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Book Forum: Historical, Philosophical, and Religious Perspectives   |    
Sanity and Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem
YORAM BILU, Ph.D.
Am J Psychiatry 2003;160:609-610. doi:10.1176/appi.ajp.160.3.609
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By David Greenberg, M.D., and Eliezer Witztum, M.D. New Haven, Conn., Yale University Press, 2001, 389 pp., $40.00.

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Like other fundamentalist groups, for whom the sacred is a phenomenological constant, ultra-orthodox (haredi) Jews seek to insulate themselves from the polluting effects of the secular society in which they are uncomfortably situated. Since they tend to view mental health care as a potential source of such effects, they use psychiatric services reluctantly and parsimoniously, often as a last resort. This attitude charges the cultural gap between Western-trained psychiatrists and Jewish ultra-orthodox patients with moral overtones, which makes it all the more difficult to bridge. In Sanity and Sanctity, psychiatrists David Greenberg and Eliezer Witztum, who have been working for more than two decades in the community mental health clinic that serves the ultra-orthodox communities of northern Jerusalem, rise to the challenge of bridging the gap between medical and sacred realities. Combining clinical case studies, ethnographic vignettes, and group data analyses tinged with Talmudic exegeses and Hasidic tales, they portray the peculiar ways in which clinical manifestations prevalent among the ultra-orthodox are shaped by their religious and mystical beliefs and practices and the culture-sensitive interventions designed to combat these problems.

For me, the most impressive aspect of this fascinating report is the authors’ attempt to use the unique setting of the clinic for exploring theoretical issues regarding the interface of religion and psychopathology. In the domain of religious ideation, for example, they seek to discern messianic beliefs from psychotic delusions, generalizing from their clinical cases that unlike the former, the latter are secretive, assigning a grandiose personal role to the individual, and are out of step with current religious thinking. Yet they concede that these criteria may become blurred in times of crisis. In the realm of religious rituals, they ask whether the code of Jewish law, with its meticulous emphasis on separation, repetition, and avoidance, is the natural habitat of obsessive-compulsive disorder (OCD) or perfect medicine. Their conclusion, supported by a review of the syndrome in a variety of cultural settings, does not implicate religious background as a causative factor. Rather, religious symptoms of OCD are merely the form OCD typically takes in patients for whom religious beliefs and practices predominate. In the area of religious change, they show that, although mental illness is significantly more common among baalei teshuva (religious penitents or returnees), religious change per se should not be viewed as the cause or precipitating factor underlying mental illness. The fact that the majority of the returnees had a previous history of serious psychiatric disturbances and they came for help an average of 5 years after their religious change indicates that the uplifting transformation and the structured life regimen that followed had an assuaging effect, albeit short-lived, on their problems. Regarding the complex relations of mental illness and mysticism, to which many of the penitents are attracted, the authors again note that mystical pursuits, often motivated by unresolved losses, may reflect a new avenue for a person suffering from a long-standing psychopathological process.

The conclusions regarding these and other culturally informed symptoms among the ultra-orthodox (e.g., nocturnal hallucinations, "the Jerusalem syndrome") are compatible with the common psychiatric wisdom that makes analytic distinction between culturally molded (particular) surface manifestations and preexisting pancultural (universal) structures of psychopathology. Although most of the work in cultural psychiatry subscribes to this "stratification model," the authors should be commended for the rich and nuanced portrayal of the religious and mystical idioms of distress that shape psychopathology in the community under study. No less interesting is their discussion of the culture-sensitive guidelines for working with ultra-orthodox patients they distilled from their rich clinical data.

Far removed from a standard psychiatric text, this book is written in a friendly, jargon-lean style, which sometimes surprisingly resonates with Jewish traditional discourse. I liked the authors’ modest, disillusioned, sometimes even self-deprecatory stance regarding the limits of their interventions, their frankness in discussing their failures and misunderstandings (sometimes turned into insights in an arduous trial and error process), and, above all, their genuine respect and empathy for their reluctant patients. At a time when multicultural encounters in the psychiatric clinic become the rule rather than the exception, Sanity and Sanctity has much to offer.

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