Dr Judith Guedalia

Sharmila Devi

Psychological after-effects of the recent evacuation of the Gaza strip are starting to show in both soldiers and settlers. But, says Sharmila Devi, mental-health professionals often have difficulty treating ultra-Orthodox Jews because few fully understand the religion's strict rules for daily life.

The beliefs and psychology of Jewish settlers, many of whom are fiercely nationalistic and religious, came under the media spotlight recently after some 8000 of them were evacuated by Israeli forces from the Gaza Strip and northern West Bank in August.

But within weeks, much of Israeli society appeared to have considered the withdrawal over and embraced the start of the Jewish high holy days. However, the psychological effects of evacuation on the settlers were appearing. More than 50 people had been to the Soroka medical centre in the southern Israeli town of Beersheva within 2 weeks of the evacuation, according to the Israeli daily Ma'ariv.Health professionals report that some Israeli soldiers, several of whom were called "Nazis" by screaming settlers as they were removed from their homes, have suffered psychological trauma along with the settlers themselves.

Dealing with the effects of the withdrawal is likely to feature at next January's sixth conference organised by Nefesh-Israel, the local branch of the international voluntary network of Orthodox mental-health professionals.

Nefesh-Israel was founded in 2001 by Judith Guedalia, director of the neuropsychology unit at Jerusalem's Shaare Zedek Medical Centre, and Leah Abramowitz, a senior social worker. Nefesh was originally set up in New York around 10 years for mental-health professionals who treat observant Jews to swap experiences and knowledge at conferences and training courses.

Guedalia, who trained in the USA, was moved to set up Nefesh-Israel after hearing about some of the problems faced by ultra-Orthodox Jews. She heard of one case in which a man whose request for a male psychiatrist was turned down three times. "Can you imagine a woman being turned away if she asked for a female gynaecologist? I felt that the ultra-Orthodox as a group were under respected and their values were viewed as odd by many mental-health professionals", she says.

Observant Jews follow their faith in many different ways. Within Israel, there is a majority who consider themselves Jewish but secular. There are those who call themselves modern Orthodox, such as Guedalia, who feel their beliefs are not incompatible with modern life. Meanwhile, the ultra-Orthodox, known as haredim in Hebrew, strictly follow Jewish laws and believe much of modern life poses a threat to their spirituality.

Within the ultra-Orthodox community there are further divisions, with groups following different rabbis and traditions varying according to their European Ashkanazi or eastern Sephardi origins. There is also a gamut of different political views, ranging from nationalistic to even anti-Zionist.

In Israel, as elsewhere, many psychiatrists come from a secular or at least non-religious background that can stand at odds with those who are strictly observant. Guedalia seeks to bridge these gaps. "If an ultra-Orthodox man comes to me and does not look at me in the eye but looks at the floor or wall, I can understand it and I say he doesn't deserve any less in the way of treatment", she says.

Within ultra-Orthodox society, daily life is governed by a series of Jewish laws known as mitzvot. These laws cover everything from the segregation of the sexes, distinct clothing, living in a defined geographic community, sexual relations, and ritual purity. Men are encouraged to study the Bible, Jewish laws, and commentaries well into adulthood, while women are often responsible for the family budget and for rearing children. Modern conveniences such as television, computers, and even mobile telephones are viewed with suspicion.

There is a strong taboo surrounding mental illness, mainly because of its adverse effect on prospective couples whose family histories are scrutinised before an arranged marriage. But gradually, more ultra-Orthodox are beginning to seek the help of professionals who are learning about their way of life.

Such all-encompassing religious belief can prove a minefield for mental-health professionals when dealing with ultra-Orthodox individuals. Nefesh-Israel also tries to help professionals who hold their own religious convictions to reconcile them with modern therapies. Guedalia says there are parallels with the treatment of Catholics, Muslims, and other religious minorities in the west.

The last Nefesh-Israel conference included papers on topics including: menstrual psychiatric disorders; the cognitive-behavioural aspects of the views of several classic Jewish commentators and the rabbinic attitude towards the use of manipulation for therapeutic purposes; coping with the aftermath of a terrorist attack; divorce; and child abuse. Meanwhile, segregated seating is provided for the conference participants, who range from ultra-Orthodox to secular.

Helen Sheinfeld, a non-Orthodox psychiatrist, spoke of a haredi woman with a severely disturbed husband who wanted to have sex with her throughout the month. Under Jewish law, a woman is considered ritually impure during and after menstruation and before she has visited a mikve or ritual bath as called for after each period as a cleansing ceremony. The woman developed amenorrhea, or lack of menstruation, and consequently the couple were not violating Jewish laws by having sex throughout the month. Sheinfeld used this case to highlight the need to identify psychological and environmental triggers for physical disorders.

Michael Bunzel, a haredi psychiatrist, spoke of genetic disorders in terms of how they can affect marriage prospects and when a rabbi should be consulted. Some disorders, such as Tay-Sachs disease that affects the nervous system, occur most frequently among descendants of Ashkenazi Jews. He also noted that some haredi women hide a psychiatric problem before marriage and take their medication in secret only to have to stop when they get pregnant, causing their husband to learn of their illness.

Meanwhile, another participant accused the Israeli government of freezing funding for psychological help for settlers in the Gaza Strip ahead of the withdrawal. Eliahu Ackerman, an educational psychologist, said the leftwing views of many psychologists and other therapists had diminished the number of volunteers willing to help settlers suffering from trauma and anxiety arising from the withdrawal.But, post-withdrawal, Tzahi Ben-Zion of the Soroka Medical Centre told Ma'ariv that emotional preparation and processing by mental-health professionals was "laudable". He also expected a flood of cases to emerge.

"The evacuees touched very sensitive nerves when interacting with the soldiers. It is very hard for a soldier to have someone shouting at him that he will remember him in his dreams and that he is a Nazi", he says.Among the settlers, he continues, "People feel they have been uprooted from everything that is familiar … What intensified the effect with those people is the fact that they believed with their heart that [withdrawal] wouldn't take place and for political reasons they did not prepare for the evacuation. Thus, from the emotional perspective, disengagement came to them as a sort of surprise that led to a crisis of faith and identity."

It remains to be seen whether Ariel Sharon, Israeli prime minister, will order any further withdrawals from the occupied territories as part of his plan of disengagement from the Palestinians. But aside from political upheavals, expected or unexpected, Jewish mental-health practitioners continue to search for ways to apply their faith in developing modern treatments.

Guedalia is a regular contributor to A Journal of Jewish Medical Ethics and Halacha and co-wrote an article for the August issue on using Biblical metaphor in diagnosis and therapy. She used the Bible's account of a Ben Sorer u-Moreh, or recalcitrant and rebellious son, to illustrate ways of helping children in abusive family environments.

"We see this case as an example of how ethnographic understanding of patients will benefit the therapist in his/her work, specifically in the Orthodox Jewish community (and certainly in the larger therapeutic community as well)", says the article. "Fluency with the cultural milieu of one's patients allows the therapist to hear and be heard with a sort of 'third ear', namely a sensitivity to the subtext that is unique to each ethnic group."

Questions such as how to distinguish between a fervent believer and a deluded psychotic who believes he is the Messiah, or how to identify obsessive-compulsive disorder from religious rituals are examined in the book Sanity and Sanctity: A Better Understanding by the Israeli psychiatrists David Greenberg and Eliezer Witztum. "If our reader is a therapist, he may tend to be unaware of his own self-definition as a member of the culture of mental health professionals and how this shapes his beliefs and behaviour", says the book. "There is hardly a country in the world that does not contain a variety of cultures and religions, whether historically or as a result of recent immigration."

Tags: Disengagement | Effects Of The Withdrawal | Gaza Strip | Nefesh-Israel | Ultra-Orthodox