Dr Judith Guedalia

Editor’s note: In addition to the rabbis consulted by the authors, ASSIA-Jewish Medical Ethics has approached a number of leading halakhic authorities, seeking their opinions on the course of treatment outlined in this case study. These authorities were kind enough to provide us with their written responses, including halakhic sources, justifying the therapy. They emphasized that this is not a generally applicable ruling; each case must be individually dealt with by a competent halakhic authority.

Acting out can be an expression of a conduct disorder. When a person experiences conflict, his or her frustrations are often played out through inappropriate behavior, of which there are many subcategories. In the following case report, we will discuss an instance of conduct disorder and the effective cognitive therapy as best exemplified by Colin A. Ross’s model. It must be noted that not only the therapy model used but also the referral itself can be described as “unorthodox” given the cultural realities of this case, as will be seen.

The Patient

The patient, whom we will call Yisrael, was a sixteen-year-old boy from a close-knit Hasidic sect that, like many haredi groups, sets strict parameters on its members’ lifestyles. These communities are not open to the attitudes or developments of secular society and attempt to shield their members from its influences. Nonconformist behavior is frowned upon and eliminated, especially violations of Orthodox Jewish law (halakha).[1]

Yisrael had already been expelled from one yeshiva entirely and from the dormitory of another because of repeated incidents in which other boys sexually stimulated him, brought him to ejaculate, and he did the same to them. Yisrael stressed that finding willing partners was not difficult and he never forced anyone to participate.

Understanding the Jewish position on masturbation is essential to fully grasping the severity of Yisrael’s conduct disorder. According to Kitsur Shulhan Arukh, a popular work on Jewish law, “spilling seed” is among the most severe prohibitions in the Torah, similar to that of adultery. Loss of any potential for creating life is comparable to killing, and therefore one who engages in it is ostracized. Many restrictions are placed upon the Jewish male so that he should not come to perform this sin: he is not allowed to think about women in a sexual way, he is not allowed to watch animals copulating, certain foods are prohibited at night, and he may only sleep on his side, not on his back or stomach.[2] For a boy who cannot—or does not want to—control his urges, repeated masturbation can cause tremendous feelings of guilt.

Over the course of therapy, it became clear that Yisrael was acting out certain conflicts. Shortly before the problem began, his young, married cousin died. He was profoundly affected by this and it raised serious questions in his mind about death and the injustice of a young man dying, leaving a widow and orphans. To make matters worse, the Rebbe or Admor (“our master, our teacher, our rabbi”), the revered leader of his community, had assured the family that the cousin would live. Not long afterward, the Rebbe died as well. Yisrael’s religious beliefs, which were tied into a magical faith in the powers of the Rebbe, were deeply shaken.

In Hasidic communities, mythic qualities are ascribed to the Rebbe. He is seen as the intermediary between his followers and G-d. Everything he comes into contact with takes on mystical significance—for example, it is considered a great merit to be present at the Friday-night gathering called the tish and to receive a piece of bread that the Rebbe has touched (sherayim). The Rebbe is the source of advice, often about the most minute matters. His words are cherished and his instructions are obeyed to the letter. One can understand, therefore, why the Rebbe’s death had such a devastating effect on Yisrael, especially considering his particular circumstances.

Yisrael’s antisocial behavior can be understood as a cry for help, for a way to reconcile the conflict that was shaking the very foundations of his faith, his lifelines: his connection to religion and his community. From the halakhic perspective, masturbation is intimately connected to the interplay between life and death, the potential for life and its destruction. “Spilling seed” might have been his way of challenging or defying G-d: “Will you kill me just as you killed my cousin?”

Masturbation can also be seen as part of normal development. In Yisrael’s community, however, this normalcy is repressed and seen as an inability or lack of desire to control the sexual urge.

It must be noted that Hasidic boys are, for the most part, separated from women (other than their immediate family members) starting at the age of three. Their contact with women, therefore, is limited. After bar mitsva (thirteen years of age), their daily routine involves sitting and studying for most of the day. No time is allotted for exercise or any other sort of physical release, which is seen as glorifying the body and therefore forbidden. Even non-Hasidic teenagers have trouble maintaining a healthy, balanced attitude toward their bodies and growing sexuality. In the Hasidic context Yisrael’s behavior was much more aberrant, widening the circle of damage.

Yisrael’s parents were interviewed by the therapist and his father in particular presented as a disorganized person who had difficulty setting limits. He appeared disheveled and clearly did not know how to relate to the therapist in a professional manner—for example, at the end of the first session he asked Yisrael in the office whether he felt the therapist had done a good job. The lack of standards and limits in the boy’s household undoubtedly contributed to his inability to control his urges in an appropriate way.

There may be another reason why Yisrael’s conduct disorder took on such a pronounced sexual tone. It seems that the patient grew up in a household where sexual tension was rife and actions with a sexual overtone may have been a way of expressing frustration and/or asserting control. The salience of this particular symptom of his crisis, therefore, was hardly surprising.

Yisrael’s conduct disorder was not simply a repressed sexual urge gone awry or the result of growing up in a home with inappropriate parameters for behavior. As stated, it was a cry for help from a confused and torn individual. Only an extremely severe and pressing conflict would cause him to endanger his position in his community—as he said to the therapist early on, “If I don’t have hasidut, I don’t have life.” Yisrael knew perfectly well that his behavior would result in ostracization from his community— as previously mentioned, he had already been expelled from one yeshiva entirely and from the dormitory of the yeshiva he was then attending.

Course of Treatment

Yisrael was treated over a ten-month period, first in one-hour bi-weekly sessions, then in weekly sessions. Therapy was based on a model formulated by Colin A. Ross for dissociative identity disorder.[3] This therapy follows the cognitive model and is based on collaboration between patient and therapist. In this particular therapy, the therapeutic relationship was emphasized. Yisrael was made to feel valued as a person by the therapist and, as a result, he began to value himself independently. The atmosphere was a comfortable one in which he and the therapist built a relationship based on mutual respect, even friendship.

Ross states that gentleness, flexibility, humor, and the therapist’s ability to listen should characterize the therapy. The therapy style is problem-oriented and a historical, focusing on the problem at hand and its solution as opposed to probing into the past.

The relationship aspect of Ross’s model was particularly important. Yisrael had entered the therapy believing that he was worthless and the relationship with the therapist demonstrated that he was not. Someone in a position of importance—a doctor in a hospital, no less!—found him worth befriending. That his parents, who were not well-off, had found the money to pay for the therapy sessions seemed to reinforce his growing sense of self-worth. Despite the asocial quality of his problem and the embarrassment he was causing his family, he was not being written off. In addition, his yeshiva allowed him to continue attending (although he was stigmatized by not being allowed to board).

Ross’s first step is to address the faulty learning model. Yisrael’s dysfunctional behavior was attributed to maladapted learning. An important part of his therapy, therefore, was to acquire more functional learning methods. At the beginning of the therapy, it was immediately clear that Yisrael was ignorant of—and curious about—human anatomy in general and sexual matters in particular. This was due to his extremely parochial upbringing, which censored all information about such matters, deeming them immodest.

To correct his ignorance, the therapist showed Yisrael a children’s book about the different parts of the human body and their functions.[4] For the first time, he was able to be open about these taboo topics.

He was able to converse openly with a woman, something which simply was not possible in his community, and this boosted his confidence as a young man. The ignorance and unclean atmosphere that had, for him, characterized sexual issues were replaced with awareness and a sense of control. The sanitized atmosphere of the hospital and his white-coated therapist helped him regard sexuality in a different, more positive way. He began to feel better about himself as a man and developed an understanding of the feelings and urges he had been unable to discuss with anyone else.

Another form of relearning occurred when Yisrael became more aware of his emotions and moods. The “How Am I Feeling Today?” poster, which shows different faces displaying various emotions and states of mind, was a particularly helpful tool.[5] Yisrael would, on his own initiative, search the poster for a face that matched his mood. He realized that the “guilty” face was one he used when he was insulting, someone else. It was in the safe environment of the therapist’s office that he felt secure enough to admit this. He also realized that through his own actions he was degrading himself and creating his intense guilt feelings.

Yisrael’s new environment, during therapy, was unlike any he had ever experienced and may have been an important factor facilitating his learning. It was easier to reconstruct his idea of reality after his reality had, indeed, changed. Yisrael had been in therapy before. His therapist—a religious, bearded male— reminded him of the world from which he came. He had terminated the therapy because he “did not feel that it was helping.” Now he was seeing a female therapist who, though religious and able to understand his background, was part of the larger world and thus able to help him see a broader reality.

Therapeutic Homework

Homework is an integral part of Ross’s therapeutic process. The idea is to give the patient a more active role in the therapy, thereby cementing and developing what is accomplished during the therapy sessions. In this case, the therapist took something over which Yisrael felt he had no control—masturbation—and attempted to give him a certain amount of control. Paradoxically, his assignment was to masturbate. Five times per day, three days per week, he had to masturbate, immersing himself in the ritual bath (miqve) each day that he masturbated (the miqve is prescribed by Hasidic custom for anyone who ejaculates sperm). His actions—which, until now, he could not control—were raised to a voluntary and controllable level. The nexus of control was thus shifted from Yisrael to the therapist and then back to Yisrael again. The realization that he was in control of his actions increased his self-respect; he no longer saw himself at the mercy of mysterious, uncontrollable urges.

Yisrael was given a second “homework assignment.” He would occasionally travel by bus to visit relatives in an ultra-Orthodox enclave about an hour away. Because of security considerations in Israel, the passenger seated in the front seat of the bus must be physically able to help the bus driver in case of a terrorist attack (much like the airplane passenger seated by the emergency exit). Yisrael’s assignment was to sit in the front seat every time he went to visit his relatives, putting himself in a position of responsibility, thus reinforcing his growing self-confidence. It served a second purpose: it kept him from the back of the bus, where troublemakers tend to sit.

As stated above, collaboration between therapist and patient is a prominent characteristic of Ross’s therapy model.[6] In this case, the therapist contributed her medical, psychological, and worldly knowledge, and Yisrael contributed by sharing parts of his world that the therapist had no access to—the Rebbe’s tish, for example.

Ross’s therapy is active and directive. While the therapist must create a warm atmosphere, he or she must also be focused and fairly strict about the treatment. This particular therapy’s structure was consistently maintained. Each session opened the same way. Yisrael would report how often he had masturbated, how he felt about it, and whether he felt he was developing more control. The discussion would take its own course from there, but even if only briefly, each session began the same way.

Ross’s model uses the method of Socratic questioning, which leads the patient to independently identify his own feelings rather than passively be diagnosed by the therapist. Since this method of questioning is used in the Talmud, it was familiar to Yisrael and he was able to internalize it to help identify his problems even though the therapy process itself was completely foreign to him. A bridge was built between the two worlds, and his ability to relate the two helped in the progression of the therapy.

Socratic questioning succeeded in taking Yisrael on a cognitive journey starting in his own community and reaching the new and different world of the therapist’s office. He was ultimately able to return to his own community with a deeper understanding of himself. He came to realize what was truly important to him: his community and the sense of belonging it engendered.

Openness is another characteristic of Ross’s therapy model. It was imperative that Yisrael and the therapist be open with each other. During the first appointment, when Yisrael told the therapist that he engaged in homosexual acts, she was very clear with him about the unacceptability of his conduct. She told him that he was abusing himself as well as others, stressing that just as he would not allow someone to reach into his pocket and steal his money, so was this a form of being taken advantage of, of self-abuse, and she would not tolerate it. He mentioned frequenting a public park where male and female prostitutes gather and where unprotected sex takes place. Again, the therapist made it very clear that she would terminate the therapy if he continued going to this park. “I don’t want to work with a dead person,” she stated, because of his risk of contracting AIDS through unprotected sex.

The therapist came to symbolize openness because she acted as a window to the outside world. For someone who was not even allowed to read the secular press (the Hasidic community generally reads its own, censored newspapers), this was an eye-opening experience. It was at this time, the summer of 1997, that the Sojourner vehicle, Rover, was exploring planet Mars. Yisrael was interested in Rover’s progress and the therapist kept him updated on its journey, a journey that became a symbol for Yisrael’s own. Just as Rover had to navigate rocks and hard places to gain knowledge and understanding, so did Yisrael have to endure the difficulties of therapy to gain a deeper understanding of himself.

Ross outlines five session targets, goals to be achieved over the course of therapy: defining the problem, identifying associated negative thoughts, answering negative thoughts, evaluating the effect of the answer on belief in original thought and on emotion, and establishing how the answer could be pursued in action.

Once his conduct disorder and acting out were identified, Yisrael and the therapist began identifying his associated negative thoughts, or mindset. In addition to the religious conflicts previously described, Yisrael’s problem with masturbation created feelings of alienation from and anger toward his community. He felt trapped because he had no outlet for his sexual urges. Engaging in a practice forbidden by Jewish law—which he equated with murder—created intense feelings of guilt, frustration, and worthlessness.

The therapeutic relationship was effective in battling these negative thoughts. Through it, Yisrael began to feel valued as a person. He formed a friendship with the therapist as they laughed together, talked together, and built a relationship of mutual respect and fondness, and this relationship played a large role in disproving his belief that he was worthless and “bad.” He began to realize that while his behavior was unacceptable, he had the power to control it and to set boundaries. This was further reinforced by the homework assignments discussed earlier. Additionally, continuing to attend yeshiva and to board there once a week allowed him to test and verify his new perceptions in the “real” world.

For someone from a community where innovations are frowned upon and suspected, where openness about feelings and opinions is not the norm, the therapeutic experience had the potential to be frighteningly unsettling. Yisrael’s rosh yeshiva, therefore, appointed a teacher from the community to discuss his problems with him and to explain why it was unacceptable from the community’s perspective. The parallel processing was effective in keeping him rooted in his own world while journeying to new and unknown, yet often enlightening and liberating frontiers.

Discussion

From the perspective of cognitive therapy, the therapy was effective because of its success in changing the way Yisrael thought. Faulty thought processes were identified, analyzed, and replaced.

Certain beliefs had irrevocably changed. Even before he entered therapy, the bases of his religious belief had been shaken by the deaths of his cousin and the Rebbe. To help reconcile this, the therapist introduced the concept of death and new beginnings. She had recently lost her father at almost the same time that her grandchild was born. Her experience acted as a metaphor for his. Through the new insight and more sophisticated understanding he had gained, he was able to resolve his own issues through the experiences of the therapist. As Bowen suggests, it is not only the therapeutic alliance that can be therapeutic, but the therapist him or herself.

It is significant that Yisrael shared a Talmudic insight (devar Tora) that the Rebbe had delivered before his passing. It showed that he was able to reaccept him as a pious and wise man.

Another aspect of his new mindset was a greater respect for women. His therapist was an Orthodox woman who was also a professional, respected by his father and by the leaders of his community. He had confided in her and worked through his problems with her. She had been able to understand him and even to discuss Torah, a topic seen by his community as beyond the abilities of a woman.

Just as the Rover metaphor was so significant, so too were others used during the therapy. Metaphor is effective in therapy because it functions as metacommunication; its meanings are absorbed on a number of different levels.

A significant symbolic exchange occurred when Yisrael brought sunflower seeds to eat during the session. Sunflower seeds are a popular ethnic snack in Israel. Their flesh is tasty, but the shell is large and messy to remove. When Yisrael asked the therapist whether she would mind if he ate them during the session, she said that she felt that they had their place, but that they mostly create more mess than food. They may look big, but there is little nourishing value in them. While it may be acceptable to eat them, it is important to put the mess in its place. Implicit in her response was that she was prepared to accept his faults, but that he had to learn to identify them and with them directly—in other words, to put them in their place.

Another symbolic event occurred on Purim, when children dress up in costumes and deliver packages of food to friends and neighbors. Yisrael dressed up as a monster for the therapist. Hiding and revealing at the same time, he used the customs of the holiday to test his own identity. Was he a monster, as he appeared on the outside, or a “good guy,” as he was on the inside?

Through the therapy, particularly through metaphors such as these, healthier and more positive metaphors replaced Yisrael’s negative thoughts. Many of his former ideas about the world had been shattered, but he replaced them with new, healthier ones.

What was there in the relationship between patient and therapist that allowed changes in such basic, ingrained patterns of thought to take place? A psychodynamic perspective on the therapy will help explain why the cognitive changes occurred.

Transference and countertransference played pivotal roles in the therapeutic relationship. Boys in his community live in dormitories from the age of thirteen until they are married. Even beforehand, as mentioned, once they reach the age of three and begin to attend heder, they are separated from their mothers and sisters for most of the day. This highlights the uniqueness of Yisrael’s interaction with the female therapist, and the transferential experience that simultaneously occurred on many levels.

The therapeutic relationship became the relationship with his mother that Yisrael never had. Separated as he was from her, and from any other loving, nurturing female figure, he had no one to turn to when experiencing sexual or existential confusion. The therapist was an accessible female who cared about him (as demonstrated by her firm refusal to allow him to engage in any behavior that would endanger his life), who valued him as a person, and who wanted to help him work through his issues. Through the relationship with the therapist, he resolved the relationship with the mother he had never, for all intents and purposes, had.

Although in reality he never would have been able to have such an open relationship with his mother, the transferential relationship with the therapist gave Yisrael the opportunity to attach to his “mother” and then separate from her when he had gained the self-confidence and maturity (from the relationship itself) to do so. Yisrael’s cognitive and emotional perspectives underwent a change once he had resolved an early deficiency in his psychological development.

Countertransference occurred on the part of the therapist. Since Yisrael was in need of a mother, the therapist adapted to play that role. She created an atmosphere in which he felt comfortable disclosing himself, making himself vulnerable but also open to help. She showed respect and trust for him and he ultimately reciprocated. This partnership is what allowed for resolution of Yisrael’s issues and his return to a predominantly male world.

The therapy sessions were to end at the conclusion of the yeshiva academic year, roughly corresponding to the month of July. As July approached, the sessions took on a different tone. Yisrael began bringing stories of the late Rebbe’s acts of piety and also related lessons he had learned in his Talmud studies. At the therapist’s request, the yeshiva increased the number of times he was allowed board, from once a week to twice. This was a tangible effect of his newfound faith in himself and proof of the yeshiva’s faith in him. These events seemed to signify a rapprochement with his community, with himself.

Is reentry into the environment that fostered the problem considered a success? We maintain that it certainly is. When assisting individuals from different cultural backgrounds, avoiding imposing one’s own values is imperative. The therapist must, whenever possible, assume the patient’s perspective and help him achieve his goal without transplanting him into the therapist’s world, which may be foreign to him. This particular patient wanted, more than anything else, to return to his community as a functioning member. This desire was reflected in his “contractual statement” at his first meeting with the therapist: “If I don’t have hasidut, I don’t have life.” Yet, although he was able to return as a functioning, contributing member of the Hasidic community, his journey into a broader and more accepting world had rendered him different.

References

1.       Bilu, Yoram, and Witztum, Eliezer. “Working with Ultra-Orthodox Patients: Guidelines for a Culturally Sensitive Therapy.” Culture, Medicine and Psychiatry 17 (1993): 197-233.

2.       Blackburn, Marie, and Davidson, Kate. Cognitive Therapy for Depression and Anxiety, 51-53. Blackwell Science, 1995.

3.       Bowen, Murray. The Family Therapy and Clinical Practice. New York: Jason Aronson, 1982.

4.       Gantzfried, Rabbi Shlomo. Kitsur Shulhan Arukh.

5.       Gil, Eliana, and Cavanaugh Johnson, Toni. Sexu- alized Children: Assessment and Treatment of Sexualized Children and Children Who Molest. Rockville, Md.: Launch Press, 1993.

6.       Mills, Joyce C., and Crowley, Richard J. Therapeutic Metaphors for Children. New York: Brunner/Mazel, 1986.

7.       Heilman, Samuel, and Witztum, Eliezer. “Patients, Chaperons and Healers: Enlarging the Therapeutic Encounter.” Social Science and Medicine 39, no. 1 (1994): 133-43.

8.       Therapeutic Interventions. “How Am I Feeling To- day?” (poster).

9.       Viederman, M. “Metaphor and Meaning in Conver- sion Disorder: A Brief Active Therapy.” Psychosomatic Medicine 57 (1995): 403-409.

Tags: ASSIA | Conduct Disorder | Dissociative Identity Disorder | Hasidic | Jewish Medical Ethics | Masturbation