Community Ment Health J (2017) 53:613–625

DOI 10.1007/s10597-016-0056-9

ORIGINAL PApER

Cultural Psychiatry: A Spotlight on the Experience of Clinical

Social Workers’ Encounter with Jewish Ultra-Orthodox Mental
Health Clients
Anat Freund1 · Tova Band-Winterstein2

Received: 9 November 2015 / Accepted: 28 September 2016 / Published online: 8 October 2016
© Springer Science+Business Media New York 2016

Abstract Community is a complex issue, especially in Keywords Religion · Psychiatry · Qualitative research ·
two particular populations overlap: Haredi society, which Clinical social work · Cultural sensitivity
embraces cultural codes common to closed communities,
and the mental health population characterized by its own
unique needs. The present study explores the encounter Introduction
experience of social workers with the cultural perceptions
of mental health clients in the Haredi community in light Cultural Psychiatry is a branch in Psychiatry dealing with
of Community Cultural Psychiatry. A qualitative-phenom- mental diseases and/or disorders existing within a certain
enological approach was adopted. In-depth semi-structured culture. While mental pathologies are universal and exist
interviews were conducted with 27 social workers, mental within numerous populations, expressions of mental distress
health professionals, who are in contact with ultra-Ortho- are culture-dependent, characterizing certain communities
dox Jewish clients. Three major themes emerged from the or geographic regions (Bains 2005). Cultural psychiatry
data analysis: (1) Exclusion vs. grace and compassion. (2) advocates understanding illness in terms of the local cul-
Mental health: A professional or cultural arena? (3) Mental tures; therefore, it attempts to understand the complex and
health help-seeking changing processes. This study shows subtle ways in which culture relates to mental functions,
that the attitude in the Haredi community toward mental particularly distress (Bains 2005). In the Haredi (J ewish
health therapy undergoes a process of change. It is impor- ultra-Orthodox) community, as in other similar communi-
tant to strengthen this process, together with preserving ties in Israel—such as Arab Muslims (Dwairy 2006)—the
existing community informal structures of help. unique needs of the mental health population are added to
the community’s cultural codes (Witztum and Goodman
2003). This challenges professionals to attempt to better
understand the subject’s emotional world, while passing on
their relevant professional knowledge (Freund and Band-
Winterstein 2013).
Haredi society, as a faith-based community, is segre-
Anat Freund and Tova Band-Winterstein have contributed equally to
this paper. gated, despite its interaction and complex relationship with
the secular surroundings (Strean 1994). The community is
Anat Freund generally fearful of the negative stigma frequently associ-
[email protected]
ated with the mentally ill, while mental disorders are often
Tova Band-Winterstein understood and labeled as basic faults of the individual (Wit-
[email protected]
ztum and Goodman 2003). Furthermore, seeking out mental
1
University of Haifa, School of Social Work, Mount Carmel, health professionals is not an obvious alternative (Freund
Haifa 31905, Israel and Band-Winterstein 2013). The present study describes
2
Department of Gerontology, University of Haifa, and analyzes the cultural-professional encounter of Israeli
Mount Carmel, Haifa 31905, Israel social workers treating Haredi mental health clients.

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614 Community Ment Health J (2017) 53:613–625

Multiculturalism as a Theoretical Framework community leaders understand that disclosure and coopera-
tion contribute to improving the situation of Haredi women
Multiculturalism refers to the existence and acceptance of who experience IPV (Leshem 2003).
ethnic cultural variety. It includes multi-traditional societ-
ies, different lifestyles, personal identities and multi-soci- Haredi Community, Collectivistic Culture and Mental
etal experience. The main concept of multiculturalism is Health
diversity, meaning existing side by side among multiple
ways of life. Multiculturalism is based on the assumption Individualism and collectivism provides a theoretical
that in order to live a fulfilling life, people need the support framework for exploring the interplay between culture
of their cultural communities, whose embedded values can- and mental health (Triandis 2001). Members of the Haredi
not be classified on the same value scale. Thus, there is no community, as an extreme collectivistic culture, are obliged
preference for one culture over another, and each culture to subordinate their personal goals to the goals of the col-
can be relatively adequate in regard to time, social, political lective, usually a stable in-group (e.g., family, band, tribe),
and economic contexts. There is a dialectic tension between and much of the behavior of individuals may be related
the known and the un-known that can create segregation, to goals that are consistent with the goals of this in-group
resistance and restraint on one hand, and acceptance, open- (Caldwell-Harris and Aycicegi 2006). The individual in
ness and interest on the other. collectivist societies relates to a few very important in-
groups, organized in concentric circles, and whose chosen
Characteristics of the Jewish Ultra-Orthodox Society goals do not threaten group harmony (e.g., the nuclear fam-
ily, extended family, clan, city, state) (Triandis et al. 1988).
The J ewish ultra-Orthodox community is a differentiated In such a culture, there is a strong influence on the way
group within Jewish society in Israel and worldwide, char- relationships between the self and others are perceived. In
acterized by extreme views regarding faith and religious the context of mental health, collectivism provides social
practice (Smith 2003). It is characterized by community support, and feelings of belonging, but it may also result in
discipline stemming from its subordination to rabbinical stress if the individual does not comply with the expected
authority, which encourages strong loyalty to the com- social obligations (Triandis 2001). Engaging in “deviant”
munity, while dictating strict behavioral codes. The ultra- behavior often results in social control and social sanctions,
Orthodox society is further characterized by a developed such as negative consequences regarding the match-mak-
and diversified system of mutual assistance based on phi- ing process for the individual and other family members,
lanthropy (Kagitcibaci 1996). Contrary to existing stereo- occupational integration within the society, social relations,
types, the ultra-Orthodox society is not a homogeneous and and integration in educational institutes (Barth and Ben-Ari
unified group of people in black (Erhard and Erhard-Weiss 2014). Compliance with social-cultural-collectivist codes
2007; Heilman and Friedman 1991). However, scholars (Haj-Yahia 2011) in the community and family is a cen-
agree that a clearly defined set of values characterizes all tral psycho-cultural theme in Haredi society, which reflects
groups within it, such as common views, perceptions of the nature of the relationship between the individual and
reality, faith, adherence to religious precepts, and a persis- society.
tent resistance to secularism (Hakak 2011). Menta l disorders refers to a wide range of behaviors
This group is determined to segregate itself from exter- classified by psychologists as abnormal (American Psychi-
nal society. Their isolation is reinforced by religious norms, atric Association 2013), and is a constant threat to the well-
behavioral modes, perceptions, education and external being of both the individual and the community (Gerrig and
appearances (Coleman-Brueckheimer et al. 2009; Goodman Zimbardo 2008). The stigma regarding mental health does
and Witztum 2002). not only affect the ill individuals; it applies to the clients’
The Haredi sector is composed of different factions family as well (Sartorius and Schulz 2005). According to
and groups with specific leadership (Heilman and Witz- the Haredi society, this stigma is based on a collectivistic
tum 1997) and institutions whose aims are to assist peo- culture including myths and beliefs associated with mental
ple belonging to that specific group (Shelif and Wallinger diseases. When the mental illness is perceived as represent-
2008). Historically, social conflicts in collectivist societ- ing a family illness, the entire family image deteriorates,
ies were handled internally by the rabbinical authority—in increasing the fear of “being labeled” mentally ill. While
other words, seeking advice from the Rabbi or a commu- the surrounding society is relatively more receptive to men-
nity source, while avoiding welfare involvement because tal disorders, in the Haredi community, as well as in similar
exposure to state institutions might be interpreted as a form communities (Arab Muslims), stigma and labeling threaten
of betrayal or denouncement, especially when referring to the social status of the mentally ill and their family members
sensitive issues such as family integrity. Today, Rabbis and (Dwairy 2006; Kitai 1997).

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Since we are talking about a society characterized by aware and eager to use external services, this basic ambiva-
severe enforcement and supervision patterns (Lev-On and lence still prevails, and conflicts are often solved within the
Neriva-Ben Shahar 2009), individuals are strictly super- community, by consulting rabbis and/or additional validated
vised, and are expected to follow and fulfill demanding authority figures recognized by the religious leadership
rules and procedures. It should be emphasized that stigma (Ringel and Bina 2007).
and labeling regarding social status is latent in the Haredi Mental health is one of the few fields through which the
society. A negatively perceived individual is associated with Haredi population remains in contact with the “other [secu-
a lower social status and inferiority, and should be avoided. lar] world”. The Haredi society has developed marginaliz-
This stigma affects various contexts, particularly match- ing concepts in regard to the individual at risk on behalf
making prospects (Freund and Band-Winterstein 2013). of society. This represents an extremely difficult dilemma
Despite the different ideologies of ultra-Orthodox and secu- for professionals, who must carefully maneuver between
lar societies in Israel, they are both interrelated, as a result the two worlds, by explaining the nature of their work to
of an ever-growing population with more complex needs. influential rabbis in order to make them understand the
In addition, recent years have witnessed more Haredi thera- importance of focusing on the individual in distress or at
pists working in these fields. The ultra-Orthodox “negoti- risk. Recently, many rabbis and ultra-Orthodox leaders have
ate” and depend on the secular society, especially regarding been encouraging contact with mental health professionals.
general and mental health, family violence, addictions, etc. In summary, two mental health help-seeking patterns
(Baum 2007; Goodman and Witztum 2002). have been identified in Haredi society. Firstly, this popu-
lation tends to avoid seeking mental health services, while
Seeking Help and Community Mediation only a handful of community members actually contact
in Non-Western Communities them, usually after a long period of time. Secondly, more
ultra-Orthodox in extreme psychiatric categories seek help.
Studies shows differences between ethnic groups and
the secular society in regard to seeking help patterns, Culturally-Sensitive Mental Health Intervention
access, and service utilization (Abe-Kim et al. 2004). Among the Ultra-Orthodox Population
Haredi society, as a collectivistic culture, faces a range
of obstacles, such as low awareness of services, denial of The therapy encounter between a secular social worker and
the possibility of mental illness in the community, and a a mentally disabled ultra-Orthodox client is often charac-
negative attitude towards professional help-seeking, due terized by distrust and a difficulty to accept cultural differ-
to cultural constraints that have an impact on help-seeking ences. Professionals must relate to how the client’s culture
p (Nobles and Sciarra 2000). These include the process of affects his/her expression of distress. In order to understand
problem identification, receiving health and welfare ser- the client’s point of view, the social worker must speak his/
vices, and the choice of treatment providers (Cauce et al. her “language” (Freund and Band-Winterstein 2013). Pro-
2002). In this context, Social work as a profession is a fessionals must keep in mind the notion that, besides avoid-
cultural mediator, aimed to advocate collaborative work ing the sharing of painful and intimate stories, the Haredi
with a long-standing cultural tradition. In addition, it has population also has difficulty developing these narratives
the potential to render more culturally appropriate inter- within a socially and culturally strange environment. This
ventions, bridging gaps between cultural and professional is often followed by a reluctance to cope with identity, reli-
canons (Al‐Krenawi and Graham 2001). In order to bridge gious and halachic questions. Professionals who treat others
this gap, social workers turn to other sources of help, such must take into consideration each person’s cultural identity
as family, religious leaders, traditional healers, and local in order to understand him and his conflicts, work with him,
professionals who promote affective help-seeking (Abe- and improve his quality of life.
Kim et al. 2004). Professionals can handle this culturally-sensitive therapy
by becoming more acquainted with the clients’ culture,
Seeking Mental Health Care in the Haredi Community viewpoints, and explanatory model in order to successfully
connect with them (Witztum and Goodman 2003). Strean
In the Haredi society, as a collectivistic culture, each thera- (1994) relates to the available similarities between psycho-
peutic encounter has its own advantages and disadvantages therapy and the Orthodox culture. He discusses the fact that
related to Haredi help-seeking perceptions for the mentally speech and dialogue are important factors in J udaism. He
ill (Kitai 1997). There is a constant conflict between cop- suggests comparing this concept to culturally-sensitive ther-
ing with difficulties privately and autonomously within apy in order to bridge the intercultural gap. Professionals
the community, and seeking help from external sources. treating the Haredi population should implement this impor-
Despite the fact that the Haredi population is currently more tant tool to bond with the ultra-Orthodox cultural world.

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Table 1 Description of
Participants Gender Years of Work Sector
participants
experience

1 Tal F 5 Fellowship National religious

2 Shir F 10 Fellowship Haredi
3 Avi M 7 Hospital Haredi
4 Zvia F 27 Hospital Secular
5 Menachem M 7 Hospital Haredi
6 Hanni F 13 Welfare office Haredi
7 Lea F 28 Welfare office Haredi
8 Haya F 10 Shelter Haredi
9 S. F 10 Fellowship Haredi
10 A. F 6 Fellowship National religious
11 M. F 11 Hostel National religious
12 H. F 10 Welfare office National religious
13 O. M 2 Hostel Secular
14 Z. F 1 Hospital Traditionalist
15 K. F 4 Hostel National religious
16 T. F 7 Welfare office National religious
17 Haya F 2 Hostel Secular
18 Ariel M 2 Hospital National religious
19 Shira F 2 Welfare office National religious
20 Yoel M 2 Welfare office Secular former religious
21 Rachel F 2 Welfare office National religious former
Haredi
22 Miriam F 6 Hospital National religious
23 Avital F 5 Hospital Religious former Haredi
24 D. F 5 Welfare office Haredi
25 H. F 4 Welfare office Secular
26 L. F 7 HMO Secular
27 Z. F 4 School for the mentally ill Haredi
HMO Health Maintenance Organization

In summary, mental health in the Haredi community is a questions are as follows: How do social workers deal with
highly complex and sensitive issue. This society has adopted the existing gap between their professional world and their
its own cultural codes, characterized by segregation and dis- clients’ cultural world? How do social workers describe
tance from the surrounding society, added to the difficulty Haredi society’s coping abilities with the mentally ill in
of accepting diversity. Social workers must understand this their community?
complexity, accept it, and become deeply familiar with its
characteristics in order to implement the most appropriate
culturally-sensitive therapy intervention. Method
Vast research is available on mental disorders, in general.
However, few studies deal with the mentally ill in Haredi Sample and Population
society (Freund and Band-Winterstein 2013). Research lit-
erature mainly relates to help-seeking mechanisms of the The study was conducted using the qualitative-phenom-
mentally ill in the Haredi community, addressing the need enological method, based on a purposeful sample (Pat-
for culturally-sensitive therapy. Nevertheless, very few ton 2002), which focuses on the selection of participants
studies, if any, have discussed the encounter experience of who best represent their population and best reveal the
mental health professionals with ultra-Orthodox mentally ill examined phenomenon (Mason 1996). Thus, the sample
clients and their families. included 27 social workers with different religious identi-
The present study seeks to describe the encounter expe- ties who are in daily contact with ultra-Orthodox J ewish
rience of social workers with the cultural perceptions of clients across Israel. Participants included 5 males and 22
mental health clients in the Haredi community. The research females; a total of 9 defined themselves as ultra-Orthodox,

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11 were Orthodox, 1 was conservative, and 6 were secu- study. Interviews lasted 60–90 min, and were recorded and
lar, with 1–28 years’ experience (see Table 1). It should be transcribed verbatim.
mentioned that despite the fact that while Orthodox and
ultra-Orthodox beliefs are based on religious faith, cultural Data Analysis
diversity exists between these two groups, including aspects
such as openness, collectivism vs. individualism, and the Data analysis was conducted according to the interpreta-
way of corresponding and participating within the general tive phenomenological method and involved several stages
society (Band-Winterstein and Freund 2015). All partici- (Smith et al. 2009). In the first stage—the reading and
pants are mental health professionals in the public, private reflection of the interviews—open encoding was performed,
and third sectors, working in hospitals, welfare offices and emphasizing relevant statements. The next step was group-
fellowships. They treat mental health clients who have ing the statements into units of meaning, including quotes to
been diagnosed by psychiatrists according to the DSM, and describe the participants’ experiences and perceptions. The
whose mental disorders influence their normative function- last step involved identifying the emerging themes by shift-
ing, such as working, interpersonal relationships, sleep- ing from the descriptive to the interpretive level of analy-
ing, eating, etc. As the participating social workers include sis. During the content analysis, the researchers discussed
Haredi, modern Orthodox, and secular people, each theme disparities and sought agreement regarding theme content
will be illustrated according to the similarities and differ- and interpretation of meaning. Data was organized based
ences existing among these three groups. on agreed-upon themes identified in participants’ narratives
(King and Horrocks 2010). Hence, adherence to this pro-
Research Tools cedure enhanced the study’s credibility (Lincoln and Guba
1985).
A semi-structured in-depth interview was implemented in
order to shed light on the participants’ experiences and their Validity and Reliability
attributed meanings. The interview guide included four
major content categories. Category 1: “The social worker in Trustworthiness (Lincoln and Guba 1985) was achieved
a multicultural society”, e.g., Mention three things that come as follows: Firstly, the interview was transcribed verba-
to mind regarding the ‘multicultural’ concept. Category 2: tim, enabling a glance at the original narrations. Secondly,
“The social worker in ultra-Orthodox Jewish society”, e.g., each of the researchers analyzed the material separately.
How do you experience your encounter with ultra-Orthodox Finally, researchers engaged in peer debriefing by working
clients? Category 3: “Coping strategies of the ultra-Ortho- with another qualitative researcher, serving as an external
dox society with mental health issues”, e.g., Which difficul- qualitative research expert who discussed and analyzed the
ties distinguish the ultra-Orthodox from the secular society dialogue with the researchers (Lincoln and Guba 1985; Cre-
regarding coping strategies? Category 4: “The social worker swell 2007).
in the ultra-Orthodox society from a time perspective”, e.g., The two researchers are senior social workers, experi-
How does ultra-Orthodox society relate to mental health enced in both academic theory and social work practice.
issues today, as opposed to in the past? Both are liberal Jews, acquainted and rooted in Jewish tradi-
tion. Furthermore, the researchers were in constant contact
Research Procedure with the ultra-Orthodox population within the framework
of their BA and MA degree social work studies. Therefore,
The interviewers were ultra-Orthodox and Orthodox social the researcher bias analysis and the assessment of the inter-
work students. They were qualified for the interviews and viewer-participant encounter was conducted through reflec-
had gone through a reflection process (Finlay and Gough tion and bracketing (Liamputtong 2010). Finally, reliability
2003) prior to the interviews, including awareness of issues was increased by the wide range of participants who nar-
related to their personal background, attitudes, and opinions rated similar bonding experiences, as is represented by the
of social work areas mentioned in their interviews. Brack- findings.
eting was performed prior to the data analysis (Moustakas
1994) in order to gain insight into our personal opinions Ethical Issues
as secular researchers and our involvement in the research
subject. The study was conducted within a closed society. There-
After being identified, participants expressed their agree- fore, client confidentiality was essential (Corbin and Morse
ment to participate in the interviews and determined where 2003), as participants pointed out that privacy in the ultra-
the interview would be held. Each participant signed a writ- Orthodox society is a major issue. Furthermore, some of
ten consent form and received an explanation about the the participants belonged to the ultra-Orthodox community

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and were acquainted with the people involved in the study. mentally ill look different or behave differently, which
This issue generated a great deal of ambivalence between is a problem… anyone who is different in Haredi soci-
confidentiality and the value of the research. This conflict ety is segregated, isolated, showing a certain behavior
was solved by withholding clients’ personal details and real that isn’t… this is the reason why they are not well
names from the participants. married or else, get the odds and ends. … By the way,
mental illnesses are not disclosed, they are confiden-
tial; they are strictly hidden in order to avoid harming
Results the entire family. (T. —7 years’ experience)

Three major themes emerged: (1) Exclusion vs. grace and com- Social workers describe the structured difficulty to accept
passion; (2) Mental health: A professional or cultural arena?; “abnormality” in Haredi society. Another expression of this
and (3) Mental health help-seeking changing processes. separation is associated with the fact that the mentally ill are
perceived as second-class individuals and, as such, should
Exclusion, Grace and Compassion as a Parallel Process settle for less compared to the normative population.
People are very reluctant; it’s very frightening. This is
This issue relates to Haredi society’s general ambivalence
the strongest fear related to matchmaking. I once had
toward the mentally ill. Social workers describe the con-
a client who suffered from depression and was very
cealment resulting from the labeling and rejection of the
concerned about making a good match: “Who is going
mentally ill leading, as well as the expressions of benevo-
to take me? I am second-class goods”… (Z. —4 years’
lence and acceptance expressed toward the labeled excep-
experience)
tional individual.
Secrecy and concealment of the mentally ill in Haredi The family makes great efforts to avoid labeling, due to the
society derives from fear of family labeling, which often matchmaking process, including attempts to “fix” the men-
leads to matchmaking difficulties: tally ill:
M. relates to the matchmaking issue as a major reason for
He (the mentally ill individual) is unable to sit and
hiding mental illness:
study Torah; he just isn’t capable… we often hear
Haredi society tends to hide them (the mentally ill) from them (the families) that he is lazy and would
even more, and this affects the family; people must not benefit if he would just invest some effort… they
know—it is a very difficult situation, a stigma, which have trouble understanding the real nature of the ill-
affects the family’s reputation and matchmaking pros- ness… Accordingly, this is not about not being capa-
pects. In secular and religious societies, it is alright if ble, but about not trying hard enough… Then, he is
people don’t get married; it is always better if they do, compelled to study with a partner in joint cooperation
but it is still alright, provided that one has a girlfriend, and the family refuses to understand that he can’t do
someone to be with. There is no such thing in Haredi this because he has something else in mind. (H. —10
society. Either you are married or you do not exist. Being years’ experience)
single is a real problem. (M. —11 years’ experience)
Torah study is a basic and important activity in Haredi soci-
M. discusses the matchmaking issue. In Haredi society, ety. Those who have trouble adjusting to it are “marked” as
couples marry through matchmakers who match men and exceptional. Therefore, families make huge efforts to inte-
women according to family, a common source of status. grate the mentally ill in regard to this activity. There are
Thus, if the existence of a mentally ill individual in a family attempts to blur the mere existence of such an illness by
is widely known, the family’s status is significantly reduced. using terms such as “lazy” or by saying one should “make
Since this is the only way to get married, and as the option more of an effort”. This unsuitable demand not only doesn’t
of remaining single is unacceptable, the family is compelled help, but may harm the mentally ill. The family seeks ther-
to hide the mentally ill family member. apy as the very last option:
Another form of labeling applies to the exclusion and
The family comes to us as their last option, after try-
rejection of the mentally ill and their families:
ing to cope by themselves, consulting the rabbi, trying
I believe that this is not only related to the mentally alternative treatment… parents wait until they can’t
ill, but that it has to do with all exceptional people in deal with it anymore and only then turn to therapy.
society. I see this according to different orientations, They try every other possible option before therapy,
regarding somebody who is ill or adopted, god for- such as spending a lot of money on natural foods,
bid, or someone who looks different—and some of the treatments or other bizarre alternatives. Families

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waste valuable time and money before they come to by three major dimensions: the client’s collective percep-
us. (L. —28 years’ experience) tion vs. an individual approach in therapy; the question of
which professional best suits the client—one who is a part
The family seeks all kinds of help in an attempt to avoid of the Haredi community or one who is from outside; and an
professional assistance for as long as possible. They turn outstanding rabbi’s involvement in the therapeutic process.
to therapy only in extreme cases, when the relative’s situa-
tion is unbearable and the parents are helpless. The family
goes through a great deal of suffering and many disap- The Client’s Collective Perception vs. an
pointed hopes in the process of recognizing their need for Individualized Approach in Therapy
professional mental health assistance. In addition, the men-
tally ill wastes valuable time until he finally receives treat- Haredi society focuses on community, rather than individual
ment. This recognition and acceptance of mental illness in benefits. Thus, when its members experience mental dis-
the family is a long and complex process. At this point, the tress, they often prefer to avoid talking about themselves:
mentally ill family member is labeled as such, while the
I believe that the Haredi society, from childhood or
individual and his family receive appropriate professional
even from infancy does not focus on the individual.
treatment, community assistance and support through grace
People don’t understand when a conversation focuses
and compassion:
on themselves. What is this all about? How long can
There are various expressions of help and mutual one talk about oneself? Each time, a greater effort
involvement among the mentally ill… The Haredi is involved, as if to expand the scope… and the dif-
population is strongly aware of benevolent acts and ferent language used in secular and religious society
kindness… One of my clients lives in a Haredi neigh- [is a problem] as well… being in therapy and talk-
borhood and the neighbors help a lot; they really care. ing about oneself, and what one feels, is so trivial.
It’s incredible. (S. —10 years’ experience) …According to the fundamental approach in Haredi
society, one is not at the center, so therapy is very dif-
Haredi society strongly advocates values of mutual assis-
ficult. Bringing people to dialogue about themselves
tance and care for the disadvantaged, provided that it rec-
is extremely difficult, for some, impossible. (H. —4
ognizes the existence of members in need. This attitude
years’ experience)
contradicts the rejection and stigma noted previously.
The therapy issue raises unpleasant feelings in the men-
I have seen a lot of grace in the Haredi community.
tally ill within the Haredi community. Their reluctance is
If things are open, the community is very supportive.
explained by the prevailing notion that the individual should
Many of my clients receive food every day, are invited
not place himself at the center of things. In an effective
over for Shabbat, and receive support… Many fami-
therapeutic dialogue, the client focuses on himself, his feel-
lies host the client for a period of time… especially
ings and desires, while the ultra-Orthodox individual has
the young. Others are willing to constantly help and
difficulty talking about himself. In other words, referring
say that they “have a child in a similar situation and
to one’s self and one’s personal distress is not only illegiti-
therefore will do such and such a thing in order to help
mate, the ability to verbalize personal distress is completely
people with these problems. I will offer my home on
unfamiliar to the ultra-Orthodox client. This brings us to the
Shabbat because I know how hard it is”. (R. —2 years’
question of who is the most appropriate social worker for a
experience)
Haredi client.
Exceptional expressions of help toward the mentally ill and
their families are common when the community shares the
secret, meaning when the issue is publicly disclosed and Who Best Fits the Haredi Client: A Professional
recognized. Furthermore, a family that has experienced the From Within the Ultra-Orthodox Community or
labeling process of one of its members and recognizes him One From Outside?
as mentally ill, considers helping and supporting a similar
family as a sort of personal mission. The question of who is the most appropriate social worker
for the Haredi client is extremely important. Answers to this
Mental Health: A Professional or Cultural Arena? question are ambivalent and vary between cultural and pro-
fessional compliance. Some people would rather be treated
Mental health professionals in Haredi society are exposed to by a social worker from another culture; while M. discusses
the issue of therapy in the context of the cultural characteris- the importance of having a social worker from the same
tics of this society. This exclusive background is expressed culture:

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Indeed, one does not need to be a drug addict in order Law” (associated with the “Communicating Vessels Law”)
to understand drug addicts, but I strongly believe refers to the fact that as religious people often know each
that you should be assisted by someone from within other, especially in such a closed and segregated commu-
your own society… There are many cultural issues nity, this represents an obstacle for the client.
that someone from the outside cannot grasp. Less Other voices view social worker-client cultural diversity
resistance is met when you work from the inside and as an advantage:
understand the culture. (M. —11 years’ experience)
I believe that in many cases, a Haredi client should be
assisted by someone from another society… Someone
M. discusses the idea that the social worker need not nec-
far from his/her own cultural world. It is often harder
essarily come from a similar background or have similar
to share things one does not talk about when sitting
experiences in order to understand the client. However, in
with someone “similar”. In this case (referring to a
the case of a therapeutic encounter, she believes the cultural
client), the fact that I am not someone she is familiar
context is extremely significant. Furthermore, identification
with and do not follow the same pattern allowed her
and treatment of mental illnesses may be deceiving for the
to ask questions and relate to them without hesitating.
secular social worker who does not distinguish between
(O. —2 years’ experience)
behavior resulting from Jewish precepts or mental disorder:
O. believes that a Haredi client benefits most by receiving
It is often hard to identify conflicts because they seem
treatment from a social worker from a different cultural
to be hidden beneath religious texts. Only people in the
world. This creates a safe, therapeutic space where issues
same sector can define whether this is normative and
not discussed within the community may be disclosed with-
highly spiritual or whether it has become something
out being concerned about the social worker’s response (“It
obsessive, unacceptable and external. Obsessions slip
is often harder to share things one does not talk about when
into precepts, demanding accuracy and this is where
sitting with someone ‘similar’”).
obsessive individuals fall… they trick themselves. For
example, a 9-year-old child I work with became very
obsessive with regard to blessings. That is, he began
The Rabbi vs. the Social Worker: Whose
saying all his blessings out loud, demanding that oth-
Authority is it Anyway?
ers listen and say “Amen”. His parents support him.
We have explained that this is not righteous behavior;
In the Haredi community, it is a way of life to consult with
it is non-normative behavior leading to obsessiveness.
one’s rabbi on many issues relevant to everyday life. This
(H. —13 years’ experience)
is also true as regards coping with illness, in general, and
Mental disorders and pathologies often come “wrapped up” mental health, in particular. How does the rabbi’s involve-
in the existing conventional thinking, body language, emo- ment influence all stages of the advance of mental illness?
tion and behavior of the Haredi society. This leads to delu-
People often know that the son or daughter has diffi-
sion and the inability to distinguish between religion, faith,
culties and makes a big effort to hide them. The men-
Jewish law or psychopathology. A religious social worker is
tally ill individual takes pills before the wedding and a
able to identify the subtleties and the twilight zone between
rabbi decides when he should stop taking them. Finally,
normative religious and exceptional behavior, which can
people realize that the person is no longer medicated
indicate mental pathology.
and therefore is not ill anymore. From my experience,
Additional opinions contradict cultural suitability:
the person then experiences a breakdown and things
Sometimes, people choose a social worker from get out of control. (M. —7 years’ experience)
another culture because they don’t want to disclose
The involvement of an additional source in therapy is com-
situations or share intimate issues with someone from
plex, demanding the social worker’s cultural sensibility.
their own community, due to what is referred to as the
“Communicating Religious People Law”. In the end, The rabbi controls the situation and decides which
you might realize that your social worker is indeed actions should be taken; that’s how things work in
married to your wife’s aunt’s niece… Therefore, peo- Haredi society. So, we must follow this line of thought
ple prefer to receive assistance from someone whom and be familiar with what the rabbi says… This is an
nobody will ever speak to. (A. —7 years’ experience) essential element when working with mental health
clients in Haredi society. I sometimes refer parents of
A. claims that cultural distance leads to openness and cre-
mentally ill children to the rabbi for advice, and this
ates appropriate conditions for less mistrust and fear of
helps. They would never turn to a parent–child center
stigma. The metaphor “Communicating Religious People

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Community Ment Health J (2017) 53:613–625 621

in the surrounding society; it wouldn’t be effective. The differences in mental health help-seeking patterns
(M. —11 years’ experience) indicate an increasing openness:
I see that there are more requests these days, from
According to M., cooperation between the social worker
a time perspective, and the level of requests is also
and the rabbi is essential in order to reduce client resistance,
changing. Today, people who are able to function turn
serving as an alternative therapeutic option as well. M. adds
to us, those who in the past were afraid to seek help
that, since the rabbi is a major figure in the client’s life, the
because they could hide their illness, as it was less
social worker should become acquainted with him so that
apparent… those who would say “people can’t see
they can work together as partners in the necessary cultur-
that I’m ill”… I believe this reflects the process taking
ally-sensitive therapy process.
place within Haredi society. I don’t quite know if there
On the other hand, O. relates to rabbinical intervention
is more openness, but people are more willing to seek
in therapy as a detrimental factor in the therapeutic process:
help. (T. —5 years’ experience)
When therapy is supervised by a rabbi, it is never
Change is expressed in two ways. The first relates to the
clear or clean enough. Some rabbis believe they can
amount of requests, while the second describes the variety
help through psalms and recommend not seeking
of requests to receive help from mental health social work-
assistance outside the community. This is a conflict-
ers. The transition from considering treatment as “taboo” to
ing approach for the mentally ill. I have heard several
the fact that people in mental distress choose to waive their
clients say that their rabbi tells them they are the prob-
need for confidentiality and even disclose conflicts in order
lem: “You need to be happier; you are depressed—be
to get help contributes to an optimistic view of the future:
happier, show your positive side”. This does not help
much… it does not lead to real openness in therapy. I believe that this will improve over time… There is a
The social worker is often unable to implement a clean great deal of openness, people talk about things more,
intervention because there is always someone else and the higher the peoples’ awareness, the easier it will
watching and supervising, so that unspeakable things be for them to request a social worker… People used
don’t come up. I believe that they [the rabbis] must let to be reluctant to do so, and preferred to run away.
go, allow treatment without supervising every session. Today, they are more active and cooperative. (L. —7
(O. —2 years’ experience) years’ experience)
O. is aware that the role of the rabbi is an integral part of Mental health social workers in contact with the Haredi
therapy, but expresses his disapproval of absolute inter- community experience greater openness towards the field,
vention supervision on the part of the rabbinical authority, leading to an optimistic view of the current and future
claiming that this intervention is detrimental to the quality process. This optimistic approach is based on wider help-
of the therapy. seeking awareness, increased requests for treatment, and
stronger involvement of additional community sources
Mental Health Help-Seeking Change Processes for the benefit of the mentally ill and his/her family. This
dynamic spreads within the community and influences the
Change processes in the Haredi community regarding men- general climate toward professional mental health therapy.
tal health are described by social workers. The negative
image of social workers is slowly changing, as the Haredi
community shows more of an inclination to seek out the Discussion
help of mental health social workers:
The article focuses on the experience of social workers’
Everyone says that it used to be harder; once, no one
encounters with Haredi mental health clients. Three topics
was willing to talk to mental health social workers.
are discussed: (1) Exclusion vs. grace and compassion; (2)
Nowadays, rabbis refer people to social workers; edu-
Mental health: A professional or cultural arena?; and (3)
cational counselors and school principals consult with
Mental health help-seeking changing processes.
us. (H. —4 years’ experience)
Cultural psychiatry deals with the mental disorders and
Significant openness in Haredi society is expressed by the diseases present in a certain culture (Bains 2005). Further-
increased inclination to share difficulties and seek therapy more, cultural sensibility is a major value in social work-
and advice from mental health professionals. Today, rabbis ers’ intervention. Results on therapy for the mentally ill in
refer people to professional assistance and have more trust Haredi society indicate an essential linkage between cul-
in therapy, thus legitimizing requests from additional fami- tural psychiatry and cultural sensitivity. A combination of
lies to get professional help. both elements may help mental health social workers create

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622 Community Ment Health J (2017) 53:613–625

an appropriate and effective therapeutic relationship, while personal concerns are secondary issues. This perception
dealing with stigma, reluctance and fear in Haredi society, should be taken into account in the therapeutic encounter. In
all of which prevent the mentally ill and their families from other words, the person-in-environment methodology refers
seeking help (Greenberg and Shefler 2002; Popovsky 2010). to a variety of approaches, which focus on the client, while
One interesting research finding relates to the first topic, all related circles—such as the nuclear and extended family,
describing the mental health complexity in Haredi society the peer group and the community (Makaros 2006). Thus,
as being comprised of a conflicting combination of exclu- in the therapeutic encounter with a Haredi client, the social
sion, grace and compassion. This complexity is a result of worker must understand the subject’s difficulty: not only is
the direct distress associated with the disease and the Haredi “talking about himself” illegitimate, the individual is also
community’s response, which views mental disorders as a often unable to verbalize his own difficulties.
comprehensive deficiency with far-reaching implications Another significant finding deals with the following
(Schnitzer et al. 2011). These conclusions have a direct questions: Which social worker is the most appropriate for
influence on the mentally ill and his/her family, and threaten a Haredi client? What is the meaning of being assisted by
the community as a whole. The study shows that mental dis- a mental health professional from the same culture or from
orders highly affect matchmaking prospects and the ability a different framework outside the community? There is no
to receive appropriate treatment on time. Mental health cli- unanimous agreement or uniform answer to these questions.
ents are expected to remain hidden for as long as possible, in Research results indicate that Haredi clients do not always
order to preserve community integrity, thus fostering their benefit from ultra-Orthodox social workers and often feel
exclusion. In Haredi society, narrow, closed attitudes and more comfortable with someone outside the Haredi commu-
labeling reinforce the exclusion of the mentally ill, increas- nity—someone neutral, unacquainted with the ultra-Ortho-
ing their shame, guilt and alienation. These dynamics con- dox establishment, holding unbiased views, and with a
tinue until the disease or the mentally ill individual can no different level of religiosity (Al-Makhamreh and Lewando-
longer be hidden or ignored by consulting rabbis. In these Hundt 2008). Furthermore, a social worker who is not “one
extreme situations, the family is willing to seek professional of us” meets the client’s needs for anonymity, concealment
help in order to formally diagnose and define the mentally and secrecy required by the closed Haredi community. On
ill. Extreme mental health situations are those in which the the other hand, diagnosis of the mentally ill involves a deep
family finally understands that any attempt and form of understanding of religious and halachic norms. That is to
treatment might be helpful. This is a “sobering experience”, say, the Haredi social worker must be able to fully distin-
leading to the family’s agreement to finally perceive the guish between the interpretation of texts and prayers suited
true and serious reality of the situation (Yalom 2008), and to religious behavior, and to identify behavior indicating a
engage mental health professional treatment. This pattern of mental disorder (Huppert et al. 2007).
conduct leads to the fact that most of the requests for mental The encounter between professional and religious author-
health frameworks in Haredi society relate to extreme situ- ities is one of the most significant research findings regard-
ations. In other words, as long as the family can hide the ing treatment of the mentally ill (Lifshitz and Glaubman
mental disorder, the person is kept at home at the expense of 2004). The religious authority is the highest influence in a
necessary and timely appropriate treatment. This phenom- traditional closed society. The rabbi is also involved in the
enon leads to the increased distress of the mentally ill and treatment of the mentally ill, often in opposition to the thera-
family members, as well as irreversible damage to the dis- pist’s views. The more social workers understand the need
turbed individual (Corrigan 2000). for their joint cooperation with rabbis, and the more the rab-
Once the family and mentally ill individual have been bis understand the true need to consult with mental health
exposed as such, they are labeled by the community as dis- professionals, the more the client benefits from this mutual
advantaged, leading to grace and compassion—basic values mediation. Internal community forces, such as rabbis and
in the Haredi society. The theme “Exclusion vs. grace and external forces like social workers together result in change.
compassion” describes this process, allowing us to learn Both parties are involved in joint collaboration and mutual
more about the journey experienced by the mentally ill and respect. The changing process is spiral in nature: stronger
their families within a cultural context, as well as the ability awareness leads to less concern. More consultations lead to
of mental health social workers to provide culturally-sensi- more professionals’ involvement. This contributes to dimin-
tive therapy. ished fear, increased legitimacy through community author-
Another issue raised by the study applies to the profes- ity sources, more consultation, and so on.
sional identity and authority of mental health social work- Another aspect deriving from change is that clients look
ers in the Haredi community. Ultra-Orthodox society is for help earlier, before reaching high distress levels. These
founded on collective principles, meaning that community change processes also provide the community with more
needs and interests are fundamental, whereas individual and legitimate therapeutic options. These courses of action are

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Community Ment Health J (2017) 53:613–625 623

not taken as a default, but out of the understanding that they their personal stories, clients also have a hard time sharing
are the best solution for the mentally ill and their family. their stories in an unfamiliar social and cultural atmosphere,
Despite the change processes taking place in Haredi together with the difficulty of coping with questions of iden-
society, based on the transition from an absolute commu- tity, religion and Jewish law. In sum, this study shows that
nity approach to an integration of ideological components, a the attitude in the Haredi community toward mental health
strong exclusion problem is still prevalent. therapy is undergoing a change process. It is important to
Haredi community members’ lives are determined by strengthen and accelerate this process, whilst preserving the
social and cultural codes leading to different coping strate- existing community’s informal sources of help, so as not to
gies than those used by Israeli secular society. The inter- “throw the baby out with the bathwater”.
views revealed the outstanding characteristics of Haredi
society, which social workers should be aware of in order to Practical Implications
meet the unique needs of this population. A Haredi family
with a mentally ill member normally avoids bringing this The social workers’ description of the Haredi society, its
issue to light, mainly due to concern over the matchmaking characteristics and attitudes toward mental disorders raised
prospects of the other children in the family. Scholars relate the issues of concealment, fear of stigma, and implications
to the tendency to hide the disorder from community mem- for the future as detrimental factors to the rehabilitation of
bers, as it is considered a severe fault affecting the status of the mentally ill. An insight into this complex issue and its
both individual and family members alike. This hiding is direct practical implications demand the taking of appropri-
followed by segregation and feelings of isolation and fear. ate measures in order to lessen the concealment and stigma.
In general, Haredi society is reluctant to seek assistance out- Professionals in contact with this population can operate
side its own framework and would rather handle conflicts within the community and through mediating factors such
through community-based, informal sources (Witztum and as rabbis who, as the communities’ religious leaders, can
Goodman 1998). Furthermore, when professional therapeu- bridge the gap between cultural and professional aspects.
tic intervention is required, members often consult with the Moreover, rabbis would be able to mediate among the
rabbi for guidance, request advice or blessings, thus further diverse groups in the ultra-Orthodox society. Social workers
protecting themselves from any secular influence (Ringel can use their professional skills to enhance the mediators’
and Bina 2007). Mental health is one of the few areas where effectiveness and advance the mediation process (Al‐Kre-
the ultra-Orthodox are compelled, against their will, to con- nawi and Graham 2001). At the same time, social workers
tact experts from the “other world”. This encounter leads to can learn from local leadership about how to render cul-
a great deal of tension and constant conflict between solving turally-appropriate interventions. In addition, in their com-
issues automatically within the community and consulting munity work social workers can engage professionals from
external professional sources. Lately, increased trust and the education and health systems by promoting awareness
consultations have taken place as a result of the training of and combating stereotypes to encourage the absorption of
Haredi or religious community mental health professionals. the mentally ill into the community. Furthermore, the cre-
Mentally ill individuals in Haredi society experience ation of support groups for families of mental health cli-
delicate and sensitive situations within the different circles ents may enhance their acceptance into their nuclear family.
surrounding them. Routine changes considered “normal” However, these support groups could be stigmatized by the
by most of the population, are experienced by the mentally Haredi community; therefore, mutual work between cultural
ill as sources of psychological turmoil, which threaten their mediators and professional social workers may help over-
delicate stability. The interviews reveal that instability and come this barrier. Community recognition is a platform that
social marginality is intensified in Haredi clients by their enables dialogue on issues regarded as taboo, thus contrib-
efforts to hide the secret and the stigma. Families of the uting to reducing related anxieties. Long-term appropriate
mentally ill are more concerned about social reactions and and effective activities within the Haredi faith–based com-
their public image than their own distress, as they belong to munity and among families of the mentally ill may foster the
a sub-culture and require services from the wider culture. On acceptance and rehabilitation of mentally ill individuals. In
the one hand, Haredi society needs the services provided by sum, our recommendation is that professionals will provide
the state; on the other hand, these services are often incom- the local leadership with a systematic, ecological mapping
patible with their religious and cultural perceptions. Thus, of families who cope with mental illness, identifying and
despite the distress expressed by Haredi clients and their utilizing leverage points, as well as providing skills for the
currently increasing desire to overcome segregation and entire process. In this way, professionals may successfully
engage in therapy, social workers are often still unable to achieve the integration of modern and traditional helping
meet their needs. Scholars relate to a triple exclusion claim- approaches, while remaining committed to their profession
ing that besides the difficulty of speaking intimately about and its ethics. Moreover, emphasizing ongoing professional

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624 Community Ment Health J (2017) 53:613–625

reflectivity processes during the encounter with local lead- communities in Israel. International Journal for the Advancement
of Counselling, 29, 149–158.
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values, opinions and beliefs and be more open to and aware resea rchers in hea lth a nd socia l sciences. Oxford: Blackwell
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Freund, A., & Band-Winterstein, T. (2013). Between tradition and
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