Soul Sickness? Ultra-Orthodox Battle Mental Health Stigma

Whether they stay close to home or venture further afield, the ultra-Orthodox are becoming increasingly open to seeking treatment for psychological disorders, and thus to speaking the universal 'language of the soul.' A glimpse at an old-new psychiatric facility for Bnei Brak's masses.

Gil Cohen-Magen

BNEI BRAK – Standing tall in the center of this ultra-Orthodox city in central Israel, the state-of-the-art psychiatric facility, which is due to open within six months, has something to say: It states unequivocally that even here, in this most traditional society, attitudes toward those suffering from mental health problems are changing.

Eleven years ago, American-born Michael Bunzel sent up a trial balloon, as he calls it, when he took on the job of chief psychiatrist at the precursor of the new facility – a small clinic operating for now out of a few prefab structures, located behind the Mayanei Hayeshua Medical Center with which it is affiliated.

“In terms of mental health, it was a desert here at the time. If anyone in Bnei Brak had a problem – and recognized it – they would travel as far away as they could [for treatment] so as not to be seen,” says the 50-year-old Bunzel. “To open up [a clinic] here was to go up straight in the face of the stigma. People predicted no one would show up.”

But they did.

For most of the 20th century, the country's ultra-Orthodox treated professional care of mental health problems, and even the very existence of those problems, with suspicion, says Bunzel. The psychiatrist was born in Orange Country, California, studied at Stanford University, did his psychiatric residency at John Hopkins before immigrating to Israel – and is himself Orthodox.

The reasons for the aversion vary, but to begin with, explains Bunzel, this is a community that looks to its rabbis for help. Basing treatment on the wisdom of atheist personalities like Sigmund Freud, the founder of psychoanalysis, or other secular "fathers" in the field – makes people uncomfortable, to say the least.

But in the last two decades, with growing evidence that there are also clear biological underpinnings to mental illness, Israel's ultra-Orthodox, like the broader population, have became more open to treatment. “There has been something of a revolution,” says Bunzel. “The rabbis, and their communities, have gone from abhorring the field, to having high expectations of it.”

But still, stresses the psychiatrist, “I would say we have challenged the stigma – not broken it.”

Probably the biggest reason mental illness remains problematic within this community has to do with its system of matchmaking. In a society where one’s background, including, prominently, one’s health history is highly scrutinized before matches are made – anyone with a mental illness, or even with a relative who is afflicted, is automatically considered a less desirable match.

“It’s not like in secular society people are rushing to get into a marriage with someone with mental health problems,” says Nechami Samuel, a psychotherapist in the children’s unit at the Mayanei Hayeshua Medical Center (MHMC). “But in secular society, typically you first fall in love, and maybe later take an interest in the person’s background – whereas in our society, it’s the other way around.”

In Hebrew, Samuel points out, the term used for a mental health illness is mahalat nefesh, literally, "sickness of the soul." “The soul, in our community, is something very special – so to have something wrong with it is hard to accept,” she explains.

When members of the country's ultra-Orthodox community are ready or are forced to accept the fact that they or their loved ones need professional mental health care, they often find themselves in a secular medical system – one that does not always understand them, says Bunzel.

“For an ultra-Orthodox child to be hospitalized in a public hospital is a major challenge to everything he or she stands for,” he explains. “Oftentimes children are exposed to things they could not have imagined in their wildest dreams. Even something as simple as watching television interferes with the family values and the system they know.”

There are those who argue that certain aspects of ultra-Orthodox life can exacerbate or even trigger neuroses: the matchmaking process and the negative perception of mental health issues within that, for starters, but also the pressures of marrying young and having many children, for example, or the strict rituals of religious life, or the rejection of homosexual behavior. But these and other aspects of community life have to be well understood for treatment to be effective, says Bunzel, who adds, “Cultural differences need to be respected if you want a way into someone soul."

“There is an overall trend toward more culturally sensitive medicine,” he stresses. “There is something unique about having psychiatric service rendered by those with a similar philosophical and religious outlook, who will be aware of the idiosyncrasies of the subculture.”

A secular doctor who is not attuned to the ways of the ultra-Orthodox community, for example, might misinterpret ritual behavior, religious observance and even reliance on a higher power as being psychological problems in and of themselves, Bunzel argues. He gives the example a young ultra-Orthodox man who washes his hands 12 times a day. “Out of context this might be interpreted as a obsessive compulsive disorder,” the psychiatrist says. “But here we see it for what it is: part of a religious ritualistic lifestyle.”

Psychiatrist Michael Bunzel in front of Mayanei Hayeshua Medical Center's new mental health building in Bnei Brak. (Credit: Shlomo Hoffner)

“So many kids are misdiagnosed,” he goes on, "because they talk about divine intervention, or mention messianic issues. These things can be construed as psychosis.”

Psychotherapist Samuels gives another example: a situation where the father of a child she might be treating refuses to look her in eye. “A secular psychologist might conclude that there is a communication problem in the household, or even autism,” she says. "But in fact, the issue is that it is not accepted in our society for an ultra-Orthodox man to meet the gaze of a woman.”

Moreover, treating a patient, the two professionals say, often also involves treating a whole family, and in the case of the ultra-Orthodox, also involving their rabbis.

“Accessibility, cooperation and follow-through will all be much easier if the family and community feel they are safe, in the hands of those who understand them,” says Bunzel.

According to data on the MHMC website, 65 percent of the adults and 70 percent of the children who come in for mental health help would not have sought treatment in other clinics, because those are “not suitable to their special needs and unique lifestyle.”

A fresh take on illness

Esti Galili-Weisstub, head of pediatric and adolescent psychiatry at Jerusalem's Hadassah University Hospital, Ein Kerem, which serves a large ultra-Orthodox community, differs from this approach. First, she points out, in cases of severe illnesses, it is obvious to her that the only important thing is how professional the care is – not the religious identification of the caregiver.

“For someone who comes in, say, in a psychotic fit, similar to someone who comes in needing an urgent operation, the questions of whether the doctor is a man or a woman, an Arab or a Jew is not the important one,” she says.

That said, when it comes to psychotherapy, professionals must be sensitive to their patients’ cultural, social and religious backgrounds, Galili-Weisstub agrees. At Hadassah, like at other hospitals around the country, such sensitivity is clearly evident, she says: Male and female ultra-Orthodox patients are kept in separate therapy groups and rooms, televisions are not installed in patients' rooms, doctors and staff all dress modestly, etc.

While there is an argument for being treated within one's own community, Galili-Weisstub believes there are also cases in which patients actually prefer to leave those confines – together with its way of thinking — and get a fresh, more “pluralistic,” take on their illness.

“A patient might feel the need to talk to someone who does not know their neighborhood or their rabbis or their aunt,” agrees Noam Hass, a private psychoanalyst in Jerusalem who treats patients of all stripes and is himself modern Orthodox. “It is true that the ultra-Orthodox live within a 'language,'” says Hass. “But the language of the soul is a universal one.”

Psychiatrist Uri Nitzan, a psychiatrist at the Shalvata Mental Health Center in Hod Hasharon, is well acquainted with the Orthodox world. He agrees with Galili-Weisstub's and Hass’ observations, and comes back to the issue of stigmas.

“Sometimes," says Nitzan, "...an ultra-Orthodox patient with certain issues might feel that, if they turn to an ultra-Orthodox framework for help, they would be judged twice — once for their behavior, and a second time in terms of halakha [traditional Jewish law],” explains Hass, adding that it is sometimes helpful for a patient be seen as an individual case, not as a member of any larger cultural, religious group.

It remains the case, continues Nitzan, that despite the geographic convenience of staying near home, one will indeed find many religious patients from Safed and Jerusalem, not to mention the United States and Europe, in Bnei Brak – and also patients from Bnei Brak in Netanya or Jerusalem. “It is good to have all the options,” he says. “The most important thing is for people to seek help – wherever works best for them.”

Inspirational founder

If one thing is certain, says Chaim Fachler, MHMC’s international director of resource development, it is that the strides the ultra-Orthodox community has made toward accepting mental health care in general – and coming to the Bnei Brak clinic in particular – are a testament to their faith in the facility's founder and president, Moshe Rothschild, an 86-year-old father of 17, with more than 100 grandchildren.

Born in Switzerland, Rothschild, who comes from the German branch of the famous banking family, immigrated to Israel in 1971 and settled in Bnei Brak – becoming, according to Fachler, “the first trained religious pediatrician,” in a community of some 75,000, at the time. Today Bnei Brak is Israel’s 10th largest city (and one of its poorest and most densely populated) with some 180,000 residents, almost all of them ultra-Orthodox.

Rothschild's practice grew as the community did: starting a family clinic and becoming the personal doctor to many of the best-known rabbinical leaders here – including Rabbi Yaakov Yisrael Kanievsky, known as the Steipler Gaon, and Rabbi Yechezkel Levenstein of the Mir Yeshiva, known as Reb Chatzkel.

With the backing of these and other rabbis – without whose support, it’s safe to say, virtually no project can get off the ground in Bnei Brak – Rothschild began raising money and, in 1990, realized his dream of opening the first large medical center built in, and specifically for, the ultra-Orthodox community in Israel and, says Fachler, in the world.

Today MHMC has 250 beds, 140 doctors, 350 nurses and support staff, and 15 departments, including cardiology, neurology, gastroenterology, endocrinology, internal medicine, and surgery. Its biggest ward – unsurprisingly, in a city where 1,000 babies are born every month – is maternity, one of the busiest in the country. A full 70 percent of the hospital’s patients come to MHMC for care in its obstetrics, gynecology, neonatal and pediatric departments.

The center, which falls under the jurisdiction of the Health Ministry, offers services to anyone of any background. But the staff on hand as well as the ethos of this place is clearly geared toward the ultra-Orthodox community. Like all licensed hospitals with a majority of Jewish patients, MHMC is kosher, has a synagogue and a rabbi. But, beyond these basics, there are certain practices and innovations here that might seem unusual to secular or non-Jews.

For example, there is a separate elevator for Kohanim – as descendants of Aaron the biblical high priest are called – who are not permitted to come into contact with dead bodies. Plus various contraptions ensure that only in absolutely necessary cases is electricity turned on and off on Shabbat.

Regular television viewing is not allowed, and instead there are pre-selected videos with religious content on offer. There are no fashion or gossip magazines lying around in waiting rooms either – only religious reading materials and prayer books. Torah and Talmud classes and other services are on offer to those here for longer stays. The in-house Institute for Halacha and Medical Ethics, meanwhile, which is headed by leading authority Rabbi Yitzchak Zilberstein, keeps up an ongoing conversation on all areas of medicine and Jewish law.

A decade after MHMC was up and running, it was founder Rothschild – again after getting many important rabbis on board – who saw the need and pushed to start a small mental health clinic as part of the services provided there. “As rabbis,” says Fachler, “they know more than anyone about the problems of the community, and trusting Rothschild, they were supportive.”

“The mental health facilities at Mayanei Hayeshua ... are vital to our community,” Rabbi Chaim Kaniefsky, a leading international ultra-Orthodox authority and a posek, or legal scholar who hands down rulings related to halakha, said in a recent statement.

Today, the small clinic has grown to include 50 staff members, including six psychiatrists, four full-time psychologists, 12 residents, and a battery of social workers, nurses and therapists specializing in everything from animal therapy, to psychodrama, to gardening, to kung fu.

“We are operating at 150 percent capacity,” says psychiatrist Moshe Levy, the French-born head of the men’s day unit. For the last few years, according to MHMC statistics, over 3,000 people have made use of this clinic’s services annually.

It was time, Rothschild decided in 2007, to expand. And thanks to $20 million in private funding raised over the last five years, the prefab structures tucked away behind the main building will soon be left behind – and the MHMC mental clinic will move into the whole eight-story building going up in front of the main medical center.

The new facility is slated to house a 24-hour emergency room, outpatient wards, a day hospital, a day center for children, a psycho-geriatrics unit, a family therapy unit, consulting services for schools, a rehabilitation center and several floors, separated by gender, for in-patient services. Recruitment for new staff is ongoing, notes Fachler.

Will the ultra-Orthodox feel comfortable with such a large, conspicuous complex? Will they show up in even greater numbers? Bunzel believes so. “It has become clear that despair and the need for help outweigh any shame or stigma that remains,” he says.

“A mental health patient who is not treated suffers a double blow,” Rothschild said at the cornerstone laying for the new building a few years ago. “A lack of medication and rejection by his own family members. His silent cry fills the home with a great scream, yet nobody can hear.” But the situation, he added in conclusion, does not have to be this way.