Following up from yesterday, here is Part 2 of the source sheet; Part 3, the Bibliography, is set to post on Monday morning...
Treating observant Jewish patients with OCD:
Recommendations for Psychologists
1. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 927-928
Appropriate behavior is
environmentally determined, and just as healthy surgeons wash their hands
relatively often, it may be the case that people in certain cultures or
religious groups are slightly more bothered by intrusive thoughts.
2. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 932
Cognitive–behavior therapy
for OCD requires a clear conceptualization of the individual patient’s core concerns
and fears. For example, it is not sufficient to know that someone washes
excessively. A fear of contracting HIV/AIDS is very different from one of
touching dirt (just because it is disgusting), which is very different from an
obsession that one will become like the person whom one touches. Thus,
understanding the ultimate consequence or core fear is important.
3. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 936
In addition, there are
times that OCD patients ritualize by praying to prevent bad things from
happening after doing an exposure. Some therapists would encourage patients to
“spoil” or undo this ritual by praying for bad things to happen. However, given
that religious patients believe in the efficacy of prayer, they may be
reluctant to engage in such an act. An alternate approach is to ask them to
undo the ritual by praying instead to “allow God’s will.” This suggests that if
the person is to die, then allow that, and if not, then not. It inserts ambiguity
and removes active attempts to prevent the negative outcome.
4. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
There are notions within
Judaism that one should not articulate bad things for fear of them happening
(al tiftach peh), and that some thoughts are forbidden (hirhurim). When
treating a religious patient with OCD, engaging in a debate about whether
thoughts are inconsequential can sidetrack treatment because religious patients
may believe that some thoughts are in fact sinful. Instead, it is more
productive to address different aspects of OCD thoughts…
5. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
Other subtle differences in
framing identical information during psychoeducation are also important. With
nonreligious patients, for example, we often discuss the evolutionary function
of anxiety and how it has gone awry in OCD. Some religious patients are
resistant to the theory of evolution or find it heretical; for them, it can be
useful to express the same concepts in religious terms: “Why did God endow us
with the ability to feel anxious? What purpose does it serve?”
6. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
[O]vercorrection allows the
individual to return to a normal level of behavior after they complete
treatment… In Judaism, the concept of overcorrection was elucidated by the
medieval scholar, Maimonides, who described the process in reference to working
on one’s character traits. He advised that to refine character flaws one must
adopt the extreme opposite behavior, and that by doing so, one will arrive at a
middle path. Orthodox patients place great value on the study of rabbinic texts
and are used to considering behavior in reference to sources in rabbinic
literature. Hence, it can be useful to refer to the overcorrection process used
in response prevention as part of the writings of a foremost Jewish scholar
rather than a new scientific concept.
7. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 928
Understanding that OCD is
not caused by religious adherence, but rather that such adherence can influence
how OCD manifests in religious patients (i.e., in religious obsessions and
compulsions) enables the clinician to use the patient’s religious beliefs as a
framework to treat the disorder more effectively. Recruiting rather than
combating patient religiosity in service of treatment supports the patient in
reclaiming religion as an aspect of their life that brings meaning and comfort,
rather than distress.
8. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
By providing a sensitive
rationale, the therapist can alleviate the skepticism and create an open,
therapeutic environment. For example, a number of patients have articulated “If
I just weren’t religious, I wouldn’t have this problem.” Although not
necessarily intended to test the therapist, a statement such as this creates an
opportunity for psychoeducation and alliance building. One response might be,
“You might not have OCD about halacha, but you would likely have it about
something else instead. You cannot run away from OCD.” Such statements dispel
concerns that the therapist believes that religion is part of the problem.
9. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
Another part of the
rationale for treatment that should be conveyed early on is that OCD is likely
a barrier to the spiritual connection religious patients want to have with God,
and that EX/RP can be a way to help them rebuild that relationship.
10. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
When treating religious
patients, we believe it is not necessary or appropriate to include exposure to
actual sin. Obsessional fears are usually driven more by actions that lead to
increased (albeit small) risk than by actions that truly cause the feared consequence.
For example, patients who are afraid of touching a book on AIDS, leaving the
house with the oven on, or handling knives around their baby, typically believe
that these are risky behaviors, not ones that will definitely lead to the
feared consequences. During EX/RP, it is helpful for patients to accept risks
by acknowledging the possibility of their feared outcomes, but most individuals
do not need to state that they are definitely going to get AIDS, burn their
house down, or kill their child. Exposures do not usually require individuals
actually to experience the ultimate negative consequences, but rather to
tolerate risk, ambiguity, and uncertainty. Similarly, scrupulous patients need
not actually sin or tell themselves that they are doing so; instead, they need
to allow for slightly greater risk than others normally would, without actually
making the violation occur.
Treating observant Jewish patients with OCD: How
Judaism can help
11. Talmud, Yoma 44b
בכל יום היה חותה
בשל כסף וכו', מאי טעמא? התורה חסה על ממונן של ישראל.
"Every day, the kohen raked the coals with a
silver receptacle [and then put the coals into a gold receptacle]." Why?
The Torah spared Israelite property.
12. Code of Jewish Law,
Yoreh Deah 248:7
אדם שוע שנותן
צדקה יותר מהראוי לו, או שמיצר לעצמו ונותן לגבאי כדי שלא יתבייש, אסור לתובעו
ולגבות ממנו צדקה, והגבאי שמכלימו ושואל ממנו, עתיד הקב"ה ליפרע ממנו.
Regarding a generous
person who gives more than is appropriate for him, or who pains himself to give
to the collector to avoid shame, one may not demand and collect tzedakah from
him. Gd will punish a collector who shames him and asks of him.
13. Proverbs 3:17
דְּרָכֶיהָ
דַרְכֵי־נֹעַם וְכָל־נְתִיבֹתֶיהָ שָׁלוֹם:
Her ways are pleasant
ways, and all of her paths are of peace.
14. Mishnah Pesachim 1:2
אין חוששין שמא
גררה חולדה מבית לבית וממקום למקום דאם כן מחצר לחצר ומעיר לעיר אין לדבר סוף:
We are not concerned
that a rodent may have dragged leaven from house to house or place to place,
for then from yard to yard and city to city – there would be no end to the
matter!
15. Talmud, Yoma 30a
אמר רב פפא: צואה
במקומה, אסור לקרות קריאת שמע. היכי דמי? אי דנראית, פשיטא! אי דלא נראית, לא
ניתנה תורה למלאכי השרת!
Rav Pappa said: If
feces is on the spot where it emerges from the body, one may not recite Shema.
What is the case? If it
is visible, this is obvious! If it is not visible, the Torah was not given to
the ministering angels!
16. Nachmanides, Laws of
Niddah 9:25
ומדיני החציצה: לא
טוב היות האדם מחמיר יותר מדאי ומחפש אחר הספיקות לפסול טבילתה בדבר הקל, כי אם כן
אין לדבר סוף... לא יכניס אדם ראשו בספיקות החמורות אשר אין להן קץ וסוף, כגון
עצמה עיניה ביותר קרצה שפתותיה ביותר ומשאר הספיקות, כי מי יוכל להבחין בין עצמה
ביותר ובין לא עצמה ביותר.
Among the laws of chatzitzah:
It is not good to be overly strict, seeking doubts to disqualify her immersion
for a light reason, for there would be no end to it… One should not insert his
head into serious, interminable doubts, such as whether she closed her eyes too
much or pursed her lips too much or other doubts, for who could evaluate
whether she closed them too much or not?
17. Deuteronomy 22:26
וְלַנַּעֲרָ
לֹא־תַעֲשֶׂה דָבָר אֵין לַנַּעֲרָ חֵטְא מָוֶת כִּי כַּאֲשֶׁר יָקוּם אִישׁ
עַל־רֵעֵהוּ וּרְצָחוֹ נֶפֶשׁ כֵּן הַדָּבָר הַזֶּה
You shall do nothing to
her; the girl has no fatal sin. This is like someone who has been attacked and
murdered.
18. Talmud, Avodah Zarah
4b-5a
א"ר יוחנן
משום ר"ש בן יוחאי: לא דוד ראוי לאותו מעשה, ולא ישראל ראוין לאותו מעשה; לא
דוד ראוי לאותו מעשה... אלא למה עשו? לומר לך, שאם חטא יחיד - אומרים לו: כלך אצל
יחיד, ואם חטאו צבור - אומרים להו לכו אצל צבור.
Rabbi Yochanan cited Rabbi Shimon bar Yochai: David was not suited for
that deed, and Israel was not suited for that deed [the Golden Calf]… Then why
did they do it? To teach you that if someone sins, we tell him, "Go to the
individual." And if a community sins, we tell him, "Go to the
community."
19. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 936
[T]he McDonald’s test is
useful: “Is doing this the same as going to McDonald’s and eating a bacon
cheeseburger?” Often this can help the person gain perspective about the
reality of what they are being asked to do. They are not being asked to sin,
but rather to tolerate a small (and halachically permissible) possibility that
they may sin.
20. Talmud, Berachot 17b
כיון דכולי עלמא
עבדי מלאכה ואיהו לא קא עביד - מיחזי כיוהרא
[Regarding a personal stringency
to avoid work on Tishah b'Av, in a place where the community normally does
work:] Since everyone does work, and he does not do work, this will appear like
self-righteous arrogance.
21. Rabbi Shabbtai haKohen,
Pilpul b'Hanhagat Hora'ot b'Issur v'Heter, Rule 9
כשם שאסור להתיר את האסור כך אסור לאסור את המותר... מפני שעל הרוב יש בו
צד הקל במקום אחר...
Just as one may not
permit the prohibited, so one may not prohibit the permitted… because
generally, this will cause a leniency in some other area…
22. Talmud, Bava Kama 91b
מאן תנא דשמעת
ליה דאמר: אין אדם רשאי לחבל בעצמו? ... האי תנא הוא, דתניא: אמר ר"א הקפר ברבי,
מה ת"ל: וכפר עליו מאשר חטא על הנפש? וכי באיזה נפש חטא זה? אלא שציער עצמו מן
היין.
The
view that says one may not harm himself matches the view of R’ Elazar haKappar
BeRebi, who said: “Why does the Torah say that the Nazirite must bring an
offering to atone for the sin he committed ‘against a life?’ Against whose life
has he sinned?! It is because he pained himself by withdrawing from wine.”
23. Psalms 2:11 and 100:2
עִבְדוּ אֶת־ד'
בְּיִרְאָה וְגִילוּ בִּרְעָדָה:
עִבְדוּ אֶת־ד'
בְּשִׂמְחָה בֹּאוּ לְפָנָיו בִּרְנָנָה:
Serve Gd with reverence, and rejoice in trembling.
Serve Gd with joy, come before Him with song.
24. Rabbi Yaakov Kanaievsky, Etzot v'Hadrachot pg. 55, as
cited at OHEL above
Such thinking is a tactic of the yeitzer hara in order
to make observance of the mitzvos so burdensome that he will eventually, G-d
forbid, shirk the yoke of the Torah.
25. Rabbi JM Grinwald,
Etzot v'Hadrachot pg. 85, cited by Greenberg/Shefler Ultra-Orthodox Rabbinic
Responses to Religious Obsessive-Compulsive Disorder, Israeli Journal of
Psychiatry and Related Sciences 45:3 pg. 186
[T]he person who, whenever
he performs the will of the Creator, finds his soul and his energies contorted
by feelings of discomfort, fear, tension and misery over the carrying out of
the commandment — and, on the contrary, this is his usual state, and to carry
out commandments out of joy is the exception — this then is clear proof that
this was not God’s intention. For “strength and joy are in His place”
(Chronicles I 16:27), meaning that the essence of performing commandments is
joy, as Maimonides wrote…
26. Yirah Tehorah pg. 18
אמנם נודע לנו גם מן
המציאות וגם מאנשים העוסקים הרבה בסוגיא שלא היה אדם מעולם שפסקו אצלו הנערוון
מאליהם אם לא שהכריזו כנגדם מלחמת חרמה מלחמת קודש!... גם המזניח הענין מחמת
עצלותו בשב ואל תעשה "חבר הוא לאיש משחית"! מפני שהורס לעצמו לגמרי צורת
התפלה.
In truth, it is known
to us, from experience and from those who are very involved in the field, that
no one ever had the nerves halt on their own, without them declaring a war of
destruction, a sacred war!... Also, one who neglects the issue due to laziness,
failing to act, "is a colleague to the destructive person (Proverbs 28:24)"!
He destroys for himself, entirely, the structure of prayer.
27. Rabbi Yisrael Ganz,
cited in Religious Compulsions and Fears pg. 132
In cases that come
before you regarding sufferers of religious compulsions, I think it is
important to recall that which the gedolei Yisrael, such as the Steipler
Rav, ztvk"l, and the gaon, Rav Shlomo Zalman Auerbach, ztvk"l, and
others, have opined on this matter, that in every case of doubt in the halachah,
one is to decide on the lenient side of the question. Likewise, even if it is
unclear whether there is a doubt, one is also to be lenient…
28. Rabbi Yaakov
Kanaievsky, Etzot v'Hadrachot pg. 45, cited by Greenberg/Shefler
Ultra-Orthodox Rabbinic Responses to Religious Obsessive-Compulsive Disorder
pg. 185
It is forbidden to give
him reasons or explanations, for every reason that he is given, he will
undermine to contradict and reject completely whatever he was told.
29. Rabbi Dr. Avigdor
Bonchek, Religious Compulsions and Fears pp. 135-136
If, on the other hand,
he does not think there is any problem with the bedikah, he should not
give her an outright heter. He should say something along the lines of:
"I don't answer such questions." She will pressure him to be more
specific, but he should not budge from his one-sentence, non-committal answer.
The rav should warn the woman before any questions come up that he will
be giving her this kind of answer to her questions, so she should not think he
is just being impatient or uncaring. He should not reassure her that the bedikah
is clean; it is not to her benefit.
30. Huppert/Siev/Kushner, Treating
Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 938
Ultimately, patients need
to be willing to engage in the exposure and accept the uncertainty about
whether it is permissible. The notion of accepting uncertainty and acting
despite the anxiety is a guideline not only for a given exposure, but also for
how OCD patients must live in general.
31. Rabbi Dr. Abraham
Twerski, Foreword to Religious Compulsions and Fears pg. 16
[A]n OCD sufferer may
not necessarily be reassured by the opinion of the poskim. One woman
with OCD threw out three sets of dishes because she could not accept the Rav's
ruling that the dishes were perfectly kosher, saying, "The Rav did not
understand my she'eilah."
