, minimizing excessive ritual may be more difficult for religious sufferers. Cleanliness, especially before reciting prayers, is required by the Torah, so having a clean body after relieving oneself is demanded. But OCD patients may spend an hour in the bathroom making sure they are clean before thrice-daily prayers. This adds up to a lot of wasted time. One yeshiva student named "Chaim" who had this compulsion would often sleep late because the thought of going through all this preparation was too exhausting. Bonchek recalls that sometimes he wouldn't pray at all since his "preparations" were too energy sapping. Religious women who observe family purity laws and suffer from OCD can get completely bogged down once a month when examining themselves for blood to determine when they are permitted to go to the ritual bath. Such compulsions can make it impossible for them to get pregnant. "Dovid," a 29-year-old married kollel yeshiva student, had an uncontrollable urge to give charity; he never turned down a beggar or even a mailed request for a contribution, and earned less than he handed out. Kashrut is another halachic demand that lends itself to obsessions. OCD patients may constantly look for insects in the vegetables, beans or rice, or endlessly wash their hands after touching a "meat" spoon before touching a dairy one. Despite such repeated tasks, worry about having a "non-kosher" kitchen can become a constant fear. Sufferers may personally make a vow about such observances, and when they are unable to carry it out, they will feel even more fearful and guilty. Observant Jews are not permitted to throw away papers printed with God's name (in Hebrew) or other holy writings. These are saved and then deposited in a genizah, a storage place, from which they are taken and buried. But compulsive hoarders will go out of their way to look for fragments of papers to see if the Tetragrammaton appears there. The phylacteries (tefillin) must be worn on the head and arm just right. An OCD patient who insists that everything be "in order" could suffer from a compulsion that forces him to put the leather box and straps on "exactly right." Bonchek notes that Sigmund Freud , the best-known psychiatrist of the 20th century, researched and treated OCD but was "not very successful with his cases." But that changed with treatments developed over the past 35 years. As Freudian psychoanalysis (dynamic psychotherapy) to enable adults to "return" to their childhood and discover motivations for OCD can take years, if it is effective at all. Bonchek prefers Cognitive Behavior Therapy (CBT), in which a therapist helps the patient "unlearn" his compulsive behaviors and obsessive thoughts. This usually works even if the OCD resulted from an imbalance of neurotransmitters and shows up in irregular brain patterns or damaging childraising behavior such as forcing unready toddlers to give up their diapers. Bonchek writes that when asked whether OCD is a medical disease or a psychological one, he answers that it is probably a "complex combination of both. It is classified as a psychiatric disorder, but that doesn't mean sufferers are 'mentally ill.'" The third approach is drugs usually prescribed by a psychiatrist. Some of these are also given for depression and other mental conditions and may have unpleasant side effects. They are not 100% effective, but the success rate is higher when combined with CBT. When going to a psychologist for CBT therapy, which Bonchek regards as having the highest potential to treat or even cure OCD, one must choose someone 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 something positive occurs after the behavior, it is reinforced. If a negative event occurs after the behavior, it is regarded as punishment. If there is no significant event after the behavior, there is "extinction," and the act will eventually "fade out." When a patient is helped to properly confront his behavior, extinction can get a boost. Sometimes, says Bonchek, a "buddy" who is regularly in the patient's environment can help when the therapist is not around. An important principle in CBT treatment, he writes, is that it has to proceed gradually, step by step, and in a precise order. In addition, guided imagery is useful. One of the interesting case studies Bonchek presents is that of a 39-year-old married actuary working for a municipality and the father of a toddler. He was unable to go to work for nearly a year because of his compulsions, which involved bathroom rituals and cleanliness. The psychologist slowly exposed the man to what caused his fears, used guided imagery, discussed his progress with him and even rehearsed a circumcision ceremony for his just-born son. The patient finally felt confident enough to return to work, armed with a credible explanation of why he had disappeared. Bonchek concludes by calling for flexibility in ritual observance. The great medieval scholar and physician Maimonides often stressed the "Golden Path" of moderation. "Sometimes less is more. And what 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!